PAIN

Definition
Most widely encountered clinical situations
o A common presenting symptom in primary
care and an important cause of morbidity.
o Most difficult aspect of care.
It is a very personal and individual experience defined as whatever the patient says it is, and it
exists wherever he or she says it does.
Pain is an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage.
The word "pain" comes from the Latin: poena
meaning punishment, a fine, a penalty.
In medicine, pain is a cardinal symptom of
inflammation.
These pathways transmit the nominally "painful"
signals, though they are not always perceived as
painful.
Scientists believe that pain evolved in the animal
kingdom as a valuable three-part warning system.
First, it warns of injury.
Second, pain protects against further injury by
causing a reflexive withdrawal from the source of
injury.
Finally, pain leads to a period of reduced activity,
enabling injuries to heal more.
Behavioral characteristics of pain
- Self-protective
- Has narrowed focus
- Withdrawal from social contact
- Has impaired thought process
- Exhibits distraction behavior
- Exhibits facial mask of pain
PAIN ASSESSMENT CHART

Classification of pain
- Based on ONSET & DURATION
1. Acute Pain
o Sudden onset
o Subsides in short period of time
o Sharp, localized sensation, with identifiable
cause.
A natural physiologic response to injury
Useful in warning individuals of disease or harmful
situations.
Concomitant physiological response include:
o Tachycardia
o Diaphoresis
o Increased respiratory rate
Goal:
o Avoidance of progression to chronic state
o Amelioration of the pain

2. Chronic Pain
Lasting longer than 3 6 months
Classified into
o chronic non-malignant pain/chronic benign
pain
Ex.: rheumatoid arthritis, pain
originating from nerve tissue
Categories: nociceptive pain,
neuropathic pain, or mixed
o Chronic malignant pain
Ex.: pain due to cancer, the tissue
itself or secondary tissue
Pain induced by disease & pain
secondary to treatment
Cancer & its treatment may activate
peripheral noceciptive pain & also
neuropathic pain.
Differentiated through careful history of the
location, quality & nature of pain, as treatment is
dictated by the cause and type of pain.
Goal:
o Decrease the pain to a tolerable level so the
patient may function in daily life.
3. Nociceptive
Nociceptive pain is caused by
stimulation of peripheral nerve
fibers that respond only to stimuli
approaching or exceeding harmful
intensity (nociceptors), and may be
classified according to the mode of
noxious stimulation;
the most common categories being
"thermal" (heat or cold), "mechanical"
(crushing, tearing, etc.) and "chemical"
(iodine in a cut, chili powder in the
eyes).
Nociceptive pain may also be divided
into "visceral," "deep somatic" and
"superficial somatic" pain.
Visceral pain is extremely difficult to
localize, and several injuries to visceral
tissue exhibit "referred" pain, where the
sensation is localized to an area
completely unrelated to the site of
injury.
Deep somatic pain is initiated by
stimulation of nociceptors in ligaments,
tendons, bones, blood
vessels, fasciae and muscles, and is dull,
aching, poorly localized pain.
Include sprains and broken bones.
Superficial pain is initiated by
activation of nociceptors in the skin or
other superficial tissue, and is sharp,
well-defined and clearly located.
Include minor wounds and minor (first
degree) burns.
4. Neuropathic
Neuropathic pain is caused by damage or
disease affecting any part of the nervous
system involved in bodily feelings.
Peripheral neuropathic pain is often
described as burning, tingling,
electrical, stabbing, or pins and
needles. Neuropathic pain, or "neuralgia",
can occur as a result of injury or disease to
the nerve tissue itself.

5. Psychogenic
Psychogenic pain, also
called psychalgia, is pain caused,
increased, or prolonged by mental,
emotional, or behavioral factors.
Headache, back pain, and stomach pain
are sometimes diagnosed as
psychogenic. Sufferers are often
stigmatized, because both medical
professionals and the general public
tend to think that pain from a
psychological source is not "real".
6. Phantom
Phantom pain is pain felt in a part of the
body that has been lost or from which
the brain no longer receives signals. It is
a type of neuropathic pain. Phantom
limb pain is a common experience of
amputees.
7. Breakthrough pain
Breakthrough pain is pain that comes on
suddenly for short periods of time and is not
alleviated by the patients' normal pain
management.
It
is
common
in cancer patients who often have a
background level of pain controlled
by medications, but whose pain periodically
"breaks through" the medication.
8. Incident pain
Incident pain is pain that arises as a result of
activity, such as movement of an arthritic
joint, stretching a wound, etc.
Pain Management
- Pain management (also called pain medicine) is the
discipline concerned with the relief of pain.
o What do we do about pain?
Analgesia
-Insensibility to painful stimuli
without loss of consciousness.
Anesthesia
-State of unconsciousness
Pain management generally benefits from a
multidisciplinary approach that includes
- Pharmacologic measures (analgesics such as
narcotics or NSAIDs and pain modifiers such as
tricyclic antidepressants or anticonvulsants)
- Non-pharmacologic
measures
(such
as
interventional procedures, physical therapy and
physical exercise, application of ice and/or heat),
- Psychological measures (such as biofeedback and
cognitive therapy).
DRUGS USED IN PAIN MANAGEMENT
Non-opioid Analgesics

All are effective at decreasing pain, with some,

having additional anti-inflammatory action
Acetaminophen
o Antipyretic, analgesic, a weak antiinflammatory drug.
NSAIDs
o Antipyretic,
analgesic,
and
antiinflammatory drug.
o a class of medications used to treat mild
pain.

Opioid Analgesia
- Also called a narcotics or painkillers
- If these are used for prolonged periods drug
tolerance, chemical dependency and psychological
addiction may occur.
- Apparent drug tolerance to the pain-relieving
effects of opioids may occur.
Pain Modifiers
- Drugs within this class act centrally on the brain to
down regulate the perceived painful stimulus.
- The first such group were the tricyclic
antidepressants (in particular amitriptyline) and the
dose required is far lower than that used to treat
depression.
- Similarly some of the anticonvulsant drugs are used
for this (in particular carbamazepine sodium
valproate and gabapentin).
- For most of these drugs, their use in chronic pain
management is off-label.
Non-Drug Strategies
- Exercise
o stretching, strengthening
o general conditioning
- Physical methods
o ice, heat, massage
- Cognitive-behavioral therapy
relaxation, imagery
- Chiropracty
- Acupuncture
- Alternative therapies
o herbals
Should a person or patient in pain (or even those taking,
looking after this person/patient) take necessary steps to
avoid it?
Pope Pius XII answers:
There are cases in which it is a grave obligation to
accept physical pain
The control & mitigation of pain is a good service.
There are cases in which analgesia could be
obligatory.
Pain & Ethical Principles
- Beneficence
- Non-Maleficence
- Autonomy
- Justice