PAIN MANAGEMENT

KEYWORDS Analgesia / Pain / Pain assessment / Patient information Provenance and Peer review: Commissioned by the Editor; Peer reviewed.

Principles of acute pain management

by Lorraine McMain
Correspondence address: WS Loan Pain Centre, Gardner Robb Building, Belfast City Hospital, Lisburn Road, Beifast, ST9 7AB. Email: iorraine.mcmain@belfasttrust.hscni.net

Acute pain is a predominant feature of the perioperative experience for the majority of patients. This paper aims to describe the adverse effects of poorly controlled acute, postoperative pain and provides an overview of the organisational aspects involved in pain management in hospitals. Following this there will be an examination of the role information giving has in improving the patient's perioperative experience. Pharmacological and nonpharmacological interventions to prevent or reduce pain will also be described and because of its importance in setting the standard for logical prescribing in pain, the Analgesic Ladder, devised by the World Health Organisation (WHO 1986) will be given special consideration. Finally, the importance of pain assessment and re-assessment will be discussed. Introduction
Failure to treat acute pain can have adverse physical and psychological consequences for the patient. Furthermore, inadequate treatment of acute pain can result in progression to a persistent or chronic pain state (Macrae 2001). This is undesirable for the patient, from a bio-psycho-social perspective and also from an economic viewpoint. Reduced blood flow to viscera and skin causing delayed wound healing (Bessey 1995, Kehlet 1997).

Haemostasis
Immobility Increased blood viscosity Hypercoagulability and risk of deep vein thrombosis (Kehlet 1997, Liu et al 1995)

Respiratory effects
Stimulation of respiration causing initial hypocapnia and respiratory alkalosis. Diaphragmatic splinting and hypoventilation, atelectasis, hypoxia and ensuing hypercapnia. Development of chest infection (Bessey 1995, Kehlet 1997, Brodner et al 1998).

Psychological effects of pain

Pain is also an emotional phenomenon (Merskey & Bogduk 1994). Acute pain, though unpleasant, tends to be viewed as having a useful purpose, in that it prompts us to seek medical help. Generally, patients try to make sense of their pain and will, to a greater or lesser extent, expect to suffer acute pain because they have experienced injury or need to have surgery. If pain is poorly controlled and becomes persistent following surgery, the patient no longer deems it to be useful. The patient's bio-psycho-social state, prior to a painful event, can positively or negatively contribute to the pain experience (Horn & Munaf 1997) but the experience of inadequately controlled pain is most likely to cause adverse psychological eftects for the patient. According to Eccleston (2001) psychological changes tend to occur more insidiously, are often less apparent and the reasons for these changes are multifactorial. Psychological and behavioural outcomes on how the pain experience is viewed can be influenced by gender, age, cultural or

Physiological effects
Adverse physiological effects result from the combination of tissue injury and pain. Broadly speaking, physiological responses include increased catabolism, immunosuppression and prolonged maintenance of the sympathetic response to surgery (Kumar & Smith 2003, ANZCA 2005). The eftects of this have been subclassified into systemic responses by Kehlet (1997) and may manifest themselves as follows:

Endocrine effects
Catabolic and anabolic changes. Decrease in insulin production. Reduction in testosterone level. Fluid retention (Bessey 1995, Kehlet & Nielsen 1998).

Metabolic effects

Cardiovascular effects
Increased heart rate. Increased blood pressure. Increased stroke volume. Increased myocardial oxygen demands, reduced myocardial oxygen supply and possible myocardial ischaemia.

Raised blood sugar levels (Kehlet & Nielsen 1998).

Gastro-intestinai effects Delayed gastric emptying Nausea Reduced gastro-intestinal motility and ileus (Kehlet 1997).

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Acute pain, though unpleasant, tends to be viewed as having a useful purpose

religious beliefs; what feelings have been internalised, regarding the significance of their injury, surgery and the reason for their pain (Skevingtonl995). Environmental factors, such as noise levels and inability to sleep may also have an impact on the patient's psyche during hospital stay. Some patterns of cognition and behaviour are listed below: Altered perception of the pain experience. Attention and hyper-vigilance. Fear. Fear avoidance behaviour. Worry and catastrophising. Anxiety. Anger. Sleep deprivation. Low mood. Self-denigratlon. Depression (Eccleston 2 0 0 1 , Horn & Munaf 1997). All of this can have implications for response to future pain and form the basis for long-term behavioural changes.

the impetus for development of structured pain service delivery across the UK. Guidelines, published by ANZCA (2005), recognise that the type of pain service needed will ultimately depend upon the setting and complexity of caseload. Most NHS hospital trusts, with theatre services, have implemented the recommendations of the Royal College Report and we now have the availability of further, joint guidelines on provision of UK pain services (RCA & British Pain Society, 2003). The consensus is that management of simple analgesic regimens should remain within the domain of those practitioners who are delivering care at the coalface. Expert clinical assistance from the pain service, education and provision of guidelines on best practice should be readily available, when called upon. More complex pain management techniques, such as epidural analgesia, should be routinely referred to and then systematically reviewed by the pain team (RCA & British Pain Society 2003). The aims of a pain service are to: Reduce the risk of poor postoperative outcome, previously described. Provide clinical support and expert advice on how best to manage patients experiencing acute pain (both surgical and non-surgical) while in hospital. Manage patients with complex pain. Organise services so that level of care and monitoring is appropriate for both the clinical condition of the patient and the analgesic modalities involved. Provide training for those staff involved in management of postoperative care. Ensure that patients have understanding of techniques and drugs used to treat pain in order to allow them to make informed choices. Audit outcomes and adverse effects to treatment. Undertake rigorous study on aspects of pain management thus expanding the evidence base for treatment (RCA & British Pain Society, 2003).

The RCA and British Pain Society (2003) have also clearly defined the main structures and resources required for maintenance of adequate acute pain service provision as follows: Specialist personnel, such as a consultant anaesthetist who has sessions devoted to pain management, a specialist nurse to coordinate day-to-day management of the service and a pharmacist. Equipment dedicated for sole use within the pain service. Drugs safely stored and pre-prepared for administration. Adepartmentor base for the team.

Patient information giving and pain

Timmins (2007) states that information giving or teaching is needed to support the patient and family. Information has become a pre-requisite for those persons making decisions on whether or not to undergo surgery and to be able to understand the therapies associated with postoperative pain management. Provision of information is an essential component of self-efficacy, self-direction and effective self-care. Accurate Information and understanding of information giving should improve patient participation with care and reduce dissatisfaction. While it is accepted that preoperative preparation is beneficial (Egbert et al 1964), coping strategies and behaviour among patients vary considerably and exert influences on the usefulness of providing detailed preoperative information. Delivery of preoperative information should therefore be tailored accordingly (Klafta & Roisin 1996, Bergman et al 2 0 0 1 , Murtagh & Thorns 2008). For instance a person may understand that morphine is used for relief of pain but may wish to find out more about the side-effects and risks of addiction before agreeing to have patient controlled analgesia (PCA). It is important to provide Information in a structured manner and this means

Persistent pain after surgery

A clear relationship between having surgery and suffering from persistent pain has been identified (Perkins & Kehlet 2000, Macrae 2001). Pathophysiological processes that occur after surgery can cause a chronic pain condition to develop. This has been demonstrated by Crombie et al (1998) who undertook an audit of 5,130 patients attending 10 chronic pain clinics and found that surgery had contributed to the referral in 22.5% of cases. Trauma was the reason in 18.7% of patients. Thus, it is proposed that early and appropriate analgesic intervention may reduce the incidence of chronic pain referrals (ANZCA 2005).

Organisational aspects of acute pain management

The report of the working party entitled Pain after Surgery (RCS, RCA 1990) was

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identifying who should deliver it. Key relationships for the patient during the perioperative period will include all members of the multi-disciplinary team (MDT) such as medicai staff, ward staff, operating department staff and physiotherapists. Those best placed to provide information will be the practitioners who have had an opportunity to develop a relationship with the patient. This can be difficult, for many reasons including organisational barriers (Timmins, 2008). Thus eliciting patient preference in clinical practice is of paramount importance (Murtagh 2008). Bergman et al (2001) found that extensive, detailed oral and written information had no effect on patients' perioperative stress indicators (such as plasma cortisol), anxiety levels or well-being when having cardiac surgery but was critical of how routine preoperative information is supplied. Chumbley et al (2004) found that written preoperative information about PCA had no effect on pain relief, anxieties about addiction, safety and knowledge about side-effects. Nevertheless, patients felt better informed and less confused after receiving it, compared with preoperative interview alone. What can also be difficult to ascertain is which method to choose for administration of patient information: where and when to offer it. Moult et al (2004) contend that only 20% of verbal information is remembered. Macfarlane et al (2002) found that 50% more information is retained, when reinforced by written information. As patients have diverse characteristics, such as differences in gender, culture, age, literacy, level of disability and preference these must be taken into account. Human diversity, in all its forms will mean that an analysis of individual patient group needs, or indeed an individual patient will inform practice but it may present difficulties for development of a generic template on which to base the information to be delivered (Timmins 2007). Several authors have looked at the type of information patients prefer to have, when

making choices. Turnbull (2003) found that patients favour learning from other patients. Berry et al (2006) examined how patients prioritised their information requirements for drug administration in nurse prescribing and found them to be: possible side effects what the drug does and how it works likelihood of efficacy outcomes if patient declines to accept the medication how medications interact.

information leaflet led to major change in leaflet design. This, in turn, produced a clearer, more attractive and informative leaflet, which was more satisfactory to patients. To further assist in the production of information leaflets the Department of Health (DH 2003) has identified key elements to preparation of information for those contemplating production of information leaflets. These are: planning writing consultation printing and distribution clarity evidence base patient participation.

Mumford (1997) has been critical of nurses' attempts to produce understandable information material. Having assessed readability of patient leaflets with relevant formulae she suggests that nurses fail to interpret medical terminology into everyday language. Chumbley (2002) sought to elicit the information patients wanted, regarding PCA and found that patients' contribution in the production of an

WHO Analgesic Ladder

The WHO analgesic ladder (1996), originally devised to provide guidance in

Figure 1 World Health Organisation (WHO) analgesic ladder

Moderate to severe pain

STEP 3 Opioid for moderate to severe pain. Plus non-opioid. With/without adjuvant analgesic.

Mild to moderate pain

Mild pain

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Local anaesthesia is not included in the ladder but is often the mainstay of pain relief

Figure 2 Ladder of decreasing pain intensity (Bandoiier 2003)

subjective experience and there may also be factors which contribute to why a patient having a minor procedure requires larger quantities of opioid than another patient having the same procedure (for exampie a cancer patient aiready established on strong opioids). Aiso neither model describes techniques or routes used to administer strong opioids in patients who are iikely to have a 'nil by mouth' status. In addition, local anaesthesia is not inciuded in the ladder but is often the mainstay of pain relief in the eariy postoperative phase for many patients having major surgery, Merskey and Bogduk (2005) also recommend that additional options to pharmacological treatment are considered. This may reduce the risk of patients suffering from inadequate ieveis of pain controi and unacceptable side-effects.

Interventions in acute pain

Causes of acute pain can be muitifactoriai and for this reason require an imaginative, muiti-modai and bio-psychosociai approach to management. Further management strategies and their subgroups are described by Hawthorn and Redmond (1998) and the evidence for use of many techniques cited in the ANZCA guideiines (2005), Choice of treatment wiil depend on the cause of pain and the status of the patient. A taxonomic approach to treatment classifies management into two main groups, with several sub-groups (see Table 1), The scope of this paper means that oniy a brief explanation of each sub-category can be set out. Routes of administration are described but not discussed.

the management of cancer pain, is the framework most often applied in logical prescription and titration of analgesia in acute and chronic pain states. Step 1 recommends the use of non-opioid analgesia for miid pain; Step 2 advocates the use of 'weak opioids', with or without non-opioids for moderate pain; Step 3 is comprised of 'strong opioids', with or without non-opioids, for severe pain. If needed adjuvant drugs can be used at any step (see Figure 1). As can be seen in Figure 1 , the threesteps recommend that anaigesia is prescribed and administered according to the intensity of pain. The ladder refers to specific medicine ciasses, not specific medicines, which permits ciinicians to use the ladder without reference to regulations and limitations used in their respective countries. Some commentators on the iadder have expressed concern in relation to the misleading interpretation of the concept of the three-step ladder, arguing that a iess

experienced clinician may diiigently foilow the recommendation of progressive placement of one foot above the other, one rung at a time, with no shortcuts. This approach wiil succeed in treating gradual, progressive pain but does not address pain that is severe to begin with. Correspondents on behalf of the lASP (Merskey & Bogduk 2005) therefore emphasise the need to be iogicai and choose anaigesia according to the severity of the pain; more analogous to taking an 'analgesic elevator' to the appropriate floor than climbing a ladder, A variation of the iadder model has been adapted to suit a scenario for acute postoperative pain (Bandoiier 2003) (see Figure 2). This modei is devised on the premise that patients having major surgery wiil experience severe pain and those having minor procedures will experience pain of more moderate intensity. However limitations to its application exist and it is important that inter-patient variability is taken into account. Pain is a very

Pharmacological management
Systemic analgesics
Designed to relieve pain through direct action, these analgesics can be administered aione or in combination with other drugs and techniques:

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Table 1 Adapted from ANZCA guidelines (2005)

Interventional techniques Non-pharmacological Neurostimulation Acupuncture Cognitive-behavioural strategies Other compiementary therapies Acute pain caused by tissue damage or distension wiii require finai resolution in the form of surgery or decompression.

Pharmacological Systemic Regional/local Condition-specific Interventional

Non-pharmacological management
Neurostimulation

Non-opioids such as paracetamoi; nefopam aiso sits within this classification. Non-Steroidai Anti-lnfiammatory Drugs (NSAiDs) such as diciofenac and COX il selective inhibitors, such as parecoxib. Opioids, of which those frequentiy used, inciude morphine, codeine, tramadol, fentanyi, oxycodone, dihydrocodeine, buprenorphine, methadone and diamorphine. Adjuvants to analgesia often have a primary indication, other than pain but assist in the management of the patient's pain. They are usuaiiy administered in combination with at ieast one or more of the primary, systemic anaigesics. The usefulness of the drug wiii depend on the presence of other symptoms associated with the pain, it is aiso important to expiain to the patient that the primary indication for the drug is not the reason for its use in their particular case. Exampies of such drugs inciude the anti-convuisant gabapentin, which is used to treat neuropathic pain. Another group of drugs are anti-depressants, iii<e amitriptyiine, also used for neuropathic pain. Other adjuvants include ketamine, antihistamines, corticosteroids, anti-spasmodics, bisphosphonates and caicitonin. it is important to note that specialist knowiedge is required when considering whether or not to add medications, such as ketamine, to the patient's analgesic regimen.

Entonox, a mixture of 50% oxygen and 50% nitrous oxide is a gas which has anaigesic properties and can be usefui for short, painfui procedures, its poor soiubiiity in blood allows rapid onset of anaigesia.

Routes of administration can be varied and imaginative but the oral or gastrointestinal route is best, if avaiiabie. Exampies of common routes of administration for some within this group of drugs include intravenous, intramuscular, subcutaneous, transdermai, rectal, inhalation and transmucosai.

Transcutaneous eiectrical nerve stimuiation (TENS) has traditionaily been used in chronic pain settings but has aiso been found to be beneficial for some acute pain situations. Efficacy wiii be dependent on the settings used, it is recommended that patients must feel a strong, but comfortable level of stimulation. The idea is to use TENS to contribute towards dynamic pain reiief, reduce consumption of opioids and incidence of opioid-induced side-effects. (Bjordal et al 2003, Proctor cited in ANZCA 2005.)

Acupuncture
This is another treatment more typicaily used in chronic pain management. However, there is limited but good quality evidence to suggest that acupuncture may be useful for pain in childbirth, treatment of headache and dentai pain (IVleichart et ai 2 0 0 1 , Smith et al 2003, Ernst & Pittier cited in ANZCA 2005). Eiectro-acupuncture was also found to reduce postoperative opioid requirements and opioid-induced side effects (Lin et al 2002, Kotani et al cited in ANZCA 2005.)

Regional and local analgesics

Locai anaesthetics bind to sodium channels and block the action potentiais for nerve conduction in every type of nerve fibre (depending on the concentration, route and rate of administration of the medicine). They can produce an absence of sensation in the part of the body to which they are appiied, without impairment of central control of vitai functions or loss of consciousness (Kumar & Smith 2003). Clinicai appiication of local anaesthesia can be topicai, ophthalmic, wound infiitration, intra-articuiar, peripheral nerve, spinal or epidural routes of administration (Hawthorn & Redmond 1998).

Cognitive-behavioural strategies (CBT)

CBT begins with two assumptions (Turk & Fernandez cited in Horn & iVlunafo 1997). First, thoughts, feelings, mood, motivation and behaviour are reciprocally interreiated. Second, patients are constantiy engaged in adaptive behaviour and making judgements about their capacity to deai with life's probiems. The threat of pain or illness invokes physiologicai, psychologicai and behavlourai responses and CBT is a

Condition-specific drugs
Required to treat pain caused by conditions such as acute angina. Giyceryltrinitrate is an example of a typical treatment for this.

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Pain measurement requires the practitioner to use a particular type of pain assessment tool

therapeutic method of taking all of this into account. CBT focuses on appraisal, interpretation and expectation as weil as physiologicai and environmental influences (Turk & Rudy cited in Horn & iVlunafo 1997). CBT programmes are collaborative endeavours between the patient and the therapist. A programme of intervention facilitates a sense of personal self-control. Elements to CBT inciude reconceptuaiisation of the pain, cognitive restructuring, probiem-soiving, relaxation, imagery and distraction (Horn & Munafo 1997),

Assistance in diagnosis and extent of injury or disease. Seiection of appropriate therapy. Evaiuation of response to therapy (Hobbs & Hodgkinson 2003).

because the group is so heterogeneous. In the field of neonatal and chiidrens nursing there is a requirement to assess the pain of infants and chiidren at different stages of physical development. Eloise Carr (2007) has described barriers to patients reporting pain and barriers that affect how receptive we are not only to what patients report but also to nonverbal cues. Carr (2007) states that there can be obstacles to patients reporting pain, even when asked about it, due to worries about being unpopular, assumption that they are in the hands of the professional who has authority, fear of injections and beiief that the pain is not harmfui and is to be expected. Patients' seif-report can also be infiuenced by mood, loss of sleep and medication effects (Hobbs & Hodgkinson 2003). it has been postulated that pain intensity should be recorded as the 5th vital sign (Joint Commission on the Accreditation of Heaithcare Organizations (JCAHO) in full first 2 0 0 1 , cited in ANZCA 2005). Frequency of observation should depend on the intensity of the pain, the type of therapy used to treat it and the need to evaluate that therapy. Dynamic pain should be assessed, particularly the patient's ability to cough and to move the affected body part. Pain at rest is aiso reievant as this can give an indication about how well a patient will be able to sleep.

Other complennentary and alternative therapies (CAMs) Defined as every available approach to healing that does not fall within the reaim of conventionai medicine in a Western, industrialised society. Types of CAMs include: B H Herbal medicine Traditional Chinese medicine Homeopathy Use of vitamins and minerais.

Pain measurement requires the practitioner to use a particular type of pain assessment tooi (Brown 2008). With this tool the aim is to ascribe magnitude and dimensions to a multi-dimensionai and subjective phenomenon, so most measures are obtained by a self-report method. The result is that a plethora of tools have been developed for this purpose. Practical and logisticai factors which infiuence the choice of best tooi for the job wiii inciude: H B Validation How easy it is to administer to the patient The time it takes to administer to the patient (Hawthorn & Redmond 1998, Hobbs & Hodgkinson 2003).

Further factors which affect outcome, when assessing pain, will include: B B How cognizant practitioners are on how it shouid be applied. The abiiity of the assessor, particuiariy in the case of chiidren, oider or cognitively impaired patients, to differentiate pain from distress. The subjectivity of the assessor undertaking the measurement. The scope allowed or delay encountered before the practitioner can act on their findings (Wong & Baker 1988, Hawthorn & Redmond 1998, British Pain Society 2007).

CAMs in management of acute pain is an area where more evidence needs to be coiiected (ANZCA, 2005).

Pain assessment
One of the recommendations of the Working Party Report on Pain after Surgery (1990) was that patients shouid have their pain systematicaiiy assessed and recorded (the idea being to improve the levels of pain experienced by patients in British hospitais). Therefore, one of the functions of the Pain Team has been to educate and reinforce to practitioners the need to regularly assess and document levels of pain and effectiveness of pain relief (RCA & British Pain Society, 2003), Assessment of acute pain refers to the comprehensive, ciinicai process of describing pain and its effect on patient function in sufficient detaii to achieve: B

Conclusion
This paper has discussed why having organised pain services can improve the acute, postoperative pain experience for patients. Also included was an examination of the contribution information-giving makes. Pharmacologicai and non-pharmacological interventions to prevent or reduce pain were described and advice on the use of the Analgesic Ladder provided. Finally, the importance of pain assessment and re-assessment was discussed, B

There are many factors, such as the presence of severe cognitive impairment, communication difficuities or ianguage and cultural barriers, which affect the abiiity of even the most experienced and patient assessor to effectiveiy assess pain. Oider people with severe cognitive impairment can find it difficuit to articuiate their pain (British Pain Society 2007). Paediatric pain assessment is a challenge

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References
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About the author

Lorraine IVlcMain RGN, BSc(Hons), MSc Chronic Pain Nurse, Beifast City Hospital, Beifast Health and Sociai Care Trust

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