Upon successful completion of this course, you will be able to:

• Define and explain the use of the word “pain”
• Explain the etiology and epidemiology of pain
• Identify the protocols currently in use today caring for patients in pain
• Identify JCAHO’s role and new standards in regard to the management of pain
• Explain the role of state, local, and federal regulations relating to treating pain

Pain in Medical Care Today

Pain is one of the most common reasons people consult a physician, yet frequently it is inadequately assessed and under treated, leading to enormous social costs in the form of needless suffering, lost productivity, and excessive health care expenditures. Much progress has recently been made in understanding the origin and progression of pain, yet many health care professionals are untrained in pain management.

Chronic pain is not a single entity but may have a myriad of causes and perpetuating factors. Therefore, chronic can be much more difficult to manage than acute pain, requiring a multi disciplinary approach and customized treatment protocols to meet the specific needs of each patient.

Chronic pain afflicts 10-20% of the adult population. Approximately half of these people experience pain, which is inadequately treated, but could be relieved with proper treatment. Forms of chronic pain include:

• Neuropathic Pain
• Post Mastectomy Pain
• Phantom Limb Pain
• Musculoskeletal (back, knee, hip) Pain
• Fibromyalgia
• Migraine
• Rheumatoid Arthritis
• Osteoarthritis
• Cancer pain

Successful long-term pain management is achieved by including the physician, patient, family and other health care providers. Patients with pain or other distressing symptoms that persist despite the best efforts of their current health care provider should request a referral or seek specialists in pain management or palliative care.

This course provides you with updated information on a wide variety of pain-related issues, including: definitions, etiology, medications, protocols (current and proposed), government regulations at all levels, international standards, and provides you with an in-depth look at the newly developed standards from JCAHO.

Some facts you should know about pain and the scope of the problem in the United States:

• 90% of all diseases may be associated with pain
• 65 million Americans suffer painful disabilities at any given time
• 61% of medical directors of pain centers are anesthesiologists
• It is estimated that of all pain practitioners, fewer than 10% are proficient in more than 8 out of 130+ diagnostic or therapeutic (treatment) procedures relative to pain
• It is possible that an individual that is untrained and unskilled in the treatment or surgery that is being offered can legally treat you!
• 75% or more of patients in hospitals hurt and suffer more than they should.
• Thirty-one million Americans have low back pain at any given time. One half of all working Americans admit to having back symptoms each year. One third of all Americans over age 18 had a back problem in the past five years severe enough for them to seek professional help. And the cost of this care is estimated to be a staggering $50 Billion yearly--and that's just for the more easily identified costs! (Data according to the American Chiropractic Association)
• 40 million visits to health care providers and prolong hospital stays are due to pain. (Last two items according to NIH)

When dealing with such an enormously complex topic such as “pain” one finds it necessary to look at how pain impacts the life process from the beginning to the end, From the birthing process to the now often drawn out process of dying. Regarding birth, there are some issues on which healthcare profession don’t always agree:

Management of labor pain: promoting patient choice - Editorial

American Family Physician, Sept 15, 2003

In 2001, the Nature and Management of Labor Pain symposium (see Leeman, et al., (1) in this issue) brought together family physicians, obstetrician--gynecologists, nurse-midwives, childbirth educators, and anesthesiologists for a critical analysis and discussion of systematic reviews on labor pain. (1) The symposium occurred in the context of the increasing use of epidural analgesia, which is now used in almost two thirds of labors in the United States. (2) Presentations showed that epidural analgesia is a more effective pain-relief method than intravenous narcotics, (3,4) the second most common pharmacologic method of pain relief (used in 30 percent of labors). (2,5) In the First National U.S. Survey of Women's Childbearing Experiences, (2) 78 percent of women rated epidural analgesia as very helpful.

Most women in the United States deliver infants in hospitals where epidural analgesia or intravenous narcotics are the only pain-relief options. Alternative pharmacologic methods for pain relief, including nitrous oxide and paracervical blocks, are used infrequently in the United States. Despite numerous studies showing that use of doulas and continuous labor support results in a de-creased need for medical intervention, improved maternal and newborn outcomes, and increased maternal satisfaction, few women are afforded this option. (6)

Although epidural analgesia clearly is a highly effective and popular method of providing labor analgesia, it has significant potential side effects. Symposium presentations showed that epidural analgesia may increase the length of labor, the need for operative vaginal delivery, and the likelihood of perineal laceration. (4,7) Epidural analgesia can cause maternal fever, with consequent increased use of neonatal antibiotics and sepsis evaluations. (4,7) Whether epidural analgesia results in a higher rate of cesarean delivery or is a confounder based on its use in "difficult" labors remains a point of controversy. Physicians who frequently use epidural analgesia may have a maternity practice style that leads to higher cesarean rates as a result of earlier hospital admission, increased use of oxytocin augmentation, and decreased presence of the physician. (8)

The childbirth survey showed that many women are poorly informed about the potential side effects of epidural analgesia. (2) To make an informed choice, women should be told of the risks and benefits during prenatal care rather than in the midst of labor. Symposium participants acknowledged the scarcity of data about the effects of epidural analgesia on newborn behavior, breastfeeding, and maternal-infant bonding, and they highlighted the need for future research in these areas.

A technologic birthing model that uses labor induction, epidural analgesia, continuous electronic fetal monitoring, and cesarean delivery increasingly dominates labor and delivery wards in the United States and other industrialized countries. Conference participants expressed concern that when institutional epidural rates are high, other methods of labor support, such as childbirth classes, doulas, nurses trained in supporting nonmedicated childbirth, and availability of other pain control modalities, may not be offered. In many hospitals, labor pain management options are limited to epidurals, parenteral analgesics, or rudimentary labor support from overextended nurses. An anesthesiologist at the symposium remarked that "While there may be problems with high epidural usage, in the presence of our nursing shortages and economic or business considerations, having a woman in bed, attached to an intravenous line and continuous electronic fetal monitor and in receipt of an epidural may be the only realistic way to go."

Access to professional labor support is considered a luxury for patients in most U.S. hospitals, and lack of access to epidural analgesia may result in legal action. (9) The issue of patient choice is being used as a pretext for increasing technologic intervention in the birth process. A past president of the American College of Obstetricians and Gynecologists called for the right of a patient to choose cesarean delivery in the absence of maternal or fetal indications, (10) and the American Society of Anesthesiologists suggests closing smaller hospitals that are unable to support universal access to epidural analgesia. (11) However, neither organization advocates a broader range of labor support and pain management options to promote patient choice. Brazilian women are "choosing" cesarean delivery partly out of concern that they won't receive adequate medical care during labor. (12,13) Similarly, in many hospitals, American women may feel that epidural analgesia is the only real choice they have.

Family physicians providing maternity care may feel "out of the loop" as a result of the predominant use of epidural analgesia for labor pain. The request for epidural analgesia may be conveyed to the anesthesiologist by the nursing staff, with only a perfunctory nod from the primary caregiver. In contrast to this inappropriate trend, the request should be viewed as a consultation. (14) As with any consultation, the family physician has the responsibility to be a knowledgeable advocate for the patient--taking the time to learn which epidural drugs and techniques are used in a specific hospital and understanding their effectiveness, potential side effects, and limitations.

Family physicians can seek ways to learn alternative approaches to epidural analgesia and incorporate them into practice. They, along with other maternity care providers, should be knowledgeable about and supportive of a range of pain management options in their hospitals, birthing centers, and communities. The Family-Centered Maternity Care course sponsored by the American Academy of Family Physicians (www.aafp.org/x14376. xml) offers sessions on labor support, labor positions, and sterile water injections for women with "back labor." Family physicians should support prenatal childbirth preparation and education; these steps are essential to set appropriate expectations for an event that can be a sentinel experience for many women and their families.

Labor and delivery units should not operate on the expectation that every woman will use epidural analgesia during labor. Other choices, such as labor support and doulas, nonpharmacologic pain-relief methods, and pharmacologic pain-relief methods other than intravenous narcotics or epidurals, should be available. We await research into which pain-relief options women would choose if they had a greater range of choices, how these methods can be used most effectively, and how all methods affect the birthing woman, her labor, and her infant. (15)

REFERENCES

1. Leeman L, Fontaine P, King V, Klein MC, Ratcliffe S. Nature and management of labor pain: part I. Nonpharmacologic pain relief. Am Fam Physician 2003;68:1109-12.
2. Declercq ER, Sakala C, Corry MP. Listening to mothers: report of the First National U.S. Survey of Women's Childbearing Experiences. New York: Maternity Care Association/Harris Interactive Inc, 2002.
3. Bricker L, Lavender T. Parenteral opioids for labor pain relief: a systematic review. Am J Obstet Gynecol 2002;186(Suppl 5):S94-109.
4. Leighton BL, Halpern SH. The effects of epidural analgesia on labor, maternal, and neonatal outcomes: a systematic review. Am J Obstet Gynecol 2002;186(Suppl 5):S69-77.
5. Hawkins JL, Beaty BR, Gibbs CP. Update on obstetric anesthesia practices in the U.S. Anesthesiology 1999;91:A1060.
6. Simkin PP, O'Hara M. Nonpharmacologic relief of pain during labor: systematic reviews of five methods. Am J Obstet Gynecol 2002;186(Suppl 5): S131-59.
7. Lieberman E, O'Donoghue C. Unintended effects of epidural analgesia during labor: a systematic review. Am J Obstet Gynecol 2002;186(Suppl 5): S31-68.
8. Klein MC, Grzybowski S, Harris S, Liston R, Spence A, Le G, et al. Epidural analgesia use as a marker for physician approach to birth: implications for maternal and newborn outcomes. Birth 2001; 28:243-8.
9. Birnbach DJ. In the spotlight: epidural analgesia for labor--a necessity or a luxury? ASA Newsletter 1998;62.
10. Harer WB Jr. Patient choice cesarean. ACOG Clinical Review 2000;5:1,13-6.
11. American Society of Anesthesiologists Committee on Obstetric Analgesia, American College of Obstetricians and Gynecologists Committee on Obstetric Practice. ACOG Committee Opinion. Committee on Obstetric Practice. Optimal goals for anesthesia care in obstetrics. Obstet Gynecol 2001;97:suppl 1-3.
12. Potter JE, Berquo E, Perpetuo IH, Leal OF, Hopkins K, Souza MR, et al. Unwanted caesarean sections among public and private patients in Brazil: prospective study. BMJ 2001;323:1155-8.

Cancer Pain

When it comes to “end of life” there are similarly “issues” to be explored. At the end of 2001, the National Cancer Policy Board released a report entitled “Improving Palliative Care for Cancer” in which it stated :

“This year, over 550,000 Americans will die from cancer. At least half will experience pain, nausea, difficulty breathing, depression, fatigue, and other physical and psychological conditions that vastly diminish the quality of their remaining days. Too often, clinicians and hospitals are not trained or mandated to provide good symptom control and supportive therapy to cancer patients, particularly those who are dying. With federal research and training efforts centering largely on trying to cure patients, palliative care is often overlooked.”

The report went on to say that, “Despite billions of dollars spent on research in cancer biology and cancer therapeutics, there has been little investment in research that might significantly alleviate the physical and psychological distress of patients at the end of life. The types of distress experienced by these patients are shared, in a temporary or more lasting fashion, with patients being treated for cancer and, at least to some extent, by some who survive the disease....

Patients with advanced cancer typically experience multiple symptoms related to cancer and cancer treatment. These symptoms can include physical (e.g., nausea, dyspnea), cognitive (e.g., delirium, memory problems, impaired concentration), and affective (e.g., depression, anxiety) experiences associated with the disease and its treatments. Symptom severity is related to the extent of disease and the aggressiveness of therapies such as surgery, chemotherapy, radiotherapy, and biological therapies. Common symptoms of cancer and cancer treatment significantly impair the daily function and quality of life of patients. Pain is a good example. When pain is present, it adversely affects patients’ mood, activity, and ability to relate to others (Serlin et al., 1995). Similarly, fatigue, gastrointestinal symptoms, cachexia, anorexia, shortness of breath, and psychological distress add tremendously to the distress that patients experience.

At present, the severe distress, multiple symptoms, and inadequate treatment faced by many patients at the end of life are well documented. Several studies have examined cancer-related symptoms in patients with advanced disease. Coyle and colleagues found that fatigue, weakness, pain, sleepiness, and cognitive impairment were frequent symptoms of patients with terminal disease enrolled in a supportive care program. Fatigue (58percent) and pain (54 percent) were the most prevalent symptoms. Donnelly and colleagues prospectively studied the prevalence and severity of these symptoms in 1,000 patients with advanced cancer. Pain, fatigue, and anorexia were consistently found to be among the 10 most prevalent symptoms at all 17 primary cancer sites studied. When pain, anorexia, weakness, anxiety, lack of energy, severe fatigue, early satiety, constipation, and dyspnea were present, a majority of patients rated them as moderate or severe.

As part of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), McCarthy and colleagues (2000) evaluated more than 1,000 cancer patients during the three days before death and also at one to three months before death, and three to six months before death. As expected, as they progressed toward death, their estimated six-month prognosis decreased significantly and the severity of their disease worsened. Patients’ functional status also declined significantly as they approached death, such that most patients had four or more symptoms within the three days before death. Patients with cancer experienced significantly more pain and confusion as death approached. Severe pain was common; more than one-quarter of patients with cancer experienced significant pain three to six months before death and more than 40 percent were in significant pain during their last three days of life. However, dying patients were only modestly depressed and anxious during their last three days of life.

Recent studies have described the prevalence and severity of pain due to cancer and have documented that pain is often under-treated with available analgesics. These studies present a model for the study of other major symptoms, such as depression and fatigue. Approximately 55 percent of outpatients with metastatic cancer have disease-related pain, and 36 percent have pain of sufficient severity to impair their function and quality of life despite current analgesic therapy. Despite national and international guidelines for its management, many patients with pain are not prescribed an analgesic appropriate to the severity of their pain. Evidence suggests that patients in minority groups may have an even greater risk for under-treatment of pain.

Two studies of outpatients with metastatic or recurrent cancer receiving treatment at Eastern Cooperative Oncology Group (ECOG) institutions found that more than 40 percent of those with pain were not prescribed analgesics strong enough to match the severity of their pain A discrepancy between the physician’s and patient’s rating of the severity of the pain was a major predictor of under-medication for pain. Pain has to be appreciated before it can be treated. In addition, patients seen at centers that treated predominantly minority patients were three times more likely than those treated elsewhere to have inadequate pain management. Other factors that predicted inadequate pain treatment included age of 70 years or older, female sex, and better performance status. These results support the opinion of oncology physicians that poor assessment of symptoms is a major barrier to adequate symptom management.

A recent study (Cleeland et al., 2000) repeated the ECOG study format with physician members of the Radiation Therapy Oncology Group. On average, physicians estimated that two-thirds of cancer patients suffered pain for longer than one month. Assessing a case scenario, 23 percent would wait until the patient’s prognosis was six months or less before starting maximal analgesia, indicating a very conservative approach to pain management. Adjuvants and prophylactic side-effect management were underutilized in the treatment plan for the case presented. Perceived barriers to good pain management were very similar to the ECOG study, with poor pain assessment being ranked number one. Compounded by inadequate training for physicians in the palliative treatment of cancer, these problems influence decisions made in the management of incurable cancer and profoundly affect end-of-life care.

In spite of recent concerns over symptom management at the end of life, provoked in large part by the debate over euthanasia, there is substantial evidence that symptoms that could, in principle, be well managed are under-treated, especially for patients who are still in active treatment. There is evidence that many symptoms could be controlled more adequately if we systematically applied the knowledge that we now have about symptom management.”

As you can see from the information above, pain presents complex issues for medical professionals from birth to death! Now, let’s take a look at what makes pain such a complex topic.

Before going into more detailed issues and controversies regarding pain, we should look some definitions and concepts related to pain:

Pain, unpleasant sensory and emotional experience caused by real or potential injury or damage to the body or described in terms of such damage. 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 efficiently.

Pain is difficult to measure in humans because it has an emotional, or psychological component as well as a physical component. Some people express extreme discomfort from relatively small injuries, while others show little or no pain even after suffering severe injury. Sometimes pain is present even though no injury is apparent at all, or pain lingers long after an injury appears to have healed.

Physiology of Pain

The signals that warn the body of tissue damage are transmitted through the nervous system. In this system, the basic unit is the nerve cell or neuron. A nerve cell is composed of three parts: a central cell body, a single major branching fiber called an axon, and a series of smaller branching fibers known as dendrites. Each nerve cell meets other nerve cells at certain points on the axons and dendrites, forming a dense network of interconnected nerve fibers that transmit sensory information about touch, pressure, or warmth, as well as pain.

Sensory information is transmitted from the different parts of the body to the brain via the spinal cord, which is a complex set of nerves that extends from the brain down along the back, protected by the bones of the spine. About as wide as a finger, the spinal cord is like a cable packed with many bundles of wires. The bundles are nerve pathways for transmitting information. But the spinal cord is more than just a message transmitter, it is also an extension of the brain. It contains neurons that process incoming sensory information, and generates messages to be sent back down to cells in other parts of the body.

Information being transmitted between and within the brain and spinal cord travels through the nervous system using both chemical and electrical mechanisms. A message-carrying impulse travels from one end of a nerve cell to another by means of an electric signal. When the electric signal reaches the terminal end of a nerve cell, a gap called a synapse prevents the electric signal from crossing to the next cell. The electric signal triggers the cell to release chemicals called neurotransmitters, which float across the synapse to the neighboring nerve cell. These neurotransmitters fit into specialized receptors found on the adjacent nerve cell, much as a key fits into a lock, generating an electric impulse in the neighboring cell. This new impulse travels to the end of the long cell, in turn triggering the release of neurotransmitters to carry the message across the next synapse. Not all neurotransmitters initiate a message in a neighboring nerve cell. Some specialize in preventing neighboring cells from generating an electrical signal, while others function as helpers, facilitating the message's journey to the brain.

While most of the sensory nerves in the skin and other body tissues have special structures covering their nerve endings, those nerves that signal injury have free nerve endings. These simple nerve endings specialize in detecting noxious stimuli—a catchall term for injury-causing stimuli such as intense heat, extreme pressure, or sharp pricks or cuts. The nerve endings that detect pain are called nociceptors, and the process of transmitting pain signals when harmful stimulation occurs is called nociception. Several million nociceptors are interlaced through the tissues and organs of the body.

In general, pain can be divided into two categories:

1. nociceptive pain
2. neuropathic pain

Nociceptive pain is that which travels through a normal intact nervous system. Nociceptive pain is often treated successfully with simple pain relieving drugs such as acetaminophen, aspirin, ibuprofen or opioids.

Neuropathic pain is that which travels through an injured nervous system. It is as if the nervous system is reporting its own injury. Patients often describe neuropathic pain as burning, or electric shock-like.

Neuropathic pain is not as responsive to pain-relieving drugs that work in nociceptive pain. However, other drugs such as the antidepressants and anticonvulsants work on neuropathic pain. When evaluating a cancer patient, we often try to determine if the pain is nociceptive or neuropathic. So do not be confused if your doctor starts you on an antidepressant for pain management. Your doctor is not treating depression but is treating your pain with these drugs. In addition to the physical component of the pain, we also evaluate the patient’s psychosocial response to the pain. Our pain psychologists are very helpful in treating the emotional response to pain. So if a psychologist is recommended as part of the treatment plan, this does not mean your doctor feels your pain is in all in your head. Psychological counseling together with the medical management of pain can be very effective.

With nociceptive pain, an injury triggers pain signals in two types of nociceptors, one with large, insulated axons known as A-delta fibers and one with small, uninsulated axons known as C fibers. The large A-delta fibers conduct signals quickly, and the smaller C fibers transmit information slowly. The difference in the functions of these two fibers becomes obvious to a person who stubs a toe. At first the injured person is aware of a sharp, flashing pain at the point of injury. Generated by the A-delta fibers, this short-lived pain intrudes upon the thoughts and perceptions occurring in the brain. Just as this first pain subsides, a second pain begins that is vague, throbbing, and persistent. This sensation is derived from the C fibers.

Pain information from the A-delta and C fibers travels through the spinal cord to the brain. When it receives the pain message, the spinal cord generates impulses that travel back down to muscles, which lead to a reflexive contraction that pulls the body away from the source of injury. Other reflexes may affect skin temperature, blood flow, sweating, and other changes.

While this reflex action is underway, the pain message continues up the spinal cord to relay centers in the brain. The sensory information is routed to many other parts of the brain, including the cortex, where thinking processes occur.

Psychology of Pain

When messages from pain-generating nerve endings finally reach higher centers in the brain, they are processed much like other forms of perception—that is, the sensory information is integrated with memories, expectations, emotions, and thoughts in order to form a complete perceptual experience. While it seems convenient to think of pain as a simple message that sounds an alarm in the brain, contemporary understanding stresses that pain is much more complicated. The emotional aspects of an injury may be more significant than the extent of the physical damage in determining the perceived intensity of pain.

Each person perceives pain a little differently, and as a result, each person also responds to painful stimulation differently. Pain research specialists have observed a wide variety of subtle variations in pain response. For instance, children are quicker to cry after a relatively minor injury than are adults. Learned cultural behaviors often dominate the way individuals express pain. Older children and young adults are often taught that crying, sometimes viewed as a sign of weakness, is inappropriate behavior, while younger children have no such understanding. Some people are more willing to express pain than others, but this does not mean they hurt more.

Broad cultural differences in pain responsiveness have also been documented. In some aboriginal societies, people undergoing important rituals often incur extreme tissue injury willingly, and typically, pain is not expressed. Male Australian aborigines, for instance, traditionally celebrated passage into manhood with a ritual that involved circumcision, extensive scarring of the chest, and extraction of the two upper front teeth. The initiate was expected to show no reaction to the injury. It may be that the person undergoing the rite managed to suppress expressions of suffering, but it may also be that the individual was able to perceive less pain by making use of natural pain control mechanisms.

Pain Control

The body has many mechanisms that amplify or reduce pain. When cells are damaged, they release chemicals, such as bradykinins and prostaglandins. These chemicals intensify pain sensation both by making nociceptor nerve endings more sensitive and by causing inflammation around the damaged cells. Without these chemicals, nociceptors would cease transmitting pain information as soon as the source of injury was removed. Some scientists suspect that bradykinins activate nociceptors in the first place.

Other mechanisms reduce pain sensation by blocking, or inhibiting, the transmission of the pain message to the brain. To alter the pain sensation, the brain and spinal cord release specialized neurotransmitters called endorphins and enkephalins. These chemicals interfere with pain impulse transmission by occupying the nerve cell receptors required to send the impulse across the synapse. By making the pain impulse travel less efficiently, endorphins and enkephalins can significantly lessen the perception of pain. In extreme circumstances, they can even make severe injuries nearly painless. If an athlete is injured during the height of competition, or a soldier injured during combat, they may not realize they have been injured until after the stressful situation has ended. This happens because the brain produces abnormally high levels of endorphins or enkephalins in periods of intense stress or excitement.

In addition to the body's own mechanisms, humans have devised many different ways to manipulate the body's ability to control pain. Drugs that relieve pain, known as analgesics, usually interfere with pain impulse transmission in the nervous system. Narcotic analgesics, such as codeine, have chemical structures that are similar to the pain-blocking neurotransmitter endorphin. Other drugs that relieve pain alter the way damaged nerves transmit information. Nonsteroidal anti-inflammatory drugs, such as aspirin and ibuprofen, are analgesics that reduce pain by inhibiting the synthesis of prostaglandins, the body chemicals that intensify pain and cause inflammation.

Another way humans control pain is by injection of drugs that temporarily deaden the nerves that transmit pain signals. These drugs bring about anesthesia, a loss of sensation that renders the body completely or partially insensitive to pain, or even touch. Local anesthetics, such as procaine, deaden nerves in a particular area of the body but interfere little with other body functions. General anesthesia renders people unconscious so they do not feel pain at all. People who undergo general anesthesia also have no memory of events that occurred while they were unconscious.

Many people learn to control their pain with strategies that do not rely on drugs or surgery. Some people control the normally involuntary components of pain message transmission using a behavior modification technique called biofeedback. Acupuncture is widely used for pain relief. Many scientists now believe that this ancient medical procedure may trigger the release of endorphins and enkephalins, the body's own pain-inhibiting neurotransmitters. Others suspect that the pain-relieving attributes of acupuncture are due, in part, to a patient's expectation of relief. Although it is not completely understood, physicians and pain specialists have found that when a person suffering from pain expects that a particular procedure—in this case acupuncture—will make their pain subside, it actually does.

In cases where no treatment effectively relieves pain, doctors may recommend a surgical procedure in which pain-transmitting nerves in the brain or spinal cord are severed. Only a small fraction of pain sufferers need such surgical treatment. Another pain-relieving procedure involves placing electrical stimulators on the skin, nerves, spinal cord, or brain to reduce pain sensation.

Some injuries take a long time to heal, and even then, pain does not always completely subside. People suffering from this condition, known as chronic pain, may continue to experience debilitating pain for years, without having any apparent tissue damage. This may be the result of permanent damage to the nervous system. There is new evidence that the nerves in the spinal cord and brain can alter their connections after severe pain—that is, even after healing, the nervous system never returns to normal. Pain that subsides and then returns periodically, such as headaches or low back pain, also falls under the category of chronic pain. In their search for pain relief, many chronic pain sufferers become dependent on strong painkilling medicines, and they often fall into an endless cycle of pain, depression, and inactivity.

The complexity of human pain often requires a combination of pain therapies to achieve relief. Pain management specialists are usually medical doctors with specialized training in neurology, psychiatry, or surgery who have restricted their practice to the analysis and treatment of pain. Psychologists are usually important members of a pain management team. Many people are turning to alternative healthcare practitioners, such as those that specialize in acupuncture or chiropractic, for pain relief. Often, pain management specialists and practitioners of alternative pain therapies join forces in multidisciplinary pain clinics.

Some Thoughts About Pain

Pain is universal. You can trace its trail through time--from a toothache evident in fossil remains of a human jawbone to today's drugstore shelves packed with pain relievers. Almost half of all Americans seek treatment for pain each year, 7 million from newly diagnosed back pain alone.

Pain is complex. Sometimes it's beneficial. A sharp stab alerts you to injury when you burn your finger, hurt your back or break a bone. But other pain--the day-after-day ache of arthritis or the anguish of cancer--serves no useful purpose, and its relentlessness can become overwhelming.

Above all, pain is unique. The varieties of misery are as many as its sufferers. Your pain is an interplay of your own particular biological, psychological and cultural makeup.

Pain remains the most common source of suffering. Its relief—the relief of all symptoms—is the hallmark of care aimed at the relief of suffering. However, it remains true that adequate relief for severe and continuing pain is unusual in the modern hospital. There is no longer any excuse, however, for doctors and other health care providers not to relieve pain because so much has been written on the subject—and now even the JCAHO is stepping in.

New insight into these components is changing the concept of pain management. Pain is no longer seen as just a companion of disease or injury. It can become a damaging process in its own right that requires early and aggressive treatment.

In addition, effective management increasingly focuses on attitude as well as medication and other therapies. You must understand the reasons for pain and how to control it.

By working closely with their doctor and health-care team, patients can learn to manage pain and enjoy a more fulfilling family, work and leisure life.

Exercise, relaxation techniques, and physical, occupational and psychological therapies play important treatment and prevention roles. And new drug-delivery systems can keep some types of pain under continuous control. But despite these advances, some painful conditions are still inadequately treated.

The Physical Sensation of Pain

Most pain originates when special nerve endings, called nociceptors (no-si-SEP-turs), detect an unpleasant stimulus. Humans have millions of nociceptors in your skin, bones, joints, muscles and internal organs. There may be as many as 1,300 in just one square inch of skin.

Some nociceptors sense sharp blows, others heat. One type senses pressure, temperature and chemical changes. Nociceptors can also detect inflammation due to injury, disease or infection. Nociceptors use nerve impulses to relay pain messages to networks of nearby nerve cells (your peripheral nervous system). Messages then travel along nerve pathways to your spinal cord and brain (the central nervous system). Each cell-to-cell relay is almost instantaneous, thanks to chemical facilitators called neurotransmitters. These chemicals flow from one nerve cell to the next in less than a thousandth of a second.

Some nerve pathways are faster than others. One type makes connections with many surrounding nerve cells en route. They transmit more slowly. People feel this type of pain as dull, aching and generalized. Another type relays impulses almost instantaneously and signals sharp pain focused in one spot.

Scientists believe that pain signals must reach a threshold before they're relayed. This "gate control" theory holds that specialized nerve cells in your spinal cord act as gates that open to allow pain messages to pass, depending on the strength and nature of the pain signal.

A message-routing section in the brain

Pain signals travel from the peripheral nerves to the spinal cord to your thalamus, a message sorting and switching station in your brain. The thalamus sends two types of messages. One goes to the cerebral cortex, the thinking part of the brain, which assesses the location and severity of damage. The second is a "stop-pain" message back to the injury site to tell local nociceptors to stop sending any more pain messages. Once alerted, the brain doesn't need additional warning. But sometimes, this mechanism fails and pain persists

Meanwhile, the cerebral cortex relays the pain message it received to the brain's limbic center. The limbic center produces emotions, such as sadness or anger, in response to pain messages. The limbic center can affect the way the cerebral cortex perceives pain messages, and can lessen or intensify the pain.

The cerebral cortex also sends messages to your autonomic nervous system, which controls vital body functions such as breathing, blood flow and pulse rate.

Several types of neurotransmitters (proteins and hormones produced in the brain or nervous system) can increase or decrease pain signals. A hormone--one of the prostaglandins--speeds transmission of pain messages and makes nerve endings more sensitive to pain. And a protein called substance P continuously stimulates nerve endings at the injury site and within the spinal cord, increasing pain messages.
Serotonin and norepinephrine (nor-ep-i-NEF-rin) seem to decrease pain by causing nociceptors to release natural pain-relievers called endorphins.

The emotional component

Pain is not simply a matter of passing messages up and down the spinal cord. When a pain signal reaches the brain, it passes through a filter of personal experience. The emotional and psychological state at the moment, memory of past pain experiences, outlook and stress level all affect how a person interprets a pain message and their ability to tolerate it. Upbringing and cultural attitude toward pain also play a role. And age, level of information about the pain, and even lack of sleep may have an impact.

The emotional responses of shock, fear and anxiety can increase the perception of pain. For example, a minor pain sensation, such as a dentist's probe, combined with anxiety can cause undue pain.

But the emotional state can also diminish major pain messages. One pain study compared survivors of a major battle in World War II with men in the general population of a major U.S. city, matched injury for injury. The combat veterans required less pain relief than those in the general population.

People who learn from upbringing and cultural background that the normal response to pain is great suffering and distress actually experience more pain than people who grow up in an environment where pain is often ignored. The common expressions "suffer in silence," "bite the bullet," "grin and bear it," and "no pain, no gain" point to American cultural patterns that discourage acknowledgment of pain.

Types and characteristics of pain

In general, pain is divided into two general categories--acute and chronic.

• Acute--Acute pain is temporary, related to the physical sensation of tissue damage. It can last from a few seconds to several months, but generally subsides as normal healing occurs. Examples include a burn, a fracture, an overused muscle, or pain after surgery. Cancer pain may be long-lasting but acute due to ongoing tissue damage.
• Chronic--Chronic pain lingers long beyond the time of normal healing. Some chronic pain is due to damage or injury to nerve fibers themselves (neuropathic pain). Although it may begin as acute pain, neuropathic pain often develops gradually and becomes chronic pain that's difficult to treat.

Chronic pain can result from diseases, such as shingles and diabetes, or from trauma, surgery or amputation (phantom pain). It can also occur without a known injury or disease. Like a gate that's blocked open, nerves continue to send pain messages even though there is no continuing tissue damage.

Chronic pain ranges from mild to disabling and can last from a few months to many years. Significant emotional and psychological components may develop. The essential ingredient is that the chronic pain changes behavior. For example:

A person experiences the actual physical sensation of acute pain--the immediate, sharp stab in arthritic finger joints as they try to open a lid. Next is the emotional response-- anger and frustration with fumbling fingers. Eventually, behavior changes may occur. A person may avoid using aching fingers and hands. Hands become weak from inactivity, and the person in pain depends on others for assistance.

Chronic pain can result in lowered self-esteem, sadness, anger and depression. Over the long term, a sense of helplessness to control chronic pain can lead you to develop characteristic "pain behavior." Behavioral changes can become habitual--crutches that can undermine the ability to effectively manage pain.

Evaluating pain

Pain is subjective, but there are ways to measure it. Doctors and other care providers may use questionnaires, have patients fill out a pain-rating scale, or have them select words that best describe their pain.

When repeated attempts to find a cause fail, and treatments aren't effective, the patient may benefit from a team approach offered by a pain clinic. A thorough evaluation may involve specialists in anesthesiology, neurology, psychology and psychiatry, rheumatology, physiatry and physical therapy. The goal is to treat all facets of the pain.

Specialized tests can evaluate how the body senses nerve impulses and how the impulses travel through the nervous system. Imaging techniques, such as X-rays, computed tomography (CT), magnetic resonance imaging (MRI), bone scans and ultrasound, may help detect problems in bones, muscles, joints and soft tissue.

Treat pain early and aggressively

For many years, standard practice called for treating moderate to severe acute pain with injections of narcotic medication "as needed." This method often resulted in delays and widely varying levels of pain relief. Pain rose and fell based on the dose timing. For most people, pain relief was effective only part of the time. Even today, pain is often under-treated.

Inadequate pain control can occur for many reasons. The choice, dose and timing of medication are critical in obtaining effective relief. Also, patients and their care providers may be unduly concerned about the use of narcotics in treating acute pain. But addiction is rare when narcotics are used for short-term relief of acute pain. It may become a problem when narcotics are inappropriately used for chronic pain relief. Addiction is not an issue in treatment of pain from a terminal illness.

Adequate acute pain control following surgery is important because it can allow patients to recover their strength faster and start walking earlier. This can help avoid problems, such as pneumonia and blood clots, due to inactivity.

Inadequately treated acute pain can prolong recovery and make you more susceptible to chronic pain. Continued pain messages enhance subsequent pain responses. Peripheral pain receptors become more sensitive. And continued pain may cause long-lasting modifications in nerve cells along spinal cord pain pathways. These changes make established pain harder to suppress.

As pain persists, feelings of anxiety, stress, anger, helplessness and depression can worsen. Tension and pain may initiate a downward pain spiral that's difficult to break. Early, aggressive treatment, and working with care providers to prepare a pain plan, can help prevent this.

Pain-relieving medications

Pain treatment often includes medications and non-drug therapies. Over-the-counter pain-relieving (analgesic) drugs include:

• NSAIDs--Nonsteroidal anti-inflammatory drugs, or NSAIDs (en-SAYDS), are used to treat acute pain from inflammation, such as from arthritis. They relieve pain by inhibiting production of pain-intensifying neurotransmitters activated by tissue damage. NSAIDs include aspirin (Anacin, Bayer, Bufferin), ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve) and ketoprofen (Orudis KT). All can cause gastrointestinal bleeding. All are also available in prescription form.
• Acetaminophen--Acetaminophen (Tylenol) is used to treat pain and control fever, but has only a limited effect on inflammation. It doesn't cause gastrointestinal bleeding like NSAIDs. Prolonged, high-dose use can cause kidney and liver damage.

Drugs available only by prescription include:

• Narcotics--These drugs are the most effective medication for moderate to severe pain. They're used for cancer pain and acute pain when the cause is known and other medications are ineffective. Narcotics also have an important role in the treatment of pain associated with terminal illness. They're not approved for chronic pain. Narcotics include drugs derived from opium (opiates), such as morphine and codeine, and synthetic narcotics (opioids), such as oxycodone, methadone and meperidine (Demerol).
• Side effects can include drowsiness, nausea, constipation, mood changes, and with prolonged use, addiction.
• Antidepressants--These medications may offer some relief for people with chronic pain, whether or not they also have depression. Amitriptyline (Elavil), trazodone (Desyrel) and imipramine (Tofranil) may be used with other analgesics. These drugs aren't addicting. They're especially useful for neuropathic, head and cancer pain. Side effects can include drowsiness, constipation and mouth dryness.
• Anticonvulsants--Developed for epilepsy, these drugs, such as phenytoin (Dilantin) and carbamazepine (Tegretol), can also help control chronic nerve pain. Side effects include drowsiness and confusion.

Other drugs may be used for specific types of pain. Corticosteroid medications may help relieve pain due to inflammation and swelling. Prolonged use can result in widespread problems, such as bone thinning, cataracts and increased blood pressure.

Tramadol (Ultram) is a synthetic analgesic used primarily for chronic pain, but is also prescribed for acute pain. Side effects may include dizziness, drowsiness, nausea, constipation and sweating.

Sumatriptan (Imitrex), now available in tablet form, may reduce pain from migraine headache by constricting blood vessels in your brain. Because the drug may increase blood pressure and constrict arteries to your heart, it's not used for people with uncontrolled high blood pressure or heart disease.

Capsaicin (Zostrix), a topical cream made from an extract of red peppers, can help relieve skin sensitivity resulting from shingles. It's also used to treat pain from arthritis, cluster headaches, diabetic neuropathy and pain after mastectomy. You may have an initial burning sensation where the cream is applied. Benefits are temporary so you'll need repeated application. Capsaicin probably relieves pain by interrupting transmission of pain messages from nociceptors.

Managing pain

Short-lived acute pain generally responds to medication and goes away with healing but persistent pain can lead to depression, inactivity, de-conditioning and increased dependence on others.

Chronic pain can interfere with sleep and eating habits, exercise, social activity and work. Breaking this cycle usually requires a coordinated approach offered in a pain rehabilitation program. Physical, occupational and behavioral therapies, and assistance with the psychological components of chronic pain, are the cornerstones of successful treatment. Here are some strategies for coping with chronic pain:

• Relaxation techniques--Stress increases muscle tension and worsens pain.
  Relaxation techniques--such as meditation and yoga--involve activities in which you focus on something other than the pain. Patients can do many at home.
  Listening to music, visualizing a relaxing scene, trying a new hobby or visiting a friend may also help. These techniques can alter peripheral and central pain processes and are especially effective for chronic headache and muscle tension.
  Biofeedback may also help by teaching patients to be aware of autonomic pain responses such as skin temperature, muscle tension, blood pressure and heart rate, and how to modify these.
  Patients need to ask their doctor or other care givers about where to find help in learning relaxation and biofeedback techniques.
• Occupational therapy--This helps patients return to ordinary tasks around the home and work. Focusing on home responsibilities, work or volunteer activities--perhaps for limited hours at first--is a first step in pain rehabilitation.
• Physical therapy and exercise--Patients may fear exercise will increase pain, but if they start gently and increase gradually, exercise usually doesn't cause injury or additional pain. A regular program should include stretching, strengthening activities and aerobic exercise, such as walking, swimming or cycling. Slow stretching can relax muscles and release tension. If the patients have chronic back pain, you they get enough relief from muscle-strengthening exercises alone, thereby avoiding surgery.
• Family therapy--Chronic pain can change personalities and unravel relationships. The person with pain feels guilt and family members become stressed taking over additional responsibilities and new roles. The key is to maintain their normal responsibilities and roles as much as possible.

Pain may be universal--perhaps even unavoidable. But it doesn't have to control a person’s life. The keys to successful pain control are early treatment, ongoing assessment, and clear communication between care givers and their patients.

There have been several extremely important events in the world of pain management.

1. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has announced new standards and requirements for the assessment of pain in accredited hospitals and other healthcare settings. The new standards are a product of a collaborative effort between the Department of Standards of the Joint Commission and the Pain Management Improvement Group at the University of Wisconsin-Madison Medical School headed by Dr. June Dahl. Hospitals, Nursing homes, home health care agencies , behavioral health facilities and health plans will be called upon to:

a. Recognize the right of patients to appropriate assessment and management of pain

b. Assess pain in all patients

c. Record the results of the assessment in a way that facilitates regular reassessment and follow up

d. Educate relevant providers in pain assessment and management

e. Determine the competency in pain assessment and management during the orientation of all new clinical staff

f. Establish policies and procedures which support appropriate prescription or ordering of pain medications

g. Assure that pain does not interfere with participation in rehabilitation, educate patients and their families about the importance of effective pain management

h. Include patients’ needs for symptom management in the discharge planning process and

i. Collect data to monitor the appropriateness and effectiveness of pain management.

The new standards explicitly acknowledge that pain is a co-existing condition with a number of diseases and injuries, and requires explicit attention. For example, a patient with breast cancer should effectively be treated not only for the actual illness but also for any associated pain.

"Unrelieved pain has enormous physiological and psychological effects on patients. The Joint Commission believes that the effective management of pain is a crucial component of good care," says Dennis S. O’Leary, MD, president of the Joint Commission. "Research clearly shows that unrelieved pain can slow recovery, create burdens for patients and their families, and increase costs to the healthcare system."

The pain management standards - along with examples of compliance - were included in 2000-2001 standards manuals for the Joint Commission accreditation programs. The standards were first scored for compliance in 2001.

"These standards are put the importance of pain management at center stage, ensuring that health care providers and professionals will take pain management in a serious way," says Russ Portenoy, MD, president of the American Pain Society, which has endorsed these standards.

(To view the new standards, please visit the Joint Commission website: www.jcaho.org)

An article published in the Journal of The American Medical Association (JAMA) challenge the conventional wisdom that drugs used for the relief of severe pain - such as morphine - are widely abused. Research done at the Pain & Policy Studies Group of the University of Wisconsin Comprehensive Cancer Center found that while there were significant increases in the amounts of opioids prescribed by physicians in the U.S., it also found that abuse of opioids was low and stable. In contrast to a 109% increase in abuse with cocaine and heroin, abuse with opioids increased only 6.6% from 1990 to 1996.David Joranson, lead author of the article, noted that, "at a time when abuse of illicit drugs continues to increase, it is reassuring that abuse of opioid pain medications is a small part of the U.S. drug problem."

One of the reasons for inadequate pain management is that health professionals fear opioid medications will be abused. The JAMA report states that increased use of opioids resulting in abuse may be based more on myth than reality. These results suggest that the U.S. can be a model for how to achieve a balanced controlled substances policy, that is, one that can improve the availability of pain relief while limiting abuse. Research has disproved the widespread belief that the use of opioids results in addiction. A statistically insignificant number of cases of addiction (14 out of 10,000 cases) were determined in previous research quoted on the Wisconsin website. This article can be viewed at The Pain & Policy Studies Group, University of Wisconsin website: www.medsch.wisc.edu/painpolicy

It should be remembered that it took the medical profession 37 years to accept the hypothesis of Anton Simmelweis, MD, that the failure to wash hands before delivering infants caused the widespread incidence of "childbirth fever" by Austrian physicians. It is the deepest hope of the National Foundation for the Treatment of Pain that scientific knowledge will replace mythology more rapidly in the management of pain.

The argument can now be made that, with the universal availability of standards and guidelines for the treatment of pain; no medical practitioner can credibly defend failure to adequately treat pain relief, except for a frank lack of expertise and/or training. We will discuss the new standards at greater length in this COURSE.

A number of medical groups have weighed in on the issues relating to pain management and the changes needed to create a more humane and effective way to deal with patients. What follows here is a compendium of some of those viewpoints and recommendations:

Introduction

Across America, two opposing attitudes or paradigms of thinking currently exist in regards to the medical management of intractable pain. Empirical, long-range medical research has brought new light into the darkness of the Old Paradigm. However, despite the studies that support the New Paradigm, millions of people in our country continue to suffer needlessly because regulatory agencies and healthcare professionals deny safe, medical treatment to them. The Old Paradigm ignores three decades of international studies that support opioid pain treatment in cancer pain patients and severe intractable pain patients. An important goal of the National Foundation for the Treatment of Pain is to make public this new information that will bring the Old Paradigm thinking into the New Paradigm.

The Old Paradigm believes:

• It is not safe or prudent to prescribe pain medication on a continual basis.
• Opioid pain medicine is addictive and can cause long-term damage to internal organs.
• Pain patients should be tough and learn to live with pain.
• When pain patients continue to ask for increased pain medication, they are exhibiting addictive behavior.

Physicians who prescribe pain medicine are no different than illicit drug dealers and should be treated as such.

The New Paradigm knows (supported by three decades of empirical medical research):

• Opioid pain treatment is safe and effective when monitored by licensed physicians.
• Less than 1% of chronic pain patients become addicted or experience long-term physiological damage as a result of prolonged,