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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
-
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.
-
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.
-
Bricker L, Lavender T. Parenteral opioids for labor pain
relief: a systematic review. Am J Obstet Gynecol 2002;186(Suppl
5):S94-109.
-
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.
-
Hawkins JL, Beaty BR, Gibbs CP. Update on obstetric anesthesia
practices in the U.S. Anesthesiology 1999;91:A1060.
-
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.
-
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.
-
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.
-
Birnbach DJ. In the spotlight: epidural analgesia for labor--a
necessity or a luxury? ASA Newsletter 1998;62.
-
Harer WB Jr. Patient choice cesarean. ACOG Clinical Review
2000;5:1,13-6.
-
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.
-
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.
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Some
Definitions and Concepts
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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:
-
nociceptive pain
- 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.
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New
Hospital Pain Policy Standards from JCAHO
|
There
have been several extremely important events in the world
of pain management.
-
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:
|
Perspectives
in Intractable Pain Management An
analysis of current diverging viewpoints
|
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,
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