Pain Management

The goal of pain management is to maximize quality of life, even though some level of pain may still exist.

Pain is a symptom usually caused by an injury or illness that causes tissue inflammation. Pain is an individual experience, and its definition is vague, allowing each patient to determine the quality and quantity as it affects them in the moment.

The most recent accepted definition of pain is “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” Pain is always a personal experience influenced to varying degrees by biological, psychological, and social factors. - International Association for the Study of Pain

The Association added six keynotes to help understand the definition:

• Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
• Through life experiences, individuals learn the concept of pain.
• A person’s report of an experience as pain should be respected.
• Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
• Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

Whether a patient experiences pain from an acute injury or has a long-standing painful condition, one of the responsibilities of the health care provider is to ease suffering and improve the quality of life.

An acute injury, whether a broken bone or appendicitis, usually has attention to pain control as part of the treatment plan of the underlying condition. The pain management may be short term analgesia (an=absence + gesia=pain), like pain medications, while the injury or condition resolves.

For those with long term or chronic pain, a multidisciplinary approach to pain management may be required. The skills of a team of health care providers, physical therapists, chiropractors, pharmacists, and psychologists may be needed to help the patient.

The goal of pain management is to maximize quality of life, even though some level of pain may still exist. This goal may be achieved by either lessening the pain, increasing the patient’s understanding of it, or both. Each treatment option by itself or in combination, has potential benefits, complications, and risks. A pain management plan will try to minimize risks while maximizing benefits.

Because every patient has different personal circumstances, perceptions of pain, and expectations, there is no one formula for pain treatment. Each treatment plan is individualized and needs to be modified as the patient’s physical condition changes, their disease state changes, and their life circumstances change.

Please note this article addresses general pain management guidelines that may not necessarily apply to children or those at the end of life.

• Nociceptive pain is associated with tissue damage or inflammation. It could be related to an injury or an illness that causes acute inflammation. This pain is a signal to the brain, an alarm that a noxious stimulus is present, and that the protective mechanisms of the body need to be activated. Examples of these protections might include withdrawing from a hot object, holding an injured limb motionless, or seeking medical help for abdominal or chest pain. There are two types of nociceptive pain:
  • Somatic pain is caused by injury or inflammation. Examples are a toothache, or a sprained or broken ankle. Other examples include pain after surgery, arthritis pain, or cancer-related bone pain.
  • Visceral pain is caused by inflammation or distention of a hollow organ in the body. It is often associated with symptoms related to the autonomic nervous system (the automatic or unconscious part of the brain that controls systems like heart rate, blood pressure, temperature control, and more). There may be sweating, nausea, and vomiting. As well, the pain from organs deep in the body may be referred to places on the skin. Gallbladder pain is often referred to the shoulder blade, pancreas pain to the back, and heart pain to the arm or jaw.
• Neuropathic pain is due to damage to the nervous system and does not need to occur in response to an outside stimulus, like injury or any other circumstance. This pain often develops into a chronic condition. Some common diseases that can cause neuropathic pain include diabetes, cancer, stroke, multiple sclerosis, infections, and amputations. There are two parts of the nervous system and there are different types of pain syndromes associated with each:
  • Central nervous system consists of the brain and the spinal cord.
  • Peripheral nervous system includes all the nerves that enter and leave the spinal cord, sending instructions from the brain to the body regarding movement, and returning sensory signals from the body to the brain. These include touch, pain, pressure, position, and in the head, sight, smell, and sound.

There are other types of pain that do not necessarily fit neatly into the above two categories. Chronic low back pain and recurrent migraine headaches are examples of pains that may be both nociceptive and neuropathic.

In addition, there are other types of pain that are neither of the above. Examples include the following:

• Dysfunctional pain is a type of chronic pain that seems to be neither nociceptive nor neuropathic, but perhaps both. It is characterized by widespread or regional pain syndromes. Examples include the following:
  • Somatoform pain is a chronic pain for which no physical cause can be determined, producing distress, and often impairing an individual's normal functioning and decreasing life enjoyment.
  • Fibromyalgia “is a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping. Scientists do not fully understand what causes it, but people with the disorder have a heightened sensitivity to pain.” - National Institutes of Health
  • Interstitial bladder disease
  • Irritable bowel syndrome (IBS)
• Cancer pain
  • Pain associated with cancer may be caused directly by the cancer, or its compression or invasion into other body parts, like nerves, organs, and bone.

Time definition of pain

The International Association for the Study of Pain has no time definition for acute or chronic pain. Some have defined acute pain as pain of recent onset and probable limited duration, with an identifiable temporal and causal relationship to an injury or disease. Chronic pain can be defined as pain that persists past the normal time of (tissue) healing, lasting three to six months or longer. But this definition does not work well for neuropathic pain or chronic inflammatory conditions like rheumatoid arthritis.

The use of time to classify pain does not help address or direct diagnosis or treatment.

When patients present with pain, regardless of the cause, the first expectation may be that they will be given medication for relief. That may be a viable option, but medication is only one of the options available to a health care provider and a pain management team to control pain in the short and long term.

Pain management medication

There are numerous medication options for treating pain and each has its role dependent on the injury, illness, and underlying medical conditions.

• Over-the-counter medications (OTC) may be used as an initial step, but it is important to remember that OTC medicines have the potential for risk if used inappropriately or in excess. Patients who take prescription medications or have underlying medical conditions should check with their care provider or pharmacist prior to taking OTC meds.
  • Nonsteroidal anti-inflammatory medications (NSAIDs) such as ibuprofen (Advil, Motrin) or naproxen (Aleve) may irritate the stomach and small intestine and cause bleeding. Patients with a history of peptic ulcer disease, or GERD, or those taking blood thinners such as coumadin, apixaban (Eliquis) or rivaroxaban (Xarelto) are at higher risk of bleeding. NSAIDs may also potentially cause kidney damage and those with kidney disease or diabetes should check with their health care provider before using these medications.
  • Acetaminophen (Tylenol, Panadol, paracetamol) is found in many OTC medications and can be harmful to the liver in higher doses. Patients with liver disease or those who drink alcohol to excess should be cautious in using this medication and should check with their care provider before use.
• Narcotic and other prescription medications may be used for pain management, but the benefit of their use must be balanced with the risk of complications, including drug abuse and dependence.
• Antidepressant and anti-seizure medications act within the brain affecting pain centers and may help those with neuropathic pain like shingles, trigeminal neuralgia, diabetic neuropathy, or complex regional pain syndrome. Some medications in this class include amitriptyline (Elavil), carbamazepine (Tegretol), and gabapentin (Neurontin).

Physical therapy pain management

The use of exercise, stretching, ultrasound, and electrical stimulation may be helpful in patients who have musculoskeletal pain from a muscle or ligament origin. This includes back and neck pain, two of the most common causes of chronic pain.

Providers whose skills fall into this category include physicians specializing in physical medicine and rehabilitation, physical therapists, chiropractors, massage therapists, and acupuncturists.

Interventional pain management procedures

In an acute injury, an emergency physician might use a nerve block, a local anesthetic injected near a nerve to numb it and help alleviate the pain of a dislocated shoulder or broken hip. This might lessen the need for narcotic pain medication.

For those with longer-term pain, interventional radiologists, anesthesiologists, or neurosurgeons can perform a variety of procedures to help with pain, such as:

• Nerve blocks
• Nerve ablation, where the sensory nerve that carries pain signals is destroyed
• Steroid injections into a joint or into the spinal canal
• For patients with back pain that has not responded to less invasive treatments, options may include:
  • A spinal cord stimulator, where small electrical pulses are generated near the spinal cord that alter the way a patient perceives pain.
  • Intrathecal pumps, where a small amount of medication is dripped into the spinal canal.

Psychologic treatment for pain management

Pain can consume a patient’s life and psychologic counseling may be a helpful adjunct in addition to other treatment options in helping control pain. Psychologists are important members of the pain management team.

Some treatment therapies that may be of help include the following:

• Cognitive behavioral therapy (CBT)
• Mindfulness and meditation
• Acceptance therapy
• Hypnosis

The goal of pain management for each patient is to minimize suffering and improve quality of life. This goal may be different depending on the patient’s circumstances and disease or injury. For example, the approach to a patient with a broken leg will be different than a patient at end of life in hospice requiring pain control. Both deserve dignity and pain minimization, but the plan will be different for each.

Being free of pain is not always achievable, but the goal of alleviating suffering, minimizing pain, and allowing quality life should be in reach of the patient in coordination with the members of their pain management team.