This tutorial was prepared as a background paper for the our Pain Management Committee.
"The ethical obligation to manage pain and relieve the patient's suffering is at the core of a health care professional's commitment."
Acute Pain Management: Operative or Medical Procedures and Trauma Clinical Practice Guideline Agency for Health Care Policy and Research February 1992
Mental illness does not spare its sufferers from pain. Indeed severe pain with no apparent organic basis is characteristic of depression and other disorders. Nonetheless pain management has been given little attention in behavioral health.
Much of what has been learned about dealing with physical pain applies to psychological pain. Both are under-assessed and under-treated. Even when pain is recognized more attention is paid to the causes than to the pain itself. Pain sufferers are often left to contend with pain alone.
Severe pain has the same impact both physically and psychologically. Anxiety, sleeplessness, fatigue, depression, and anger set in. These modify and aggravate the pain. They elicit changes that increase stress, which further drives pain. Severe pain is disruptive of any therapeutic regimen and destructive to the patient.
Worsening pain attacks self-control and self-esteem. It generates fear and powerlessness. It creates a sense of profound isolation. Pain overwhelms coping and leaves helplessness in its wake.
Pain travels in the company of suffering, which has been defined by Cassell as "a state of severe distress induced by the loss of intactness of person or by a threat that the person believes will result in the loss of...intactness."
Those with chronic pain share the same experience irrespective of the source. Recurrent stress and intense pain decreases endorphin (natural substances that relieve pain) levels in the brain. This increases their vulnerability. This must be offset. This is the function of pain management.
* Concern about limited knowledge/training in pain management
* Concern about limited knowledge of available modalities
* Concern about use of controlled substances
* Concern about patient addiction
* Concern about c side effects and withdrawal
* Concern about patient tolerance to analgesics
* Concern about use of opioids with patients with history of substance abuse
* Concern that pain is "normal" with somatic disease or trauma or in the elderly
* Concern about reporting pain and becoming a "bad" patient (i.e., a complainer)
* Concern that pain is to be expected and accepted
* Concern about pain management extending behavioral health treatment
* Concern about becoming addicted or being regarded as an addict
* Concern about analgesic side effects and withdrawal
* Concern about the use of psychotropic and analgesic medications
* Concern that pain management always means using opioids
* Concern about becoming tolerant to pain medications
* Concern about physical pain is generally nominal to nonexistent
* Concern about psychological pain is minimal (and unrecognized as a factor in depression and suicidality)
* Concern that pain is manipulative or malingering behavior
* Concern that pain management is somebody else's problem (i.e., not a behavioral health treatment goal)
* Concern that pain management will impact cost
* Concern that pain management will induce or aggravate addiction
A. Physical Pain - "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."
nternational Association for the Study of Pain (IASP)B. Psychological Pain (AKA Emotional Pain)- Severe pain caused by loss, depression, and other psychiatric disorder or emotional trauma. Psychache is the internal psychological pain of excessively negative emotions associated with suicidality (Edwin Shneidman).
C. Acute Pain - An unrelieved non-pathological condition comprising normal neural functioning signifying actual or potential physical or psychological trauma, lasting less than 2 weeks.
D. Chronic Pain - An unrelieved pathological, dysfunctional, physically and psychologically debilitating condition lasting longer than 2 weeks.
A. MYTH: Opioid analgesics cause addiction:
FACT: Addiction is the compulsive and purposeful use of substances for their physical and psychological effects. Addiction involves "drug seeking" behavior. Pain patients manifest "pain avoidance" behavior. Addiction is of nominal probability when using opioid analgesics to treat pain patients with no history of substance abuse.
B. MYTH: Discontinuation of opioid analgesics involves severe withdrawal.
FACT: Withdrawal is a physical effect of the body's adaptation to the drug so that a "rebound" occurs if it is abruptly discontinued. Patients treated with opioid analgesics over a period of time can experience withdrawal if the drug is significantly decreased or suddenly stopped. However, good pain management practice involves the tapering down of a drug, which will avoid the withdrawal syndrome.
C. MYTH: Patients treated with opioid analgesics will require increasing amounts of the drug until it is ineffective because of the development of tolerance.
FACT: Tolerance to opioid analgesics can occur but not in the course of good pain management practice. Patient dosing should be increased gradually until analgesia is achieved and this dosage level can be maintained. Increases in the level of pain under such circumstances may be more likely attributed to disease progression or aggravation of the underlying trauma.
D. MYTH: Opioid analgesics or other pain drugs should only be given PRN.
FACT: Opioid analgesics and other pain medications should be given on a consistent basis so that a stable clinical level of analgesia is achieved and maintained. Administering an analgesic before pain becomes intolerable will result in more effective pain relief with less medication and fewer side effects.
E. MYTH: Opioid analgesics always produce sedation and impair functioning.
FACT: Sedation is a temporary side effect of opioid analgesics. Once stabilized on the medication patients experience no impairment of normal thinking or performance.
A. WHO Three-step Analgesic Ladder
* Use the least invasive routes, simplest modalities, and the most basic dosages initially.
* Use, as appropriate, aspirin, acetaminophen, or non-steroidal anti-inflammatory (NSAID) drug with mild to moderate pain (WHO Step 1).
* Use an opioid when pain persists or increases (WHO Step 2).
* Use increased opioid potency or dose if pain continues or becomes moderate to severe (WHO Step 3).
* Use a regular dosing schedule (i.e., "by the clock" not PRN) to maintain a drug level to prevent recurrence of pain.
B. Philosophical Pain Management Guidelines
* Screen for pain initially and on an ongoing basis.
* Believe the individual. Trust their pain testimony.
* Involve the individual and their support system.
* Deal with the pain -- give relief not insight.
* Care for the pain.
* Regard chronic pain as a disorder in its own right and not a secondary symptom.
A. Pharmacological Modalities
* Oral Administration
* Transdermal Administration
* Rectal Administration
* Subcutaneous Administration (intermittent and continuous)
* Intramuscular Administration (Intermittent injection)
* Intravenous Administration (Bolus and continuous)
* Intraspinal Administration (Epidural and Intrathecal)
* IntraventricularB. Physical Modalities
* Cutaneous Stimulation
* Heat and Cold Applications
* Massage, pressure, vibration
* Exercise
* Repositioning
* Immobilization
* Counterstimulation (TENS, acupuncture)
C. Psychological Modalities
* Relaxation and imagery
* Cognitive distraction and reframing
* Patient education
* Psychotherapy and structured support
* Support groups
D. Invasive Modalities
* Radiation therapy
* Surgery
* Nerve blocks
* Neurosurgery (ablation of pain pathways)
Substance abusers experience pain and are entitled to meaningful assessment and intervention. Effective pain management is complicated but not precluded by the presence of substance abuse in the patient. Pain and substance abuse represent a co-morbidity rather than a treat/no treat dichotomy. Patients with a substance abuse history are a special needs group (like children or the elderly). Some basic guidelines include:
A. Clinicians should attempt identify the source of the pain and to resolve the primary problem (i.e., injury, infection, post-operative stress, or other trauma), wherever possible regardless of the patient's substance abuse history.
B. Clinicians should follow the "ladder of analgesia" strategy and turn to opioid analgesics based on demonstrated appropriateness to the patient's level of and type of pain.
C. Clinicians should consider the appropriateness of non-pharmacological therapies as an adjunct to or replacement for opioids where indicated regardless of the patient's substance abuse history.
D. Clinicians should clarify the timeframe of the substance abuse. Patients with a past history of abusive behavior may be treated similarly to those with no history of substance abuse.
E. Clinicians should follow basic pharmacological principles of opioid use. Opioid tolerant patients may require higher doses to achieve the same analgesic effect regardless of their substance abuse history.
F. Clinicians should consider secure drug delivery devices when using opioids with active substance abusers and respond firmly to any attempts to interfere with the process of analgesia or access to medications by the patient.
G. Clinicians should set limits regarding drug options in pain management with active substance abusers.
02.01