Management of Pain

Introduction

The International Association for the Study of Pain (IASP) defined pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Acute Pain are pain that last less than 30 days.

Complication

Delay of appropriate treatment in acute pain prolongs misery and leads to irreversible pathologies. The complicating problems are as follows:

  1. Functional Impairment : the elderly may need help for their daily activities as a lot of them have impaired ambulation as a result of pain.

  2. Delirium : There are incidences of older patients becoming delirious and restless when they are in pain and this is especially so in those who are cognitively-impaired.

  3. Increased healthcare utilisation cost.

Acute pain if not treated will eventually lead to chronic pain and this causes psycological pain. Psychologicall pain causes suffering and undue misery! Mood  gets changed and the person becomes more irritable. Sleep disturbance is a real issue. Some patients get isolated with decreased socialization and eventually become depressed.

Treatment

Please take into consideration the difficulties in assessing pain in the elderly. The assessment may at times be difficult and frustrating task because of:

  1. unusual presentation,

  2. multiple concurrent diseases and multiple sources of pain,

  3. disability with sensory deprivation from poor hearing and vision,

  4. cultural barriers  where there is a tendency   to under-report pain experienced both by patients and caregivers .

  5. decreased cognitive  capacity for example in patients with dementia making expression of pain unclear.

Detail assessment is important as at the end of assessment, clinicians will have a clearer idea of the following which will be very useful in managing the pain and improving quality of life:

  1. Type of pain i.e. soft tissue, bone pain, neuropathic nerve pain, deep-seated internal organ pain, etc

  2. Severity of Pain. In Malaysia pain is now the 5th vital sign .   A visual analog or face expression chart to tag or chart out the severity of the pain may be used

  3. Probable cause of pain and eventual options for pain relief

Successful treatment is highly dependent on successful resolution of the causes of pain and it’s underlying problem.

Educate patients and caregivers about lifestyle modification, non-pharmacological methods and the most appropriate analgesic matched for the most appropriate type of pain and severity.

Clinicians must balance the risks of side effects of analgesic with the benefits of being pain-free. The key is flexibility and creativity in prescribing these various types of analgesics.

Very important – review, review and review the patient regularly!

Factors’ affecting most appropriate choice of analgesic drug includes:

  1. Co-existing disorders

  2. Interactions with other medications used for concomitant conditions

  3. Tolerability and cost of  the analgesic

When prescribing, consider the following:

  • Given the most appropriate analgesics for the most likely cause of the pain. For example:

    • COX2 inhibitors for gouty arthritis attack, metastatic bone pain or

    • Carbamazepine or gabapentine for trigeminal neuralgia or post-herpatic pain.

  • Match the severity of pain to the strength of the analgesic i.e. strong analgesics for severe pain for example SC morphine for acute pancreatitis or acute myocardial infarction.

  • Pain killers must be given  orally (by the mouth), regularly (by the clock) and via the WHO ladder of 3-step model to guide the most appropriate analgesic choice depending on the severity of the patient’s pain.

  • Always consider adjuvant analgesics. Examples are anti-depressants, anti-convulsants, local anesthetics and steroids.

  • For mild pain use anti-pyretics (e.g. paracetamol); whilst for moderate severe pain we must consider using mild opioids. In patients with severe pain use strong opioids (e.g. morphine) plus adjuvants.

  • Drugs for mild to moderate pain are NSAIDs, COX2 inhibitors, acetaminophen, tramadol. Anticipate problems with the non-selective NSAIDs. Try avoiding using them in elderly as they have a higher risk of adverse drugs events.

  • Use opioids for moderate to severe pain. Morphine is the prototype. Expect increased sensitivity to opioids in elderly patients because of age-related changes in the pharmacokinetics of these drugs.

Prevention

PATIENT AND CAREGIVER EDUCATION is very important and the followings should be discussed:

  1. Diagnosis, prognosis, natural history of underlying disease

  2. Communication and explanation of the nature and mechanism of pain after a careful assessment of the pain

  3. Explanation of drug strategies

  4. Management of potential side-effects

Last Review : 20 June 2014
Writer : Dr. Yau Weng Keong
Reviewed : Dr. Ungku Ahmad Ameen bin Ungku Mohd Zam