This document provides an overview of pain pathophysiology and management. It begins with objectives and introduces topics like neuroanatomy, pathophysiology, types of pain, assessment, and management. It describes how pain is a subjective experience transmitted by nociceptors and modulated by various factors. The neuroanatomy of pain transmission from the periphery to the CNS is outlined. Different types of pain like nociceptive, neuropathic, referred, acute, and chronic are defined. Common pain syndromes and their characteristics are mentioned. Non-opioid and opioid medications as well as non-pharmacological approaches for pain management are summarized.
3. Pain is an unpleasant , sensory and emotional experience
usually associated with noxious stimuli
Pain is
◦ Subjective
◦ Protective
◦ And it is modified by developmental, behavioral
personality and cultural factors
4. The word “pain” is derived from the Latin word “poena”
meaning fine, penalty, or punishment.
Pain Threshold – level of noxious stimulus required to alert
an individual of a potential threat to tissue
Pain Tolerance – amount of pain a person is willing or able to
tolerate
5. A person experience pain through
◦ Sensory- discriminative system: this processes the
information about the strength, intensity, quality, spatial,
temporal aspects of pain.
◦ Motivational- affective system: It determines the
individuals avoidance- approach behavior.
◦ Cognitive –evaluative system: It overlies the individuals
learned behavior concerning the experience of pain. It
may block, modulate or enhance the perception of pain.
7. Large fibre Small fibre
Unmyelinated Myelinated
Slow conducton Fast conduction
Responds to thermal chemical and
mechanical stimuli
Responds to mechanical and
mechanothermal stimuli
Produces sensation of sharp
pain(epicritic pain)
Produces sensation of dull
pain(protopathic pain)
8. Neuroanatomy of pain
The areas of nervous system responsible for pain
pathways are:
Afferent pathways
CNS
efferent pathways
9. Pain pathway
Afferent pathways terminate in the dorsal horn of the spinal
cord(1st order neuron)
The nerve fibers from the dorsal root ganglia enter the spinal cord
through dorsal root and send branches 1-2 segments up and down
the spinal cord.
Second order neurons transmit the impulse from the substantia
gelatinosa and lamina through the ventral and lateral horn
crossing the same or adjacent segment to the other side of the
cord.
10. Pain pathway
The impulse is then carried through the spinothalamic tract
to the somatosensensory cortex, frontal cortex and cingulate
gyrus. There are two divisions of spinothalamic tract which
transmit in different areas of brain.
Neospinothalamic tract
Paleospinothalamic tract
Neospinothalamic tract projects to VPL nucleus of thalamus.
Paleospinothalamic tract projects to central nuclei of
Thalamus.
16. Sensitization
When intense, repeated, or prolonged stimuli are applied to
damaged or inflamed tissues, the threshold for activation is
lowered, and the frequency of firing is intensified.
mediators - bradykinin, nerve-growth factor, and leukotriene
Sensitization occurs
◦ At peripheral nerve terminal (peripheral sensitization)
In damaged or inflamed tissues an increase in the production,
transport, and membrane insertion of chemically gated and
voltage-gated ion channels occurs.
◦ At the dorsal horn of the spinal cord (central sensitization).
21. Gate-Control Theory –
Ronald Melzack (1960s)
Described physiological mechanism by which
psychological factors can affect the experience of pain.
Neural gate can open and close thereby modulating
pain.
Gate is located in the spinal cord in SG.
When the gate is closed signals from small diameter
pain fibres do not excite the dorsal horn transmission
neurons.
When the gate is open pain signals excite dorsal horn
transmission cells
24. Three Factors Involved in Opening and
Closing the Gate
The amount of activity in the pain fibers.
The amount of activity in other peripheral fibers.
Messages that descend from the brain.
25. Conditions that Open the Gate Conditions That Close the Gate
Physical conditions
◦ Extent of injury
◦ Inappropriate activity level
Emotional conditions
◦ Anxiety
◦ Tension
◦ Depression
Mental Conditions
◦ Focusing on pain
◦ Boredom
Physical conditions
◦ Medications
◦ Counter stimulation (e.g.,
heat, massage)
Emotional conditions
◦ Positive emotions
◦ Relaxation, Rest
Mental conditions
◦ Intense concentration or
distraction
◦ Involvement and interest in
life activities
26. Types
Pain can be categorized according to inferred pathology:
Nociceptive pain
Somatic - Skin, tendons, ligaments, bone etc..
Visceral – Organs, cavity linings
Neuropathic pain- stimuli abnormally processed by the
nervous system. Ex- diabetic neuropathy, phantom limb
pain.
Referred pain
By duration:
Acute
Chronic
27. Somatic pain
Source: Skin, muscle, and connective tissue
Examples: Sprains, headaches, arthritis
Description: Localized, sharp/dull, worse with
movement or touch
Pain med: Most pain meds will help, if severe, need a
stronger medication
28. Visceral pain
Causes
Abnormal distention and contraction of the hollow viscera
muscle walls
Rapid stretching of the capsule
Abrupt anoxemia
Direct action of chemical stimuli (oesophagus)
Traction or compression of ligaments and vessels
Inflammatory processes and Necrosis of some structures
(myocardium)
29. Visceral pain
Characteristic features of visceral pain
It is dull aching, deep, not well defined, and differently
described by the patients
Difficult to locate
Induces strong autonomic reflex phenomena
Much more pronounced than in pain of somatic origin
(psychic alarm reaction -"angor animi" - in angina pectoris)
30. Referred pain
Figure 10-13b
Skin
(usual stimulus)
Kidney
(uncommon stimulus)
Primary sensory
neurons
Secondary
sensory
neuron
Ascending sensory
path to somatosensory
cortex of brain(b)
31. Acute pain
It is a protective mechanism that alerts the individual to a
condition that is immediately harmful to the body. Which
leads to the following responses:
◦ Increased HR & RR
◦ Elevated BP
◦ Pallor or flushing, dilated pupils
◦ Psychological and behavioural response to acute pain
Fear
General sense of unpleasantness
Anxiety
32. Chronic pain
It is persistent or intermittent usually defined as lasting at least 3-
6 months
The cause is often unknown, often develops insidiously, very often
is associated with Depression.
Chronic pain produces significant behavioural and psychological
changes:
depression
an attempt to keep pain - related behaviour to a minimum
sleeping disorders
preoccupation with the pain
tendency to deny pain
33. Common pain syndrome
Neuropathic pain
1. Peripheral nerve
pain
2. Central pain
CRPS
Pain in association with
psychiatric disease
Chronic pain of
indeterminate cause
Cancer pain
Post stroke pain
syndrome
Cervicogenic headache
Low back pain
Migraine
Phantom limb pain.
Neuralgias
34. Neuropathic pain
Dysesthesia-Any abnormal sensation described as unpleasant
by the patient
Hyperalgesia- Exaggerated pain response from a normally
painful stimulus
Hyperesthesia (hypesthesia) - Exaggerated perception of touch
stimulus
Allodynia - Abnormal perception of pain from a normally
nonpainful mechanical or thermal stimulus
Analgesia - Reduced perception of pain stimulus
Paresthesia - Mainly spontaneous abnormal sensation that is
unpleasant; usually described as "pins and needles"
35.
36. Complex regional pain syndrome
Old terminology - Casualgia.
It is a painful condition that includes regional pain, sensory
changes, abnormal sudomotor activity , skin changes, edema
following an inciting event such as trauma.
Commonly seen in females in 3rd n 4th decade
Precipitating factors:
-Fracture -Strain/ sprain
-Post surgery -Crush injury
37. Types
CRPS I- No definable nerve lesion
CRPS II- Involves nerve lession.
C LINICAL FEATURES:
Excruciating pain
Edema of affected limbs.
Autonomic dysfunction.
Motor dysfunction.
38. Cancer pain
Mechanism
Direct tumour invasion of local tissues.
Metastatic bone pain.
Osteoporotic bone and degenerative joint pain in older
people.
Visceral obstruction.
Nerve compression and plexus invasion.
Ischaemia.
Inflammatory pain.
Chemotherapy induced neuropathy, paraneoplastic
neuropathy and arthropathy.
Post-surgical pain and radionecrosis.
39. Post stroke pain syndrome
Patients complaints of spontaneous severe paroxysmal and
burning type pain sensation.
It has been postulated that damaged sensory pathways or
damage to the central inhibitory may be responsible for
pain.
Following stroke about 40- 60 % patients develop shoulder
pain. It usually improves following physiotherapy.
40. Phantom limb pain
Phantom = ghost. Phantom limb feels real. Sometimes
amputees try to walk on their phantom limb.
Several studies have shown that 75% of patients with
PLP develop pain within the first few days after
amputation.
Usually intermittent; only few patient’s are in constant
pain. Located in distal parts of the missing limb.
Mechanism- stump neuroma, spinal plasticity , cerebral
reorganization.
Treatment – multi disciplinary approach. TCAs, TENS,
Mirror box therapy etc..
42. Mirror box therapy
Persons with amputated limb use either a mirror or
mirror box to reflect an image of the intact limb. It is
hypothesized that this works by preventing cortical
restructuring
43. History
Site of pain
Primary location
Radiation
Circumstances associated with pain onset including details of
trauma or surgical procedures
Character of pain - Sensory descriptions eg sharp, throbbing,
aching
Intensity of pain
At rest
Movement
44. Temporal factors
Duration
Current pain, during last week
Aggravating or Relieving factors
Associated symptoms (eg nausea)
Effect of pain on activities and sleep
Treatment history
Current and previous medications
Other treatment eg. transcutaneous
electrical nerve stimulation
45. Assesment of pain
McGill pain questionnaire
◦ Part I - To localize the pain
◦ Part II- Incorporates the visual analogue scale.
◦ Part III- The pain rating index. It includes 20
categories and 76 descriptions.
51. Adjuvant therapy ‐
Tricyclic anti‐depressants
Anticonvulsant medications – Gabapentin, Pregabalin, and
Carbamazepine
NSAIDs (non‐steroidal anti‐inflammatories) ‐ can be used
as co‐analgesics and are useful in reducing inflammation
52. NSAIDS
Drugs dosages Adverse effects Uses
Acetylsalicylic
acid
650 mg PO Reye’s syndrome in children
Avoid in women in late
pregnancy, kidney or liver
disease, asthma, high blood
pressure, or bleeding disorders.
Peptic ulcer.
Headache, muscle
ache, backache, fever,
and arthritis menstrual
cramps .
Acetaminophen 650 mg PO May be harmful for people with
kidney or liver disease or those
who drink alcohol heavily
Headache, muscle
ache, backache, fever,
and arthritis.
Ibuprofen 400 mg PO May be harmful for people with
kidney or liver disease, asthma,
bleeding disorders, or those who
drink alcohol heavily.
Headache, muscle
ache, fever, sprains,
menstrual cramps,
backache, and arthritis
pain.
Naproxen 250-500 mg
PO
Not recommended for children
without a health care
professional’s supervision Cardio
vascular risks and G.I toxicity
Headache, muscle
ache, fever, menstrual
cramps, backache,
arthritis pain and
inflammation.
53. Drugs Dosages Adverse effects uses
Celecoxib 100-200 mg PO Generally well-
tolerated
Muscle aches, joint
pain, arthritis, pain
and inflammation
Ketorolac 15-60 IM/IV May be harmful for
people with kidney
or liver disease or
those who drink
alcohol heavily.
Not recommended
for children
Headache, muscle
ache, fever,
menstrual cramps,
cold or flu aches
54. OPIOIDS
Most potent analgesics
It produces analgesia by activating pain-inhibitory neurons
and directly inhibit pain-transmission neurons.
Modes of delivery:
Oral
IV and IM
Nasal spray
Transdermal & transmucosal patch
Sublingual route
Suppository
Epidural & Intrathecal route
55. Short acting opiods
Peak effect - 1–2 hrs
Duration – 4 hrs
Uses
Acute pain - in moderate to severe chronic pain.
Rescue medication for break through pain.
Eg –
Codeine( 30- 60 mg PO QID)
Tramadol (50- 100 mg PO QID)
Morphine( 30 mg PO QID , 5 mg 4 hourly IV)
56. Long acting opiods
Steady pain relief for 12 hours.
Used for chronic pain.
Eg-
Hydromorphone(2-4 mg PO QID)
Methadone(5-20 mg PO/IV TDS)
Buprenorphine
Fentanyl( 25-100 µg/hour transdermal patch for 72
hour)
Oxy codone(5-10 mg POQID)
57. What Dose to Give an Opioid Naïve
Patient?
For opioid naïve start at a morphine equivalent of 2 to 5
mg IV or 10 mg PO
Dose escalation should be more than 30 to 50% of base
dose to observe a meaningful change.
Frequency of parenteral dosing can be as often as every
15 to 30 minutes until adequate analgesia is achieved
58. Opiod Analgesic Usual Starting
DoseDrug Equianalgesic
parenteral
dose
Starting iv
dose
iv:po ratio Starting dose
po
/transdermal
Duration of
Action
Morphine 10 mg Bolus
dose=0.05-0.1
mg /kg q 2-4
hours
Continuous
infusion=0.01-
0.04 mg/kg/hr
1:3 0.15-0.3
mg/kg/dose q
4 hours
3-4 hours
Hydromorphone 1.5 mg 0.015-0.02
mg/kg q 4
1:5 0.06 mg/kg q 3
to 4 hours
2-4 hours
Oxycodone 5-10 mg N/A 0.1-0.2 mg/kg
q 3 to 4
3-4 hours
Fentanyl 100mcg 1 to 2
mcg/kg/hr as
continuous
infusion
25 mcg
patch/hour
72 hours
Methadone 10 mg 0.1 mg/kg q 4
to 8 hours
1:2 0.2 mg/kgq 4
to 8 hours
12 to 150
hours
59. Opioid-responsiveness – It is the ability to achieve pain relief
with evidence of improved function without the
development of unmanageable or intolerable side effects.
Addiction-
1. Compulsive use and preoccupation with the drug and
its supply.
2. Inability to consistently Control the quantity used.
3. Craving the psychological effects of the drug.
4. Continued use despite adverse effects from the drug.
60. Physical dependence - manifested by a withdrawal syndrome
which includes
Sleeplessness -
Anxiety and agitation – Anxiolytics
Stomach cramps - Dicyclomine
Body aches (flu-like symptoms) - Anti-inflammatory pain relievers
Muscle cramps - Muscle relaxants
Nausea, vomiting, diarrhea, sweating and skin crawling
Alternative opioids - during detoxification.
Methadone
Buprenorphine decrease by 10-20 % per week.
Tramadol
61. Therapeutic monitoring
Four A’s:
Analgesia (pain relief – often measured by a
10-point rating scale).
Activities of daily living (physical, psychological,
and social functioning).
Adverse effects.
Aberrant or abnormal drug-related behaviors.
62. Is the person’s day centered around taking medication?
Does the person take pain medication only on
occasion, perhaps three or four times per week?
Have there been any other chemical (alcohol or drug)
abuse problems in the person’s life?
Does the person in pain spend most of the day
resting, avoiding activity, or feeling depressed?
Is the person in pain able to function (work, household
chores, and play) with pain medication in a way that is clearly
better than without?
63.
64. Three Complications of Chronic High Dose
Opioid Therapy
1. Neurotoxicity
2. Tolerance
3. Opioid Induced Hyperalgesia
Tolerance
Due to prolonged use of opiates
It occurs when there is a progressive lack of response
to a drug requiring increased dosing
Higher doses of opiates are required to elicit same
amount of analgesia
65. Opioid-induced Neurotoxicity
Mediated through non-opioidergic mechanisms
Due to neuro-excitatory metabolites of opioids
(morphine-6-glucuronide, oxymorphone-3-glucuronide)
Causes spectrum of symptoms ranging from mild
confusion or drowsiness to hallucinations, delirium and
seizures
Typically develops on initiation to a week of initiating an
opioid or reaching a dose that causes metabolite buildup.
66. Opioid Induced Hyperalgesia
Clinical features- Hyperalgesia, allodynia,Myoclonus,
Confusion etc..
Related to but different from tolerance
Different from opioid neurotoxicity
Has been observed and documented in literature since
19th century (Observed by Albutt in 1870)
Treatment – dose reduction, Utilize NMDA antagonists,
Interventional pain techniques or neurosurgical
procedures
67. Anti Depressants
Tricyclic anti depressants:
Amitriptyline (25- 300 mg PO)
Imipramine (75-400 mg PO)
Desipramine (50- 300 mg PO)
Nortriptyline (40- 150 mg PO)
Adverse effects- Dry mouth, Blurred vision, Constipation,
Difficulty urinating , Worsening of glaucoma, Palpitations, Wt
gain and hypotension.
68. SSRIs(Selective Serotonin reuptake Inhibitors
Examples
Fluoxetine
Sertraline
Citalopram
Escitalopram
Fewer side effects and are less sedating than TCAs.
Effective for prevention of migraine but less effective for
other types of pain.
69. SNRIs
Selective Serotonin and Nor-adrenaline Reptake
Inhibitors
Duloxetine (30- 60 mgPO)
Venlafaxine (75-400 mg PO)
Milnacipran(25-100 mg PO)
Serotonin syndrome.
Antidepressant medications included in this warning are
fluoxetine, sertraline, paroxetine, escitalopram ,
duloxetine, milnacipran, and venlafaxine.
Migraine drugs include Triptans.
70. ANTI CONVULSANT DRUGS
Gabapentin ( 600-1200 mg PO) Neuralgia
Pregabalin (150- 600 mg PO) Postherpetic neuralgia, diabetic
neuropathy, and fibromyalgia
Carbamazepine (200- 300 mg PO QID) Trigeminal neuralgia
Valproic acid (400- 600 mg PO OD) Prophylaxis of migraine
Lacosamide (100 mg PO BD) Diabetic neuropathic pain
Topiramate (25- 200 mg PO OD) Prophylaxis of migraine
71. SODIUM CHANNEL BLOCKING & ORAL ANTI-
ARRHYTHMIC AGENTS
Drugs commonly used are
1. Lidocaine
2. Flecainide
3. Mexilitine
Lidocaine has anti-arrhythmics with local anesthetic
properties and it is occasionally used in refractory pain.
These drugs interrupt premature firing of damaged nerves
hence less capability of the nerve to trigger pain.
72. TOPICAL PAIN RELIEVERS
Topical agents work locally and must be applied directly
over the painful area
Transdermal drugs have effects throughout the body and
work when applied away from the area of pain
Transdermal medication in a patch is absorbed through
the skin by the bloodstream over a period of time.
Eg –
EMLA(Eutectic Mixture of Local Anesthetic; contains lidocaine and
prilocaine)
L.M.X.4 (contains lidocaine 4%),
Used primarily prior to painful procedures such as while
lumbar puncture (spinal tap), and wart removal.
73. DRUGS USED AS MUSCLE RELAXANTS IN
CHRONIC PAIN
Carisoprodol (200 mg PO BD)
Metaxalone (800 mg PO TDS)
Chlorzoxazone (250 – 750 mg PO TDS)
Baclofen ( 5 mg PO TDS)
Tizanidine (4 mg PO TDS)
74. Botulinum toxins
Botulinum toxins have been found to be effective in
decreasing tone in overactive (hypertonic) muscles
It is used for the treatment of the postural
abnormalities and pain associated with dystonias . Ex-
torticollis .
Onabotulinumtoxin A is additionally approved by FDA to
prevent headaches in adults with chronic migraine
75. Interventional therapy
1. Intra articular steroid injections
2. Viscosupplementation
3. Spinal cord stimulation
4. Implanted targeted intra thecal drug delivery
5. Epidural analgesia
6. Nerve plexus block
76. Spinal cord stimulation:
Chronic radicular pain
CRPS type I and II
Painful peripheral neuropathies
Peripheral vascular disease not amenable to
Surgical by pass or conventional therapy.
Central pain
Phantomb limb pain.
79. Epidural analgesia:
Indication:
Disk herniation, degeneration, and spondylosis
Radiculopathy - cervical thoracic, lumbosacral
Spinal stenosis and facet arthropathy
Pelvic pain - Aid with pelvic floor physical therapy
Labor epidural analgesia
80.
81. TENS
TENS is a method of treating pain that is non-invasive
and does not use pharmaceuticals.
The TENS device sends impulses through the skin that
stimulate the nerve
Indications:
Chronic post operative pain
Chronic post traumatic pain
84. Rules of thumb
Use the lowest effective dose by the simplest route.
Start with the simplest single agent and maximize it’s
potential before adding other drugs.
Use scheduled, long-acting pain medications for
constant or frequent pain.
Treat breakthrough pain with with parentral, short-
acting medication
85. Source of information
Harrison 18th edition
Bradley neurology
ACPA guidelines for pain management
WHO guidelines for pain management
86. “Pain is a more terrible lord of mankind than
death itself.”
Albert Schweitzer
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