1. OverviewOverview
of Painof Pain

2. ObjectivesObjectives
 Define pain.Define pain.
 Discuss the differencesDiscuss the differences
between acute and chronicbetween acute and chronic
pain.pain.
 Classify pain based onClassify pain based on
pathophysiologicpathophysiologic
mechanisms.mechanisms.

3. ObjectivesObjectives
 Identify pain measurementIdentify pain measurement
scales/tools.scales/tools.
 Discuss therapeutic options.Discuss therapeutic options.

4. CASE 1.
Patient is a 44yo/M, no comorbidities,
coming with a chief complaint of right upper
quadrant pain. Pt was diagnosed with calculous
cholecystitis and underwent elective open
cholecystectomy under general anesthesia. At the
recovery room, patient complained of pain during
inspiration. Pain was localized to the surgical site
and described as sharp and tender on palpation.

5. ASSESSMENT:
What is your assessment
What are your differentials
Is the pain acute or chronic?

6. What are your treatmentWhat are your treatment
options?options?
 Opioids?Opioids?
 NSAIDs?NSAIDs?
 Adjuvant analgesia?Adjuvant analgesia?
 Regional Analgesia?Regional Analgesia?

7. CASE 2.
Patient is a 50 yo/F, with a 10 yr history of
mandibular pain described as burning, shooting
and intermittent pain VAS of 9-10 seeks consult for
this symptom. The patient was subjected to
multiple dental extractions with no relief of
symptoms. Patient was then referred to the pain
service.

8. ASSESSMENT:
What type of pain is the patient feeling?
Differentiate the character of somatic, visceral and
neuropathic pain?
Is this acute or chronic in character?

9. Treatment Options?Treatment Options?
 Opioids?Opioids?
 NSAIDs?NSAIDs?
 Adjuvants?Adjuvants?
 What is the role of Gabapentinoids?What is the role of Gabapentinoids?
Tricyclic antidepressants?Tricyclic antidepressants?
Anticonvulsants?Anticonvulsants?

10. CASE 3.
Patient is a 55 year old female diagnosed
with stage 4 breast cancer, who came in for
generalized weakness with low back pain
radiating to the back of thigh. The pain was
further characterized as lightning like with deep ,
gnawing pains on both upper flanks. Intake of
around–the-clock tramadol with paracetamol
afforded partial relief. Her pain score remains 5/10
with a feeling of doom.

11. ASSESSMENT:
What type of pain is the patient experiencing ?
Acute or chronic?
Somatic, visceral or neuropathic?
TREATMENT:
Describe the WHO stepladder approach to pain
control.

12. What is Pain?What is Pain?
 EtymologicallyEtymologically
– Greek –Greek – “poine”“poine”
– LatinLatin – “poena”– “poena”
** Words suggesting punishment and theWords suggesting punishment and the
consequent effect thereofconsequent effect thereof

13. What is Pain?What is Pain?
 As used todayAs used today
– Greek –Greek – “algos”“algos”
– Latin –Latin – “dolor”“dolor”
– Italia –Italia – “dolore”“dolore”
– French –French – “douleur”“douleur”

14. What is Pain?What is Pain?
 From the dictionaryFrom the dictionary
– Suffering or loss inflicted for an offenseSuffering or loss inflicted for an offense
– A primary condition of sensation orA primary condition of sensation or
consciousness, the opposite of pleasureconsciousness, the opposite of pleasure
– The sensation that one feels when hurtThe sensation that one feels when hurt
(in body or mind)(in body or mind)

15. What is Pain?What is Pain?
 From the dictionaryFrom the dictionary
– The bodily suffering or distressing sensationThe bodily suffering or distressing sensation
of soreness in a particular part of the bodyof soreness in a particular part of the body
(physical)(physical)
– Mental suffering, trouble, grief, or sorrowMental suffering, trouble, grief, or sorrow
(psychological)(psychological)

16. What is Pain?What is Pain?
““Pain is an unpleasantPain is an unpleasant sensory andsensory and
emotionalemotional experience associated withexperience associated with
actual or potential tissue damage oractual or potential tissue damage or
described in terms of such damage.”described in terms of such damage.”
International Association for the Study of Pain, 1979

17. ACUTE PAINACUTE PAIN
 the normal, predictedthe normal, predicted
physiologicalphysiological response to anresponse to an
adverse chemical, thermal oradverse chemical, thermal or
mechanical stimulusmechanical stimulus
associated with surgery,associated with surgery,
trauma and acute illnesstrauma and acute illness

18. ACUTE PAINACUTE PAIN
 Pain acts as a warningPain acts as a warning
of potential damageof potential damage

19. ACUTE PAINACUTE PAIN
 Pain is well localizedPain is well localized
 Pain is transientPain is transient
Features:Features:
• intact nervous systemintact nervous system
• increased autonomic responseincreased autonomic response

20. ACUTE PAINACUTE PAIN
 PainPain (A delta and C fibers)(A delta and C fibers) can becan be
differentiated from touchdifferentiated from touch (A beta fibers)(A beta fibers)

21. CHRONIC PAINCHRONIC PAIN
 Pain that persistsPain that persists
beyond expectedbeyond expected
healing periodshealing periods
 no clearly identifiableno clearly identifiable
causecause

22. CHRONIC PAINCHRONIC PAIN
 Clinical painClinical pain
(pain is disease itself)(pain is disease itself)
 Depression/anxiety
 Vegetative signs

23. CHRONIC PAINCHRONIC PAIN
• Pain can be elicited by A delta, C fibersPain can be elicited by A delta, C fibers andand
A beta fibersA beta fibers

24.  No definite timeNo definite time
 It’s aIt’s a spectrumspectrum
of eventsof events
When does acute painWhen does acute pain
become chronic pain?become chronic pain?

25. NeuroplasticityNeuroplasticity
 Morphological changes in cellular levelMorphological changes in cellular level
 Altered gene expressionAltered gene expression
 Functional changesFunctional changes –– rewiring, sympatheticrewiring, sympathetic
involvementinvolvement
 Structural changes:Structural changes: “sprouting”“sprouting”
 AA ββ fiber (allodynia)fiber (allodynia)
 Altered modulation -Altered modulation - ↓↓ inhibitoryinhibitory
-- ↑↑ excitatoryexcitatory
 Altered pain perception/interpretation inAltered pain perception/interpretation in
sensory cortex, limbic systemsensory cortex, limbic system

26. SOMATIC PAINSOMATIC PAIN
 Pain from primary afferentPain from primary afferent
nerves in somatic tissuesnerves in somatic tissues
(skin, muscle, bone,(skin, muscle, bone,
connective tissues)connective tissues)
 Involves A deltaInvolves A delta (fast pain)(fast pain)
and C fibersand C fibers (slow pain)(slow pain)
 May be acute or chronicMay be acute or chronic

27. SOMATIC PAIN (CUTANEOUS)SOMATIC PAIN (CUTANEOUS)
 Pain derived from skin,Pain derived from skin,
subcutaneous tissue, andsubcutaneous tissue, and
mucous membranemucous membrane
 Localized, sharp, pricking,Localized, sharp, pricking,
burning, throbbing,burning, throbbing,
stabbingstabbing
 Follows dermatomesFollows dermatomes

28. SOMATIC PAIN (DEEP)SOMATIC PAIN (DEEP)
 Pain derived fromPain derived from
muscles, tendons, joints,muscles, tendons, joints,
and bonesand bones
 Less localized,Less localized,
sharp/dull, achingsharp/dull, aching
 Follows myotomes andFollows myotomes and
sclerotomessclerotomes

29. VISCERAL PAINVISCERAL PAIN
 Pain from afferent nerves inPain from afferent nerves in
thoracic, abdominal, and pelvicthoracic, abdominal, and pelvic
visceraviscera
 Involves sympathetic andInvolves sympathetic and
parasympathetic afferent fibersparasympathetic afferent fibers
 May be acute, chronic, orMay be acute, chronic, or
recurrentrecurrent

30. VISCERAL PAIN (TRUE)VISCERAL PAIN (TRUE)
 MidlineMidline
 Occurs early in the diseaseOccurs early in the disease
 Vague, poorly localized,Vague, poorly localized,
dull, achingdull, aching
 Marked autonomicMarked autonomic
phenomenaphenomena

31. VISCERAL PAINVISCERAL PAIN
(REFERRED)(REFERRED)
ViscerotomesViscerotomes

32. VISCERAL PAINVISCERAL PAIN
(REFERRED)(REFERRED)
Viscero-somatic convergenceViscero-somatic convergence

33. VISCERAL PAINVISCERAL PAIN
(PARIETAL)(PARIETAL)
 Pleura or peritoneumPleura or peritoneum
 Localized, sharp,Localized, sharp,
stabbing, lancinatingstabbing, lancinating
 Hyperalgesia,Hyperalgesia,
 skeletal muscle spasmskeletal muscle spasm
 sympatheticsympathetic
hyperactivityhyperactivity

34. NEUROPATHIC PAINNEUROPATHIC PAIN
 Pain from aberrantPain from aberrant
somatosensory processingsomatosensory processing
in the peripheral or centralin the peripheral or central
nervous systemnervous system
 Related to nerve injuryRelated to nerve injury

35. NEUROPATHIC PAINNEUROPATHIC PAIN
 Dysesthesia:Dysesthesia: abnormal pain complaintabnormal pain complaint
– Burning, shooting, shock-like, lancinating,Burning, shooting, shock-like, lancinating,
numbing, heavynumbing, heavy
 Allodynia:Allodynia: pain from a stimulus that does notpain from a stimulus that does not
normally evoke painnormally evoke pain
 Hyperalgesia:Hyperalgesia: an increased response to aan increased response to a
stimulus that is normally painfulstimulus that is normally painful

36. Neuropathic pain
Predominantly “central”
pain generator
Predominantly
“peripheral”
pain generator
Deafferentation pain
Sympathetically-
maintained
pain
Mononeuropathies
Lancinating neuralgias
Nerve compression or
inflammation
Nerve transection
Polyneuropathies

37. NEUROPATHIC PAINNEUROPATHIC PAIN
Post-mastectomy Pain SyndromePost-mastectomy Pain Syndrome

38. NEUROPATHIC PAINNEUROPATHIC PAIN
Epidural Spinal Cord CompressionEpidural Spinal Cord Compression
metastasis

39. NEUROPATHIC PAINNEUROPATHIC PAIN
Brachial PlexopathyBrachial Plexopathy

40. PSYCHOGENIC PAINPSYCHOGENIC PAIN
 Pain in one or more sites that is thePain in one or more sites that is the
predominant focus of clinical attention,predominant focus of clinical attention,
which is notwhich is not fullyfully accounted for by aaccounted for by a
nonpsychiatric medical or neurologicalnonpsychiatric medical or neurological
conditioncondition
 Associated with emotional distress andAssociated with emotional distress and
functional impairmentfunctional impairment

41. SystemSystem
AffectedAffected
Mechanism ofMechanism of
EffectEffect
Clinical EffectClinical Effect
RespiratoryRespiratory Increased muscle tensionIncreased muscle tension
Decreased lung complianceDecreased lung compliance
Hypoxemia, hypercapnia,Hypoxemia, hypercapnia,
perfusion problems,perfusion problems,
atelectasisatelectasis
EndocrineEndocrine Increased ACTH/epinephrineIncreased ACTH/epinephrine
Decreased insulinDecreased insulin
concentrationsconcentrations
Protein catabolism,Protein catabolism,
hyperglycemiahyperglycemia
CardiovascularCardiovascular Increased myocardial workIncreased myocardial work Arrhythmias, angina,Arrhythmias, angina,
myocardial infarction, CHFmyocardial infarction, CHF
Physiologic Effects of PainPhysiologic Effects of Pain

42. SystemSystem
AffectedAffected
Mechanism ofMechanism of
EffectEffect
Clinical EffectClinical Effect
ImmunologicalImmunological Depression of immune cellDepression of immune cell
productionproduction
Decreased immune functionDecreased immune function
GenitourinaryGenitourinary Increased sphincterIncreased sphincter
tone/decreased muscle tonetone/decreased muscle tone
Urinary retentionUrinary retention
GastrointestinalGastrointestinal Increased sphincterIncreased sphincter
tone/decreased muscle tonetone/decreased muscle tone
IleusIleus
Physiologic Effects of PainPhysiologic Effects of Pain

43. ANXIETY
SLEEPLESSNESS PAIN ANGER
DEPRESSION
PSYCHOLOGICAL VISCIOUS CYCLE

44. Advantages of EffectiveAdvantages of Effective
Pain ManagementPain Management
 Patient comfort andPatient comfort and
satisfactionsatisfaction1,2,31,2,3
 Earlier mobilizationEarlier mobilization44
 ↓↓ hospital stayhospital stay3,43,4
 ↓↓ costscosts44
1. Eisenach JC, et al. Anesthesiology. 1988;68:444–448.
2. Harrison DM, et al. Anesthesiology. 1988;68:454–457.
3. Miaskowski C, et al. Pain. 1999;80:23–29.
4. Finley RJ, et al. Pain. 1984;2:S397.

45. JCAHO Revised Standards:JCAHO Revised Standards:
The Patient’s RightsThe Patient’s Rights
 Patients have the right to appropriatePatients have the right to appropriate
assessment and management of pain.assessment and management of pain.
 The patient’s right to pain management isThe patient’s right to pain management is
respected and supported.respected and supported.
 Patients are involved in all aspects of theirPatients are involved in all aspects of their
care, including pain management.care, including pain management.
Joint Commission on Accreditation of
Healthcare Organizations. 1999

46. Assessment andAssessment and
EducationEducation
Are the Keys to ProperAre the Keys to Proper
Pain ManagementPain Management

47. Pain: ThePain: The 5th5th Vital SignVital Sign
1.1. TemperatureTemperature
2.2. Blood PressureBlood Pressure
3.3. PulsePulse
4.4. Respiratory RateRespiratory Rate
American Pain Society. 1998
5. Pain Assessment5. Pain Assessment

48. Patient’s Perception of PainPatient’s Perception of Pain
Pain is subjective and may bePain is subjective and may be
influenced by:influenced by:
 AgeAge
 GenderGender
 CultureCulture
 Communication/languageCommunication/language
skillsskills
 Previous experiencePrevious experience

49.  
ComponentsComponents
MeasurementMeasurement
1. Physiologic Physiologic1. Physiologic Physiologic
techniquestechniques
2. Behavioral2. Behavioral BehavioralBehavioral
observationobservation
3. Cognitive3. Cognitive Self-reportSelf-report
PAINPAIN

50. SELF-REPORT SCALESSELF-REPORT SCALES
““GOLD STANDARD”GOLD STANDARD”
Manne et al Pain 1992Manne et al Pain 1992
McGrath et al Pain 1996McGrath et al Pain 1996
Chambers et al Pain 1999Chambers et al Pain 1999
Soetenga et al Pediatric Nursing 1999Soetenga et al Pediatric Nursing 1999
Voepel-Lewis et al Anesthesia and Analgesia 2002Voepel-Lewis et al Anesthesia and Analgesia 2002
Willis et al Pediatric Nursing 2003Willis et al Pediatric Nursing 2003

51. Categorical ScaleCategorical Scale
 No painNo pain “walang kirot”“walang kirot”
 Mild painMild pain “konting kirot”“konting kirot”
 Moderate painModerate pain “katamtamang kirot”“katamtamang kirot”
 Severe painSevere pain “malubhang kirot”“malubhang kirot”

52. Visual Analogue Scale (VAS)Visual Analogue Scale (VAS)

53. Numeric Pain Intensity ScaleNumeric Pain Intensity Scale

54. Wong-Baker FACES ScaleWong-Baker FACES Scale

55. Faces Pain Scale - RevisedFaces Pain Scale - Revised
0 2 4 6 8 10

56. OUCHER (African American version)OUCHER (African American version)

57. FLACC Behavioral ScaleFLACC Behavioral Scale
PARAMETERPARAMETER 00 11 22
FACEFACE no particularno particular
expression or smileexpression or smile
occasional grimaceoccasional grimace
or frown;or frown;
disinteresteddisinterested
frequent to constantfrequent to constant
quivering chin;quivering chin;
clenched jawclenched jaw
LEGSLEGS normal position ornormal position or
relaxedrelaxed
uneasy; restless;uneasy; restless;
tensetense
kicking or legskicking or legs
drawn updrawn up
ACTIVITYACTIVITY lying quietly; normallying quietly; normal
position; movesposition; moves
easilyeasily
squirming; shiftingsquirming; shifting
back and forth;back and forth;
tensetense
arched; rigid orarched; rigid or
jerkingjerking
CRYCRY no cryno cry
(awake or asleep)(awake or asleep)
moans or whimpers;moans or whimpers;
occasionaloccasional
complaintscomplaints
crying steadily;crying steadily;
screams or sobs;screams or sobs;
frequent complaintsfrequent complaints
CONSOLABILITYCONSOLABILITY content, relaxedcontent, relaxed reassured byreassured by
occasional touchingoccasional touching
hugging or beinghugging or being
talked to;talked to;
distractabledistractable
difficult to console ordifficult to console or
comfortcomfort

58. Taking the Pain HistoryTaking the Pain History
OLD CART :OLD CART :
O – onsetO – onset
L – locationL – location
D – durationD – duration
C - characteristicC - characteristic
A – aggravating factorsA – aggravating factors
R – relieving factorsR – relieving factors
T – therapies triedT – therapies tried

59. WHO Analgesic LadderWHO Analgesic Ladder
1
2
3
Freedom from
cancer pain
Opioid for moderate
to severe pain
± Non-opioid
± Adjuvant
Opioid for mild to
moderate pain
± Non-opioid
± Adjuvant
Pain persisting
or increasing
Non-opioid
± Adjuvant
Pain persisting
or increasing

60. WHO RecommendationsWHO Recommendations
 By the mouthBy the mouth
 By the clockBy the clock
 By the ladderBy the ladder
 For the individualFor the individual
 With attention to detailsWith attention to details

61. Multimodal AnalgesiaMultimodal Analgesia
 Reduced doses of eachReduced doses of each
analgesicanalgesic
 ImprovedImproved
antinociceptionantinociception
due todue to
synergistic/additivesynergistic/additive
effectseffects
 May reduce severity ofMay reduce severity of
side effects of eachside effects of each
drugdrug
MorphineMorphine
NSAIDs,NSAIDs,
acetaminophen,acetaminophen,
nerve blocksnerve blocks
PotentiationPotentiation

62. Nonsteroidal Anti-Inflammatory DrugsNonsteroidal Anti-Inflammatory Drugs
(NSAIDs)(NSAIDs)
 Decrease levels of inflammatory mediators byDecrease levels of inflammatory mediators by
inhibiting the enzymeinhibiting the enzyme cyclooxygenasecyclooxygenase, which, which
catalyzes the conversion of arachidonic acid tocatalyzes the conversion of arachidonic acid to
prostaglandins and leukotrienesprostaglandins and leukotrienes
 NSAIDs have aNSAIDs have a ceiling effectceiling effect on their analgesicon their analgesic
potentialpotential
 Antipyretic and anti-inflammatory effectAntipyretic and anti-inflammatory effect

63. NSAIDsNSAIDs
– Acetaminophen/Paracetamol 650 mgAcetaminophen/Paracetamol 650 mg
q4H orq4H or
– Aspirin 650 mg q4H orAspirin 650 mg q4H or
– Ketorolac 30 mg PO/IV q6-8H orKetorolac 30 mg PO/IV q6-8H or
– Ketoprofen 100 mg PO/IV q8-q12H orKetoprofen 100 mg PO/IV q8-q12H or
– Ibuprofen 400-800 mg q6-q8H orIbuprofen 400-800 mg q6-q8H or
– Naproxen 250-500 mg q12H orNaproxen 250-500 mg q12H or

64. NSAIDsNSAIDs
– Meloxicam* 7.5-15 mg OD orMeloxicam* 7.5-15 mg OD or
– Nimesulide * 100-200 mg BID orNimesulide * 100-200 mg BID or
– Valdecoxib* 40 mg PO/IV OD-BID orValdecoxib* 40 mg PO/IV OD-BID or
– Etoricoxib* 90 mg BID or 120 mg OD orEtoricoxib* 90 mg BID or 120 mg OD or
– Celecoxib* 200 mg BIDCelecoxib* 200 mg BID
*COX-2 specific*COX-2 specific

65. OpioidsOpioids
 analgesia by binding to specific receptorsanalgesia by binding to specific receptors
both within and outside the CNSboth within and outside the CNS
 morphine, codeine, oxycodone, andmorphine, codeine, oxycodone, and
fentanyl, tramadolfentanyl, tramadol
 Morphine is the most commonly usedMorphine is the most commonly used
opioid for moderate to severe painopioid for moderate to severe pain

66. Weak OpioidsWeak Opioids
– Tramadol 50-100 mg immediate releaseTramadol 50-100 mg immediate release
tablet/capsules q4-6Htablet/capsules q4-6H
– Tramadol 100, 150, and 200 mgTramadol 100, 150, and 200 mg
sustained release tablet form q8-12Hsustained release tablet form q8-12H
– Tramadol 50-100 mg IV q4-8HTramadol 50-100 mg IV q4-8H
 Note: Maximum daily dose: 600 mgNote: Maximum daily dose: 600 mg

67. Strong OpioidsStrong Opioids
opioidopioid parenteraparentera
ll
oraloral
agonistagonist morphinemorphine 10 mg10 mg 30 mg30 mg
pethidinepethidine 100 mg100 mg 300 mg300 mg
oxycodoneoxycodone 15 mg15 mg 20-30 mg20-30 mg
fentanylfentanyl 100 ug100 ug NANA
partialpartial
agonistagonist
nalbuphinenalbuphine 10 mg10 mg

68. Adjuvant DrugsAdjuvant Drugs
 Tricyclic antidepressantTricyclic antidepressant
– ImipramineImipramine 25-50 mg tab at bedtime25-50 mg tab at bedtime
 AnticonvulsantsAnticonvulsants
– CarbamazepineCarbamazepine 200 mg tab BID200 mg tab BID
(max: 1,200 mg/day)(max: 1,200 mg/day)
- GabapentinGabapentin 100 mg cap TID100 mg cap TID
(max: 3,600 mg/day)(max: 3,600 mg/day)

69. Adjuvant DrugsAdjuvant Drugs
 CorticosteroidsCorticosteroids
– DexamethasoneDexamethasone
 Local anestheticsLocal anesthetics
– Lidocaine patchLidocaine patch
 KetamineKetamine
– Subanesthetic dosesSubanesthetic doses
– N-methyl-d-aspartate (NMDA)N-methyl-d-aspartate (NMDA)
receptor blocker in the dorsal hornreceptor blocker in the dorsal horn

70. Interventional TechniquesInterventional Techniques
 Epidural and intrathecal drugEpidural and intrathecal drug
delivery systemsdelivery systems
 Neural BlockadeNeural Blockade
 CordotomyCordotomy

71. RadiotherapyRadiotherapy
 for painful bone metastasesfor painful bone metastases
 Radioactive strontiumRadioactive strontium should beshould be
considered for the management of painconsidered for the management of pain
due to widespread bone metastases fromdue to widespread bone metastases from
prostatic carcinoma.prostatic carcinoma.

72. Nonpharmacologic TreatmentNonpharmacologic Treatment
Cognitive-BehavioralCognitive-Behavioral
 RelaxationRelaxation
 Preparatory informationPreparatory information
 ImageryImagery
 HypnosisHypnosis
 BiofeedbackBiofeedback

73. Nonpharmacologic TreatmentNonpharmacologic Treatment
Physical AgentsPhysical Agents
 Application of superficial heat and coldApplication of superficial heat and cold
 MassageMassage
 ExerciseExercise
 Immobilization (eg, to provide rest andImmobilization (eg, to provide rest and
maintain alignment after musculoskeletalmaintain alignment after musculoskeletal
procedures)procedures)

74. Nonpharmacologic TreatmentNonpharmacologic Treatment
 Electroanalgesia (eg, TENS)Electroanalgesia (eg, TENS)
 Chiropractic techniquesChiropractic techniques
 AcupunctureAcupuncture

75. Thank YouThank You