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Pain Management: Its various aspects


GlobalRPh Student writer. Update in progress.

Pain management is an extremely important part of the process for the relief of chronic pain. The field or branch of pain management reduces pain and enhances the life of the patient through the use of a multi-tiered approach.

Pains effects on your mind and emotions (PIS)

Whenever there is pain, a person has a certain mental reaction as well as an emotional reaction. Dalhousie University’s Michael J. L. Sullivan and Scott R. Bishop developed a Pain Intensity Scale. Its purpose was to resolve the debate of what chronic pain does to the mind, the emotions and the body. There are 13 items in the PIS, and 3 subscales, namely pain intensity, effects on the mind and effects on the emotions. It is a perfect tool for identifying a reliable chronic pain scale in the clinical as well as non-clinical populations.

Uses of the Pain Scale:

In clinical and nonclinical cases, this scale helps healthcare providers identify the intensity of the pain of the patient and provide proper tools to help relieve their everyday pain. This is possible through better comprehension of the patient’s pain. The PIS helps determine which patients will have a more severe perception of their pain, as well as which patients will have a more severe reaction emotionally and mentally to pain. In other words, this determines a patient’s pain threshold. Each person has a physical as well as an innate mental reaction to pain. Some people feel pain more strongly than other people would and this is the patient’s pain threshold. The health provider has to determine what each person can and can not tolerate physically, mentally, and emotionally, and give the patient the proper tools determined for that specific patient. 

Guidelines for effective pain management:

Here are some guidelines and information needed by the health care provider that will help to determine the course of treatment for the patient. 1. The intensity of pain  2. Area of the body where the pain is the greatest. 3. What the patient does at home to help with the pain i.e. heat, ice, massage, etc. 4. Determine what the patient might do at home to manifest the pain and the intensity of the pain. 5. Determine when the pain started, especially for chronic pain patients. As in how many days, months or years.

Risks associated with pain management:

Some of the risks that can occur in pain management are listed below:

  1. It may not be enough to have only one treatment option. Most chronic pain patient’s need a multitude of different treatments to control their pain.
  2. Excessive use of opioids can cause problems. If the patient is well educated by their health care provider on how to use these medications properly, there is no reason not to use this method as part of their treatment plan. Given the proper dose and an educated patient should resolve any problems of the chance of an overdose.  Physicians and pain management physicians need to realize that medications are part of the overall treatment of chronic pain. They need to stop withholding these medications because they are afraid of the recent outcry of people overdosing on opioid medications. These are not ordinary people as they would have you believe who is overdosing, these are people with a drug abuse problem. If properly educated by their physician or pain management physician there should be no chance of an overdose. If a physician has a new patient, the physician needs to assess if this patient has a drug abuse problem through a series of questions and observations. A highly educated physician should be able to tell if there is a problem with giving a new patient opioids or not. They are hurting people of all ages by withholding these medications. This goes hand in hand with their treatment plan. Take away a part of their treatment plan, then the treatment plan will not work properly.   

Medications for various levels of pain:

The medication for managing pain varies with intensity. 

1. Mild pain:

Use Tylenol or an NSAID such as Ibuprofen.

2. Moderate pain:

This requires a combination of Tylenol and some weak opioids like Tradamol, Codeine, Hydrocodone, Percocet, Norco, or Vicodin.

3. Severe pain:

In cases of acute pain from an accident i.e. broken leg or pain occurring after an operation. Medications used for these conditions are listed below.

  • Hydromorphone (Dilaudid), Oxymorphone (Numorphan, Opana), are some of the Morphine’s semi-synthetic derivatives.
  • Fentanyl is another pain medication that has fewer side effects. It is because the histamine release of this drug is low. A transdermal patch of this drug is useful for chronic pain management. It has 2 FDA approved versions. One is a spinal patch  and the other one is Sublimaze, which is an injectable drug. These are beneficial for breakthrough pain in cancer patients.
  • In America and Europe, Oxycodone is the drug for managing chronic pain. OxyContin is its slow-release formula. There are also capsules, syrup, ampules, and short-acting tablets of Oxycodone that are quite beneficial for breakthrough or acute pain.

Other categories of pain medications:

Here are some other pain medication classifications:

1. Opioids:

When the opioid analgesics are taken as per prescription and are managed well, it becomes safe as well as effective in reducing the pain, without the risk of addiction. Depending on the medication formula as well as specific characteristics, such medications can ensure short term, intermediate-term as well as long term analgesia. Their mode of administration can be oral, or injectable through nasal mucosa or oral mucosa. Rectal, transdermal, intravenous, epidural and intrathecal are other modes of application of the drug. OxyContin, Exalgo and Methadone are certain long-acting medications that are prescribed along with certain short-acting drugs. Like Morphine, Hydromorphone, and Oxycodone. These are recommended:
oxycodone pain management

Their long term use can lead to chemical dependency, tolerance to the drug, as well as chances of addiction. Patients having a history of substance abuse can be at such risk. So the health care provider needs to assess this before prescribing it. They also need to check if the patient is undergoing Therapy for drug abuse. Along with this, consistent monitoring of the patient ensures that the opioid is effective in the goal achievement of pain reduction.

2.NSAID or nonsteroidal anti-inflammatory drugs

Aspirin, Ibuprofen, and Naproxen are some of the common NSAIDs that doctors prescribe. This category of analgesics operates by causing the release of the prostaglandins to be reduced, which are responsible for inflammatory pain.
Tylenol doesn’t always fall under this classification and can be used singly or with NSAIDs and opioids. Ketoprofen and Piroxicam are the NSAIDs that are somewhat useful in chronic pain disorders but have various side effects.

3. Antidepressants and antiepileptics

Such drugs are known to operate through peripheral mechanisms as well as in the pain pathways of the central nervous system. They are beneficial for the treatment of disorders associated with neuropathic pain. The use of antidepressants can be very beneficial. Studies have shown that people with chronic pain are more stressed and depressed than people without chronic pain. By giving antidepressants the patient often feels less overall pain and now has a greater tolerance for pain.

.4 Cannabinoids

A study conducted in Canada demonstrated 84% of the participants using medical marijuana experienced pain reduction. Institute of Medicine’s detailed report in 1999 also tells that cannabinoids have an analgesic impact. Similarly, the Fundamental & Clinical Pharmacology’s study in 2013 showed that these are better than opioids in case of chronic pain.

5. Other analgesics:

There are medications known as analgesic adjuvants which help in managing different kinds of pain. Doctors prescribe certain drugs having anticholinergic properties with muscle relaxants to treat musculoskeletal pains. They are also efficient in enhancing the effect of opioids.

Methods of pain management in children:

Children experience injury, illness, and undergo certain medical procedures, in which case their need for pain control is important. Children are harder to determine which medication to use and how much to use. Children experience pain differently then adults do. They find it harder to cope with pain because they haven’t experienced it as much as an adult has. Children need to be carefully dosed on their medication. It is easy to give a child too much medication. Start out slowly and increase in small intervals. Until pain control is achieved. 

1. Assessing the pain:

This is the toughest task as children have less ability to express how much pain they are in. So in such situations, you need to ask the child a number of questions to try and determine the amount of pain they are in. If the child will not answer or can’t express how much pain they have then you have to determine yourself if you need to take your child to the emergency room. If you feel they are in great pain immediately take them to the emergency room.

2. Providing non-pharmacologic treatment:

Accessing a child’s pain is the hardest part of pain management for children. Unlike the pharmacological method. It is different for children of different ages to obtain proper pain management and effective pain relief because of different developmental stages. In the case of infants, swaddling, rocking, or providing sucrose through a pacifier are the physical interventions to reduce pain. Similarly, massage, hot or cold applications and acupuncture help in pain reduction in both children and adolescents.

Cognitive Behavioral Therapy is also a way to learn skills to cope with chronic pain in adults, adolescents and children.
This enhances the everyday functioning of the children and adolescents suffering from pain. Caregivers attend the sessions conducted by therapists to help them learn the strategies for pain management. This method concentrates on altering their thought and emotion patterns and teaches them tactics for adaptive coping. Biofeedback, mindfulness, acceptance, and methods of relaxation are the integrated interventions that Cognitive Behavioral Therapy makes use of.

3. Pharmacologic treatment method:

Pediatricians generally recommend that children, as well as adolescents, experiencing acute pain symptoms use certain nonsteroidal anti-inflammatory agents, opioid analgesics or Acetaminophen.

Pain management team:

In order to alleviate the pain effectively, members from various fields add to the overall treatment of the patient. Using a team approach for each patient to cover all areas of chronic pain management greatly helps with the overall pain. This includes physiotherapists, mental health specialists, occupational therapists, physician assistants, massage therapists, nurses, medical practitioners, pharmacists, and clinical psychologists. Their treatment methods include the use of home health care processes
. Like the use of ice or heat or a combination of the two. Physical therapy also plays a large role in helping the patient with chronic pain. Giving them exercises and tools to use at home on a daily basis to help reduce the pain. Providing help even occurs by providing biofeedback, cognitive behavioral therapy, providing patients with analgesics, antidepressants, and anti-convulsants.

The need for certified pain physicians:

There has been a significant rise in demand in the pain management field. Which is why numerous practitioners have entered into it. This also includes those who are non-ACGME board-certified. The fellowship-trained physiatrists, anesthesiologists, psychiatrists or neurologists who received board certification can be pain specialists. There are certain boards that give sub-specialty certification to qualified candidates in pain medication. This occurs after the completion of ABMS(American Board of Medical Specialties) or AOABOS(American Osteopathic Association Bureau of Osteopathic Specialists) recognized fellowship training. Here are the boards which provide subspecialty certification in pain management:

  • American Board of Anesthesiology
  • The AOABOS recognized American Osteopathic Board of Anesthesiology
  • The American Board of Physical Medicine and Rehabilitation
  • The American Board of Psychiatry and Neurology

In summary if done properly. With various methods of treatment and with a team approach. Utilizing several different fields of specialty. Chronic pain can be if not cured, at least controlled.

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