Volume 23, Number 7: July 2022

On June 21, the International Association of Hospice and Palliative Care launched the first of 10 modules of its Comprehensive Pain Assessment and Management Course, free to members, intended for pharmaceutical, medical, and nursing professionals.

An Overview of Principles of Pain & Pain Management: The first 3 modules of the IAHPC course on pain

By Alison Ramsey
IAHPC Newsletter Editor

Dr. Lukas Radbruch begins the course with a definition of pain that has held for more than 50 years, with little change: Pain is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.

The patient “can be lying in bed, looking pretty relaxed, and it’s hard to believe they’re in pain, but the pain they say they have should be respected.” Even if no nociceptors are aroused, people can still feel pain, he said, as it is influenced not strictly by biological factors, but also psychological, social, and spiritual factors.

Radbruch cites a 2020 survey that reported pain felt by people in their last year of life was widespread and persistent.

How chronic & acute pain differ

Acute pain has an important function as a warning instrument, provoking people to rest or seek medical help. But “once it becomes chronic,” said Dr. Radbruch, “the pain is only burdensome.”

“With chronic pain, the pain response gets bigger within seconds of repetitive stimulation of a nerve. If it continues, the nerve ending becomes more sensitized, and the feeling is more intense. You can feel this easily if you cut yourself when, hours later, that tissue will be much more sensitive to touch.”

Pain types & diagnosis

Pain can be nociceptive: bone (exacerbated by movement), soft tissue (more severe when touched), or visceral (not easy to localize: it may be a constant and dull). Pain can also be neuropathic: peripheral (burning) or central (shooting).

As with other diseases, pain diagnoses require information: its location, origin, type, and intensity.

“The easiest way to know the intensity is a verbal rating scale. I like this one best: No pain, Slight pain, Moderate pain, Severe pain. If it’s severe or moderate, you definitely have to treat them or, in the case of moderate pain, discuss it with the patient.” To discern the pain level of someone with dementia, look for clues, such as perspiration or defensive movements.

Pain management guidelines

The World Health Organization’s 1986 guidelines for Cancer Pain Relief are still very effective, said Dr. Radbruch. In short:

• do not use an invasive application if you can use an oral route;
• give pain medicine regularly, not just prn (as needed);
• use an analgesic ladder with several steps; and
• pay attention to detail throughout, including the patient’s preferences.

Up & down the analgesic ladder

For chronic pain, start with non-opioids. For acute pain, an inverted analgesic ladder is warranted: start with opioids. A major medical mistake is writing 30-day prescriptions for post-surgery pain, says Dr. Radbruch: assess pain daily and give no more than necessary.

“The main goal is not to get them pain-free, but show if they start working again, getting active, they will have a better life.”

Essential pain medicines

Dr. Radbruch prioritized these analgesics on the WHO list of essentials: morphine, ibuprofen (e.g., Advil/Motrin), paracetamol (e.g., Tylenol/Panadol), fentanyl, and methadone. He then discussed each one.

• Ibuprofen. A strong anti-inflammatory, can be used 3x daily, 400-800 mg for a good effect. Prolonged use (10 years+) leads to renal impairment.
• Paracetamol. 500-1,000 mg can be used 5-6x daily. Liver failure is risked with larger doses.
• Avoid costly COX-2 selective NSAIDs, which retain renal side effects.
• Co-analgesics include antidepressants, anticonvulsants, steroids, and bisphosphonates.
• Cannabinoids. “My baseline conclusion is that they’re pretty lousy analgesics,” and often discontinued due to unwelcome side effects. However, it may help habitual users relax and disconnect from their pain.
• Methadone offers excellent pain control and rivaled morphine for gold standard status, but morphine won out for being more widely available globally.

New developments

In a nutshell: “there’s not much” that is new, said Dr. Radbruch. The good news is that oral and transdermal medicines have effectively allowed doctors to abandon more invasive techniques, such as nerve blocks.

Opioids: Highly effective pain control

Thanks to her rapid speaking style, Dr. Sammi Ahmed, a pharmacist specializing in palliative care, covers a vast amount of information in the first of her two presentations on opioid therapies. She begins by noting that doctors often give precedence to treating the disease instead of the pain it causes. The unhelpful reputation of opioids as “bad” and severe legal restrictions or lack of access in some countries exacerbates their underuse.

Advantages/disadvantages of each form

After identifying the categories (short acting and long acting) and chemical classes of opioids, Dr. Ahmed details the advantages and disadvantages of each form—oral, intravenous, intramuscular, subcutaneous, rectal, buccal, and, in the case of fentanyl, the patch—including when and for whom each works best.

Long-acting forms are well-suited to chronic pain, she said. Physicians “don’t have to chase the pain. It’s under control so that people can enjoy a better quality of life.”

She noted that fentanyl is suited for chronic and long-lasting pain, but is much more expensive than morphine and should never be used for acute pain. The patch needs a fatty body part for proper absorption, making it a poor choice for patients with cachexia. Absorption improves if heated, so never apply it to the posterior and be careful if a patient develops a fever, takes hot baths, is exposed to a hot sun, or if a heat blanket is used.

Methadone: Fantastic, but with caveats

Methadone is “a fantastic, fantastic drug, but you need to understand it.” Though best known as a treatment for opioid use disorder, methadone for pain “is efficacious, of long duration, and extremely cheap.”

Physicians must be aware, however, that it takes five to seven days after initiation of a dose to know its effectiveness, because the lipophilic medicine “hides” in tissue then is slowly released. So, unlike morphine, it is not useful for acute pain. There is also a potential risk of serious drug interactions, so a pharmacist should be consulted. As with each form of opioid, Dr. Ahmed outlines its most useful applications: such as those with a morphine allergy, refractory pain despite opioids, and significant renal issues.

She concludes the presentation by discussing opioids and physical dependence, tolerance, pseudoaddiction, and addiction. Each patient, she said, should be evaluated for their particular risks and benefits.

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