1. ESSENTIAL PAIN MANAGEMENT CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License.

2. EPM Aims • To improve understanding of pain • To teach a simple framework for managing pain • To reduce pain management barriers

3. Workshop Plan 1 • Pain basics • What is pain? • Why should we treat pain? • Classification of pain • Physiology and pathology • Pain treatment • Barriers to treatment

4. Workshop Plan 2 • Practical pain management • Case discussions • Overcoming barriers

5. Untreated Pain

6. Untreated Pain • Often hidden (not recognized) • Causes a lot of suffering • But … can often be treated simply and cheaply

7. Approach to Pain • Recognize • Assess • Treat

8. Approach to PainR • Recognize • Does the patient have pain? • Do other people know the patient has pain?

9. Approach to PainA • Assess • How severe is the pain? • What type of pain is it? • Are there other factors?

10. Approach to PainT • Treat • What non-drug treatments can I use? • What drug treatments can I use?

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12. IntroductionSummary • At the end of this course, you will be able to: • Understand the importance of treating pain • Recognize, assess and treat different types of pain • Identify and address barriers where you work

13. What is Pain? CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License.

14. What is Pain?Aims • To define pain • To give examples of pain

15. What is Pain? • Group discussion • Think of a patient / friend / relative who had pain. • How did the person describe the pain? • How was it treated?

16. What is Pain? • International Association for the Study of Pain • Pain is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. • What does this mean? • Are there any other definitions?

17. What is Pain? • Unpleasant • Emotions are important • The cause is not always visible • “Pain is what the patient says hurts.”

18. Is this man feeling pain?

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20. What is Pain?Summary • Pain is an unpleasant sensory and emotional experience • Pain is what the patient says hurts!

21. Why Should We Treat Pain? CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License.

22. Why Should We Treat Pain?Aims • To understand the reasons for treating pain • To understand the benefits for the patient, family and society

23. Case 1 • Mr T is a 29-year-old man with a fast growing mouth cancer that has spread to his bones. He has severe face pain. He is expected to die within 6 months and the surgeons do not want to operate. He is married with two children, aged 11 and 8 • Why should we treat his pain?

24. Case 2 • Mrs G is a 54-year-old woman who has just had a laparotomy for bowel obstruction. You see her on the surgical ward soon after the operation. She appears to be in pain. • Why should we treat her pain?

25. Why Pain Matters • For the patient • Physical • Suffering, poor sleep, decreased appetite • Medical complications (e.g. heart attack, pneumonia) • Psychological • Depression, anxiety

26. Why Pain Matters • For the family • Unable to function as part of the family (e.g. as a father / mother) • Lost income • For society • Greater health costs (e.g. delayed hospital discharge) • Unable to contribute to the community

27. Painful SCC (xeroderma pigmentosum)

28. Advantages of Treating Pain • For the patient • Fewer physical and psychological problems • Greater dignity (esp. cancer pain) • For the family • Able to function as part of the family • Able to provide for family • For society • Lower health costs

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30. Why Should We Treat Pain?Summary • Treating pain is the “humane” thing to do! • Treating pain has many benefits • For the patient • For the family • For society

31. Classification of Pain CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License.

32. Classification of PainAims • To classify types of pain • To understand that treatment depends on the pain type

33. Classification of Pain • Not all pain is the same! • Three main questions: • How long has the patient had pain? • What is the cause? • What is the pain mechanism?

34. Classification of Pain

35. Acute versus Chronic • Acute • Pain of recent onset and probable limited duration • Chronic • Pain persisting beyond healing of injury • Often no identifiable cause • (Pain lasting for more than 3 months)

36. Cancer versus Non-Cancer • Cancer pain • Progressive • May be mixture of acute and chronic • Non-cancer pain • Many different causes • Acute or chronic Can you give examples?

37. Invasive oral cancer

38. Nociceptive Pain • Obvious tissue injury or illness • “Physiological pain” • Description • Sharp ± dull • Well localised Can you give examples?

39. Neuropathic Pain • Nervous system damage or abnormality • “Pathological pain” • Tissue injury may not be obvious • Description • Burning, shooting ± numbness, pins and needles • Not well localised Can you give examples?

40. Examples of Pain Types

41. Acute Non-Cancer Pain • Examples • Fracture, appendicitis • Symptom of tissue injury or illness • Useful • Usually nociceptive • Occasionally neuropathic (e.g. sciatica)

42. Chronic Non-Cancer Pain • Examples • Headache, back pain • Usually no obvious injury • Not useful • Complex, may be mixed nociceptive and neuropathic • Does not respond to usual drug treatment

43. Cancer Pain • Examples • Oral cancer, uterine cervical cancer • Features of acute and chronic pain • May be acute on chronic • Often mixed nociceptive and neuropathic pain • Usually gets worse over time if untreated

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45. Classification of PainSummary • Deciding on the type of pain is important • Acute / chronic • Cancer / non-cancer • Nociceptive / neuropathic • Treatment depends on the pain type

46. Pain Physiology and Pathology CC BY-NC-SA: This work is licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 3.0 License.

47. Pain Physiology and PathologyAims • To understand normal pain physiology • Pain pathway • Factors affecting the pain signal • To understand the basis of neuropathic pain(pathology)

48. Nociception and Pain • Nociception • How pain signals get from the site of injury to the brain • Pain perception • How we “feel” pain • Nociception is not the same as pain!

49. Is this man feeling pain?

50. Nociception is not the same as pain! Injury Beliefs/concerns about pain Other illnesses Psychol. factors anxiety/anger/depression Coping strategies Cultural issues Language, expectations Social factors e.g. family, work Pain What the patient says hurts. What must be treated. Modified from Analgesic Expert Group. Therapeutic Guidelines 2007