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Pain Management: What are your treatment options?

Written by C. Fookes, BPharm on Nov 19, 2018

Assessing | Types | What is Pain | Identifying | Management | Medications

Pain is defined as a highly unpleasant physical sensation caused by illness or injury. Despite it being the most common symptom people seek medical help for, it remains one of the most misunderstood and ineffectively treated.

This is partly due to it being highly subjective - one person’s experience of the same painful event (such as a fracture) can be significantly different from another’s.

Effective pain management requires:

  • A thorough assessment to determine the type of pain (for example, bone-related, internal [related to body organs such as the gastrointestinal tract, kidneys], musculoskeletal, nerve-related, soft tissue-related)
  • Acknowledging the presence of comorbidities and risk factors (such as heart disease, previous peptic ulcer disease), as well as psychological, social, emotional, and spiritual factors that contribute to a person’s “total pain” experience
  • Adequate knowledge of the different pain medications available and their side effects
  • Regular, ongoing assessment of tolerability, effectiveness, and continued need for pain relief.

Pain management must always be individualized to the person who has the pain. There is no one-size-fits-all approach.

Properly Assessing Pain

Research has shown that an inadequate assessment is one of the main barriers to optimal pain management.

Some doctors and nurses rely on their own observations when assessing a person’s level of pain, rather than directly asking the patient to describe their pain. This ignores the patient’s perspective and does not take into consideration spiritual, psychological, and social aspects.

Compounding this is the fact that it can sometimes be extremely difficult for a patient to pinpoint exactly what is causing the pain, or they lack awareness that the pain they are experiencing is dependent on a combination of factors, and is not just a physical sensation.  Examples of spiritual, psychological, and social factors that may contribute to pain include:

  • A child not visiting
  • Being isolated from a much-loved pet
  • Feeling that “God has left me”.

Talking to a person in pain in a holistic way and asking questions that reach beyond just describing the location of their pain or rating it on a scale of one to ten is vital for good pain management. Only then can these other, equally important issues, be acknowledged and addressed.

Types of pain

There are many different types of pain. Asking people to keep a pain diary – a notebook where they write down their pain experiences and rate their pain levels on a scale of 1 to 10 every day for one to two weeks – can help identify any patterns of pain. The most common types of pain are:

  • Acute pain: This starts suddenly and only lasts for a short period of time (ie, minutes, hours or a couple of days)
  • Chronic pain: This is a persistent type of pain that tends to be experienced every day for at least three months. Chronic pain can range from mild to severe
  • Breakthrough pain: Pain that occurs in between regular, scheduled painkillers
  • Bone pain: Felt as a constant aching or discomfort in a bone, common with bone injury, the late stages of osteoporosis, and cancer
  • Nerve pain (also called neurological pain): Associated with nerve damage, usually feels sharp or stabbing
  • Phantom pain: Pain is felt in a part of the body that has been amputated (removed) 
  • Soft tissue pain:  Pain or discomfort from damage or inflammation of the muscles, tissues, or ligaments. May be associated with swelling or bruising
  • Referred pain: Pain is felt in a different part of the body from the source (for example pain in the pancreas is usually felt in the back).

Total pain acknowledges the fact that pain has more than just a physical component and is dependent on psychological, social and spiritual factors as well.

What is pain?

Pain is a subjective experience, which means it is based on or influenced by personal feelings, tastes, or opinions. Put simply, pain is what a person says it is. But this does not mean that somebody who can’t communicate their pain (such as babies, or people with intellectual disabilities or dementia) aren’t in pain.

Pain is generally defined as a highly unpleasant physical sensation caused by illness or injury. Its severity varies between individuals; one person’s experience of the same painful event (such as a fracture) can be significantly different from another’s. Severity can also vary on an hour to hour or day to day basis within the same individual, for example, pain may feel more severe at night than during the day when there are no other distractions.

Many different factors influence how sensitive a person is to pain and their response, including their:

  • Ability to communicate
  • Co-existing medical conditions, such as fibromyalgia, migraine headaches, and irritable bowel syndrome
  • Current state of mind at the time of pain (eg, anxious or depressed, frightened, stressed, worried). Pain is more prevalent in individuals with depression, anxiety or low self-esteem. People with a pessimistic attitude towards pain or who anticipate negative outcomes tend to suffer more than those who don’t
  • Gender – women are more likely to report more frequent, severe, and longer-lasting pain than men
  • Genetics – various genes have been identified that play a role in the sensitivity, perception, and expression of pain. Genetics can also influence a person’s response to pain medication
  • Individual factors such as your upbringing, coping strategies, general attitude, and need for attention. Also, the expectations already placed on you with regards to how you should think or react
  • Past experiences of pain – memories of past painful experiences can influence current experiences. Pain itself predisposes you to more pain and the most consistent factor for developing a painful condition is a previous episode of pain
  • Social factors such as stress or isolation tend to enhance the experience of pain. A higher prevalence of pain is reported in people with lower education levels, lower income, or who are unemployed.
  • Suggestion from others about how much pain you should be experiencing
  • And the sensory nerve patterns that are evoked by whatever is causing the pain.

In summary, pain is not only a physical sensation but, because it passes through the emotional and thinking regions of our brain, a highly emotive one as well. Put simply, your level of pain is influenced by what is in your head as well as what is happening to your body.

What type of pain am I having?

Identifying exactly what type of pain you are experiencing can help your doctor chose the right medication for you. The checklist below identifies the many things that can contribute to your pain.

A helpful thing to do before you see your doctor is to keep a pain diary for up to two weeks. This should include a description of what you were doing when you had the pain, the type of pain you are experiencing, and how bad the pain was on a scale of 1(no pain) to 10 (the most severe pain ever).

Pain Identification Checklist

If you have a child that is experiencing pain, The Faces Pain Scale may help. This uses a series of diagrams depicting a face with no pain (0) to intense pain (10).

Faces Pain Scale

Chronic pain management

More than one in ten Americans live with severe pain on a daily basis, and despite the fact that pain can be controlled, poor pain relief is a reality for many people. Research has indicated that less than 10% of people in chronic pain gain access to effective care.

In addition, sufferers frequently feel misunderstood, discriminated against, stigmatized, and many report their complaints are not taken seriously.  Comorbidities such as depression, anxiety, post-traumatic stress disorder, and substance misuse are typical, with pain-related issues being implicated in up to one in five suicides.

Effective chronic pain management requires a multidimensional approach, which means not only taking into account the physical component of pain, but also the psychological, social, emotional, and spiritual aspects. This has been referred to as “Total pain control”.

There are some key factors that need to be considered when managing pain:

  • Pain management should consist of both pharmacological and nonpharmacological treatments. Social, spiritual, and emotional issues may also need to be addressed
  • Choice of treatment must consider effectiveness for that particular type of pain and side effects of the medicine. The choice should be revisited periodically and modified if pain changes
  • Some types of pain (such as cancer-related pain) have an unpredictable course that can vary dramatically in severity and duration, depending on the type of treatment and disease progression. Pain management needs to have some flexibility to account for this
  • Some people will have more than one type of pain
  • Changing the method of delivery of a pain medication may improve its effectiveness; for example, changing from oral treatments to a targeted drug delivery system, subcutaneous continuous infusions, patches, or patient-controlled analgesia.

Pain Management Ladder

Types of pain medication

There are many different types (classes) of pain-relieving medications and each works in a slightly different way. Some may be better for nerve-related pain, whereas others are better suited to postoperative pain. In addition, nonpharmacological treatments, such as physical therapy, stress management techniques, and occupational therapy also play a role in relieving many different types of pain, either alone or in combination with pharmacological measures.

The aim of pain management is to provide treatment to reduce pain with minimal side effects. Traditionally, most experts have recommended a stepwise approach to pain management, starting with acetaminophen or NSAIDs, then progressing to a weak opioid (such as codeine, dihydrocodeine, or tramadol), before changing to a strong opioid (such as fentanyl, morphine, oxycodone). However, this “Pain Ladder” was developed in 1986, and other medications that are not analgesics can also be effective at relieving pain. In addition, opioids should only be used for certain types of pain, because of their risk of addiction.

Determining the comparative strengths of pain medications can be difficult. This is because of factors such as genetics, dosage form, dose, type of pain, and coexisting conditions all impact on what an equivalent dose is. Opioid comparison charts are therefore not recommended, and only healthcare practitioners with adequate competence and enough experience should attempt to change a person from one opioid to another.

Always talk to your doctor about which pain medication is right for you. Below is a summary of all the different types of pain medications available as well as nonpharmacological treatments.

Nonopioids

Weak opioids

Combination opioids

Strong Opioids

Other

Adjuvant treatments

Anxiety

Bone pain

Bowel-related pain

Muscle or joint pain/spasm

Nerve Pain

Widespread pain

Nonpharmacological treatments

  • Acupressure
  • Acupuncture
  • Alexander technique
  • Biofeedback
  • Braces and supports
  • Chiropractic therapy
  • Cognitive behavioral therapy
  • Comfort therapy
  • Diathermy
  • Distraction
  • Electromuscular stimulation
  • Functional restoration training
  • Guided imagery
  • Hot/cold packs
  • Hypnosis
  • Interferential therapy
  • Low level laser therapy
  • Magnetic therapy
  • Massage
  • Mindfulness
  • Multidisciplinary rehabilitation
  • Osteopathy
  • Physical and occupational therapy
  • Psychosocial therapy/counseling
  • Qigong
  • Radiofrequency ablation
  • Relaxation techniques
  • Tai Chi
  • Transcutaneous electrical nerve stimulation (TENS)
  • Ultrasound
  • Yoga

See Also

Sources

  1. Park HJ, Moon DE. Pharmacologic management of chronic pain. Korean J Pain. 2010;23(2):99-108.
  2. Mehta A, Chan L. Understanding of the Concept of ‘‘Total Pain’’ A Prerequisite for Pain Control. Journal of hospice and palliative nursing v Vol. 10, No. 1, Jan/Feb 2008
  3. Häuser W, Fitzcharles MA, Radbruch L, Petzke F. Cannabinoids in Pain Management and Palliative Medicine. Dtsch Arztebl Int. 2017;114(38):627-634.
  4. Non-opioids and Other Drugs Used to Treat Cancer Pain. American Cancer Society. 2018. https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/pain/non-opioids-and-other-drugs-to-treat-cancer-pain.html
  5. Lussiera D, Huskeyb A, Portenoya R. Adjuvant Analgesics in Cancer Pain Management
  6. The Oncologist. April 23, 2004, http://theoncologist.alphamedpress.org/content/9/5/571.full
  7. Skelly AC, Chou R, Dettori JR, et al. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review. Comparative Effectiveness Review No. 209.
  8. AHRQ Publication No 18-EHC013-EF. Rockville, MD: Agency for Healthcare Research and Quality; June 2018.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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