What is pain management?

Indications and Procedures

Pain is experienced as an unpleasant reaction to either an external stimulus (such as a burn) or an internal process (such as a disease). The initial evaluation of pain is aimed at determining the cause. A good description by the patient aids diagnosis. The person experiencing the pain must be able to communicate the intensity, location, pattern (such as throbbing, steady, intermittent) and type (crushing, burning, sharp, or dull). In addition, factors that make the pain better or worse must be known and communicated. Duration is important; recent onset is termed “acute” pain while long-standing pain or pain that returns periodically is termed “chronic.”

Generally, the best way to treat pain is to prevent its occurrence. Failing that, a number of different interventions should be used together. Whatever treatment is used, the therapy must be tailored both to the patient and to the nature and severity of the pain. When medications are used, review of some important principles is essential, such as the pharmacology, duration of effectiveness, and optimal dose of a certain medication. Even the route of administration must be considered in every case.

Treatment may include combinations of simple analgesics, narcotics, and other treatments. Combinations take advantage of the additive pain relief while sparing the patient potential side effects. When choosing pain medications, a stepwise approach is often used. It starts with the simple analgesics: aspirin, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs). These medications are generally well tolerated, although aspirin and NSAIDs can produce gastrointestinal distress ranging from mild heartburn to bleeding ulcers. Additionally, adjuncts to these types of medications might be icing or heat, depending on the nature of the problem.

For more severe pain, the second step often includes a narcotic analgesic with or without the simple analgesics. Narcotics are very potent and have a potential for addiction. Furthermore, they may produce problems such as confusion, nausea and vomiting, constipation, and drowsiness. If the pain has a significant inflammation component that does not resolve easily with milder analgesic approaches or with narcotics, then corticosteroids may be used to alleviate the pain. This approach does not lend itself well to longer-term pain management, however, because of side effects such as fluid retention, stomach irritation, thrush, muscle weakness, weight gain, bone loss, suppressed adrenal function, and increased risk of infections, among others.

The third step in pain control involves alternative methods of pain control. Treatments here include physical therapy, nerve-blocking injections, transcutaneous electrical nerve stimulation (TENS), and behavioral approaches. The latter method seeks to identify the causes of preventable pain (physical or mental) and takes steps to minimize pain.

Medical research is leading to interesting discoveries about the management of pain. In 2002, researchers announced that they had identified a key protein that controls severe pain, a discovery that could lead to better pain management for patients who suffer from chronic pain or pain associated with terminal cancer. The protein, known by the acronym DREAM, protects the neural reflex critical to survival, allowing individuals to feel pain and quickly pull away from its source, but over time, DREAM seems to help sharp pain fade as the protein becomes disabled. Moreover, while there are many types of pain, disabling the DREAM protein appears to reduce the severity of all of them. The next step in research will be to examine ways to disable the protein, a task that scientists deem difficult because of its location deep within individual cells. Additional research in this area recognizes that pain has different causes and that it may be more productive to examine mechanisms of pain rather than taking a disease-based approach.

Bibliography

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