PAIN Review 08

The Concept ofThe Concept of

Asst. Prof. Chanell Jan C. Concepcion, Asst. Prof. Chanell Jan C. Concepcion, RN, MHSSRN, MHSS

Reviewer

Significance of PainSignificance of Pain

A.Subjective response: only felt by the person

B.Negative: discomfort

C.Protective role:

• warning of potential threat to health;

• prompt for person to seek medical attention

D.Fifth vital sign

What is What is Pain?Pain?

video

PAIN DefinedPAIN Defined

• "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (International Association on the Study of Pain).

Pain:Pain:

• Pain has personal meaning to individual experiencing pain

• All pain is real

Pain:Pain:

• Response to and warning of actual or potential trauma

• Difficult to measure

Pain:Pain:

Dimensions of Pain

Types of PainTypes of Pain Location Duration Intensity Etiology

• pain perceived in area distant from stimuli

• intense although there is little or no pain at the point of noxious stimuli.

• eg. myocardial ischemia is not felt as pain in the heart. Rather it is felt as left arm, shoulder or jaw pain.

Referred PainReferred Pain

• Visceral Visceral – arises from body organs; dull and

poorly localized; with nausea and vomiting; may radiate or is referred

• Superficial (Cutaneous) Superficial (Cutaneous) – Arise from skin and subcutaneous

tissues– tends to be easily localized

• Somatic (Deep Somatic Pain)Somatic (Deep Somatic Pain)– Tissues of body wall, muscles, bone,

periosteum, cartilage, tendons, deep facia, ligaments, joints, BV, nerves

• Acute Pain

• Chronic Pain

• Cancer Pain

Pain According to Pain According to DurationDuration

Acute PainAcute Pain• sudden onset

• usually sharp and localized

• less than 6 months

• significant of actual or potential injury to tissues

• initiates flight or fight stress response

Chronic PainChronic Pain• prolonged pain

• more than 6 months

• often dull, aching, diffuse

• not always associated with specific cause, often unresponsive to conventional treatment

• most common is lower back pain

CHARACTERISTICHARACTERISTICSCS

ACUTE CHRONIC

1.1. ONSETONSET RECENTRECENTINTERMITTENTINTERMITTENT

CONTINUOUSCONTINUOUS

2. 2. DURATIONDURATION

LESS THAN LESS THAN 6MONTHS6MONTHS

MORE THEN MORE THEN 6MONTHS6MONTHS

3.3. AUTONOMIC AUTONOMIC

REPONSEREPONSE

Sympathetic Sympathetic Response Response

Absence of Absence of Autonomic Autonomic ResponseResponse

4. 4. PSYCHOLOGIC PSYCHOLOGIC COMPONENTCOMPONENT

ASSOCIATED ASSOCIATED ANXIETYANXIETY

WITHDRAWALWITHDRAWAL

DEPRESSIONDEPRESSION

5. OTHER 5. OTHER TYPES OF TYPES OF RESPONSERESPONSE

Libido Libido

Appetite Appetite ChangesChanges

Characteristics of Acute and Chronic Pain

The truth about Chronic PainThe truth about Chronic Pain(Today @ NBC)(Today @ NBC)

CANCER –

RELATED PAIN

malignant pain is considered to

have qualities of both acute and chronic pain.

Intensity

1-3 =Mild

4-6 =Moderate

7-10 = Severe

(Kozier, 2008)

Etiology

• Physiologic Pain– Experienced when an

intact, properly functioning nervous system send signals that the tissues are damaged, requiring attention and proper care.

•

• Subcategories of Physiologic Pain– Somatic Pain– Visceral

Etiology

• Neuropathic Pain– Experienced by people

who have damaged or malfunctioning nerves.

May be due to:• Illness (postherpetic

neuralgia, diabetic peripheral neuropathy)

• Injury (e.g. phantom limb pain, spinal cord injury pain

• Undetermined reasons

Injury or Damage of the Nerve • After damage of nerve may cause

continuing pain• Regeneration of nerves can lead to

changes in nociceptive pathways that contribute to pathological pain.

• Healing process could be accompanied by hyperalgesia ( sensitivity to pain) due to proliferation of regenerating nerve fibers

• Neuroma formation – can be a constant cause/source of pain

• (Show Nerve Injury Flash)

Concepts Associated with PainConcepts Associated with Pain

1. Pain threshold1. Pain threshold

2. Pain tolerance 2. Pain tolerance

Concepts Associated with PainConcepts Associated with Pain

1.1. Pain thresholdPain threshold- The least amount of stimuli that is needed for - The least amount of stimuli that is needed for

a person to label a sensation as pain.a person to label a sensation as pain.

2. Pain tolerance 2. Pain tolerance

- is the maximum amount of painful stimuli - is the maximum amount of painful stimuli that a person is willing to withstand without that a person is willing to withstand without seeking avoidance of the pain or relief.seeking avoidance of the pain or relief.

Pain ThresholdPain Threshold

• the point at which an individual first acknowledge or interprets a sensation as being painfulThe least experience of pain which a subject can recognize. (IASP)

–the individual’s ability to endure the pain being experienced

–The greatest level of pain which a subject is prepared to tolerate. (IASP)

Pain Tolerance Pain Tolerance

Nociceptive vs Neuropathic PainNociceptive vs Neuropathic Pain

• Nociceptive PainNociceptive Painpain in which normal nerves transmit

information to the CNS about trauma to tissues

Pain in response to obvious stimuli

• Neuropathic PainNeuropathic PainDoes not require the presence of an

identifiable noxious stimulipain in which there are structural and/or

functional nervous systemEx. post herpetic (or post-shingles) neuralgia

A. Nociception

B. Pain pathway

C. Chemical Mediators

D. Endorphins (endogenous morphines/ opiates)

• nerve receptors for pain ends

• located in numerous skin and muscles

• stimulated by direct cellular damage or local release of biochemicals from cellular damage (e.g. bradykinin)

• the system involved in the transmission and perception of pain

nociceptors (nerve cell endings)

nociceptorsnociceptors

• mechanical- instruments, equipments

• thermal – flames, hot liquids, steam

• chemical - noxious substances

• mechanical- instruments, equipments

• thermal – flames, hot liquids, steam

• chemical - noxious substances

PROCESS OF PAINPROCESS OF PAIN

• threatened or actual tissue damage stimulates nociceptive neural receptors

• Damage to the pain transmission system itself

• Specific structures in the nervous system are involved in transforming a stimulus into a pain sensation

Neurons Neurons Involved in Involved in

Pain Pain Perception:Perception:

• A-delta (A-delta ())

• C Fibers C Fibers

• Transmits signals more rapidly

• Delivers information on pain-producing stimulus

• Determine the location, severity and type of pain

• Perceived as sharp, cutting or stabbing sensation

A-delta (AA-delta (A))

• Conducted more slowly Conducted more slowly along pain pathwayalong pain pathway

• Characterized as dull, Characterized as dull, burning sensations burning sensations associated with sufferingassociated with suffering

C Fibers C Fibers

• Transduction

• Transmission

• Perception

• Modulation

TransductionTransduction• Cell damage causes release of

sensitizing chemicals (prostaglandin, bradykinin, serotonin, substance P, histamine)

• Stimulus is detected by nociceptive receptors

• conversion of mechanical, chemical and thermal information into electrical activity in the nervous system.

TransductionTransduction• Process of Depolarization

– Na enters; K exits

• Generates action potential

• Electrical energy travel to spinal cord

TransmissionTransmission• Movement of pain impulse from site

of transduction to the brain

• Message is relayed from receptors to the CNS

TransmissionTransmission• 3 segments involved in

nociceptive signal transmission:

• Level of spinal cord

• Dorsal horn processing

• Transmission to thalamus & cortex

Transmission of pain impulsesTransmission of pain impulses

• Substance P and other neurotransmitters transfer the impulse from the nociceptors to the spinothalamic tract.

PerceptionPerception• Only when the impulses reach the

brain are they intellectually recognized as pain.

• Brain perceives the sensation as painful

PerceptionPerception• Dynamic and changing in response

to many factors

• May be brief (seconds or hours), prolonged (hours or weeks) or even permanent

• Adjustment

• Refers to internal and external ways of reducing or increasing pain

– Where does modulation occur?

ModulationModulation

ModulationModulation• Pain modulation is determined by

activity in the endorphinergic system and other pain modulating systems.

• In the endorphinergic system, analgesia is mediated by– the binding of endogenous opioid

compounds to special subsets of receptors: mu, delta, and kappa.

• Endorphins

• other neurotransmitters that play a role in the endogenous pain modulating system include serotonin and norepinephrine, GABA

ModulationModulation

Summary of Noceceptive Summary of Noceceptive Processes Processes

Drug TherapyInterrupting the Pain Pathways

Pain Medication Mechanism of Action

TransductionTransduction – NSAID Local Anesthetics Antiseizure agents Corticosteroids

-Blocks prostaglandin production-Blocks action potential initiation -Blocks action potential initiation -Blocks action potential initiation

TransmissionTransmission – Opioids -Blocks release of substance P

PerceptionPerception – Opioids NSAIDs Adjuvant (antidepressants)

- conscious experience of pain

ModulationModulation – Tricyclic antidepressants (Elavil, Prozac)

- Interferes with reuptake of serotonin & norepinephrine

PainATHWAY

• First, nerve endings in the finger sense the injury to the finger (sensory neurons)

• and they send impulses along axons and enter the spinal cord in an area called the dorsal horn (magenta (magenta pathway).pathway).

• The incoming axons form a synapse with neurons that project up to the brain.

• The neurons that travel up the spinal cord then form synapses with neurons in the thalamus, which is a part of the midbrain (magenta circle).(magenta circle).

• The thalamus organizes this information and sends it to the sensory cortex (blue),

• Sensory cortex interprets the information as pain and directs the nearby motor cortex (orange)(orange) to send information back to the thalamus (green pathway).(green pathway).

• Again, the thalamus organizes this incoming information and sends signals down the spinal cord, which direct motor neurons to the finger and other parts of the body to react to the pain (e.g., shaking the finger or screaming "ouch!").

Pain Pain PathwayPathway Ascending

Pain Pathway

Other pain pathways:

• Descending pathway– Pain modulation

• The spinothalamic pathway.

• The spinoreticular pathway

• The dorsal column pathway

• The spinomesencephalic tract.

• The spinohypothalamic pathway.

1. Bradykinin – a powerful vasodilator that increases capillary permeability and constricts smooth muscles.

3. Acetylcholine – a neurotransmitter substance widely distributed in body tissues which functions as a vasodilator and cardiac depressant

2. Histamine – a compound found in all cells. It is released in allergic inflammatory reactions.

4. Substance P – •stimulant at pain receptor sites involved in inflammatory response in local tissue

•Release of plasma by increasing vascular permeability availability of bradykinin

•Contributes to prostaglandin release

CHEMICAL MEDIATORS OF PAINCHEMICAL MEDIATORS OF PAIN

• 5. Prostaglandin – chemical substance thought to increase the sensitivity of pain receptors by enhancing the pain provoking effect of bradykinin

• 6. Endorphin/Enkephalin – reduce or inhibit the transmission of pain. Both are found in heavy concentrations in the CNS

CHEMICAL MEDIATORS OF PAINCHEMICAL MEDIATORS OF PAIN

• EndogenousEndogenous – produced by the body

• OpiatesOpiates – produce analgesia by direct action on the CNS

• The endogenous opiates consists of naturally occurring opioids and their receptors

• OpioidsOpioids – (e.g. endorphines, enkephalins, dynorphin)

INFLUENCE OF ENDOGENOUS OPIATES

Endorphin-Endorphin- (endogenous morphines) bind with opiate

receptors on neuron to inhibit pain impulse

transmission

INFLUENCE OF ENDOGENOUS OPIATES

Enkephalins –Enkephalins – (endogenous opiates in the “kephalus”-

Greek for brain) a naturally occurring analgesic thought to

inhibit substance P release

Opioids- are morphine-

like substances synthesized

in many regions of the CNS (including pituitary gland)

EndorphinsEndorphins• Levels vary among individuals

• People with: endorphinendorphin levels feel less painless pain

endorphinendorphin levels feel more painmore pain

Gate Control Theory Melzack and Wall (1965)

•holistic nature of pain.

•many interventions such as imagery and distraction are used to help relieve a client’s pain.

•related to the transmission of painful stimuli

•relationship between pain & emotions.

1.1. SmallSmall diameter nerve fibers - conductconduct excitatory pain stimuli toward the brain

2.2. LargeLarge diameter nerve fibers - appear to inhibitinhibit the transmission of pain impulses from the spinal cord to the brain

The theory states that:

4. The excitatory/inhibitory signals at the gate in the spinal cord determine the

impulses that eventually reach the brain

The theory states that:

3. gating mechanismgating mechanism that is believed by some to be located in the substantia substantia

gelatinosagelatinosa cells in the dorsal horn of the spinal cord

5. Limited amount of sensory information can be processed by the

nervous system at any given moment.When too much information is

sent thru, certain cells in the spinal column interrupt the signals as if

closing the gate.

6. The brain also appears to influence 6. The brain also appears to influence the gating mechanism.the gating mechanism.

The theory states that:

• Works on the premise that the SG (located in dorsal horn) modulates afferent nerve impulses and influence transmission of T cells. This activates a central controlling mechanism

Gate Control Theory Con’t…

• gate closes - impulses are less likely to be transmitted to the brain.

Gate Control Theory Con’t…

• In Dorsal Horn of Spinal CordIn Dorsal Horn of Spinal Cord

T

Brain. A-BetaSensory, Proprioception, Etc

A-Delta, C FibersPain Transmission

SG

*Facilitator Synapse (Small Diameter NF)

*Inhibitory Synapse (Large Diameter NF)

Gate Control Theory Melzack and Wall (1965)

(from Black, Hawks & Keene, 2002):

• Gate control theory is correct in predicting that nociceptive information was modifiable in the dorsal horn

• Researches have shown that the “Gate” conceptualization is no longer tenable.

• Inhibition of pain is not limited to the SG

• “This theory is out of date”

• Many researches has more fully delineated the physiologic mechanism underlying pain inhibition

• “Theory is incomplete and even incorrect in details” (Fields, in Hawthorn, 1999)

Gate Control Theory Updates

Responses to PainResponses to Pain

• Physiologic

• Behavioral

• Other affective response

Responses to Pain

• involve the activation of the sympathetic nervous system

• evokes the “fight or flight” reaction

• with catecholamine release from adrenal medulla.

PHYSIOLOGIC PHYSIOLOGIC REACTIONS TO PAINREACTIONS TO PAIN

Manifestations during the Fight-or Flight Response:Manifestations during the Fight-or Flight Response:

arterial BP

Increased mental activity • Dilated pupil

• Bronchial Dilation

RR HR Cardiac

Output glucose

fatty acids

flow to skeletal muscles

Physical Response

• Moving AwayMoving Away• Protecting painful areaProtecting painful area• RestlessnessRestlessness• Facial Expression – Grimacing, biting lips, Facial Expression – Grimacing, biting lips,

tensing of limb and body musclestensing of limb and body muscles• Voluntary and involuntary protective body Voluntary and involuntary protective body

movementsmovements (Guarding painful area)

• Refers to observable actions used to express or control the pain

Verbal statements – praying, swearing cursing, repeating non-sensical phrases

Altered responses to environment

Vocal behaviors- moan, scream, sighing, crying

Psychological or Behavioral RESPONSES:

Psychological or Behavioral RESPONSES:

• Body movements- rocking, rubbing, stretching, shifting weight, pounding, biting

• Physical contact with others

• Facial expression – grimace, clenched teeth, tight shutting lips, staring, wrinkling forehead, tearing

Other affective responses:

• Anger

• Fear

• Depression

• Anxiety

Ethic and Cultural FactorsEthic and Cultural Factors

Behavior related to pain is part of the socialization process

Developmental StageDevelopmental StageChildren are less able to articulate their

experience or needs related to pain puberty – emergence of pain syndrome (esp.

women)

* elderly – mostly affected by chronic pain

Environment & Support PeopleEnvironment & Support People

Strange environment can compound pain

Support network affects pain perception

Other factors that affect pain perception & response:Expectations Family role

Past Experience with painPast Experience with pain

affects the way we perceive our current pain

Negative experience with pain as children have reported greater difficulties managing pain

Impact of past experience may not be predictable

Earlier pain experience allows us to adopt coping mechanisms

Meaning of PainMeaning of Pain

Meaning of person’s pain influences his or her response to pain

e.g. pain in childbirth different from pain in surgery

Known vs. unknown cause of pain

Meaning or experience – negative vs. positive

Expectation and the Placebo Effect Expectation and the Placebo Effect

Client’s expectations play a major role in a person’s pain perception and effectiveness of pain relief intervention

Placebo effectPlacebo effect – may initiate the body's endogenous opiate system activated by the expectation of relief

Nursing Process in the Nursing Process in the Care of Clients in PainCare of Clients in Pain

ASSESSMENT• History and Physical

Examination

IntensityLocationQualityDurationPattern

COLDERRCOLDERR• CharacterCharacter: describe the sensation (e.g. sharp,

aching, burning)• OnsetOnset: when it started, how it has changed • LocationLocation: where it hurts (all locations)• DurationDuration: constant vs. intermittent• ExacerbationExacerbation: factors that make it worse• ReliefRelief: factors that make it better• RadiationRadiation: pattern of shooting/spreading/location

of pain away from its origin•

The alphabet of PAINThe alphabet of PAIN

Protective or Palliative (Ask what provokes or worsens pain; what relieves or causes pain to subside

Quality or Quantity (Ask for quality, associated symptoms, pattern, interruption of ADL)

Region and Radiation (Location of pain and if it is radiating)

Severity (Use Pain scale; description of Intensity)

Timing (Ask when pain began, onset – sudden or gradual, constant or intermittent?; time of day it occurs)

Assessment Scales • For adults, adolescents, and older children (including those

with language barriers) who can say or point to a number, or who can point to a face.

• a) Numerical Scale – 0 to 10 (11-point intensity Scale)

• b) Wong-Baker Faces Scale • For stoic or cognitively impaired adults, adolescents,

and children:• FLACC Scale

• For Neonates/Infants • a) N-PASS • b) CRIES • c) FLACC Scale

Intensity: Use PAIN SCALESIntensity: Use PAIN SCALES

Location of Pain

•Diffuse – pain that covers a wide area; client cannot point to a specific area without moving the hand over a large surface, eg the entire abdomen

•Dull – pain that is not as intense or acute as sharp pain but more annoying than painful. More diffuse than sharp pain

•Sharp- pain that is sticking in nature & intense

•Shifting – pain that moves from one area to another such as from the lower abdomen to the area over the stomach

QualityQuality

•Continuous Continuous – pain that does not stop

•Intermittent Intermittent – pain that stops and starts again

•Brief or transient Brief or transient – pain that passes quickly

PeriodicityPeriodicity

Patterns

• Precipitating

• Alleviating

• Associated Symptoms

• Effect on ADL

• Coping Resources

Nursing Diagnosis

• Primary Nursing DX:Primary Nursing DX:

•Alteration in Comfort: Pain related to tissue injury from incision, ischemia, tumor encroachment in organs or bone

Nursing Management of Pain

• Acknowledgement and Accepting Client’s Pain

• Assisting Support Persons

• Reducing misconceptions about pain

• Reducing fear & anxiety

• Preventing pain

• Medications: most common approach to pain management – Analgesics

• Non-narcotic (Acetaminophen)• NSAIDS• Narcotic analgesic• Adjuvant analgesics

(antidepressants, anticonvulsants)• Local anesthesia

Pharmacologic Interventions for Pharmacologic Interventions for PainPain

WHO Analgesic Ladder

Non-narcotic or non-opioid Non-narcotic or non-opioid analgesicsanalgesics

• For nociceptive or neuropathic pain

• Effective in somatic components of nociceptive pain such as joint and muscle pain

• May also reduce fever and inflammation

• For mild to moderate pain

• Drug types:

• Acetaminiophen

• Salicylates

• NSAID

Non-narcotic Non-narcotic analgesicsanalgesics

• Temporary relief from mild to moderate pain

• Long-term treatment for osteoarthritis and rheumatoid arthritis

• Acts mainly to interfere with prostaglandin synthesis

Non-Steroidal Anti Non-Steroidal Anti Inflammatory Inflammatory (NSAIDs(NSAIDs))

Advantages of NSAIDs:• Taken orally

• Don’t cause CNS or respiratory depression when used in therapeutic dose

• Generally available without prescription

NSAIDs: Main teaching points

• Act by inhibiting enzymes (prostaglandin, cyclooxygenase, etc) that normally enhance pain

• Peripherally acting painkiller

• Not addictive

• Some potential problems with gastric side-effects

• Some central S/E

Example of NSAIDs:

• Ibuprofen• Mefenamic acid• Naproxen• Piroxicam • COX-2 Inhibitors (Vioxx, Celebrex)

• Natural or synthetic medications with morphine-like actions

• Derived from opium

• (e.g. morphine) or Synthetic narcotics (Oxycodone)

• act within and outside CNS

Narcotic analgesicsNarcotic analgesics

OpioidsOpioids

• Related to morphine• Works at morphine receptors• Physical dependence• Psychological dependence• Development of tolerance• Withdrawal effects• Long term use effects (possibly

enhancing pain)• Interaction with benzodiazepines

(central effect)

Examples of Opioids

• Mixed or Weak Opioid– Butorphanol (Stadol)– Hydrocodone (Vicodin)– Codeine (Tylenol No. 3)– Tramadol

Strong Opioid Analgesic

• Meperidine HCl (Demerol)

• Morphine Sulfate (Morphine)

• Methadone (Dolophine)

Common Opioids Side Effects

• Constipation

• N/V

• Sedation– Tolerance – 3-5 days– Consider stimulants (e.g. Ritalin)– Alternative route (epidural)

Common Opioids Side Effects

• Respiratory Depression – (first 12-24 hrs)– Give opioid antagonist Naloxone

Hydrochloride (Narcan)– Stop, Change, Slow

• Pruritus

• Urinary Retention

• Drugs that have other primary indications but are used as analgesics in some circumstances.

• Given in combination with opioids or used alone to treat chronic pain.

• Examples of Adjuvant analgesics:– Antidepressants: (such as tricyclic

antidepressants) promote serotonin and inhibit pain, promotes sleep

– Anticonvulsants– Local and topical anesthetics

Adjuvant analgesics or Adjuvant analgesics or coanalgesiccoanalgesic

Medications to Ease Pain

1. Oral

2. Sublingual

3. Buccal administration (Actiq – oral transmucosal fentanyl citrate is a flavored lozenges on a stick)

4. Intranasal

5. Rectal

6. Transdermal (e.g. Lidocaine patches, EMLA)

7. Parenteral Route: IM, IV, SC - Patient controlled analgesic (PCA)

8. Intrathecal, , Narcotic Infusion, epidural

Patient Controlled Analgesia (PCA) Pumps

• Demand analgesia• A specific type of SC, IV or intraspinal delivery

system• A dose of opioid delivered when patient decides

the needed dose• Infusion system • Management of acute pain, post operative pain

and cancer pain.

PCA Advantages • Less nurse time

• Patient reports better pain relief

• Requires less total analgesic meds than patients on PRN meds

• Have greater sense of Control

• Physical Cutaneous Stimulation

• Transcutaneous Electrical Nerve Stimulation (TENS)

• Cognitive-Behavioral Interventions

Transcutaneous Electrical Nerve (TENS) Stimulation

• nerve conducts electrical current and so cannot conduct pain

Non-Pharmacologic Non-Pharmacologic Interventions for PainInterventions for Pain

a)Heat & Cold Application

b)Guided Imagery

c)Hypnosis

d)Meditation

e)Biofeedback

f) Yoga

Non-Pharmacologic Non-Pharmacologic Interventions for PainInterventions for Pain

g)Therapeutic touch

h)Cutaneous Stimulation (Massage)

i) Distraction

j) Deep Breathing and Relaxation

k)Music

l) Progressive Relaxation Training

m)Acupressure

Surgical Interventions to Manage Pain

• Nerve blocks – interrupts nociceptive transmission – Chemical interruption of pain pathway– Common in dental work

Surgical Interventions to Manage Pain

• Neurosurgical interventions – Implantation of drug-infusion system– Neuroablation – destroys nerves– Neuroaugmentation – electrical stimulation

Invasive Interventions to Manage Pain

AcupunctureAcupuncture

Non-Pharmacologic/ Non-Pharmacologic/ Alternative Interventions for Alternative Interventions for

PainPain

Alternative Therapies to Ease Pain

Evaluation & Evaluation & Documentation Documentation

• Evaluation: utilizes client perception and pain rating scale to document changes in pain

• Reassessment• Important Considerations• Documentations• (show video)

The Ten Commandments of The Ten Commandments of Pain ManagementPain Management

1. Thou shalt believe the patient’s report of pain.

2. Thou shalt assess and reassess the patient’s response to pain interventions.

3. Thou shalt not be afraid of prescribing or administering opioid analgesics.

4. Thou shalt not prescribe inadequate amounts of any analgesic.

Cont’d

5. Thou shalt not use the abbreviation PRN for continuous pain, but ATC.

6. Thou shalt reassure the patient and family that risk of opioid addiction is rare.

7. Thou shalt provide support for the whole family.

8. Thou shalt not limit thy approach simply to the use of analgesics, but also adjuvant drugs and “mind-body” techniques.

The Ten Commandments of The Ten Commandments of Pain ManagementPain Management

9. Thou shalt prevent or treat side effects of opioids.

10. Thou shalt not be afraid to ask colleagues’ advice.

Modified from Twycross, R: Practical Palliative Care Today. Spring 2000, Vol. 2. Center for Palliative Studies at San Diego Hospice, San Diego.

The Ten Commandments of The Ten Commandments of Pain ManagementPain Management