Why Don’t We Do a Better Job of Treating Pain ?

1. Why Don’t We Do a Better Job of Treating Pain? Bryan E. Bledsoe, DO, FACEP Midlothian, TX

2. Introduction • Many, if not most, medical conditions cause pain.

3. Introduction • Pain is a protective mechanism and occurs whenever any tissues of the body are being damaged.

4. Introduction • Pain occurs whenever the cells or tissues are being damaged—whatever the underlying cause.

5. Introduction • The reaction to pain may be rapid, as seen when one touches a hot pan.

6. Introduction • Or slow, as when one has been seated in the same position for an extended period of time.

7. Introduction • It is for this reason that persons with spinal cord injuries are at risk for developing decubitus ulcers.

8. Introduction • Because of their injury, they: • Cannot sense pain from the pressure area. • Cannot move to eliminate the pressure. • Or a combination of both.

9. Introduction • One of the oldest roles of medical practitioners is to help alleviate pain.

10. Introduction • Analgesia • The relief of pain without a loss of consciousness.

11. Introduction • Analgesia can be provided by: • Drugs • Surgical Procedures • Physical Modalities • Other

12. Introduction • Analgesia: • Eliminate the source of the pain. • Block or attenuate the pathways that transmit pain impulses to the brain. • Combination of the two.

13. Introduction • Pain elicits a strong emotional response that is often recorded in our memory.

14. Introduction • “Lest we be like the cat that sits down on a hot stove-lid. She will never sit down on a hot stove-lid again—and that is well; but also she will never sit down on a cold one anymore.”

15. Problems in Pain Management

16. Problems • Pain appears to be under treated: • Failure to assess pain. • Failure to quantify pain. • Fear of addiction. • Legal constraints of utilizing controlled substances. • Ignorance

17. Problems • UCLA Medical Center Study: • Hispanic patients with isolated long-bone fractures were twice as likely to receive NOpain medication when compared to their non-Hispanic white counterparts. • Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993;269(10):1537-9

18. Problems • Grady Memorial Hospital: • Black patients with isolated long-bone fractures were less likely to receive adequate analgesia when compared to their white counterparts. • Todd KH, Deaton C, D’Adamo AP, Goe L. Ethnicity and analgesic practice. Ann Emerg Med. 2000;35(1):11-16

19. Problems • Nationwide survey of burn patients: • Only half of burn patients treated in emergency departments received adequate analgesia for their burn pain. • Singer AJ, Thode HC Jr. National analgesia prescribing patterns in emergency department patients with burns. J Burn Care Rehabil. 2002;23(6):361-5

20. Problems • EMS Study (Pediatrics) • Few pediatric patients receive prehospital analgesia, although most ultimately received ED analgesia. • Swor R, McEachin CM, Sequin D. Grall KH. Prehospital pain management in children suffering traumatic injury. Prehospital Emergency Care. 2005;9(1):40-43

21. Prehospital Pain Management is even worse!

22. Prehospital Pain Management • Pain in the prehospital setting is often: • Not identified, • Under treated, • Both. • Ricard-Hibon A, Leroy N, Magne M, et al. Evaluation of acute pain in prehospital medicine. Ann Fr Anesth Reanim. 1997;16(8):945-9

23. Prehospital Pain Management • Patients with extremity fractures receive inadequate analgesia. • Study of 1,073 patients found only 1.5% received analgesia in the prehospital setting. • White LJ, Cooper LJ, Chambers RM, Gradisek RE. Prehospital use of analgesia for suspected extremity fractures. Prehosp Emerg Care. 2000;4(3):205-8

24. Prehospital Pain Management • Prehospital patients with lower-extremity fractures (including hip fractures): • Only 18.3% of eligible patients received analgesia. • McEachin CC, McDermott JT, Swor R. Few emergency medical services patients with lower extremity fractures receive prehospital analgesia. Prehosp Emerg Care. 2002;6(4):406-410

25. Prehospital Pain Management • Femoral neck fractures are among the most common orthopedic injuries encountered in prehospital care.

26. Prehospital Pain Management • Hip fractures: • Only a modest proportion of these patients receive prehospital analgesia for this painful and debilitating injury. • Vassiliadis J, Hitos K, Hill CT. Factors influencing prehospital and emergency department analgesia administration to patients with femoral neck fractures. Emerg Med (Fremantle). 2002:14(3):261-6

27. Prehospital Pain Management • Nothing is more cruel than: • Retrieving elderly patient with isolated hip fracture. • Tying them to a sheet of plywood or plastic. • Wrapping a hard collar around their arthritic neck. • Placing them in a 2-ton truck. • Driving them to the hospital over rough roads.

28. Prehospital Pain Management • Without adequate analgesia!

29. What is Pain? • A sensory or emotional experience or discomfort. • Single, most common medical complaint.

30. Qualities of Pain • Organic versus Psychogenic • Acute versus Chronic • Malignant versus Benign • Continuous versus Episodic

31. Types of Pain • Acutepain: • Pain associate with an acute event • Chronicpain: • Pain that persists after an acute event is over • Pain that last 6 months or more

32. Pathophysiology of Pain

33. Pathophysiology • The generation of pain involves interaction between all parts of the nervous system.

34. Pathophysiology • Significant strides have been made as to how the body senses and interprets pain over the last 2 decades. • Pain-generation pathways more clearly understood. • Chronic pain better understood.

35. Pathophysiology • Pain is more than a just a feeling or sensation, but linked to the complex psychosocial factors that surround traumatic events. • Pain is the brain’s interpretation of the painful stimulus.

36. Pathophysiology • Perceiving pain: • Algogenic substances—chemicals released at the site of injury. • Nociceptors—Afferent neurons that carry pain messages. • Referred pain—pain that is perceived as if it were coming from somewhere else in the body.

37. Pathophysiology • Nociception • Derived from the word noxious meaning harmful or damaging to the tissues. • Mechanical event that occurs in tissues undergoing cellular injury.

38. Pathophysiology • Nociceptive stimulus is detected by free nerve endings in the tissues. • Three type of stimuli excite pain receptors: • Mechanical • Thermal • Chemical

39. Pathophysiology • Pain fibers are free fibers.

40. Pathophysiology • Pain fibers principally located in the superficial layers of the skin. • Pain fibers also located in: • Periosteum • Arterial walls • Joint surfaces • Falx and tentorium of the cranial vault.

41. Pathophysiology • Deep structures: • Sparsely supplied with pain fibers • Widespread tissue damage still causes the slow, chronic, aching-type pain.

42. Pathophysiology • Visceral Pain: • Ischemia • Chemical stimuli • Spasm of hollow viscus • Over distension of a hollow viscous

43. Pathophysiology • Chemicals that excite pain receptors: • Bradykinin • Serotonin • Histamine • Potassium ions • Acids • Acetylcholine • Proteolytic enzymes

44. Pathophysiology • Chemicals that enhance the sensitivity of pain endings, but do not necessarily excite them: • Prostaglandins • Substance P

45. Pathophysiology • Types of pain: • Fast Pain: • Felt within 0.1 second after painful stimulus • Also called: sharp pain, pricking pain, electric pain and acute pain. • Felt with needle stick, laceration, burn

46. Pathophysiology • Types of pain: • Slow Pain: • Felt within 1.0 second or more after painful stimulus • Also called: dull pain, aching pain, throbbing pain and chronic pain. • Usually associated with tissue destruction

47. Pathophysiology • Pain fibers transmit impulse to spinal cord through fast or slow fibers: • A-δ (delta) fibers—small myelinated fibers that transmit sharp pain. • C fibers—small unmyelinated fibers that transmit dull pain or aching pain.

48. Pathophysiology • Pain is often a “double” sensation as fast pain is transmitted by the Aδ fibers while a second or so later it is transmitted by the C fiber pathway.

49. Pathophysiology • Pain impulses enter the spinal cord from the dorsal spinal nerve roots. • Fibers terminate on neurons in the dorsal horns.