Assessment and Treatment of Pain:Issues and Challenges

* Underassessment and undertreatment
* Interpatient variability 
* Patient not believed
* OPIOIDS 
* Complex pathophysiology

Defining Pain
  By definition……  a disease process alters the way a system or organ system responds to different types of homeostatic processes within the body.





Suffering
People suffer from what they have lost of themselves…..

it continues until the threat of disintegration  has passed or until the integrity of the person can be restored in some other manner.          
                             Eric J Cassel, NEJM , 1982



PAIN is a sensory processing system with a known anatomy and physiology
Overview of Pain Perception


         Nociceptive Pain
          SOMATIC
* Well-localized
* Aching,throbbing,
         gnawing

> bone         
> joints
> soft tissue 
> muscle
> skin
         VISCERAL
* Poorly localized
* Deep  aching, cramping,pressure,
* Referred

> Bowel obstruction
> Biliary colic
> liver pain
> appendix




Overview of Pain Perception


Neuropathic Pain: injury to peripheral  nerves and/or CNS
* Burning
* Stinging
* Shooting
* Lancinating
* Pins and needles
* Vicelike
* Electric
* Tingling



Myofascial Pain
* Deep aching pain
* Burning or stinging sensation
* Restricted movement in involved areas
* Muscle spasms
* Trigger points- feel indurated to palpation
* Taut muscle bands

Pain Assessment
* What is the pain generator ?

* What is the pain mechanism ?
* Nociceptive
* Neuropathic
* Myofascial
* Mixed
Pain Assessment
* Are there pain amplifiers ?

* Anxiety
* Depression
* PTSD
* Substance Abuse Disorder
Are there RED FLAGS ?????
History and Physical Exam

* Events at pain onset
* Pain:  
* site & radiation
* quality 
* intensity (numeric score 0-10)
* temporal pattern
* provocations & sources of relief
* Activities and functional limitations
* Sleep disruption
* Previous therapies
		                   	                                
Conclusions
     Chronic Pain ? Chronic Disease

Chronic Disease Management Approach
                          based on
            Biopsychosocial Model
Conclusions
* Not all patients with the same pain diagnosis have the same pain mechanisms
* Different mechanisms can coexist
* Treatment approaches that target each pain generator can improve outcomes  
Conclusions
Secondary prevention depends on
early and aggressive assessment and management of pain