Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++ Pain is a warning mechanism; tissue damage causes release of prostaglandins & other substances that send signals via peripheral nerves (nociceptors) to dorsal horn of spinal cord; from spinal cord, neurotransmitters transmit pain signals to spinothalamic tract & thalamus which process the pain signal in the brain; neurotransmitters (NE, 5HT) & endogenous opioids in brain & spinal cord modulate pain signal ++ Signs/symptoms → physical signs associated with acute pain (↑ HR, BP, diaphoresis) may be absent in those with chronic pain Nociceptive pain: somatic pain & visceral pain Somatic pain → injury to bones, joints, muscle, skin connective tissue; often described as dull, throbbing, aching; localizedVisceral pain → internal organs; GI tract, liver, stomach, pancreas; described as deep, cramping, sharp, stabbing; usually diffuseNeuropathic pain: damage to peripheral or central nerves vs noxious stimuli; often described as burning, tinglingPain Assessment Effective pain relief requires a thorough pain assessment; a pain rating scale such as 0–10 describes intensity only—numerous acronyms available to identify elements of pain assessment ++Table Graphic Jump Location | Download (.pdf) | PrintClinical Pearl 45-1PAINEDPlace: where is the pain?Amount: present & past intensity of pain, worst? best? how often? constant? intermittent? when did it begin? (use numeric, verbal & visual analog scales depending on patient ability)Intensifiers: what makes pain worse?Nullifiers: what makes pain better? What pharmacological & non-pharmacological approaches (including complementary/alternative therapies) have been used? effective?Effects: side effects from past/present therapies? quality of life: physical, psychological & social function?Descriptors: what does it feel like? sharp, stabbing, burning, shooting, dull, aching, throbbing, crampy…? ++ Drug selection & dosingComplete thorough pain assessment & determine etiology of pain → diagnosis should guide drug selection; World Health Organization (WHO) analgesic ladder helps determine approachIndividualize regimen → easier to prevent pain than relieve pain; keep dosing schedules simple & use least invasive therapy possible → PO preferred for convenience & cost-effectiveness; avoid IM administration → painful, erratic absorption; use scheduled doses vs PRN for persistent painDrug selection considerations → pain type & diagnosis, past medication use, age, organ function, & drug-specific factors (ex. PK, metabolism route, dose form)Nonopioids indicated in mild-to-moderate somatic & visceral pain APAP has ↓ AE, drug interactions & contraindications vs NSAIDs → considered 1st line; use may be limited by lack of anti-inflammatory effectsNSAIDs best for somatic or inflammatory pain; continue if/when opioids added → may be limited by hematologic, GI, CV, renal toxicityOpioids indicated for moderate-to-severe acute & chronic pain → no max pharmacologic dose; dose often limited by side effects & individual patient response; combination opioids limited by max dose of nonopioid ingredient; may limit appropriate dose titration Use round the clock long-acting or continuous infusion dosing for persistent pain; initiate 75% of prior 24h use & continue PRN dosing for breakthrough pain (BTP); adjust based on PRN use BTP dose selection based on ... Your MyAccess profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth