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pain [odyn-]

Odyn- is a prefix meaning pain. An unpleasant sensory & emotional experience associated with actual or potential tissue damage or described in terms of such damage. 3 hierarchichal levels of pain 1) sensory-discriminatory component - location, intensity, quality 2) motivational-affective component - depression, anxiety, unhappiness 3) cognitive-evaluative component - thoughts concerning the cause & significance Classification: 1) nociceptive pain a) trauma or burns - infection or inflammation - ischemia - mechanical deformity - distension - arthropathies - rheumatoid arthritis - osteoarthritis - gout - post-traumatic arthropathies - mechanical neck & back syndromes b) myalgia (i.e myofascial pain syndromes) - non-articular inflammatory disorders (e.g. polymyalgia rheumatica) c) visceral pain - pain of internal organs & viscera 2) neuropathic pain a) peripheral nervous system - postherpetic neuralgia - trigeminal neuralgia - painful diabetic polyneuropathy - post-amputation (phantom limb) pain b) central nervous system - post-stroke pain (central pain) - myelopathic/radiculopathic pain - multiple sclerosis - spinal stenosis - arachnoiditis - root sleeve fibrosis c) sympathetic nervous system - reflex sympathetic dystrophy - causalgia (complex regional pain syndromes) 3) mixed or idiopathic pathophysiology a) chronic recurrent headaches - tension headaches - migraine headaches - mixed headaches b) vasculopathic pain syndromes (painful vasculitis) 4) psychologically-based syndrome a) somatization disorders b) hysterical reaction c) negative emotions may increase itching & pain [9] 5) acute pain: pain lasting < one month 6) subacute pain: pain lasting from 1-3 months 7) chronic pain: pain lasting > 3 months Epidemiology: - in long-term care facilities pain correlates with - fractures - pressure ulcers - falls in the elderly - sleeping disorders - cancer - unstable health - depression - number of drugs - female gender - 49% of long-term care residents experience pain [16] History: (pain characteristics) 1) temporal a) acute, recurrent or chronic b) onset & duration c) course & daily variation, including breakthrough pain 2) intensity (average, worst, least, "right now") 3) topography (focal, multifocal, referred, superficial or deep) 4) quality a) aching, throbbing, stabbing, burning b) familiar or unfamiliar pain 5) exacerbating & relieving factors - volitional or nonvolitional 6) response to treatment [1] Clinical manifestations: 1) facial expressions, grimmacing, tears, crying 2) vocalizations a) moaning, groaning b) outbusrts c) explicit expressions of pain 3) noisy breathing 4) body language a) spliting or restricted movement b) rigid or tense body posture c) rocking or pacing d) guarding 5) social features a) social withdrawal b) lability c) resistance to interventions d) aggression, combativeness 6) loss of appetite, refusal of food 7) change in sleep patterns 8) confusion, irritability, delirium [12] 9) nausea & constipation from opiate use * observing behavioral manifestations of pain is the primary mode of pain assessment in patients with dementia [11] Management: 1) ABCDE for pain assessment & management [4] a) Ask about pain regularly. Assess pain systematically. b) Believe the patient & family in their reports of pain & what relieves it c) Choose pain control options appropriate for the patient, family & setting d) Deliver interventions in a timely, logical & coordinated fashion e) Empower patients & their families. Enable them to control their course to the greatest possible extent 2) principles a) individualize management - despite ABCDE recommendations, GRS11 recommends obtaining a medical interpeter over using family to assess patient's pain concerns if patient not fluent in english [11] b) use simplest approach c) identify & treat source of pain d) recognize & treat emotional & cognitive components [6] e) pain is most often undertreated, not overtreated f) consider combined pharmacologic & non-pharmacologic therapy g) analgesia 1] all analgesic regimens should include a nonopioid drug (NSAID, acetaminophen) unless contraindicated, even if pain is intense enough to require opiate 2] <= 3 days of opiate therapy for severe pain generally adequate 3] avoid > 1 week of opiate therapy for acute pain 2] consider analgesic adjuvant h) anticipate adverse effects i) address patient concerns - physical vs psychologic dependence j) avoid placebos 3) elderly a) acetaminophen should be the initial drug treatment for persistent particularly musculoskeletal pain b) nonselective NSAIDs & COX-2 selective inhibitors may be considered 'with caution' for patients in whom other (safer) therapies have failed c) salsalate may be less nephrotoxic & have less anti-platelet activity than other NSAIDs [11] (evidence supporting the is sparse) [11] d) patients with fibromyalgia or neuropathic pain are candidates for adjuvant analgesics e) breakthrough pain should be anticipated with opioid use; use short-acting, immediate-release opioids - start bowel regimen with opioid (Senna) f) in nursing home, residents age > 95 years, cognitively impaired or black or Asian race less likely to receive prescription analgesics [11] 4) investigational - cold analgesia can block pain signaling

Related

allodynia angina assessment of pain; assessment of pain in patients with dementia central pain syndrome familial pain syndrome indifference to pain insensitivity to pain neurochemical mediators of pain pain & temperature sensation pain intensity scale pain management in palliative care pain threshold level RICED somatoform pain disorder (psychogenic pain, psychalgia) World Health Organization (WHO) pain ladder

Specific

abdominal pain abdominal wall pain acute pain back pain breakthrough pain (BTP) buttock pain; pygalgia cancer pain cheilodynia chest pain chronic pain coccygodynia deafferentation pain dysmenorrhea (menstrual pain) earache; otalgia eye pain (ocular pain, orbital pain) facial pain headache hip pain intractable pain ischemic pain jaw pain limb pain musculoskeletal pain neck pain; cervicalgia nociceptive pain odynophagia (swallowing pain) oral pain pelvic pain postoperative pain procedural pain radicular pain rectal pain (anorectal pain, proctalgia) referred pain respiratory pain sacroliac pain scrotal pain/mass (testicular pain, testicular torsion) shoulder pain spinal pain stinging pain thumb pain toothache (tooth pain, dentalgia, odontalgia, odontodynia, dentagra) vaginal pain vulvodynia; vulvar pain; vulvar burning; vulvar itching

General

sign/symptom

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 19. American College of Physicians, Philadelphia 2021
  2. Tracy B, Sean Morrison R. Pain management in older adults. Clin Ther. 2013 Nov;35(11):1659-68. Review. PMID: 24148553
  3. AGS Panel on Chronic Pain in Older Persons. Clinical Practice Guidelines: The management of chronic pain in older persons, JAGS 46:635, 1998
  4. Pain Management, The American Medical Association, Overview of Physiology, Assessment & Treatment, 2003
  5. Trescot AM et al, Opioid guidelines in the management of non-cancer pain. American Society of Interventional Pain Physicians (ASIPP) Pain Physician. 2006;9:1-40 http://www.painphysicianjournal.com/2006/january/2006;9;1-40.pdf
  6. Diepenmaat AC et al, Neck/should, low back and arm pain in relation to computer use, physical activity, stress, depression among Dutch adolescents Pediatrics 2006; 117:412 PMID: 16452360
  7. Anonymous Prevention and management of pain and stress in the neonate. American Academy of Pediatrics. Committee on Fetus and Newborn. Committee on Drugs. Section on Anesthesiology. Section on Surgery. Canadian Paediatric Society. Fetus and Newborn Committee. Pediatrics. 2000 Feb;105(2):454-61. PMID: 10654977
  8. Pharmacological Management of Persistent Pain in Older Persons AGS Panel on Pharmacological Management of Persistent Pain in Older Persons http://www.americangeriatrics.org/education/final_recommendations.pdf
  9. van Laarhoven AIM et al Role of induced negative and positive emotions in sensitivity to itch and pain in women. Br J Dermatol 2012 Aug; 167:262 PMID: 22404598
  10. Abbadie C, Bhangoo S, De Koninck Y et al Chemokines and pain mechanisms. Brain Res Rev. 2009 Apr;60(1):125-34 PMID: 19146875
  11. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  12. Bjoro K, Herr K. Assessment of pain in the nonverbal or cognitively impaired older adult. Clin Geriatr Med. 2008 May;24(2):237-62 PMID: 18387454
  13. Dowell D, Haegerich TM, Chou R CDC Guideline for Prescribing Opioids for Chronic Pain. United States, 2016 http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm - Olsen Y The CDC Guideline on Opioid Prescribing. Rising to the Challenge. JAMA. Published online March 15, 2016 PMID: 26978227 http://jama.jamanetwork.com/article.aspx?articleid=2503503 - Lee TH Zero Pain Is Not the Goal. JAMA. Published online March 15, 2016 PMID: 26978460 http://jama.jamanetwork.com/article.aspx?articleid=2503504
  14. Abdulla A, Adams N, Bone M et al Guidance on the management of pain in older people. Age Ageing. 2013 Mar;42 Suppl 1:i1-57. Review. PMID: 23420266 Free Article
  15. Herr K. Pain assessment strategies in older patients. J Pain. 2011 Mar;12(3 Suppl 1):S3-S13. Review. PMID: 21396599
  16. Conrad JN Pain Management in Long-Term Care Facilities: Current Research Trends and Future Directions. Annals of Long-Term Care 2019 27(9) e15-e20
  17. Chou R, Fu R, Dana T, Pappas M, Hart E, Mauer KM. Interventional Treatments for Acute and Chronic Pain: Systematic Review. Comparative Effectiveness Review No. 247. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 75Q80120D00006.) AHRQ Publication No. 21-EHC030. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. https://effectivehealthcare.ahrq.gov/products/interventional-treatments-pain/research
  18. Ari M, Alexander JT, Weyer G Prescribing Opioids for Pain. JAMA. 2023;329(20):1789-1790. April 24. PMID: 37093596 https://jamanetwork.com/journals/jama/fullarticle/2804388
  19. MEDICAL BOARD OF CALIFORNIA GUIDELINES FOR PRESCRIBING CONTROLLED SUBSTANCES FOR PAIN.July 2023. https://www.mbc.ca.gov/Download/Publications/pain-guidelines.pdf