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Chapter
Ten:
The
Management
of Pain and
Discomfort
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Education.
•The elusive nature of pain
•Clinical issues in pain management
•Pain control techniques
•Pain management programs
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•Provides low-level feedback about the
functioning of our bodily systems
•Can lead a person to seek treatment
•Inadequate relief from pain is the most
common reason for requests for euthanasia
or assisted suicide
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•Degree to which pain is felt depends on:
• How it is interpreted
• Context in which it is experienced
• Cultural component - Members from some
cultures react more intensely to it than those
from other cultures
• Gender differences - Women show greater
sensitivity to pain
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•Verbal reports - Large, informal vocabulary
that people use for describing pain
•Pain questionnaires - Ask about the nature of
pain and its intensity
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•Addressing the psychosocial components of
pain - How much:
• Fear it causes
• It has taken over a person’s life
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•Methodological tools can be used to gain
insights about pain
•Pain behaviors: Arise from chronic pain
• Assess how pain has disrupted a patient’s life
• Help define the characteristics of different
pain syndromes
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•Protective mechanism to bring tissue damage
into conscious awareness
•Accompanied by motivational and behavioral
responses
•Negative emotions exacerbate pain and vice
versa
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Mechanical nociception
• Results from mechanical damage to the tissues of the
body
• Nociception: Pain perception
Thermal damage
• Experience of pain due to temperature exposure
Polymodal nociception
• Pain that triggers chemical reactions from tissue
damage
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•Developed scientific understanding of pain
•Nociceptors sense injury and release
chemical messengers to the spinal cord
•A-delta fibers - Small, myelinated fibers
• Respond to mechanical or thermal pain
• Transmit sharp, brief pains rapidly
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•C-fibers - Unmyelinated nerve fibers
• Involved in polymodal pain
• Transmit dull, aching pain
•Periductal gray - Located in the midbrain
• Results in pain relief when stimulated
•Processes in the cerebral cortex are involved
in cognitive judgments about pain
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•Endogenous opioid peptides: Natural pain
suppression system of the body
•Stress-induced analgesia (SIA) - Phenomenon
where acute stress reduces sensitivity to pain
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•Acute pain: Results from a specific injury
that produces tissue damage
• Disappears when the tissue is repaired
• Short in duration, lasting for 6 months or less
•Chronic pain: Begins with an acute episode
but does not decrease with treatment and
the passage of time
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Chronic benign pain
• Persists for 6 months or longer
• Relatively unresponsive to treatment
• Severity of pain varies
Recurrent acute pain
• Intermittent episodes of pain that are acute in character
but chronic in condition
• Recurs for more than 6 months
Chronic progressive pain
• Persists longer than 6 months and severity increases over
time
• Associated with malignancies or degenerative disorders
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Source: National Institute of Neurological Disorders and Stroke, 2007.
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•Both have different psychological profiles
•Chronic pain
• Has an overlay of psychological distress that
complicates diagnosis and treatment
• Patients develop maladaptive coping
strategies
• Interaction of physiological, psychological,
social, and behavioral components
• Pain control techniques are not effective
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•Reacting to a bodily insult with a specific
bodily response
• Exacerbated by stress or by efforts to suppress
pain
•High sensitivity to noxious stimulation
•Impairment in pain regulatory systems
•Psychological distress
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•Pain is exacerbated by:
• Inappropriate prior treatments
• Misdiagnosis or inappropriate prescriptions of
medications
•Lifestyle
• Quit jobs and abandon leisure activities
• Withdraw from families and friends
• Require public assistance
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• Experience loss of self-esteem
• Receive compensation
• Increases pain as it provides an incentive for being
in pain
•Relationships
• Family relationships get affected
• Positive attention from spouse may maintain
the pain
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•Behaviors - Alterations in lifestyle interfere
with successful treatment
• Factors in treating the total pain experience
• Understanding the pain behaviors
• Knowing whether they persist after treatment
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•Pain-prone personality: Predispose a person
to experience chronic pain
•Personality attributes associated with chronic
pain
• Neuroticism
• Introversion
• Use of passive coping strategies
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•The Minnesota Multiphasic Personality
Inventory (MMPI) - Instrument used to
develop pain profiles
•Conditions that increase the perception of
pain
• Depression and anger suppression
• Anxiety disorders, substance use disorders,
and other psychiatric problems
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•Area that once hurt does not hurt anymore
•Person feels sensation but not pain
•Person feels pain but is not concerned about
it
•Person is still hurting but is able to tolerate
it
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Administration of drugs
• Most common method of controlling pain
Types of drugs
• Local anesthetics - Affect the transmission of pain
impulses from peripheral receptors to the spinal cord
• Spinal blocking agents
• Antidepressants - Affect the downward pathways from the
brain that modulate pain
Drawbacks
• Undesirable side effects
• Addiction
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•Disrupt the conduct of pain from the
periphery to the spinal cord
•Interrupt the flow of pain sensations from
the spinal cord upward to the brain
•Drawbacks
• Effects are short-lived and it is very expensive
• Surgery damages the nervous system
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•Counterirritation: Inhibiting pain in one part
of the body by stimulating or mildly irritating
another area
•Exercise and other ways of increasing
mobility help the chronic pain patient
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Requires patients to actively participate and
learn
More effective for managing slow-rising pains
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•Providing biophysiological feedback to a
patient about some bodily process of which
the patient is unaware
•Target function to be controlled is identified
and tracked by a machine
• Patient attempts to change the bodily process
with the help of continuous feedback
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•Shifting the body into a state of low arousal
by progressively relaxing different parts of
the body using controlled breathing
•Beneficial physiological effects are due to
the release of endogenous opioid
mechanisms
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•Turning attention away from pain by:
• Focusing on an irrelevant and attentiongetting stimulus
• Distracting oneself with a high level of activity
•Most effective for coping with low-level pain
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•Helps chronic pain patients manage pain
•Expected duration of pain determines which
coping strategy a patient should be trained in
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•Reconceptualizes a problem from
overwhelming to manageable
•Patients:
• Believe that the required skills will be taught
to them
• Become competent individuals aiding in the
control of pain
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• Learn to break up maladaptive behavioral
syndromes
• Learn to make adaptive responses to pain
• Are encouraged to attribute their success to
their own efforts
• Are taught relapse prevention
• Are trained to control their emotional
responses to pain
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•Interdisciplinary efforts, bringing together
neurological, cognitive, behavioral, and
psychological expertise concerning pain
•Steps
• Initial evaluation
• Individualized treatment
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•Components
• Patient education
• Involvement of family
• Relapse prevention
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