Understanding pain management

An overview of pain and sedation for the prehospital provider


My understanding of pain and its management has come a long way since I first graduated from paramedic school. It turns out, my original approach: “if they break a little, bone they get a little dose of morphine; if they break a big bone, they get a big dose of morphine,” may have been too simplistic.

The truth is, pain is an incredibly complex experience and managing it is historically done poorly. There have been many calls recently to make pain more of a priority with organizations like the World Health Organization calling for pain relief to be considered a basic human right [1].

The focus of this article will be to provide an overview of what pain is, how it is classified and introduce some of the language that is used in treating pain. This knowledge is essential to use analgesic drugs safely and effectively.

"Pain is not all the same! There are a number ways that pain can differ; each may have an important impact on treatment decisions," writes Lee. (Photo/Getty Images)

What is pain?

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” [2].

A number of different definitions of pain exist. The definition used by the IASP seems most applicable for the prehospital environment. It highlights the fact that pain is more than just a response to tissue damage. In fact, pain can occur in the absence of tissue damage. Including sensory and emotional components of pain illustrates that it is highly subjective. No two people experience pain the same way.

There are also a number of different models of pain. The most practical for paramedics is the Bio-Psycho-Social Model of Illness [3]. This theory suggests that all illness, including pain, is a product of more than just pathology. Tissue damage alone (the biological component) cannot explain the pain experience. One example of this is phantom pain from an amputated limb.

A patient’s previous experience with pain can impact the level of distress during injury. This psychological component can help understand why the level of distress may be incredibly different when a high school student breaks their nose for the first time, versus a boxer who has had their nose broken half a dozen times. Socially, environmental stressors and interpersonal relationships can also influence distress levels. This is often why high levels of anxiety in parents or bystanders can increase levels of distress for the patient.

Is all pain the same?

Pain is not all the same! There are a number ways that pain can differ; each may have an important impact on treatment decisions. Common ways to classify pain include: intensity, etiology, duration and pathophysiology [4]. These distinctions are important for several reasons: First, to classify the pain, the pain must be assessed. Second, it is vital in selecting the appropriate treatment approach and finally, it emphasizes the fact that the pain experience can change.

 

Examples of pain classifications [5]

Etiology

Reference specific needs of patients with cancer-related pain

  • Malignant
  • Non-Malignant
Intensity

Commonly measured using Verbal Numeric Scale (0-10)

Numerous other available scales such as Wong-Baker Faces 

  • Mild
  • Moderate 
  • Severe
Duration
  • Acute. Short-term pain, <3 months (e.g., procedural pain, or pain that resolves with healing)
  • Chronic. Long-term pain, >3months (persistent pain beyond anticipated healing time or with indeterminate causes)
  • Episodic. Long-term pain, >3 months (a form of chronic pain with intermittent presentation)
Pathophysiology
  • Nociceptive pain. Normal response to tissue damage (may be somatic [MSK] or visceral [organ]
  • Neuropathic pain. The result of abnormal neural activity secondary to injury, disease or dysfunction

  • Inflammatory pain. Common with acute pain because of the healing process (may become persistent/pathological)

Broadly speaking, paramedics are best equipped to deal with acute pain [5]. While most paramedics would be comfortable treating a patient with 8/10 pain from a broken leg, how many would be willing to give the same dose of morphine to 8/10 neuropathic pain suffered by a diabetic? Would the same treatment be appropriate for 8/10 pain from fibromyalgia?


What is the best way to treat pain?

Every paramedic should have a consistent approach to pain management. It should encompass all of the biological, psychological and social aspects of the pain experience. The most important steps for treating pain do not involve drugs at all!

  • Step one. Treating pain begins and ends with assessment. Classifying the pain is the first step in picking an appropriate intervention. Measuring the pain intensity is important in order to both justify the interventions as well as to assess their effectiveness. Numerous pain and sedation scores are commonly available and aid with consistency.
 

Examples of published pain scales    

 
Adult pain scales [6] Brief Pain Inventory
Faces Pain Scale
McGill Pain Questionnaire
Numeric Rating Scale
Short Form McGill Pain Questionnaire
Thermometer Pain Scale
Visual Analog Scale
Verbal Rating/Descriptor Scale
BPI
FPS
MPQ
NRS
SFMPQ
TPS
VAS
VRS/VDS
Pediatric pain scales [7] Adolescent Pediatric Pain Tool
Children’s Hospital of Eastern Ontario Pain Scale 
Children’s and Infants’ Postoperative Pain Scale 
COMFORT behavioural scale
Face, Legs, Activity, Cry, Consolability
Individualized Numeric Rating Scale 
Numeric Rating Scale
Pain Assessment Tool
Revised Face, Legs, Activity, Cry Consolability
Visual Analog Scale

APPT
CHEOPS
CHIPPS

FLACC
INRS
NRS
PAT
rFLACC
VAS

Infant pain scales [7] Neonatal Pain, Agitation and Sedation Scale
Neonatal Infant Pain Scale 
Pain Assessment Tool 
Premature Infant Pain Profile
Riley Infant Pain Scale 
N-PASS
NIPS
PAT
PIPP
RPS
  • Step two. Consider non-pharmacological interventions. Basic comfort measures like heat and cold, splinting and avoiding/deferring painful procedures are available to every level of provider. It is important to remember the psychological and social components of pain. Anxiety is an important component of distress and should not be ignored!
  • Step three. Consider pharmacological interventions. These decisions are made based on underlying pathology, pain intensity and scope of practice. It is important to remember that a drug like morphine is not necessarily better than acetaminophen, it is just different. Understanding how the drugs work is important in selecting the right treatment approach.

Understanding pain, appropriate assessment and consistent use of non-pharmacological interventions are essential for every healthcare provider.


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References

  1. Cousins, M. J., Brennan, F., & Carr, D. B. (2004). Pain relief: a universal human right. Pain, 112(1), 1–4.doi:10.1016/j.pain.2004.09.002 
  2. IASP Terminology: pain terms https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698
  3. Engel G.L. (2012). The need for a new medical model: a challenge for biomedicine. Psychodynamic psychiatry40(3), 377–396. https://doi.org/10.1521/pdps.2012.40.3.377
  4. Orr, P. M., Shank, B. C., & Black, A. C. (2017). The Role of Pain Classification Systems in Pain Management. Critical Care Nursing Clinics of North America, 29(4), 407–418. doi:10.1016/j.cnc.2017.08.002 
  5. Yousefifard, M., Askarian-Amiri, S., Neishaboori, A.M., Sadeghi, M., Saberian, P. and Baratloo, A. Prehospital pain management; a systematic review of proposed guidelines. Archives of Academic Emergency Medicine. 2019; 7(1): e55.
  6. Karcioglu, Ozgur & Topacoglu, Hakan & Dikme, Ozgur & Dikme, Ozlem. (2018). A systematic review of the pain scales in adults: Which to use?. The American Journal of Emergency Medicine. 36. 10.1016/j.ajem.2018.01.008.
  7. Andersen, R. D., Olsson, E., & Eriksson, M. (2021). The evidence supporting the association between the use of pain scales and outcomes in hospitalized children: A systematic review. International Journal of Nursing Studies115. https://doi.org/10.1016/j.ijnurstu.2020.103840

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