management covers a number of methods to prevent, reduce, or stop pain
sensations. These include the use of medications; physical methods such as
ice and physical therapy; and psychological methods.
Pain serves as an alert to potential or actual damage to the body. The
definition for damage is quite broad; pain can arise from injury as well
as disease. Pain that acts as a warning is called productive pain. After
the message is received and interpreted, further pain offers no real
benefit. Pain can have a negative impact on a person's quality of
life and impede recovery from illness or injury. Unrelieved pain can
become a syndrome in its own right and cause a downward spiral in a
person's health and outlook. Managing pain properly facilitates
recovery, prevents additional health complications, and improves a
person's quality of life.
For many years it was believed that infants do not feel pain the way older
children and adults do. As of the early 2000s, however, there has been a
better understanding of the problems of pain, even in infancy.
Before considering pain management, a review of pain definitions and
mechanisms may be useful.
Pain is the means by which the peripheral nervous system (PNS) warns the
central nervous system (CNS) of injury or potential injury to the body.
The CNS comprises the brain and spinal cord, and the PNS is composed of
the nerves that stem from and lead into the CNS. PNS includes all nerves
throughout the body except the brain and spinal cord.
Once the brain has received and processed the pain message and coordinated
an appropriate response, pain has served its purpose. The body uses
natural pain killers, called endorphins, that are meant to derail further
pain messages from the same source. However, these natural pain killers
may not adequately dampen a continuing pain message. Pain is generally
divided into two categories: acute and chronic.
Nociceptive pain, or the pain that is transmitted by nociceptors, is
typically called acute pain. This kind of pain is associated with injury,
headaches, disease, and many other conditions. It usually resolves once
the condition that caused it is resolved. However, following some
disorders, pain does not resolve. Even after healing or a cure has been
achieved, the brain continues to perceive pain. In this situation, the
pain may be considered chronic. The time limit used to define chronic pain
typically ranges from three to six months, although some
healthcare professionals prefer a more flexible definition and consider
pain chronic when it endures beyond a normal healing time. The pain
, persistent and degenerative conditions, and neuropathy, or nerve damage,
is included in the chronic category. Also, constant pain that lacks an
identifiable physical cause, such as the majority of cases of low back
pain, may be considered chronic.
It has been hypothesized that uninterrupted and unrelenting pain can
induce changes in the spinal cord. As of 2004 evidence was accumulating
that unrelenting pain or the complete lack of nerve signals increases the
number of pain receptors in the spinal cord. Nerve cells in the spinal
cord may also begin secreting pain-amplifying neurotransmitters
independent of actual pain signals from the body. Other studies indicate
that even newborn and premature infants who have constant pain will reach
adulthood with greater sensitivity to pain and lower tolerance of stress.
Considering the different causes and types of pain, as well as its nature
and intensity, management can require an interdisciplinary approach. The
elements of this approach include treating the underlying cause of pain,
pharmacological and nonpharmacological therapies, and some invasive
Treating the cause of pain underpins the idea of managing it. Injuries are
repaired, diseases are diagnosed, and certain encounters with pain can be
anticipated and prevented. However, there are no guarantees of immediate
relief from pain. Recovery can be impeded by pain, and quality of life can
Pain-relieving drugs, otherwise called
nonsteroidal anti-inflammatory drugs
, anticonvulsants, and others. NSAIDs and acetaminophen are available as
over-the-counter and prescription medications and are frequently the
initial pharmacological treatment for pain. These drugs can also be used
as adjuncts to other drug therapies, which might require a doctor's
NSAIDs include aspirin, ibuprofen (Motrin, Advil, Nuprin), naproxen sodium
(Aleve), and ketoprofen (Orudis KT). These drugs are used to treat pain
from inflammation and work by blocking production of pain-enhancing
neurotransmitters, such as prostaglandins. Acetaminophen is also effective
against pain, but it is not an anti-inflammatory drug.
NSAIDs and acetaminophen are effective for most forms of mild pain, but
moderate and severe pain may require stronger medication. Narcotics handle
intense pain effectively and are used for cancer pain and acute pain that
does not respond to NSAIDs and acetaminophen.
Narcotics may be ineffective against some forms of chronic pain,
especially since changes in the spinal cord may alter the usual pain
signaling pathways. Furthermore, narcotics are usually not recommended for
long-term use because the body develops a tolerance to narcotics, reducing
their effectiveness over time. In such situations, pain can be managed
with antidepressants and anticonvulsants, which are also only available
with a doctor's prescription.
Although antidepressant drugs were developed to treat depression, it has
been discovered that they are also effective in combating chronic
headaches, cancer pain, and pain associated with nerve damage.
Antidepressants that have been shown to have analgesic (pain reducing)
properties include amitriptyline (Elavil), trazodone (Desyrel), and
imipramine (Tofranil). Anticonvulsant drugs share a similar background
with antidepressants. Developed to treat epilepsy, anticonvulsants were
found to relieve pain as well. Drugs such as phenytoin (Dilantin) and
carbamazepine (Tegretol) are prescribed to treat the pain associated with
Other prescription drugs are used to treat specific types of pain or
specific pain syndromes. For example, corticosteroids are very effective
against pain caused by inflammation and swelling, and sumatriptan
(Imitrex) was developed to treat migraine headaches.
Drug administration depends on the drug type and the required dose. Some
drugs are not absorbed very well from the stomach and must be injected or
administered intravenously. Injections and intravenous administration may
also be used when high doses are needed or if an individual is nauseous.
Following surgery and other medical procedures, patients may have the
option of controlling the pain medication themselves. By pressing a
button, they can release a set dose of medication into an intravenous
solution. This procedure has also been employed in other situations
requiring pain management. Another mode of administration involves
implanted catheters that deliver pain medication directly to the spinal
cord. Delivering drugs in this way can reduce side effects and increase
the effectiveness of the drug.
Pain treatment options that do not use drugs are often used as adjuncts
to, rather than replacements for,
drug therapy. One of the benefits of non-drug therapies is that an
individual can take a more active stance against pain. Relaxation
techniques, such as
and meditation, are used to decrease muscle tension and reduce stress.
Tension and stress can also be reduced through biofeedback, in which an
individual consciously attempts to modify skin temperature, muscle
tension, blood pressure, and heart rate.
Participating in normal activities and exercising can also help control
pain levels. Through physical therapy, an individual learns beneficial
exercises for reducing stress, strengthening muscles, and staying fit.
has been linked to production of endorphins, the body's natural
Acupuncture involves the insertion of small needles into the skin at key
points. Acupressure uses these same key points but involves applying
pressure rather than inserting needles. Both of these methods may work by
prompting the body to release endorphins. Applying heat or being massaged
are very relaxing and help reduce stress. Transcutaneous electrical nerve
stimulation (TENS) applies a small electric current to certain parts of
nerves, potentially interrupt pain signals and induce the release of
endorphins. To be effective, use of TENS should be medically supervised.
Three types of invasive procedures may be used to manage or treat pain:
anatomic, augmentative, and ablative. These procedures involve surgery,
and certain guidelines should be followed before carrying out a procedure
with permanent effects. First, the cause of the pain must be clearly
identified. Next, surgery should be done only if noninvasive procedures
are ineffective. Third, any psychological issues should be addressed.
Finally, there should be a reasonable expectation of success.
Anatomic procedures involve correcting the injury or removing the cause of
pain. Relatively common anatomic procedures are decompression surgeries,
such as repairing a herniated disk in the lower back or relieving the
nerve compression related to carpal tunnel syndrome. Another anatomic
procedure is neurolysis, also called a nerve block, which involves
destroying a portion of a peripheral nerve.
Augmentative procedures include electrical stimulation or direct
application of drugs to the nerves that are transmitting the pain signals.
Electrical stimulation works on the same principle as TENS. In this
procedure, instead of applying the current across the skin, electrodes are
implanted to stimulate peripheral nerves or nerves in the spinal cord.
Ablative procedures are characterized by severing a nerve and
disconnecting it from the spinal cord.
Prior to beginning management, pain is thoroughly evaluated. Pain scales
or questionnaires are used to attach an objective measure to a subjective
experience. Objective measurements allow healthcare workers a better
understanding of the pain being experienced by the patient. Evaluation
also includes physical examinations and diagnostic tests to determine
underlying causes. Some evaluations require assessments from several
viewpoints, including neurology, psychiatry, psychology, and physical
therapy. If pain is due to a medical procedure, management consists of
anticipating the type and intensity of associated pain and managing it
Owing to toxicity over the long term, some drugs can only be used for
acute pain or as adjuncts in chronic pain management. NSAIDs have the
well-known side effect of causing gastrointestinal bleeding, and long-term
use of acetaminophen has been linked to kidney and liver damage. Other
drugs, especially narcotics, have serious side effects, such as
, drowsiness, and
. Serious side effects can also accompany pharmacological therapies; mood
swings, confusion, bone thinning, cataract formation, increased blood
pressure, and other problems may discourage or prevent use of some
Nonpharmacological therapies carry little or no risk. However, it is
advised that individuals recovering from serious illness or injury consult
with their healthcare providers or physical therapists before making use
of adjunct therapies. Invasive procedures carry risks similar to other
surgical procedures, such as infection, reaction to anesthesia, iatrogenic
(injury as a result of treatment) injury, and failure.
A traditional concern about narcotics use has been the risk of promoting
. As narcotic use continues over time, the body becomes accustomed to the
drug and adjusts normal functions to accommodate to its presence.
Therefore, to elicit the same level of action, it is necessary to increase
dosage over time. As dosage increases, an individual may become physically
However, physical dependence is different from psychological addiction.
Physical dependence is characterized by discomfort if drug administration
suddenly stops, while psychological addiction is characterized by an
overpowering craving for the drug for reasons other than pain relief.
Psychological addiction is a very real and necessary concern in some
instances, but it should not interfere with a genuine need for narcotic
pain relief. However, caution must be taken with people with a history of
—Refers to a disease or symptom that has a sudden onset and lasts
a relatively short period of time.
Central nervous system
—Part of the nervous system consisting of the brain, cranial
nerves, and spinal cord. The brain is the center of higher processes,
such as thought and emotion and is responsible for the coordination and
control of bodily activities and the interpretation of information from
the senses. The cranial nerves and spinal cord link the brain to the
peripheral nervous system, that is the nerves present in the rest of
—Refers to a disease or condition that progresses slowly but
persists or recurs over time.
—A condition that is caused by the diagnostic procedures or
treatments administered by medical professionals. Iatrogenic conditions
may be caused by any number of things including contaminated medical
instruments or devices, contaminated blood or implants, or contaminated
air within the medical facility.
—A disease or abnormality of the peripheral nerves (the nerves
outside the brain and spinal cord). Major symptoms include weakness,
numbness, paralysis, or pain in the affected area.
—A chemical messenger that transmits an impulse from one nerve
cell to the next.
—A nerve cell that is capable of sensing pain and transmitting a
—Referring to therapy that does not involve drugs.
Peripheral nervous system (PNS)
—The part of the nervous system that is outside the brain and
spinal cord. Sensory, motor, and autonomic nerves are included. PNS
nerves link the central nervous system with sensory organs, muscles,
blood vessels, and glands.
—Referring to therapy that relies on drugs.
—Anything capable of eliciting a response in an organism or a
part of that organism.
Nonsteroidal anti-inflammatory drugs
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PO Box 850, Rocklin, CA 95677–0850. Web site:
American Pain Society.
4700 West Lake Ave., Glenview, IL 60025. Web site:
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