PAIN & INADEQUATE RELIEF

Pain is an unpleasant sensation signalling actual or possible injury 1

UNDERSTANDING PAIN

Pain is common and can be the most common reason why you visit your doctor 2

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DOCTORS USE DIFFERENT TERMS FOR DIFFERENT TYPES OF PAIN:

  • ACUTE PAIN,

    such as a sprained ankle,is also called 'short-term' pain.3

  • CHRONIC PAIN,

    such as back pain, is also called 'persistent' or 'long-term' pain.3

  • BREAKTHROUGH PAIN

    is when pain medication is taken to manage a chronic pain, but there are sudden, intense spikes of pain. These spikes are known as breakthrough pain.4

  • Pain that comes and goes,

    like a headache, is called 'RECURRENT' PAIN.3

IT IS NOT UNUSUAL TO HAVE MORE THAN ONE TYPE OF

PAIN, OR TO HAVE PAIN IN SEVERAL PLACES 3

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HOW PAIN MESSAGES TRAVEL 1,3

Pain can come from any part of your body: skin, muscle, ligaments, joints, bones (nociceptive pain), injured tissue (inflammatory pain), nerves (neuropathic pain), internal organs (visceral pain) or a combination of these types of pain (mixed pain).3

Pain signals normally travel from the painful part of the body along thousands of specialised nerve fibres, through the spinal cord, to the brain.3

Pain signals are initially processed in the spinal cord and then in the brain, where there are connections with centres associated with anxiety, emotions, sleep, appetite and memory.3 This creates a very personal experience of pain for each individual.3

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EVALUATION OF PAIN

Neither examinations nor tests can prove that you are in pain.3

Therefore, your doctor will ask you about the history and characteristics of your pain. Your answers will help him/her identify the cause and develop a suitable treatment strategy.

Some examples of the questions your doctor might ask you are:

  • Where is the pain? How does it feel?
  • When did the pain first start? Was there any injury?
  • How did the pain start? Did it begin suddenly or gradually?
  • Is the pain always present, or does it come and go?
  • Does it occur predictably after certain activities (such as after a meal or physical exertion) or in certain body positions?
  • Does anything else makes the pain worse?
  • What, if anything, helps relieve the pain?
  • Does the pain affect your ability to carry out daily activities or to interact with other people?
  • Does it affect your sleep, appetite, or your bowel/ bladder function? If so, how?
  • Does your pain affect your mood and sense of well-being?
  • Is the pain accompanied by feelings of depression or anxiety?

To evaluate the severity of pain, doctors sometimes use a scale of 0 (none) to 10 (severe) or they may ask you to describe the pain as either mild, moderate, severe, or excruciating 1

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TREATMENT OF ACUTE AND CHRONIC PAIN

You are an individual and you will react to pain differently when compared to another person, therefore an individual or "personal" pain plan is essential.5

There are a range of treatments available - not all of them will be suitable for you, and it is therefore important to discuss your options with your healthcare professional.3

Treatments for pain can be broadly categorised as: 2

PHARMACOLOGIC (MEDICINES)

Pharmacological approaches to pain management are the mainstay of treatment for acute and cancer pain and are increasingly being used to manage chronic non-cancer pain.

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NON-PHARMACOLOGIC

Optimal pain management may also include psychological, physical, rehabilitative and sometimes surgical treatment strategies.

These strategies should supplement, but not replace, the use of pain medications.

THE WHO PAIN MEDICATION (ANALGESIC) LADDER PROVIDES YOUR DOCTOR WITH AFRAMEWORK FOR THE PHARMACOLOGICAL MANAGEMENT OF PAIN 5

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These are the steps that your doctor may follow when developing a treatment plan to manage your pain: 5

  • Start you on Step 1 analgesics for mild pain; if these are ineffective, change your prescription to a Step 2 analgesic, and then to Step 3 if required.
  • If Step 1 or 2 analgesics don't work, your doctor would be advised not to switch you to another analgesic at the same level, but to move you up a step.
  • The choice of analgesic will be decided by your doctor and depends on the severity, site and type of pain that you are experiencing.

Pain control is a balancing act between the amount of pain you are experiencing and the amount of medication you take. This generally involves taking a regular amount of pain medication at a dose suitable for your level of pain, but not too much, or you may experience undesirable side effects.4

THE OVERALL OBJECTIVE IS TO RELIEVE YOUR PAIN AS FAST AS POSSIBLE AND PREVENT ITS RETURN, OR TO CONTROL YOUR PAIN WHILE TREATING THE UNDERLYING CAUSE(S) (E.G. INFECTION) 2,5

UNDERSTANDING BREAKTHROUGH PAIN

Breakthrough pain is a sudden and brief flare-up of pain from a chronic condition like back pain, arthritis or cancer.4,6

Even if you’ve been managing your pain with medication, during this flare-up the pain becomes severe enough to “break through” the pain medication that you are taking.6

MEDICAL RESEARCH ESTIMATES THAT BREAKTHROUGH PAIN OCCURS IN:

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CAUSES AND TRIGGERS

Episodes of breakthrough pain often start unexpectedly. The pain can be triggered by something as seemingly harmless as a cough or sneeze. Other possible causes include stress, illness, dressing, any sudden movement, walking and other forms of exercise.4,6

Sometimes you can get breakthrough pain if you have become tolerant to the pain medications you take. Tolerance means you need to take an increasingly higher dose of the medication to get the same pain relief.6

HELPFUL TIP

To help your doctor better understand the pain you're experiencing, keep a record of your breakthrough pain episodes in a pain diary. Make a note of when the pain starts, how long it lasts, and what triggers it 6

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TREATMENT OF BREAKTHROUGH PAIN

Before you can treat breakthrough pain, you need to make sure your chronic pain is well managed.6

Simply increasing the dose of your current pain medication is not thought to be an effective way to manage breakthrough pain. This is because an increase of the pain medication can lead to an overdose and cause unwanted or even dangerous side effects.4

See your doctor or pain specialist if the long-term medication you are taking isn't adequately controlling your pain. You might need to increase the dose, add another pain reliever, or incorporate other treatments.6

HELPFUL TIP

To help your doctor better understand the pain you're experiencing, keep a record of your breakthrough pain episodes in a pain diary. Make a note of when the pain starts, how long it lasts, and what triggers it 6

ASK YOUR DOCTOR ABOUT SUITABLE MEDICATION OPTIONS FOR BREAKTHROUGH PAIN AND WHICH WOULD BE BEST FOR YOU

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POSSIBLE SIDE EFFECTS

It is important for you to check with your doctor if you are unsure or concerned about the side effects of any medication you take.4

Should you experience any side effects that are worrying you, please contact your doctor immediately.4

BREAKTHROUGH PAIN OFTEN REQUIRES TAKING A DIFFERENT APPROACH TO PAIN RELIEF 4 - IT CAN BE MANAGED BY CHANGING YOUR MEDICATION, AVOIDING TRIGGERS, AND TRYING ALTERNATIVE PAIN RELIEF TECHNIQUES.6

CAUTION WITH SELF-MEDICATION

Medical research has shown that the practice of self-medication with analgesics (over-the-counter pain medication) is common among people with chronic pain.7

Self-medication comes with many risks: 8

  • Your self-diagnosis could be incorrect
  • Your choice of treatment may be inappropriate
  • You might delay seeking appropriate medical advice and proper treatment
  • You may experience adverse reactions to the over-the-counter medicine
  • The condition you are trying to self-treat could worsen
  • Some medicine or food interactions are dangerous
  • You may be masking a severe disease
  • There is a risk that you could become dependent on the over-the-counter medicine that you are taking
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INADEQUATE PAIN RELIEF IS A REAL ISSUE 2

Despite the availability of effective pain treatments, there are numerous barriers to effective management, which could result in you not being able to achieve optimal pain control.9

Barriers to pain relief, from your perspective, can include the following:9

  • You may be hesitant to report that the pain has not gone away
  • You could be concerned about distracting your doctor from the treatment of your underlying condition
  • You may fear that pain means your disease or condition is worsening
  • You are concerned about not being a 'good' patient
  • You are reluctant to take your pain medicine
  • You fear addiction to your pain medicine or being thought of as an addict
  • You are worried about unmanageable side effects that may occur
  • You worry that you could become tolerant to your pain medicine
  • You do not adhere to your pain medication regimen

INADEQUATE PAIN MANAGEMENT CAN

HAVE SUBSTANTIAL CONSEQUENCES FOR YOU 10

Unrelieved pain has consequences beyond the immediate perception of pain and can negatively impact your well-being and quality of life on multiple levels. It can: 2,10

  • Impair your sleep
  • Impact sexual function
  • Impair your physical function: Unrelieved acute pain can severely hinder your ability to perform the normal functions of everyday life
  • Cause you unnecessary suffering: With poorly controlled pain you may experience anxiety, fear, anger or even depression
  • Impact you financially: You might need to be hospitalised due to uncontrolled pain, which could be costly
  • Put you at risk of developing chronic pain

FAILURE TO TREAT PAIN IS VIEWED AS UNETHICAL AND AN INFRINGEMENT OF A BASIC HUMAN RIGHT 1,9

IT IS IMPORTANT FOR YOU TO WORK WITH YOUR DOCTOR TO DEVELOP A TREATMENT PLAN THAT ADDRESSES THE CAUSE OF YOUR PAIN AND MANAGES ANY PAIN THAT PERSISTS, DESPITE TREATMENT 11

References:

1. South African Acute Pain Guidelines. 2016. Official publication of The South African Society of Anaesthesiologists (SASA). ISSN-2220-1181.

2. National Pharmaceutical Council. Pain: Current Understanding of Assessment, Management, and Treatments. Available at: https://www.npcnow.org/system/files/research/download/Pain-Current-Understanding-of-Assessment-Management-and-Treatments.pdf Accessed: June 2020.

3. The British Pain Society. Understanding and managing pain: information for patients. Available at: https://www.britishpainsociety.org/static/uploads/resources/files/book_understanding_pain.pdf Accessed: June 2020.

4. Medical News Today. Causes and treatment of breakthrough pain. Available at: https://www.medicalnewstoday.com/articles/319604 Accessed: June 2020.

5. African Palliative Care Association. Beating Pain: A Pocket Guide for Pain Management in Africa. Available at: https://www.africanpalliativecare.org/images/stories/pdf/beating_pain.pdf. Accessed: June 2020.

6. Healthline. Breakthrough Pain. Available at: https://www.healthline.com/health/breakthrough-pain. Accessed: June 2020.

7. De Barros GAM, Calonego MAM, Mendes RF, et al. The use of analgesics and risk of self-medication in an urban population sample: cross-sectional study. Rev Bras Anestesiol. 2019;69(6):529-536.

8. Bennadi D. Self-medication: A current challenge. Journal of Basic and Clinical Pharmacy. 2014;5(1):19-23.

9. Zuccaro SM, Vellucci R, Sarzi-Puttini P, et al. Barriers to Pain Management: Focus on Opioid Therapy. Clin Drug Investig. 2012;32(1):11-19.

10. Sinatra R. Causes and Consequences of Inadequate Management of Acute Pain. Pain Medicine. 2010;11:1859–1871.

11. U.S. Department of Health and Human Services (May 2019). Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations. Available at: https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf. Accessed: June 2020.