MANIKAKA TOPAWALA INSTITUTE OF NURSING

SUBJECT: Community Health Nursing

TOPIC: “Development of protocol for pain

management”

Submitted To,
Mr. SiddaramSarate
HOD of community health nursing
MTIN.
Submitted By,
Vaibhavi Shastri
2nd year Msc
Id No: 20MNCH002
MTIN.
Submitted On,
3/01/2022
  Introduction

 Pain motivates the individual to withdraw from damaging situations, to protect a

damaged body part while it heals, and to avoid similar experiences in the future. 
 Most pain resolves once the noxious stimulus is removed and the body has healed, but it
may persist despite removal of the stimulus and apparent healing of the body.
Sometimes pain arises in the absence of any detectable stimulus, damage or disease.
 Pain is the most common reason for physician consultation in most
developed countries. It is a major symptom in many medical conditions, and
can interfere with a person's quality of life and general functioning.
 Simple pain medications are useful in 20% to 70% of cases. Psychological factors such
as social support, hypnotic suggestion, cognitive behavioral therapy, excitement, or
distraction can affect pain's intensity or unpleasantness. In some debates
regarding physician-assisted suicide or euthanasia, pain has been used as an argument to
permit people who are terminally ill to end their live.

 Definition of pain
 Pain is defined as “an unpleasant sensation caused by noxious stimulation of the sensory
nerve endings. It is a subjective feeling and an individual response to the cause. Pain is a
cardinal symptom of inflammation and is valuable in the diagnosis of many disorders
and conditions. It may be mild or severe, chronic or acute, lancinating, burning, dull or
sharp, precisely or poorly localized, or referred. Experiencing pain is influenced by
physical, mental, biochemical, psychological, physiologic, social, cultural, and
emotional factors”.
 Process of Pain Nociception is the process where information about tissue damage is
conveyed to the central nervous system through sensory receptors (nociceptors). There
can be pain without nociception (such as phantom limb pain), or nociception without
pain. Pain occurs through four activities:

1 )Transduction: Energy is converted from a noxious stimulus (thermal, mechanical, or

chemical) into electrical energy (nerve impulses) by nociceptors.

2) Transmission: The transmission of the neural signals from the transduction site to the spinal
cord and brain.
3) Perception: In higher structures, the arriving signals are appreciated as pain.

4) Modulation: It Occurs at the spinal cord level; descending input from the brain influences
(modulates) nociceptive transmission .

 Types Of Pain
 Types of Pain Pain is categorized as nociceptive or neuropathic, depending on the
underlying pathophysiology.
 Nociceptive pain is caused by the ongoing activation of nociceptors responding to
noxious stimuli (such as inflammation, injury, or disease). Visceral pain arises from
visceral organs, while pain coming from tissues is called somatic pain. In nociceptive
pain, the central nervous system is functioning appropriately. There is a close
association between the intensity of the stimulus and the perception of pain, indicating
real or potential tissue damage.
 Neuropathic Pain or pathologic pain is caused by abnormal signals in the central or
peripheral nervous systems, demonstrating injury or impairment. Causes of neuropathic
pain may include inflammation, trauma, infections, tumors, metabolic diseases, toxins,
or neurological disease.
 Acute versus Chronic Pain Pain can be classified as acute or chronic.
 Acute pain is complex, and is described as an unpleasant experience with an
identifiable precipitating cause. Acute pain generally has defined pathology, and can
resolve with healing of the underlying injury. Acute pain can also be seen as a reflexive
and protective response.
 Chronic pain is described as pain that persists at least three months beyond the
expected course of an acute injury or illness. Chronic pain can also disrupt activities of
daily living and sleep, and has no protective purpose.

 Pain Assessment
 Pain is often referred to as the fifth vital sign and should be assessed regularly and
frequently. Pain is individualized and subjective therefore, the patient’s self-report of
pain is the most reliable gauge of the experience.
 If a patient is unable to communicate, the family or caregiver can provide input. Use of
interpreter services may be necessary. Components of pain assessment include:

a) History and physical assessment

b) Functional assessment

c) Psychosocial assessment
d) Multidimensional assessment

a) History and Physical Assessment

The assessment should include physical examination and the systems in relation to pain
evaluation. Areas of focus should include site of the pain, musculoskeletal system, and
neurological system. Other components of history and physical assessment include:

• Patient’s self-report of pain

• Patient’s behaviors and gestures that indicate pain (e.g. crying, guarding, etc.)

• Specific aspects of pain: onset and duration, location, quality of pain (as described by patient),
intensity, aggravating and alleviating factors

 Medication history
 Disease or injury history

• History of pain relief measures, including medications, supplements, exercise, massage,

complementary and alternative therapies.

b) Functional and Psychosocial Assessment

 Components of the functional and psychosocial assessment include:

• Reports of patient’s prior level of function

• Observation of patient’s behaviors while performing functional tasks

• Patient or family’s report of impact of pain on activities of daily living, including work, self-
care, exercise, and leisure

• Patient’s goal for pain management and level of function

• Patient or family’s report of impact of pain on quality of life

• Cultural and developmental considerations

• History of pain in relation to depression, abuse, psychopathology, chemical or alcohol use

• Impact of pain on patient’s cognitive abilities.

d) Multidimensional Assessment

 Many tools are available for an in-depth, multidimensional pain assessment. This is
particularly important with patients that have chronic pain, mixed pain (both acute and
chronic), or complex situations (such as multiple disease processes). Common examples
of these tools include:
 Brief Pain Inventory: Provides patient input in describing pain and effects, including
psychosocial components.
 McGill Pain Questionnaire: Patients can use descriptors for their pain, which provides
information about the experience and intensity.

 Common Pain Scales

 There are a variety of pain scales used for pain assessment, for patients from neonates
through advanced ages. The three most common scales recommended for use with pain
assessment are:
1) The numeric scale
2) The Wong-Baker scale (also known as the FACES scale)

1) The numeric scale

 The numeric scale is the most commonly used pain scale with adult patients, rating pain
on a scale of 0-10. Many nurses ask for a verbal response to the question. Use of this
scale with the visual analog can provide a more accurate response. This scale is
appropriate with patients aged nine and older that are able to use numbers to rate their
pain intensity .

2) Wong-Baker Scale
 The Wong-Baker FACES Scale uses drawn faces for patients to express their level of
pain. The faces are associated with numbers on a scale ranging from 0 to 10. This scale
is most commonly used with children, and is appropriate to use with patients ages three
 and older. Adults who have developmental or communication challenges may benefit
from using this scale .

FLACC Scale

 FLACC is the acronym for Face, Legs, Activity, Cry, and Consolability. This scale is
based on observed behaviors, and is most commonly used with pediatric patients less
than three years of age. The behaviors that are described are associated with a number;
each component is totaled for a number ranging from 0 to 10. This scale is also
appropriate with patients who have developmental delays or are non-verbal.

 Pharamacological management
 The simple meaning of pharamacological management means when a patient takes a
prescribed medicine, several side effects may be expected but can involve the potential
for drug dependency or addiction.
 The World Health Organization (WHO) recommends a pain ladder for managing pain
relief with pharmaceutical medicine. It was first described for use in cancer pain.
However it can be used by medical professionals as a general principle when managing
any type of pain. In the treatment of chronic pain, the three-step WHO Analgesic Ladder
provides guidelines for selecting the appropriate medicine. The exact medications
recommended will vary by country and the individual treatment center, but the
following gives an example of the WHO approach to treating chronic pain with
medications. If, at any point, treatment fails to provide adequate pain relief, then the
doctor and patient move onto the next step.

Headache paracetamol /acetaminophen, NSAIDs

Migraine paracetamol, NSAIDs

Menstrual cramps NSAIDs

Minor trauma such paracetamol, NSAIDs

as a bruise,
abrasions, sprain

Severe trauma such Opioids

as a wound, burn,
bone fracture or
severe sprain

Strain or pulled NSAIDs, muscle relaxants

muscle

Minor pain aftrer paracetamol, NSAIDs

surgery

Severe pain after Opioids

surgery

Muscle ache paracetamol, NSAIDs

Toothache pain from paracetamol, NSAIDs

dental procedures

Kidney stone pain paracetamol, NSAIDs, opioids

Pain due to Antacid, H2 antagonist , proton pump inhibitor

heartburn or
gastroesophageal
reflux disease

Chronic back pain paracetamol, NSAIDs

Osteoarthritis pain paracetamol, NSAIDs

Fibromyalgia Antidepressant, anticonvulsant

 Mild pain
 Paracetamol (acetaminophen), or a nonsteroidal anti-inflammatory drug (NSAID) such
as ibuprofen will relieve mild pain

 Mild to moderate pain

 Paracetamol, an NSAID or paracetamol in a combination product with a

weak opioid such as tramadol, may provide greater relief than their separate use. A
combination of opioid with acetaminophen can be frequently used such as
Percocet, Vicodin, or Norco.
 Moderate to severe pain

 When treating moderate to severe pain, the type of the pain, acute or chronic,
needs to be considered. The type of pain can result in different medications
being prescribed. Certain medications may work better for acute pain, others for
chronic pain, and some may work equally well on both. Acute pain medication
is for rapid onset of pain such as from an inflicted trauma or to treat post-
operative pain. Chronic pain medication is for alleviating long-lasting, ongoing
pain.
 Morphine is the gold standard to which all narcotics are compared. Semi-
synthetic derivatives of morphine such
as hydromorphone (Dilaudid), oxymorphone (Numorphan,
Opana), nicomorphine (Vilan), hydromorphinol and others vary in such ways as
duration of action, side effect profile and milligramme potency. 
 Fentanyl has the benefit of less histamine release and thus fewer side effects. It
can also be administered via transdermal patch which is convenient for chronic
pain management. In addition to the intrathecal patch and injectable fentanyl
formulations, the FDA (Food and Drug Administration) has approved various
immediate release fentanyl products for breakthrough cancer pain
(Actiq/OTFC/Fentora/Onsolis/Subsys/Lazanda/Abstral). 
 Oxycodone is used across the Americas and Europe for relief of serious chronic
pain. Its main slow-release formula is known as OxyContin. Short-acting tablets,
capsules, syrups and ampules which contain OxyContin are available making it
suitable for acute intractable pain or breakthrough pain. Diamorphine,
and methadone are used less frequently. Clinical studies have shown that
transdermal Buprenorphine is effective at reducing chronic pain. Pethidine,
known in North America as meperidine, is not recommended for pain
management due to its low potency, short duration of action, and toxicity
associated with repeated use. Pentazocine, dextromoramide and dipipanone are
also not recommended in new patients except for acute pain where other
analgesics are not tolerated or are inappropriate, for pharmacological and
 misuse-related reasons. In some countries potent synthetics such
as piritramide and ketobemidone are used for severe pain. Tapentadol is a newer
agent introduced in the last decade.
 For moderate pain, tramadol, codeine, dihydrocodeine, and hydrocodone are
used,
with nicocodeine, ethylmorphine and propoxyphene or dextropropoxyphene (les
s commonly).
 Drugs of other types can be used to help opioids combat certain types of
pain. Amitriptyline is prescribed for chronic muscular pain in the arms, legs,
neck and lower back with an opiate, or sometimes without it or with an NSAID.
 While opiates are often used in the management of chronic pain, high doses are
associated with an increased risk of opioid overdose.[61]
 Opioids

 Opioid medications can provide short, intermediate or long acting analgesia depending

upon the specific properties of the medication and whether it is formulated as an
extended release drug. Opioid medications may be administered orally, by injection, via
nasal mucosa or oral mucosa, rectally, transdermally, intravenously, epidurally and
intrathecally. In chronic pain conditions that are opioid responsive, a combination of a
long-acting (OxyContin, MS Contin, Opana ER, Exalgo and Methadone) or extended
release medication is often prescribed along with a shorter-acting medication
(oxycodone, morphine or hydromorphone) for breakthrough pain, or exacerbations.
 Most opioid treatment used by patients outside of healthcare settings is oral
(tablet, capsule or liquid), but suppositories and skin patches can be prescribed. An
opioid injection is rarely needed for patients with chronic pain.
 Although opioids are strong analgesics, they do not provide complete analgesia
regardless of whether the pain is acute or chronic in origin. Opioids are effective
analgesics in chronic malignant pain and modestly effective in nonmalignant pain
management.[64] However, there are associated adverse effects, especially during the
commencement or change in dose. When opioids are used for prolonged periods drug
tolerance, chemical dependency, diversion and addiction may occur.

The list below consists of commonly used opioid analgesics which have long-acting
formulations. Common brand names for the extended release formulation are in parentheses.

 Oxycodone (OxyContin)
 Hydromorphone (Exalgo, Hydromorph Contin)
 Morphine (M-Eslon, MS Contin)
 Oxymorphone (Opana ER)
 Fentanyl, transdermal (Duragesic)
 Buprenorphine*, transdermal (Butrans)
 Tramadol (Ultram ER)
 Tapentadol (Nucynta ER)
 Methadone* (Metadol, Methadose)
 Hydrocodone bitartrate (Hysingla ER) and bicarbonate (Zohydro ER)

*Methadone and buprenorphine are each used both for the treatment of opioid addiction and as
analgesics

 Nonsteroidal anti-inflammatory drugs

 The other major group of analgesics are nonsteroidal anti-inflammatory drugs (NSAID).

They work by inhibiting the release of prostaglandins, which cause inflammatory
pain. Acetaminophen/paracetamol is not always included in this class of medications.
However, acetaminophen may be administered as a single medication or in combination
with other analgesics (both NSAIDs and opioids).
 The alternatively prescribed NSAIDs such as ketoprofen and piroxicam have limited
benefit in chronic pain disorders and with long-term use are associated with
significant adverse effects. The use of selective NSAIDs designated as selective COX-2
inhibitors have significant cardiovascular and cerebrovascular risks which have limited
their utilization. Common NSAIDs include aspirin, ibuprofen, and naproxen. There are
many NSAIDs such as parecoxib (selective COX-2 inhibitor) with proven effectiveness
after different surgical procedures. Wide use of non-opioid analgesics can reduce
opioid-induced side-effects.

 Antidepressants and antiepileptic drugs

 Some antidepressant and antiepileptic drugs are used in chronic pain management and

act primarily within the pain pathways of the central nervous system, though peripheral
mechanisms have been attributed as well. They are generally used to treat nerve brain
that results from injury to the nervous system. Neuropathy can be due to chronic high
blood sugar levels (diabetic neuropathy). These drugs also reduce pain from viruses
such as shingles, phantom limb pain and post-stroke pain. These mechanisms vary and
in general are more effective in neuropathic pain disorders as well as complex regional
pain syndrome. A common anti-epileptic drug is gabapentin, and an example of an
antidepressant would be amitriptyline.
  Cannabinoids

 Evidence of medical marijuana's effect on reducing pain is generally conclusive.

Detailed in a 1999 report by the Institute of Medicine, "the available evidence from
animal and human studies indicates that cannabinoids can have a substantial analgesic
effect".In a 2013 review study published in Fundamental & Clinical Pharmacology,
various studies were cited in demonstrating that cannabinoids exhibit comparable
effectiveness to opioids in models of acute pain and even greater effectiveness in
models of chronic pain.

 Other analgesics

 Other drugs which can potentiate conventional analgesics or have analgesic properties
in certain circumstances are called analgesic adjuvant medications. Gabapentin, an
anticonvulsant, can reduce neuropathic pain itself and can also potentiate opiates. Drugs
with anticholinergic activity, such as orphenadrine, cyclobenzaprine, and trazodone, are
given in conjunction with opioids for neuropathic pain. Orphenadrine and
cyclobenzaprine are also muscle relaxants, and are useful in painful musculoskeletal
conditions. Clonidine, an alpha-2 receptor agonist, is another drug that has found use as
an analgesic adjuvant.

 Non Pharamacological Management

 Non-pharmacological methods used in pain management can be classified in different
ways. In general; they are stated as physical, cognitive, behavioral and other
complementary methods or as invasive or -non-invasive methods. This method utilizes
ways to alter thoughts and focus concentration to better manage and reduce pain.
Methods of non-pharmacological pain include:

A. Education and psychological conditioning

B. Hypnosis

C. Comfort therapy

D. Physical and occupational therapy

E. Psychosocial therapy/counseling

F. Neurostimulation

G. Biofeedback techniques

H. Electrical stimulation
  Education and psychological conditioning

 High levels of pain, significant anxiety, or depressive symptoms before surgery put
patients at elevated risk for chronic pain and prolonged opioid use following surgery .
 Preoperative depression has been linked to a variety of adverse outcomes following
lumbar fusion, including increased pain, disability, and 30-day readmission rates. The
association between depression and opioid use following lumbar fusion is increasingly
relevant given the epidemic of opioid abuse sweeping the country in recent years
Current psychological approaches to the management of chronic pain include
interventions that aim to achieve increased self-management, behavioral change, and
cognitive change rather than directly eliminate the locus of pain.
 As such, they target the frequently overlooked behavioral, emotional, and cognitive
components of chronic pain and factors contributing to its maintenance

 Comfort Therapy
 Complementary therapies can increase comfort, decrease pain, promote relaxation and
increase the quality of life for hospice patients and their families. Therapies can be used
individually or in combination. All therapies are individually tailored for each patient to
offer unique benefits . Comfort therapy can help improve the quality of life by
alleviating symptoms of pain and providing relaxation and comfort. Response to
treatment or therapy is individual and that what works for some might not be as
effective for others .

 Companionship
 Patients with chronic pain from a non-supportive family tended to show more pain
behaviors and more emotional distress compared with pain patients coming from
supportive families . Due to inadequate knowledge and skill, family caregivers may be
unfamiliar with the type of care they must provide or the amount of care needed .
According to the Operant Conditioning Model of Chronic Pain, both verbal and non-
verbal forms of communication are used to convey patients’ desire for support, attention

and intimacy, and to elicit empathic responses from others. In turn, affected patients’
 communication may be maintained by social reinforcement (e.g. the sympathetic
response of significant others) .
  WHO recommend intervention to improve labor outcomes and satisfaction. Companion
of choice at birth increases the likelihood of vaginal births, therefore reduces the need
for caesarean sections and the use of forceps or vacuum during vaginal births. In
addition, it reduces the need to use pain medications during labor, it shortens the
duration of labor and improves women’s satisfaction with care. It also improves Apgar
scores (a measure of the physical condition of a newborn infant) of the newborns.
 Heat/cold application
 Cryotherapy (the use of extreme cold in surgery or other medical treatment) and
thermotherapy as therapeutic methods in the patients with acute and chronic low back
pain had an equal effect on relieving the pain based on evaluative and descriptive
measures .
 Application of cold promotes relief of pricking pain sensation and suppression of
autonomic responses, and that application of heat has no such effect . Use of cooling
therapy for musculoskeletal problems can also reduce intake of painkillers because it
reduces pain and body fluid penetration .
 Pain after thoracotomy is probably the most severe pain experienced after surgeries and
patients who underwent cardiac surgeries report having most severe pain while
coughing and deep breathing. Pain was significantly decreased with the use of cold gel
packs . Usually the chest tube removal (CTR) has been described as one of the worst
experiences by patients in the intensive care unit. Regarding the relaxation and cold
application methods showed relatively equal effects on reducing the pain owing to CTR.
 Lotions/massage therapy
 Massage is mainly used to promote relaxation, treat painful muscular conditions; it can
also foster communication, including decreased stress (and decreased cortisol),
improved sleep patterns, and enhanced immune function.

 Massage Techniques

Effleurage Gentle stroking along the length of a muscle

Petrissage Pressure applied across the width of a muscle

Friction Deep massage applied by circular motions of the thumbs or fingertips

Kneading Squeezing across the width of a muscle

Tapotement Light slaps or karate chops

 Physical medicine and rehabilitation

 Physical medicine and rehabilitation uses a range of physical techniques such as heat
and electrotherapy, as well as therapeutic exercises and behavioral therapy. These
techniques are usually part of an interdisciplinary or multidisciplinary program that
might also include pharmaceutical medicines.
 Spa therapy has showed positive effects in reducing pain among patients with chronic
low back pain. However there are limited studies looking at this approach. Studies have
shown that kinesiotape could be used on individuals with chronic low back pain to
reduce pain.
  The Center for Disease Control recommends that physical therapy and exercise can be
prescribed as a positive alternative to opioids for decreasing one's pain in multiple
injuries, illnesses, or diseases. This can include chronic low back pain, osteoarthritis of
the hip and knee, or fibromyalgia. Exercise alone or with other rehabilitation disciplines
(such as psychologically based approaches) can have a positive effect on reducing
pain. In addition to improving pain, exercise also can improve one's well-being and
general health.
 Manipulative and mobilization therapy are safe interventions that likely reduce pain for
patients with chronic low back pain. However, manipulation produces a larger effect
than mobilization.
 Specifically in chronic low back pain, education about the way the brain processes pain
in conjunction with routine physiotherapy interventions may provide short term relief of
disability and pain

 Exercise interventions

 Physical activity interventions, such as tai chi, yoga and Pilates, promote harmony of
the mind and body through total body awareness. These practices incorporate breathing
techniques, meditation and a wide variety of movements, while training the body to
perform functionally by increasing strength, flexibility, and range of motion.Physical
activity and exercise may improve chronic pain (pain lasting more than 12 weeks), and
overall quality of life, while minimizing the need for pain medications.More
specifically, walking has been effective in improving pain management in chronic low
back pain

 TENS

 Transcutaneous electrical nerve stimulation (TENS) is a self-operated portable device

intended to help regulate and create chronic pain via electrical impulses. Limited
research has explored the effectiveness of TENS in relation to pain management of
Multiple Sclerosis (MS). MS is a chronic autoimmune neurological disorder, which
 consists of the demyelination of the nerve axons and disruption of nerve conduction
velocity and efficiency. In one study, electrodes were placed over the lumbar spins and
participants received treatment twice a day and at any time when they experienced a
painful episode. This study found that TENS would be beneficial to MS patients who
reported localized or limited symptoms to one limp. The research is mixed with whether
or not TENS helps manage pain in MS patients.
 Transcutaneous electrical nerve stimulation has been found to be ineffective for lower
back pain. However, it might help with diabetic neuropathy as well as other illnesses.

 tDCS

 Transcranial direct current stimulation (tDCS) is a non-invasive technique of brain

stimulation that can modulate activity in specific brain cortex regions, and it involves
the application of low-intensity (up to 2 mA) constant direct current to the scalp through
electrodes in order to modulate excitability of large cortical areas. tDCS may have a role
in pain assessment by contributing to efforts in distinguishing between somatic and
affective aspects of pain experience. 

 Psychological approach

 Acceptance and Commitment Therapy

 Acceptance and Commitment Therapy (ACT) is a form of cognitive behavioral therapy

that focuses on behavior change rather than symptom change, includes methods
designed to alter the context around psychological experiences rather than to alter the
makeup of the experiences, and emphasizes the use of experiential behavior change
methods. The central process in ACT revolves around psychological flexibility, which
in turn includes processes of acceptance, awareness, a present-oriented quality in
interacting with experiences, an ability to persist or change behavior, and an ability to
be guided by one's values. ACT has an increased evidence base for range of health and
behavior problems, including chronic pain. ACT influences patients to adopt a tandem
process to acceptance and change, which allows for a greater flexibility in the focus of
treatment.
 Acceptance and commitment therapy (ACT) are the most common of the acceptance-
based psychotherapies. ACT is a relatively newer psychological intervention being
implemented in the chronic pain health care setting. ACT is based on behavioral
principles and the psychological flexibility model, and unlike CBT, it does not
emphasize the restructuring of distorted or catastrophic cognitions. The goal within
ACT is to reduce the dominance of pain in person’s life through increased
 psychological flexibility. Unlike other approaches, ACT does not focus on symptom
reduction – even though this can happen in ACT – but on making patients’ responses
toward symptoms more successful in relation to their own goals. When used as an
adjunctive therapy in pain management, ACT fosters the possibility of improved pain
acceptance, which can have important implications for adaptive recovery in postsurgical
patients .

 Cognitive behavioral therapy

 Cognitive behavioral therapy (CBT) helps patients with pain to understand the

relationship between their pain, thoughts, emotions, and behaviors. A main goal in
treatment is cognitive (thinking, reasoning or remembering) restructuring to encourage
helpful thought patterns.[33] This will target healthy activities such as regular exercise
and pacing. Lifestyle changes are also trained to improve sleep patterns and to develop
better coping skills for pain and other stressors using various techniques (e.g.,
relaxation, diaphragmatic breathing, and even biofeedback).
 CBT interventions are delivered within a supportive and empathetic environment that
strives to understand the patient’s pain from a biopsychosocial perspective and in an
integrated manner, most common psychologic intervention for individuals with chronic
pain. CBT is generally based on the “ABC” model and aims at changing dysfunctional
thoughts, emotions, and behaviors. Additionally, CBT has been reported to improve
quality of life and activities of daily living, chronic headache, facial pain, arthralgia, and
fibromyalgia. Behavior modification strategies to effectively reduce pain and fatigue,
and improve sleep, overall physical function and coping CBT focuses on reducing pain
and distress by modifying physical sensations, catastrophic thinking, and maladaptive
behaviors. Combining CBT approaches for pain and for sleep may produce greater
improvements in pain and sleep outcomes compared to either approach in isolation.
Women benefit more from multimodal pain therapy including CBT-oriented group
program than men. CBT had similar effects with fusion spine fusion surgery, but at 12
months the CBT group showed less fear avoidance.

 Mindfulness-based pain management

 Mindfulness-based pain management (MBPM) is a mindfulness-based intervention

(MBI) providing specific applications for people living with chronic pain and illness.
Adapting the core concepts and practices of mindfulness-based stress reduction (MBSR)
and mindfulness-based cognitive therapy (MBCT), MBPM includes a distinctive
emphasis on the practice of 'loving-kindness', and has been seen as sensitive to concerns
about removing mindfulness teaching from its original ethical framework
 within Buddhism. It was developed by Vidyamala Burch and is delivered through the
programs of Breathworks. It has been subject to a range of clinical studies
demonstrating its effectiveness.

 Behavioral approaches

 Diaphragmatic breathing is a basic relaxation technique lowering the harmful effects of

the stress hormone cortisol, HR, BP and chances of injuring or wearing out muscles.. It
improves core muscle stability, body’s ability to tolerate intense exercise . Autogenic
training (AT) combines passive concentration, visualization and deep breathing
techniques, likely to produce Diaphragmatic breathing is a basic relaxation technique
lowering the harmful effects of the stress hormone cortisol, HR, BP and chances of
injuring or wearing out muscles. It improves core muscle stability, body’s ability to
tolerate intense exercise .
 Autogenic training (AT) combines passive concentration, visualization and deep
breathing techniques, likely to produce specific cognitive effects such as reducing
anxiety and enhancing positive mood. The emphasis is to not to control these natural
healing systems, but rather to use their intrinsic potentials more fully. Autogenic
training is the preferred mode of arousal regulation in many European countries.
 Visualization/Guided imagery is one component of CBT that frequently is used and
found effective in fibromyalgia. Imagery has been defined as a dynamic, psycho-
physiological process in which a person imagines, and experiences, an internal reality in
the absence of external stimuli. The guided imagery audio is accompanied by soft
background music and directs the visualization and imagination to a pleasant and
peaceful place that has meaning for the participant to replace negative or stressful
feelings .

 Meditation
 Mindfulness meditation was introduced as a clinical intervention for conditions such as
chronic pain and anxiety in 1979 . Chronic pain patients increasingly seek treatment
through mindfulness meditation, thought to work by refocusing the mind on the present
and increasing awareness of one’s external surroundings and inner sensations, allowing
the individual to step back and reframe experiences . Meditation–based interventions
improve pain symptomology across a wide spectrum of pain-related disorders, including
fibromyalgia, migraine, chronic pelvic pain . Meditation, after the four-session
intervention, during noxious heat produced a mean 40% reduction in pain intensity and
57% reduction in pain unpleasantness ratings .
 A variety of factors are now known to either increase or decrease pain-related brain
activation, including: predictive cues, distraction, attention, expectation, beliefs,
placebo, hypnosis, stress, anxiety, mood and emotional state . Focused attention (FA),
 also known Shamatha (from Sanskrit), is associated with maintaining focus on a
specific object, often the changing sensation or flow of the breath or an external object .
By contrast, open monitoring (OM), or Vipassana (Sanskrit translation), is associated
with a non-directed acknowledgement of any sensory, emotional or cognitive event that
arises in the mind. Zen meditation is considered to be one form of OM practice.

 Music, art, or drama therapy

 Music therapy technique specifically developed for pain management . A single

session of music therapy is effective in significantly reducing cancer pain when
used along with standard palliative care in cancer patients with moderate to
severe pain, chronic pain and anxiety/depression, by altering affective,
cognitive, and sensory processes, music may decrease pain perception by
distraction, change in mood, increased control, use of prior skills, and relaxation,
reduces opioid requirements, improve QoL . Cepeda et al.shows that music
therapy was best for short term pain after surgery. Music is expressive;
individuals may trigger a variety of emotions through creating music in groups
or individually. Via its ability to modify the affective or cognitive state of the
listener, music can be adapted to function as a behavioral intervention for pain .
Tolstoy said that music is the shorthand of emotion, and Congreve explained
that music has charms to soothe a savage breast . As a treatment adjuvant to
reduce chronic pain in FM, and FM-as- 13 sociated sleep disturbances and
increase functional mobility thereby reducing the risk of disability. However,
effectiveness is higher when combined with aerobic exercise, which brings
about further improvements in quality of life and balance . Dramatherapy made
an important contribution to the healthy adjustment of some patients both to
hospital life and to acquired disability.

 Expressive Writing Intervention (EWI)

 Writing increases health and wellness in varied ways. individuals who have written
about their own traumatic experiences exhibit statistically significant improvements in
various measures of physical health, reductions in visits to physicians, and better
immune system functioning . .A positive effect of expressive disclosure specifically on
anxiety and specifically for young adults who were highly emotionally expressive . EWI
had a significant impact on reducing risk of eating pathology in female students and
distress/depression during ART therapy of infertile women . EWI with clinical samples
shows potential benefit of written time management for stressed caregivers.
 Pastor
 The Pain Assessment Screening Tool and Outcomes Registry (PASTOR) is a 20-30-
minute survey that produces a comprehensive 3-page clinician report of a patient’s
 chronic pain. PASTOR was developed as a direct result of the PMTF recommendations;
it is designed to provide an outcomes registry to improve evidence-based decision
making by health care providers and to facilitate pain research .
 PASTOR incorporates the DVPRS, pain interference assessment, neuropathic pain
scale, headache assessment, and patient-defined activity goals. In addition, PASTOR
includes screens for the following conditions: PTSD, anxiety, depression, and alcohol
misuse. Additional pain correlates including global health, fatigue, satisfaction with
social roles, anger, sleep-related impairment, and physical function are also assessed .
 It uses the computerized adaptive learning system of the NIH PROMIS which contains
a large, validated databank of patient-reported outcome surveys. PASTOR serves two
major purposes: first, it collects actionable information that can be used by clinicians to
assess response to treatment and to guide pain management; and second, when
aggregated from large numbers of respondents, it can identify best clinical practices .
PROMIS Pain Interference (PI) scores was a superior tool to gauge a patient’s
preoperative level of pain and functional ability compared to NPRS in foot and ankle
patients.
 Pet Therapy
 Pets provide companionship, unconditional love, and joy. For those with chronic pain,
pets can give their owners even more . According to the Delta Society (Non-profit), pets
decrease feelings of depression, loneliness, and isolation. Pets may also be able to do
your heart some good — they are credited with lowering blood pressure and
cholesterol .
 The American Veterinary Medical Association classifies therapeutic animal assisted
interventions (AAI) into three categories: animal assisted activities (AAA) that utilize
companion animals; animal assisted therapy (AAT) that utilizes therapy animals and
service animal programs (SAP) that utilize service animals [. Therapy dog visits in an
outpatient setting can provide significant reduction in pain and emotional distress for
chronic pain patients . Reductions in measures of cardiovascular stress, improvements
in neurophysiological stress markers (e.g., cortisol), increases in endorphins, and
enhancement of immune factors is also reported.

 Positioning
 Simply assisting a patient to change position in the bed or chair or while ambulating can
improve comfort. Additionally, appropriate body alignment and support of extremities
can improve patient comfort and outlook. Keeping items within reach also makes a
patient more comfortable. Back pain is relieved by several positions. The first is to place
the head and trunk at 20° to 30° angle.
 Wedge pillows are used to accomplish this. Then place one or two pillows under the
knees, if it is a hospital bed, this is done easily without pillows. Moving the arms and
legs while keeping the trunk still can make symptoms worse.
 For example, lifting a leg up while lying on the back tended to cause complaints of back
and leg pain. Some patients also had increased back pain when lying face down and
bending the knee or turning the hip in or out. The patient can usually do it himself using
the bed controls. Pressure reduction occurred in the sacral region with the pillow and
wedge systems resulted in increased pressures in the posterior-lateral regions of the
buttocks and thighs. When using off-loading devices, consideration should be given to
all factors, including tissue interface pressures on the sacrum, increased pressures on
other body locations, and the likelihood that these increased pressures will result in
tissue damage. The pain is worse when changing positions or when coughing or
sneezing in low back pain. Ensuring that the over-bed table, the telephone, the nurse call
button, and the PCA control button are all within a patient’s reach not only decreases
repeat demands from the patient, but also decreases patient anxiety. The following are
reasons for changing a patient’s position:
o To promote comfort and relaxation.
o To promote good circulation.
o To improve lung function.
o To relieve pressure on skin and prevent skin breakdown (pressure sores)
o To prevent loss of muscle tone 15
o To prevent atrophy and contractures
o To prevent edema

 Hypnosis
 Most of the hypnosis interventions for chronic pain include instructions in self-
hypnosis. Hypnosis interventions consistently produce significant decreases in pain
associated with a variety of chronic-pain problems. Also, hypnosis was generally found
to be more effective than nonhypnotic interventions such as attention, physical therapy,
and education .
 Medical uses of hypnosis in dermatology includes reducing discomfort from itching or
skin pain, altering ingrained dysfunctional habits such as scratching etc. Hypnosis has
been used in ophthalmic surgery for many years, and several cases of successful
hypnosis application have been reported.
 Alleviation of pain, especially for patients who experienced obvious pain during the
first-eye surgery also reported . Patients with severe chronic diseases and advanced
cancer receiving palliative care, have a complex range of pain and anxiety that can arise
early in the course of illness. Clinical hypnosis can be considered an effective adjuvant
 therapy for pain and anxiety control in cancer as well as in severe chronic diseases for
patients receiving palliative care.
 Physiotherapy
 Early physical therapy appears to be associated with subsequent reductions in longer-
term opioid use and lower-intensity opioid use for all of the musculoskeletal pain
regions examined . Physical therapy or physiotherapy is a branch of rehabilitative
medicine aimed at helping patients maintain, recover or improve their physical abilities.
PTs practice in many settings, such as private-owned physical therapy clinics, outpatient
clinics or offices, health and wellness clinics, rehabilitation hospitals facilities, skilled
nursing facilities, extend- 23 ed care facilities, private homes, education and research
centers, schools, hospices, industrial and this workplaces or other occupational
environments, fitness centers and sports training facilities.
 Yoga
 The word yoga literally means yoking or joining together for a harmonious relationship
between body, mind and emotions to unite individual human spirit with divine spirit or
the True Self . Yoga is a vast system of practices and philosophy that originate in India.
Yoga can be helpful in pain management with both physical and mental benefits, but
yoga is not a quick fix solution.
 Yoga has many of the same benefits as mindfulness practice, due to the common focus
on breath, body and present moment awareness .
 Yoga is very helpful in treating some of the mechanical aspects of pain, for example
when there are tight muscles which contribute to pain. However, practiced incorrectly or
without proper supervision yoga can also exacerbate your pain in the short term, despite
the fact that research shows yoga is as safe as usual care and exercise . Despite a
number of reports and reviews supporting efficacy of yoga in health care, the awareness
and integration of yoga in conventional healthcare remain limited.

 ROLE OF NURSE

 The licensed nurse is responsible and accountable to ensure that a patient

receives appropriate evidence-based nursing assessment and intervention which
effectively treats the patient’s pain and meets the recognized standard of care. In
order to advocate for the patient, the licensed nurse must possess the following:

A) Knowledge of Self
  The practice of nursing includes the knowledge of one’s self through
assessment of attitudes, values, beliefs, and cultural background and
influences that have formed each of us as individuals.
 These factors affect the nurse when assessing, evaluating, and interpreting
the patient’s statements, behavior, physical response, and appearance. The
greatest barrier to the patient achieving effective pain management may be
the nurse’s:
1. Individual experiences with pain;
2. Personal use of medications or nonpharmacological methods to manage pain and
3. Family’s or significant others history or experience with substances for pain
control or mood altering effect.
When the licensed nurse is influenced or constrained by personal factors, the nurse
may not assess, evaluate or communicate the patient’s pain level effectively or
objectively. This can be further compounded if the nurse does not have adequate
knowledge regarding pain management and, as a result, can not recognize the need
to seek out additional information to assess and manage the patient’s pain
appropriately. Knowledge of Pain
Pain is subjective. It is whatever the patient says it is. The nurse utilizes the nursing
process in the management of pain. Adequate measurement and management of pain
includes knowledge in the following areas:
1. Pain assessment:
a) The nurse utilizes a developmentally appropriate, standardized pain assessment
tool which includes: a pain measurement tool which has demonstrated reliability and
validity and patient participation, which is essential in the assessment process. For
those incapable of self-reporting, standardized pain assessment tools should include
behavioral observations with or without physiologic measures. i. Physiologic signs
such as tachycardia, hypertension, diaphoresis and pallor are non-specific to pain
and may be an indicator of another, unrelated physiologic problem. For patients in
pain, these physiologic signs may be present for a short period of time or not at all.
ii. Sole reliance on these physiologic signs to assess pain may be inappropriate.
b) The nurse is knowledgeable regarding the difference in categories of pain (i.e.
acute, chronic, breakthrough)
c) The nurse is knowledgeable regarding the most likely potential sources of pain
(i.e. neurological, muscular, skeletal, visceral)
d)The nurse assesses the patient’s individual pain pattern, including the individual
patient’s pain experiences, methods of expressing pain, cultural influences, and how
the individual manages their pain.
 2. Pharmacologic and Non-Pharmacologic Intervention:

a) The nurse is knowledgeable about the pharmacological interventions of opioid,

non-opioid, and adjuvant drug therapies. (including dosages, side effects, drug
interactions, etc.) which are most effective for the most likely source of an
individual patient’s pain.
b) The nurse is knowledgeable that placebos should not be utilized to assess if pain
exists or to treat pain.
c) The nurse is knowledgeable regarding nonpharmacologic strategies for pain
management (i.e. acupuncture, application of hot and cold, massage, breathing
techniques, etc.).
3. Current pain management standards and guidelines.
4. The difference between tolerance, physical and psychological dependence,
withdrawal and pseudoaddiction.
B) Knowledge of the Standard of care
The standard of care is effective ongoing pain assessment and pain management.
This includes but is not limited to:
1. Acknowledging and accepting the patient’s pain
2. Identifying the most likely source of the patient’s pain
3. Assessing pain at regular intervals, with each new report of pain or when pain is
expected to occur or reoccur. Assessment includes but is not limited to:
a) The patient’s level of pain utilizing a pain assessment tool
b) Barriers to effective pain management, which may include personal, cultural and
Institutional barriers. Sources of these barriers may include but are not limited to
patient, family, significant other, physician, nurse and institutional constraints
3. Reporting the patient’s level of pain
5. Developing the patient’s plan of care that includes an interdisciplinary plan for
effective pain management involving the patient, family and significant other
6. Implementing pain management strategies and indicated nursing interventions
including:
a.Aggressive treatment of side effects (i.e. nausea, vomiting, constipation, pruritus
etc)
b. Educating the patient, family and significant others regarding,
(i) Their role in pain management
(ii) The detrimental effects of unrelieved pain
(iii) Overcoming barriers to effective pain management,
(iv) The pain management plan and expected outcome of the plan
7. Evaluating the effectiveness of the strategies and the nursing interventions
 8. Documenting and reporting the interventions, patient’s response, outcomes
9. Advocating for the patient and family for effective pain management

 Pain management according to WHO analgesic

ladder

 The WHO analgesic ladder was a strategy proposed by the World Health Organization
(WHO), in 1986, to provide adequate pain relief for cancer patients.
 The analgesic ladder was part of a vast health program termed the WHO Cancer Pain
and Palliative Care Program aimed at improving strategies for cancer pain management
through educational campaigns, the creation of shared strategies, and the development
of a global network of support.
 This analgesic path, developed following the recommendations of an international
group of experts, has undergone several modifications over the years and is currently
applied for managing cancer pain but also acute and chronic non-cancer painful
conditions due to a broader spectrum of diseases such as degenerative disorders,
musculoskeletal diseases, neuropathic pain disorders, and other types of chronic
pain.
 The efficiency of the strategy is debatable and yet to be proven through large-scale
studies.Nevertheless, it still provides a simple, palliative approach towards reducing
morbidity due to pain in 70% to 80% of the patients.

The original ladder mainly consisted of three steps:

1. First step. Mild pain:
 non-opioid analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs)
or acetaminophen with or without adjuvants.
2. Second step. Moderate pain:
 weak opioids (hydrocodone, codeine, tramadol) with or without non-opioid
analgesics, and with or without adjuvants 
3. Third step. Severe and persistent pain:
o potent opioids (morphine, methadone, fentanyl, oxycodone, buprenorphine,
tapentadol, hydromorphone, oxymorphone) with or without non-opioid
analgesics, and with or without adjuvants 

 STEP: 1 of the WHO analgesic ladder

 Step 1: Non opioids ( paracetamol, NSAIDS, Adjuvants)

 Paracetamol

 Usual Dose: 10-12 mg/Kg Q 6H

 Up to 15 mg/Kg Q 4H when used short term-1 Day

 Maximum dose – 4 Gms/ Day

 Elderly – safe to use not > 2 Gms/ Day

 Paracetamol has predominant central action
 It is available as 500mg/650 mg tablets, 150 mg injections and 1 Gm/ infusion and as
suppositories
 It has a significant analgesic action which helps reduce total requirement of
NSAIDs and opioids
 Since they are available in combination with innumerable drugs, it would be important
exercise to estimate the total dose taken by the patient per day, before prescribing.
 Arachidonic Membrane
Acid Phospholipid

Cyclooxygenase
[COX]
NSAI
Ds

Prostaglandins Thromboxane

 COX Inhibition by NSAIDs – Reversible and by Aspirin – Irreversible

 It was expected that COX 2 selectivity would mean
pain relief without adverse effects

Natural Inducible

COX 1 COX 2

Constitutional Sites of inflammation, Trauma

Cyclooxygenase [COX] formation of Prostaglandin

The adverse effects caused by;

• COX -1 Inhibition - Gastric irritation, Diminished platelet adhesion
• COX 1 or 2 Inhibition - Renal toxicity
• Anaphylactoid reactions
• Poisoning is known to occur

COX 2 selectivity & thrombosis

Non-selective NSAIDs - worsen bleeding tendency

COX 2 selective NSAIDs - promote thrombotic events – disturbs Prostacyclin Th

 Just because COX 2 newer does not mean they are safer. The thrombotic complications
are higher with COX 2 inhibitors. The risk of renal injury is the same as non-selective
NSAIDs.

Risk factors for gastric toxicity – COX1

High NSAID dose
History of upper GI
symptoms
Advanced age
Concurrent aspirin /
corticosteroid
Comorbidities-
Rheumatoid arthritis
Gastric erosions may be silent The chances of haemorrhage increases by 3 to 10 fold

• Add gastric protection when using NSAIDs.

• For those without prior history, Histamine antagonist may suffice with adequate
follow up.
• For those with history suggestive of Acid peptic disease, Proton Pump Inhibitors
are preferred.
• Often patients take PPIs on full stomach. They need special instruction to time it
for 30-45 minutes prior to feeding.

Risk factors for Renal toxicity

Dehydration, Cirrhosis
Advanced age
Poorly controlled Diabetes
Concurrent nephrotoxic drugs e.g. antibiotics, dyes.

Mechanism: Reduced Renal perfusion and GFR

Leading to Na+, K+, water retention, Hypertension, Cardiac failure

 Educate the patient especially about maintaining hydration and urine output.
 Special precautions if they are traveling.
 Educate them to withhold the medicines intermittently when there is bearable
pain.
 Pantaprazole that is often used concomitantly, causes interstitial nephritis.
 Risk factors for
pro-thrombotic effects
Use of COX 2 drugs
All NSAIDs have COX 2 inhibition- Diclofenac very strong COXib
Advanced age, Smokers
Hypertension, Hyperlipidaemia, Diabetes
Ref: Fosbol et al - International Journal of Stroke Volume 9, Issue 7, pages 943–945, October 2014

 Avoid use in patient who are > 65 years

 Effect of COX 2 selective drugs

 On the stomach: Less gastric irritation

 On the platelets: No platelet inhibition
 On the Kidney: No Renal protection

COX inhibitors and coronary and

cerebrovascular events - Minimum risk to
maximum
Aspirin No evidence to support prevention of CVS
risk when used concomitantly with NSAIDs
Ibuprofen Longest experience – relatively safe up to
1200mg/ Day
Naproxen Relatively lower risk
Diclofenac , COX 2 selective, High Risk
Indomethacin,
Aceclofenac
Piroxicam, lornoxicam, COX 2 selective, High Risk
Meloxicam
Celecoxib - COX 2 High risk
specific inhibitors
Ref: Fosbol et al Circulation, June 8 2010

It is important to note that Ibuprofen in doses up to 1200 are safer than the more commonly
used Diclofenac Sodium, from cardio- vascular point of view.

 Diclofenac
 6 deaths from CVS/CNS events/ 100 patient years of Rx.
  The increased risk associated with Diclofenac is of particular importance
because it is one of the most commonly used NSAIDs worldwide.
 Diclofenac appears almost as COX-2–selective as
Rofecoxib.
Concomittant low dose Aspirin does NOT protect
 NSAIDs affects cardioprotective effect of Aspirin.
 When prescribed together, take the NSAID 30 minutes prior to aspirin.
 Consider additive gastric mucosal protection when using Aspirin with another NSAID
Recommendations for NSAIDS

 Lowest dose for the shortest duration

 Use with Proton Pump Inhibitor
o The choice tailored to the GI and CVS/ CNS risks
o Extra caution - Age >65 years, DM, HT, CKD, acute diseases

 Avoid combinations
 Ensure hydration - educate the patient
 Monitor kidney – baseline S.Creatinine, and 3
monthly or if physical signs or symptoms

 Look for additive adverse effects with other

medications
 Routinely use gastroprophylaxis – Proton Pump Inhibitor / Antihistaminics
 Ibuprofen (≤1200 mg / Day) & Naproxen are safer.
 Consider Diclofenac as COX 2 selective.
 Use NSAIDs at the lowest dose for shortest duration

WHO Analgesic Ladder

Step 2 Opioids
 • STEP 2: OPIOIDS

• When pain is persisting or increasing despite rational use of step 1 drugs in adequate
doses, move to step 2 – add a weak opioid to the existing analgesic regime.
• Weak Opioids are
• Codeine
• Dihydrocodeine
• D-Propoxyphene
• Tramadol
• Tapentadol

• Opioids for moderate pain

 Some Step 2 opioids have prescription advantage

o Tapentadol -u+NERI agonist–50 mg 6hrly / 8hrly [Max-500mg/D]
 Tramadol [50-100 mg 6hrly / 8hrly;Max- 400mg/D] requires triplicate prescription
 Codeine, Dihydrocodeine [30-60 mg 6hrly] are strictly controlled
drugs.
 Codeine is one of the drugs in the notified list of “Essential Narcotic Drugs –
which may be accessed, stocked and dispensed by institutions specifically
Recognised for this.
 The Recognized medical Institutions – RMIs are authorized by the State
Drug Controller.

Opioids for moderate pain

 Not commonly used

 Pethidine
 Short acting, high side effects

 Pentazocin
 Agonist + Antagonistic
 short acting, poor oral
efficiency
 limited by ceiling dose
 psychotomimetic effects

 Useful but not available

Dextropropoxyphene
Need for lifting the legal ban
 WHO ladder drugs- Step 2


 Dextropropoxyphene has had several decades of safe use before it was banned. The
issue of prolonged QT interval has been sighted as important reason for the ban.
 Efforts are on to make this medicine available as a cheaper effective alternative to other
medicines in the group.
 Tramadol can lower the seizure potential

Step 2 analgesic for children

The Step 2 does not exist in the WHO Recommendations when treating cancer p
Step 3 drugs are used directly in the right dosage, if Step 1 medicines are ineffe

• . Codeine is not recommended by WHO for treating cancer pain in children because,
• It is not a reliable analgesic as it depends on conversion to Morphine, forit’s
pharcological effect. The corresponding enzyme is found to be lacking in
children.
• Tramadol is not recommended by WHO for treating cancer pain in children because,
• There have not been adequate studies to show safety for use in children
 EAPC recommendations – Step II Weak Recommendatio
All are equally efficacious; max Side Effects with tramadol
Amongst step 2 drugs, Codeine is a controlled drug
Total Codeine dose not to exceed 360mg / D [S E]
Codeine not >240mg /D IF COMBINED with 600mg
PCM

• Note that Paracetamol is a common combination drug.

• Ensure the dose does not cross . 4 Gms / Day in healthy adults

EAPC recommendations – Step II Weak Recommendatio

Tramadol may be combined with PCM, daily doses < = 400
The division into weak or strong opioids is for convenience of use
Morphine ≤ 30 mg per day can be used as
Step 2 opioid.
Pre-emptively handle SE of Opioids

• Morphine may be used in opioid naïve patients;

• It is a cheaper and effective Step 2 option in India

• Step 3 opioids are the strong opioids.

• When patient has pain that is persisting or worsening despite adequate doses of Step 2
medicines [non-opioids and weak opioids] then it is time to move from Step 2 to step 3.
• This done by discontinuing the Step 2 and replacing it with a strong opioid.
• The step 1 medications may be continued if not contra-indicated
• Step 3 opioids are Strong Opioids
• Morphine, Fentanyl, Methadone
• Not available in India – Oxycodone, Hydrocodone
 FACTs about Opioid Access and availability

96% adults, 99% children with severe cancer pain do not have access to opioid medicines
Morphine consumption in India 1985-95
600

500

400

300

200

FACTs about Opioid Access and availability

100

96% adults, 99% children with severe cancer pain do not have access to opioid medicines
Morphine consumption in India 1985-95
600

500

400

300

200

100

Contributors to poor availability

• Medical Institutions faced stringent regulations - maintaining multiple licenses for
acquiring, stocking, prescribing and using opioids.
• Harsh punishment prescribed in the NDPS Act 1985 (e.g. possible10 years of rigorous
imprisonment even for clerical errors) alienated institutions and pharmacists from
stocking these medicines.
• Attitude and knowledge of professionals towards using opioids were negative:
• Exposure of professionals was restricted to injectable opioids as used in acute or
emergency situations. This led to exaggerated fears about addiction and
respiratory depression for all formats.
Lack of availability of opioid formats like oral Morphine at medical colleges and
hospitals, prevented exposure and training of professionals in using them for
managing chronic pain.

• This developed into unfounded fears opiophobia.

• The public associate opioids with addiction or as the last resort and are reluctant to
use the drug even if it meant great degree of suffering. This fear was often reinforced
by professionals.
 STEP 3: Strong Opioids and Adjuvant Agents

 It recommending opioid analgesia with or without an adjuvant.

 However, the original WHO ladder focused primarily on oral morphine as the strong
opioid of choice. There are good reasons for this selection: oral morphine is familiar,
readily available, and inexpensive.
 Indeed, oral morphine is more or less the “gold standard” against which other opioid
analgesics are measured.
 However, today’s armamentarium of opioid analgesics has vastly expanded to include
some new agents, new formulations of older agents, and new routes of administration,
and reflects improved understanding of these agents.
 The various available opioid agents have important pharmacokinetic,
pharmacodynamic, and clinical differences that in some cases may facilitate optimized
individualized care. 
 Buprenorphine—which arrived on the market in a transdermal formulation after 1986
and is thus not incorporated into the WHO pain ladder—may be the most appropriate
opioid analgesic to prescribe in the presence of renal compromise.
 Tapentadol (Nucynta)—another post-1986 opioid agent—has a dual mechanism of
action.
 Rather than focusing on “weak” versus “strong” opioids, clinicians should consider the
overall drug profile and then begin with a low dose, ramping up gradually to meet
analgesic demand under the old saying, start low and go slow.

 Conclusion

 At last I conclude my topic, it is not sufficient to treat pain. Anticipatory planning and
prevention care plans must be part of the overall pain management strategy. To be
successful in preventing pain, a thorough history that incorporates nutraceutical use,
an in-depth social history, an evaluation of resource access, and determination of
patient expectations must be part of the process.
 Preemptive measures may include nonpharmacological therapies as well as nonopioid
and opioid medications. When drug-seeking behavior is a concern in a patient who is
suffering from pain, then reassessment of the patient's pain management will be
necessary. When indicated, controlled-release agents (e.g., some morphine products)
should be considered, but these should only be used when inadequate pain control is
the dominant issue. Clarification of allergy reports will also be helpful in broadening
the therapeutic options.Keeping patients comfortable requires forethought, evaluation,
and a multidisciplinary approach. Together, the goals of pain relief and pain
prevention can be achieved.

 REFERENCES
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2. Cheever.Kerry H. Textbook of medical -surgical nursing.13th edition. New Delhi:Jaypee

brothers Medical publishers. Page No.213-224.

3. Rospond R.M. Textbook of medical surgical nursing. Page No.160-170.

4. The WHO Pain Ladder: Do We Need Another Step? (n.d.). Retrieved January 4, 2022, from
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step

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in cancer pain. Int J Tissue React. 1985;7(1):93-6

7. Jadad AR, Browman GP. The WHO analgesic ladder for cancer pain management. Stepping
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8. Orhan ME, Bilgin F, Ergin A, Dere K, Güzeldemir ME. [Pain treatment practice according to
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9. Araujo AM, Gómez M, Pascual J, Castañeda M, Pezonaga L, Borque JL. [Treatment of pain
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