Basics of Pain

Assessment and
Management
Updated May 20, 2019

1
PAMI learning module content will sometimes overlap due to similar topics. The PAMI website
offers access to learning module handouts, PAMI Pain Management and Dosing Guide,
resources, toolkits, best practices and recent pain news.

We welcome your feedback on all PAMI materials and are interested in how you use them to
improve patient safety, pain education and clinical care.
Please email [email protected]

For more information please visit http://pami.emergency.med.jax.ufl.edu/

Like Us on Facebook at https://goo.gl/4Yh1cB Follow Us on Twitter @pami_painmgmt 2

Presentation Information
• An electronic pdf version of this document is available on the PAMI
website http://pami.emergency.med.jax.ufl.edu/resources/pami-
module-downloads/
• All PAMI created materials are free access and can be utilized for
educational programs or adapted to institutional needs.
• Suggested Citation: Basic of Pain Assessment and Management.
University of Florida College of Medicine - Jacksonville, Department of
Emergency Medicine. Pain Assessment and Management Initiative
(PAMI 3.0): Multimodal Approaches to Improve Pain Outcomes and
Reduce Opioid Risk, [date retrieved]. Retrieved from
http://pami.emergency.med.jax.ufl.edu/.

3
 Disclaimer
The PAMI website, learning modules, and resources are for educational and informational
purposes only. The PAMI website is not intended as a substitute for professional medical
diagnosis or management by a qualified health care professional. PAMI is not responsible for
any legal action taken by a person or organization as a result of information contained in or
accessed through this website, whether such information is provided by PAMI or by a third
party. As new research and clinical experience becomes available, patient safety standards
will change. Therefore, it is strongly recommended that physicians, nurses and other
healthcare professionals remain current on medical literature and national standards of care
and structure their treatment accordingly. As a result of ongoing medical advances and
developments, information on this site is provided on an “as is” and “as available” basis.
Patient care must be individualized. The use of information obtained or downloaded from or
through this website or module is at the user’s sole discretion and risk.
If you use any links that appear in this website or module to other websites, you will leave
the University of Florida’s website. The University of Florida is not responsible for the
contents of any linked site or any link contained in such a linked site. The University of Florida
may provide such links to you only as a convenience and the inclusion of any link does not
imply recommendation, approval or endorsement by the University of any third party site. All
such links provided on this website are intended solely for the convenience of users of this
site and do not represent any endorsement, advertisement or sponsorship of linked sites or
any products or services offered through sites that are not owned by the University. 4
 Learning Objectives
1. Understand the importance of pain recognition, assessment
and re-assessment.
2. Discuss the multi-factorial determinants of pain.
3. Identify the different classifications of pain and how this
impacts treatment selection.
4. Discuss the key elements of performing an accurate pain
history and examination.
5. Understand the different types of pain scales.
6. Describe the consequences of untreated pain.
7. Recognize patient safety issues regarding pain management,
discharge planning, and transitions of care.
5
 Consider these case scenarios throughout the module

A 54 year-old non-English speaking male is brought to the ED by EMS after sustaining a motorcycle collision
approximately 20 minutes prior to arrival; he is calm and reports mild pain. Simultaneously, a 23 year-old
female that was involved in the same accident is brought to the ED. She was the restrained backseat passenger
in a pick-up truck; reports “pain all over” and is crying hysterically.

A 3 year-old right-handed male presents with his caregiver who reports that the child has complained of pain
in his right arm since yesterday. When questioned the child denies pain but cries and pulls away when any part
of the right upper extremity is touched. He has no obvious deformity or swelling to either arm.

A 53 year-old male with chronic back pain underwent knee replacement one week ago. He presents to his
primary care doctor complaining of persistent post-op pain. The patient reports his prescribed opioid is not
controlling his pain The pain is limiting his ability to perform his daily activities of living.

6
Module Outline
1. Introduction to Pain Management
2. Defining and Classifying Pain
3. How to Perform a Pain Assessment
a. Components of the Pain History
b. Pain Focused Physical Exam
4. Pain Assessment Scales
a. Adult Pain Assessment Scales
b. Pediatric Pain Assessment Scales
5. Management of Pain
a. General Principles of Pain Management and Stepwise Approach
b. Re-assessment of Pain
c. Consequences of Unrelieved Pain
6. Discharge Planning and Transitions of Care
7. Patient Safety, Regulatory and Legal Aspects of Pain Management
8. Case Scenario Discussion
9. Summary
7
1. Introduction to Pain
Management

8
 Why is Pain Management Important?
• Pain is a complex and common complaint that leads to frequent access of the US
healthcare system.

• Chronic pain alone affects more Americans than diabetes, cancer, and heart disease
combined, with an estimated annual cost of $600 billion.

• Pain is often under recognized leading to inadequate management and numerous

patient safety concerns, particularly in special populations and minority groups.

• Untreated acute pain may lead to adverse sequelae.

• With the recent opioid epidemic and advances in pain research, there is a renewed
emphasis on early multimodal pain management, nonpharmacologic options and
nonopioid alternatives.
 General Pain Management Challenges
(part 1)
• Failure to recognize or differentiate pain from anxiety
• Lack of education for healthcare providers, especially regarding nonpharmcologic
modalities.
• Safety concerns, fear of patient addiction or prescription legal repercussions
• Lack of pre-existing physician-patient relationships i.e. knowledge of past medical
history
• Inadequate discharge pain plans resulting in return visits or admissions
• Pressure to see patients rapidly, especially those perceived to be more critical,
which can hinder time for adequate pain assessments and re-assessments

10
 General Pain Management Challenges
(part 2)
• Physiologically unstable patients are least likely to receive a
standardized pain assessment and to receive pain medications
• Outpatient settings may have limited time to perform full pain
assessments or to evaluate for psychosocial contributors to pain
(e.g. financial stress, impaired sleep, anxiety, etc.)
• Stereotypes towards patients with chronic pain being drug-
seekers
• Analgesic shortages leading to medication errors and changing
protocols
• And many more!

11
Opioid Safety Across the Continuum of Care
…continues to be a top patient safety concern

12
 Challenges Summary- Keeping Balance
• Healthcare providers face the dilemma of balancing safe
opioid/analgesic prescribing and high-risk patient recognition with
appropriate pain management strategies for those in significant pain
while being mindful of different types of pain, individual pain factors
and comorbidities.
 How Does Pain Affect Us?
• Pain is multidimensional, affecting people Demographics
physically, psychologically, socially and
spiritually.
Cognitive
• Patients’ responses to pain may be related to: Clinical
Clinical
Cognitive
Functioning
Functioning

• genetics, age, gender, ethnicity,

socioeconomic and psychiatric factors,
catastrophizing, culture, religion,
previous experiences, patient Pain
perceptions and expectations, etc. Religion
Religion Genetics
Genetics

Psycho-
Culture
social
14
 Patient Perceptions
• A patient’s response to prescribed pain treatment can be influenced by
factors unrelated to actual pharmacological treatments.

These factors include:

– Perceived effective communication with physicians and nurses by the patient

– Perceived responsiveness by the treating team

– Perceived empathy by the treating team

15
Factors Affecting Patient Response To Painful Stimuli
• Age, Gender, Ethnicity
• Socioeconomic and Psychological factors
• Catastrophizing
• Culture and Religion
• Genetics
• Previous experiences
• Patient perceptions
• Patient expectations

16
 Patient Response to Pain and Management:
Age and Gender
• Demographics such as age, gender, • Studies have shown different
race and ethnicity have all been interpretations by observers for the
reported to influence pain same facial expressions depending
perception. on patient gender.
• This behavior could explain why
• Studies on the influences of gender patients are managed differently
and age have had variable results. by providers when presenting with
• Overall, patients who identify as the same injury or painful
female display more sensitivity than condition.
males towards most painful
conditions. Females also are
believed to express their pain more
frequently and effectively than
males.

17
Patient Response to Pain and Management:
Ethnicity
• Ethnicity is associated with pain intensity and interference.
– One study found African Americans to report higher rates of pain and
interference with daily activities such as sleep.

Consider the impact of age, gender and ethnicity on pain assessment and
management but beware of labeling or stereotyping- treat the individual patient! 18
 Patient Response to Pain and Management:
Culture and Religion
• Culture and Religion/Personal Values/Coping
Mechanisms
– How patients cope with pain can be influenced by their
existing social support system.
– Those with strong cultural and religious ties tend to have
stronger support mechanisms for dealing with their pain.
– Variations in cultural norms can influence how a patient
expresses their pain and how they want their pain to be
managed.

19
Patient Response to Pain and Management:
Socioeconomic and Psychological Factors
• Health disparities research indicates that patients living in rural areas
and who are of lower socioeconomic status tend to report higher levels
of chronic pain, pain related disability, and depression. Depression and
pain often co-exist (30-60% of pain patients also report depression).
• Previous pain experiences can alter activity within certain brain regions
responsible for pain processing resulting in persistent pain.
• Additionally, mood disorders and other psychiatric disorders have been
linked to the development of chronic pain. This co-existence has
important clinical and financial implications. These patients often
report more pain, greater functional disability, worse clinical prognosis,
and accrue higher healthcare costs.
20
 Patient Response to Pain and Management:
Pain Catastrophizing
• Pain catastrophizing is an • Pain catastrophizing shares
exaggerative cognitive response to similarities with depression and
an anticipated or actual painful anxiety. It has been associated with
stimulus and affects how pain-related outcomes such as pain
individuals experience and express severity, activity interference and
pain. disability, depression, changes in
• People who catastrophize tend to social support networks, more
magnify their pain, ruminate frequent healthcare visits, and
about their pain, and feel helpless opioid usage.
in managing their pain.

21
Examples Of Catastrophizing
• Magnification: the response that
symptoms that can be or are greater
than expected. Ex: “I´m afraid that
something serious might happen”

• Rumination: when an individual

focuses repeatedly on attributes of
an event that evoke a negative
emotional response. Ex: "I can´t stop
thinking about how much it hurts“

• Helplessness: the belief that there is

nothing that anyone can do to
improve a bad situation. Ex: "There is
nothing I can do to reduce the
intensity of my pain".
22
 Patient Response to Pain:
Genetics
• Genetic polymorphisms play an integral role in how patients respond to painful
stimuli and treatment.
• For example, populations within certain ethnic groups are known to carry genetic
mutations of the liver CYP450 enzymes responsible for drug metabolism.
• Some patients are “ultra-rapid metabolizers” of certain drugs such as codeine. This means
they convert codeine to morphine more rapidly than other patients, resulting in potential
supra-therapeutic dosing.
• Some patients are “slow metabolizers” and do not efficiently metabolize codeine, and thus
never achieve therapeutic levels.
• Caucasian and African American populations have approximately equal
proportions of fast and slow metabolizers, whereas nearly 90% of certain Asian
groups are fast acetylators.

23
2. Defining and
Classifying Pain

24
 Classification of Pain

• Determining the context, history of present illness and type of pain is

complex and time consuming but is essential to developing a
successful management plan.
• Pain may be classified by underlying etiology, anatomic location,
temporal nature, and intensity.
• Underlying etiology refers to the source of the experienced pain.
• Anatomic location refers to the site of pain within the body
• Temporal nature refers to the duration of the pain.
• Intensity refers to the degree or level of the pain experience .

25
 Pain

Underlying Anatomic
Etiology
Temporal Intensity
Location

Nociceptive Acute Mild

Inflammatory Somatic
Chronic Moderate
Visceral
Neuropathic Acute on chronic Severe

26
 • Nociceptive Pain is the result of direct tissue injury from a
noxious stimulus. Nociceptive pain can be further classified as
somatic or visceral pain.
Underlying • Examples include bone fracture, new surgical incision, and acute
burn injury.
Etiology
• Inflammatory Pain is the result of released inflammatory
mediators that control nociceptive input and are released at
sites of tissue inflammation.
Nociceptive • Examples include appendicitis, rheumatoid arthritis, inflammatory
Inflammatory bowel disease, and late stage burn healing.
Neuropathic

• Neuropathic Pain is the result of injury to nerves leading to an

alteration in sensory transmission. It can be central or
peripheral in nature.
• Examples include diabetic peripheral neuropathic pain, postherpetic
neuralgia, chemotherapy induced pain, and radiculopathy.
27
• Somatic Pain, also known as musculoskeletal pain,
is pain that occurs from injury to skin, muscle,
bone, joint, connective tissue and deep tissues.
Typically pain is well-localized, sharp and worse
with movement.
• Examples include lacerations, fractures, and pelvic pain.

• Visceral Pain is internal pain and typically occurs

from internal organs or tissues that support them.
Pain is usually poorly localized and described as
vague deep aches, colicky, and/or cramping.
• Examples include appendicitis, peptic ulcer disease,
diverticulitis, endometriosis, and ureteral stones. 28
• Acute pain is defined as lasting less than 3 months and is a
neurophysiological response to noxious injury that should
resolve with normal healing.
• Examples include post-operative pain, fractured bones, appendicitis,
crush injury to finger, labor and delivery pain.

• Chronic pain is defined as lasting more than 3 months or

beyond the expected course of an acute disease or after
complete tissue healing. Chronic pain extends beyond the
time of normal wound healing with the development of
multiple neurophysiological changes in the central nervous
system.
• Examples include low back pain, neck pain, and chronic pancreatitis.

• Acute on Chronic pain refers to times of acute exacerbations

of a chronic painful syndrome or new acute pain in a person
suffering from a chronic condition.
• Examples include a sickle cell exacerbation in a patient with sickle
cell disease or an abscess in a patient with sickle cell disease. 29
Pain Intensity is determined by pain assessment scores in combination
with history and physical exam. Pain intensity is subjective and may vary
from one patient to another. Pain Scales are used to assess and quantify
the intensity of a patients pain. Remember that each scale has its’ own
scoring range and levels for mild, moderate or severe pain intensity.
• Case scenario 1 is an example of the challenges involved in determining intensity
where one patient has severe injuries but rates their pain as moderate compared to
the patient with minor injuries who complains of severe “pain all over.”

Pain intensity can range from: Scores typically range from:

Mild 1-4
Moderate 5-7
Severe 8-10

30
Table 1. Types of pain, mechanism, and clinical examples
PHARMACOLOGICAL
TYPES OF PAIN MECHANISM CINICAL EXAMPLES TREATMENT OPTIONS*
UNDERLYING ETIOLOGY
Bone fracture, fresh surgical incision, and May include both opiate and non-opiate
Nociceptive The result of direct tissue injury from a noxious stimuli.
fresh burn injury. medications depending on injury.
The result of released inflammatory mediators that control Late stages of burn healing, neuritis, and
Inflammatory nociceptive input. arthritis
Anti-inflammatory agents
Tricyclic, selective norepinephrine
The result of direct injury to nerves leading to an alteration in Diabetic neuropathy, peripheral neuropathic
Neuropathic sensory transmission. pain, and post-herpetic neuralgia.
reuptake inhibitors, gabapentinoids, or
antidepressants
May be difficult to adequately address
Chronic back pain without preceding trauma
Idiopathic Unknown
or obvious inciting event.
pain since underlying etiology is unknown,
especially in emergency settings.
ANATOMIC LOCATION
Superficial lacerations, superficial burns, Topical and/or local anesthetics, opiates,
Somatic A-delta-fiber activity located in peripheral tissues
superficial abscess non-opiates
Uterine fibroid pain, pyelonephritis, biliary
Visceral C fiber activity located in deeper tissues such as organs
colic
Opiates

TEMPORAL NATURE
A neurophysiological response to noxious injury that should
Acute resolve with normal wound healing.
Acute fracture, acute knee sprain Opiate, non-opiates

Pain that extends beyond the time for normal wound healing
Chronic with resultant development of multiple neurophysiological Chronic low back pain, fibromyalgia, arthritis Depends on the nature of the pain. Please
changes refer to the module on chronic pain for
Sickle cell disease, cancer, rheumatoid more detailed information.
Acute-on-chronic An acute exacerbation of a chronic pain syndrome
arthritis, acute injury in chronic pain patient
*Nonpharmacologic management options should be considered at any time for any type of pain

For more information on Nonpharmacologic Pain Management, please refer to the pdf or learning module
31
3. How to Perform a Pain
Assessment
a. Components of the Pain History
b. Pain Focused Physical Exam

32
a. Components of the Pain History
33
Pain History Elements and Questions
The patient’s history and physical exam can be an invaluable source when it
comes to determining the proper diagnosis and course of treatment.
Essential elements should include a detailed history of the current pain and, for
those that suffer from chronic pain, their previous pain history.

Basics Functionality
1. Onset of recent pain 1. How is pain affecting current level
2. Aggravating and alleviating factors of function?
3. Quality of pain experience 2. Is patient working?
4. Location of pain 3. How is patient coping with pain?
5. Severity of pain
6. Circumstances of original pain

34
Pain History Elements and Questions

Co-morbidities Psychosocial and psychiatric

1. Significant past medical and/or 1. Depression
surgical history 2. Suicidal ideation or past suicide attempts
2. Chronic diseases (obesity, 3. Past psychiatric admissions
hypertension, diabetes, etc. ) 4. Physical, sexual and/or emotional abuse.
3. Psychosocial and/or psychiatric co-
morbidities
4. Family history of substance abuse

Consider using the mnemonics OPQRST, SOCRATES and QISS TAPED to assess pain.

35
 Pain History Elements and Questions
Essential elements of Pain History – Basics
Basic Elements Description
1. Onset of recent pain • When did the pain start and what was the patient doing when it started
• Was the onset sudden, gradual, or an exacerbation of a chronic problem
2. Aggravating and alleviating factors • What makes the pain better and what makes it worse?
• How does physical activity or position affect pain?
• Do any nonpharmacological therapies or medications relieve the pain?
3. Quality of pain experience • Ask the patient “Can you describe the pain?” Ideally, this will elicit
descriptions of the patient's pain: whether it is sharp, dull, crushing, burning,
tearing, or some other feeling, along with the pattern, such as intermittent,
constant, or throbbing.
4. Location of pain • Where pain is on the body and whether it radiates (extends) or moves to any
other area?
5. Severity of pain • Ask the patient to describe the intensity of pain at baseline and during acute
exacerbations, typically done using a pain scale
6. Circumstances of original pain • Identify when the pain started, under what circumstances, duration, onset
(sudden/gradual), frequency, whether acute/chronic.
36
Consider using a patient pain diagram at
check-in or triage (if stable)

37
Pain History Elements and Questions
Mnemonics for obtaining pain history
OPQRST SOCRATES QISS TAPED
• Onset of event • Site • Quality
• Impact
• Provocation and • Onset
• Site
palliation of • Character • Severity
symptoms
• Radiation • Temporal
• Quality • Aggravating and
• Associations alleviating
• Region and
radiation • Time course • Past response and
preferences
• Severity • Exacerbating/Reli • Expectations and
eving factors goals
• Timing • Diagnostics and
• Severity physical exam
38
 OPQRST
O Onset of • What was the patient doing when it started? Were they active, inactive, and or stressed?
event • Did that specific activity prompt or start the onset of pain?
• Was onset of pain sudden, gradual or part of an ongoing chronic problem
P Provocation • Is the pain better or worse with:
and • Activity. Does walking, standing, lifting, twisting, reading, etc… have any effect of the pain?
palliation of • Position. Which position causes or relieves pain? Provide examples to the patient-- sitting,
symptoms standing, supine, lateral, etc…
• Adjuvant. Which type of medication relieves the pain (Tylenol, Ibuprofen, etc.. )? Does the use of
heat or ice packs alleviate pain? What type of alternative therapy (massage, acupuncture) have
you used before?
• Does any movement, pressure (such as palpation) or other external factor make the problem
better or worse? This can also include whether the symptoms relieve with rest.
Q Quality • Ask the patient to describe the quality of pain – is it throbbing, dull, aching, burning, sharp,
crushing, shooting, etc…?
• Questions can be open ended "Can you describe it for me?" or leading
• Ideally, this will elicit descriptions of the patient's pain: whether it is sharp, dull, crushing,
burning, tearing, or some other feeling, along with the pattern, such as intermittent,
constant, or throbbing. 39
 OPQRST
R Region and • Where pain is on the body and whether it radiates (extends) or moves to any other area? Referred
radiation pain can provide clues to underlying medical causes.
• Location: body diagrams may help patients illustrate the distribution of their pain.
• Dermatome map – may help determine the relationship between sensory location of pain and spinal
nerve segment (see figure next slide).
• Referred vs Localized: referred pain (also known as reflective pain) is feeling pain in a location other
than the original site of the painful stimulus. Localized pain is when pain typically stays in one location
and does not spread.
S Severity • Ask the patient to describe the intensity of pain at baseline and during acute exacerbations.
• The pain score (usually on a scale of 0 to 10) where 0 is no pain and 10 is the worst possible pain. This
can be comparative (such as "... compared to the worst pain you have ever experienced") or
imaginative ("... compared to having your arm ripped off by a bear"). If the pain is compared to a prior
event, the nature of that event may be a follow-up question.
T Timing • Identify when the pain started, under what circumstances, duration, onset (sudden/gradual),
frequency, whether acute/chronic.
• How long the condition has been going on and how it has changed since onset (better, worse,
different symptoms)?
• Whether it has ever happened before, and how it may have changed since onset, and when the pain
stopped if it is no longer currently being felt?
40
 SOCRATES
Site Where is the pain? Or the maximal site of the pain.
S
Onset When did the pain start, and was it sudden or gradual? Include also whether if
O it is progressive or regressive.
Character What is the pain like? An ache? Stabbing?
C
Radiation Does the pain radiate anywhere? (See also Radiation.)
R
Associations Any other signs or symptoms associated with the pain?
A
Time course Does the pain follow any pattern?
T
Exacerbating/Relieving Does anything change the pain?
E factors
Severity How bad is the pain?
S
41
 QISS TAPED
Quality What were your first symptoms? What words would you use to describe the pain? (achy, sharp, burning, squeezing, dull, icy, etc...)
Q Besides sensations you consider to be "pain," are there other unusual sensations, such as numbness?

Impact How does the pain affect you?

I How does the pain impact your sleep, activity, mood, appetite (other - work, relationships, exercise, etc.)
What does the pain prevent you from doing? (Depression screen) Do you feel sad or blue? Do you cry often? Is there loss of interest in
life? Decreased or increased appetite?
(Anxiety screen) Do you feel stressed or nervous? Have you been particularly anxious about anything? Do you startle easily?

Site Show me where you feel the pain. Can you put your finger/hand on it?
S Or show me on a body map?
Does the pain move/radiate anywhere? Has the location changed over time?
Severity On a 0-10 scale with 0 = no pain and 10 = the worst pain imaginable, how much pain are you in right now?
S What is the least pain you have had in the past (24 hours, one week, month)?
What is the worst pain you have had in the past (24 hours, one week, month)?
How often are you in severe pain? (hours in a day, days a week you have pain)?

42
QISS TAPED
Temporal Characteristics When did the pain start? Was it sudden? Gradual? Was there a clear triggering event?
T Is the pain constant or intermittent? Does it come spontaneously or is it provoked?
Is there a predictable pattern? (e.g., always worst in the morning or in the evening? Does it suddenly flare up?)
Aggravating and What makes the pain better? What makes the pain worse? When do you get the best relief? How much relief
A Alleviating Factors do you get? How long does it last?
Past Response, How have you managed your pain in the past? (Ask about both drug and non-drug methods)
P Preferences What helped? What did not help? (Be specific about drug trials - how much and how long?)
What medications have you tried? Was the dose increased until you had pain relief or side effects? How long
did you take the drug?
Are there any pain medicines that have caused you an allergic or other bad reaction?
How do you feel about taking medications?
Have you tried physical or occupational therapy? What was done? Was it helpful?
Have you tried spinal or other injections for pain treatment? What was done? Was it helpful?
Expectations, Goals, What do you think is causing the pain?
E Meaning How may we help you? What do you think we should do to treat your pain?
What do you hope the treatment will accomplish?
What do you want to do that the pain keeps you from doing?
What are you most afraid of? (Uncovers specific fears, such as fear of cancer, which should be acknowledged
and addressed.)
Diagnostics & Physical Examine and inspect site, Perform a systems assessment and examination as indicated
D Exam Review imaging, laboratory and/or other test results as indicated 43
Pain History Elements and Questions
Medical and Surgical History
Medical or surgical issues related to patient’s pain or treatment may include:
Cancer • Different types of pain may be caused by multiple etiologies:
• Tumors: involvement of bone, vessels, nerves, body organs
• Diagnostic procedures: may be painful such as biopsies, lumbar punctures, or
venipuncture
• Treatment: radiation, chemotherapy, or surgical excision
Recent Surgery • Incisional pain
• Complications such as anastomotic leak, bleeding, compartment syndrome, etc..
Other Conditions • Diabetes which can lead to neuropathic pain
• Herpes zoster which can lead to radicular pain
• Migraines which can lead to mixed etiology

44
Patient Factors to Consider When Assessing Pain
Assessing pain in certain special populations can be challenging and
requires multiple considerations such as:

• Age
• Level of development
• Communication skills/language
• Cognitive skills
• Prior pain experiences
• Associated beliefs

45
Medical and Pain Communication Cards
Communication cards are used
to assist healthcare providers
in communicating with scared,
nonverbal or non-English
speaking patients and families!
• History taking and
assessment
• Pain, mechanism of injury
• Explanation of treatments
• Procedures and testing
• Discharge instructions

Download and print your own set here

Medical Communication Cards or scan the QR code 46
b. Pain Focused Physical Exam

47
Pain Assessment: Physical Examination
During initial pain assessment, physical examination of the patient should be conducted.

You should be examining the Examples

patient’s:
Appearance obese, emaciated, histrionic, flat affect

Posture splinting, scoliosis, kyphosis

Gait antalgic, hemiparetic, using assisting devices

Facial Expression grimacing, tense, diaphoretic, anxious

Vital Signs sympathetic overactivity, temperature asymmetries

48
 Pain Assessment: Physical Examination
You should be examining Example
the Painful Area(s):
Inspection • Skin: color changes, hair loss, flushing, goose bumps, sweating
• Muscle: atrophy or spasm
• Edema
Palpation • Demarcation of the painful area
• Detection of changes in pain intensity within the area
• Trigger points
• Changes in sensory or pain processing
Musculoskeletal system • Flaccidity: extreme weakness (may be from paralysis)
• Abnormal movements: neurologic damage or impaired sense of proprioception,
reduced sense of light touch
• Limit range of motion: disc disease, arthritis, pain
Neurological exam • Cranial nerve exam
• Motor strength
• Spinal nerve function: deep tendon reflexes, pinprick, proprioception
• Coordination: Romberg’s test, toe-to-heal, finger-to-nose, rapid hand movement
49
Pain Assessment: Physical Examination
1. Note the patient’s vital signs as they
can provide a clue to pain severity
• An elevation in blood pressure and heart
rate can occur secondary to pain and
inadequate control of pain.
• However, normal vital signs should not
negate a patient’s reported pain. Always
review vital signs.

50
 Pain Assessment: Physical Examination
2. Take cues from your patient
• Patients will often assume a position of comfort.
• Observe vocalizations (crying child), facial expressions, body posture,
movements, and motor response (decreased movement).
• Observe physiological clues such as skin flushing, diaphoresis, and/or vital
sign abnormalities.
• Consider the patient’s baseline mental status. Are they able to effectively
communicate their pain to you?
• Perform a focused exam taking into account the information given by the
patient. The exam should also assess the patient’s functionality.
• A sensory exam should always be conducted in patients with pain especially
neuropathic pain.

51
4. Pain Assessment Scales
a. Adult Pain Assessment Scales
b. Pediatric Pain Assessment Scales

52
Pain Assessment Scales
As a healthcare provider, it is essential to know and understand which pain assessment
tools and scales are used in your institution.
• Pain scales are typically applied to all pain types. However, chronic and cancer-related pain may
require more complex evaluation tools.
• Although pain is multi-factorial, the majority of pain scales assess pain intensity.
• There are different validated pain scales available for a variety of patient populations such as:
 adults
 pediatrics
 elderly
 non-verbal
• Not all pain scales are equal and one should be chosen based on the patient.
• For example, it would be inappropriate to use a pain scale intended for
adults, such as the Defense and Veterans Pain Rating Scale 2.0, when
assessing a three-year-old child.
53
 Pain Assessment Using Pain Scales
• Once a pain scale is chosen, interpretation of the score is not so straightforward.
• There is no defined score or threshold for what score correlates to actual pain and to what
intensity the pain is felt by the patient.
• Using the same scale for two different patients doesn’t allow for comparison of pain
intensity. For example, a patient with a score of 9 on the Numerical Rating Scale may not
necessarily be experiencing more pain than one with a score of 6 on the same scale.
• Because of the subjective nature of standardized pain scales, patient functionality may be the
best indicator of pain intensity.
• Pain scales DO NOT take into account patient genetics, past experiences,
comorbidities, or other pain influencing factors.
• In patients with preexisting pain it is important to determine their baseline pain
level.

Select a scale and be consistent! 54

 Pain Assessment Using Pain Scales
• When using a pain scale in a verbal adult it is best to ground the scale by
providing context for the patient.
• For example, ask the patient at which level on the pain scale would they take an over-the-
counter pain medication? For those with chronic pain, what level of pain do they experience
every day?
• Surrogate reporting (pain history obtained from a parent, caregiver or loved one)
of a non-verbal patient’s pain and behavior or activity changes can also aid in
pain assessment.
• Try to determine who really provides the patient’s daily care and is knowledgeable about
their history, disease, and past pain management or experiences.

Don’t forget that abnormal vital signs or a change in vital

signs can also serve as an indirect marker for pain.
55
 Examples of Pain Scales
Pain Scales* Verbal, Alert and Oriented Non-verbal, GCS <15 or Cognitive Impairment

Adult 1. Verbal Numeric Scale (VNS)/ 1. Adult Non-Verbal Pain Scale (NVPS)
Numeric Rating Scale (NRS) 2. Assessment of Discomfort in Dementia (ADD)
2. Visual Analogue Scale (VAS) 3. Behavioral Pain Scale (BPS)
3. Defense and Veterans Pain 4. Critical-Care Observation Tool (CPOT)
Rating Scale (DVPRS 2.0)
Pediatric 3 yo and older Birth – 6 mos
1. Wong Baker Faces 1. Neonatal Infant Pain Scale (NIPS)
2. Oucher (3-12yrs) 2. Neonatal Pain Assessment and Sedation Scale (N-PASS)
3. Numerical Rating Scale (NRS) 3. Neonatal Facial Coding System (NFCS)
4. CRIES
(7-11yrs)
8 yo and older Infant and older
1. Revised Faces, Legs, Activity, Cry, and Consolability
1. Visual Analogue Scale (VAS)
(r-FLACC)
2. Verbal Numeric Scale (VNS)/ 2. Non Communicating Children’s Pain Checklist (NCCPC-R)
Numeric Rating Scale (NRS) 3. Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
*This is a short list of pain scales. Determine which pain assessment tools are used by your agency or facility.
56
To learn more about the different scales, visit PAMI
a. Adult Pain Assessment Scales
57
Adult Pain Scales: Verbal, alert and oriented

Measurement Scale Description

Verbal Numeric Scale (VNS)/ Self-report scale. Eleven point scale that requires understanding of numbers, addition and
Numeric Rating Scale (NRS) subtraction.

Five pain levels are indicated in large print on a sheet give to the patient: no, pain, mild pain,
Verbal rating scale (VRS) moderate pain, severe pain, unbearable pain.

A 100-mm rule with a movable cursor: “no pain” is written at he left end of the horizontal line
Visual Analogue Scale
along which the cursor is moved, and “maximal pain” at the right end.

Self-report scale. Eleven point scale that requires the patient to identify pain by numerical
Defense and Veterans Pain
rating, color intensity, facial expression, and pain disruption. Followed by four supplemental
Rating Scale 2.0 (DVPRS) questions evaluating the biopsychosocial impact of pain.

58
Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)

59
Defense and Veterans Pain Rating Scale 2.0
(DVPRS)

60
 Adult Pain Scales: Non-verbal, GCS <15 or
Cognitive Impairment

Measurement Scale Description

Adult Non-Verbal Pain Scale Behavioral scale. Based on FLACC scale and contain behavioral dimensions and physiology
(NVPS) dimensions that are graded by severity.

Assesses pain in patients with dementia. Total scores range from 0 to 10 (based on a scale of 0 to
Pain Assessment in Advanced
2 for five items: breathing. Vocalization, facial expression, body language, and consolability),
Dementia (PAINAD) Scale higher score indicates more severe pain

Behavioral scale. Three observational items (facial expression, upper limbs, and compliance with
Behavioral Pain Scale (BPS)
ventilation). Higher score, greater discomfort.

Behavioral scale. Used for intubated and nonintubated critical care patients. Four domains (facial
Critical-Care Observation Tool
expressions, movements, muscle tension, and ventilator compliance. Higher score, great pain
(CPOT) level

61
Adult Non-Verbal Pain Scale (NVPS)

62
Pain Assessment in Advanced Dementia (PAINAD)
Scale

63
 Behavioral Pain Scale (BPS)

Payen JF, Bru O, Bosson JL, Lagrasta A, Novel E, et al. Assessing pain in critically ill sedated patients by using a 64
behavioral pain scale. Crit Care Med. 2001; 29:2258-2263.
Critical-Care Observation Tool (CPOT)

65
b. Pediatric Pain Assessment Scales

66
 Pediatric Pain Scale Descriptions
Measurement Scale Age Range Description
Birth - 6 months
Neonatal Infant Pain Scale (NIPS) Preterm and full term neonates Behavioral scale.
Neonatal Pain Assessment and
Preterm and full term neonates Behavioral and physiologic scale.
Sedation Scale (N-PASS)
Facial muscle group movement, brow budge, eye squeeze, nasolabial
Neonatal Facial Coding System (NFCS) 32 weeks gestation to 6months furrow, open lips, stretch mouth lip purse, taut tongue, and chin
quiver
CRIES 32 weeks gestation to 6 months Behavioral and physiologic scale.
Infant and older (non-verbal children)
2 months to 7 years, critically ill, cognitively Behavioral scale. Scored in a range of 0–10 with 0 representing no
Faces, Legs, Activity, Cry, and
impaired, and older than three years of age pain. The scale has five criteria, which are each assigned a score of 0, 1
Consolability (FLACC)
unable to utilize a self-report scale. or 2.
Non Communicating Children’s Pain 30 items that assess seven dimensions: vocal, eating/sleeping, social,
3-19 years (with cognitive impairment)
Checklist (NCCPC-R) facial, activity, body/limb, and physiologic signs
3 years and older
Self-report scale. Please refer to specific references for those
Wong Baker Faces 3 years and older
alternative face scales.
Self-report tool consisting of a vertical numerical scale and a photo
Oucher 3 -12 years
scale with expressions of “hurt” to “no hurt.”
8 years and older
8 years and older Self-report scale. Consists of pre-measured vertical or horizontal line,
Visual Analogue Scale (VAS) where the ends of the line represent extreme limits of pain intensity.
Requires understanding of numbers, addition and subtraction.
Verbal Numeric Scale (VNS)/ Numeric Self-report scale. Eleven point scale that requires understanding of
8 years and older 67
Rating Scale (NRS) numbers, addition and subtraction.
Pediatric Pain Scales:
Birth to 6 months
Measurement Scale Age Range Description
Birth - 6 months
Neonatal Infant Pain Scale
Preterm and full term neonates Behavioral scale.
(NIPS)
Neonatal Pain Assessment
Preterm and full term neonates Behavioral and physiologic scale.
and Sedation Scale (N-PASS)
Facial muscle group movement, brow budge, eye
Neonatal Facial Coding
32 weeks gestation to 6months squeeze, nasolabial furrow, open lips, stretch mouth
System (NFCS)
lip purse, taut tongue, and chin quiver
CRIES 32 weeks gestation to 6 months Behavioral and physiologic scale.

68
 Neonatal Infant Pain Scale (NIPS)

The NIPS (Lawrence et al., 1993) was developed at Children’s Hospital of Eastern Ontario. The NIPS assesses six behavioral indicators in response to
painful procedures in preterm newborns (gestational age < 37 weeks) and full-term newborns (gestational age > 37 weeks to 6 weeks after delivery).
69
Neonatal Pain Assessment and Sedation Scale
(N-PASS)

70
Pediatric Pain Scales:
Infant and older (nonverbal children)
Measurement Scale Age Range Description

Infant and older (non-verbal children)

2 months to 3 years,
Behavioral scale. A revised FLACC (r-FLACC)
critically ill, cognitively
Faces, Legs, Activity, Cry, was developed for children with cognitive
impaired, and older than
and Consolability (FLACC) impairment (CI). It contains the same core
three years of age unable to
components as the original FLACC.
utilize a self-report scale.
Non Communicating 30 items that assess seven dimensions: vocal,
3-19 years (with cognitive
Children’s Pain Checklist eating/sleeping, social, facial, activity,
impairment)
(NCCPC-R) body/limb, and physiologic signs
Children’s Hospital of
Observational scale for measuring
Eastern Ontario Pain 1-7 years
postoperative pain in children.
Scale (CHEOPS)
71
Faces, Legs, Activity, Cry, and Consolability
(FLACC)

72
Children’s Hospital of Eastern Ontario Pain Scale
(CHEOPS)

73
Pediatric Pain Scales:
3 years and older

Measurement
Age Range Description
Scale
3 years and older
Self-report scale. Please refer to
Wong Baker Faces 3 years and older specific references for alternative face
scales.
Self-report tool consisting of a vertical
numerical scale and a photo scale
Oucher 3 -12 years
with expressions of “hurt” to “no
hurt.”
74
Wong Baker Faces

75
Pediatric Pain Scales:
8 years and older

Measurement Scale Age Range Description

8 years and older
Self-report scale. Consists of pre-measured vertical or
Visual Analogue Scale 8 years and older horizontal line, where the ends of the line represent
(VAS) extreme limits of pain intensity. Requires understanding
of numbers, addition and subtraction.
Verbal Numeric Scale
Self-report scale. Eleven point scale that requires
(VNS)/ Numeric Rating 8 years and older
understanding of numbers, addition and subtraction.
Scale (NRS)

76
Verbal Numeric Scale (VNS)/ Numeric Rating Scale
(NRS)

77
5. Management of Pain
a. General principles of pain management
b. Re-assessment of pain
c. Consequences of Unrelieved Pain

78
a. General Principles of Pain Management
- Stepwise approach
- Pharmacologic management
- Nonpharmacologic modalities
- Patient safety considerations
- Tranisitions of care and discharge planning

79
General Principles of Pain Management

In this section general principles of pain management will be reviewed.

Due to the changing landscape of pain management, specific
pharmacological and nonpharmacologic treatments will not be
discussed.

For more detailed information on specific pain

management, therapies and treatments refer to the
other PAMI modules, PAMI stepwise approach and the
PAMI Pain Management and Dosing Guide.

80
Pain Management: Putting it All Together
• No Perfect Recipe or “Cookbook”
• No Universal Recipe
 Overview of PAMI Stepwise Approach to Pain
(Adapted to Setting- ED, Hospital, EMS)
Ideal approach not always possible
Pain Management brings challenges to Step 7. Monitoring & Discharge Checkpoint
healthcare. The choice of tools you use
can be determined by using a stepwise
approach that is outlined next. Step 6. Management Checkpoint

Step 5. Patient Assessment Checkpoint

Step 4. Facility Checkpoint

Step 3. Family Dynamic Checkpoint

Step 2. Developmental or Cognitive Checkpoint

Step 1. Situation Checkpoint

Step 1: Determine the Situation: What are you
trying to accomplish or manage?
Step 1. Situation Checkpoint

• Pain only
• Pain and anxiety or agitation
• Anxiety only
• Agitation only
• Procedure that will induce pain or anxiety- transport, IV,………
• Chronic pain condition exacerbation

Determination accomplished after triage, history, and exam

Step 2: Perform a Developmental Checkpoint
Step 2. Perform a Developmental or Cognitive Checkpoint
• What is the developmental stage of patient?
• Is development normal for age?
• Developmental delay
• Autism
• Special health care needs
• Mental health concerns
• Recent traumatic events
• Regression to lower developmental stage

What are characteristics of developmental stage in response to pain?

How do you adapt your approach based on developmental level?
 Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description

Preschoolers
3–6 years Pain is a hurt; Does not relate pain to illness; may relate pain to an Active physical resistance, directed aggressive Has language skills to express pain on a
(preoperational) injury; Often believes pain is punishment; Unable to understand behavior, strikes out physically and verbally sensory level; Can identify location and
why a painful procedure will help them feel better or why an when hurt, low frustration level intensity of pain, denies pain, may believe
injection takes the pain away his or her pain is obvious to others

School-Age Children
7–9 years (concrete Doesn’t understand cause of pain; Understands simple Passive resistance, clenches fists, holds body Can specify location and intensity of pain
operations) relationships between pain and disease and need for painful rigidly still, suffers emotional withdrawal, and describes pain physical characteristics
procedures to treat disease ; May associate pain with feeling bad engages in plea bargaining in relation to body parts
or angry; recognize psychologic pain related to grief and hurt
feelings

10–12 years Better understanding of relationship between an event and pain; May pretend comfort to project bravery, may Able to describe intensity and location with
(transitional) More complex awareness of physical and psychologic pain,(moral regress with stress and anxiety more characteristics, able to describe
dilemmas , mental pain) psychologic pain
Adolescents
13–18 years Has a capacity for sophisticated and complex under-standing of Want to behave in socially acceptable manner More sophisticated descriptions with
(formal causes of physical and mental pain; Recognizes pain has qualitative -like adults; controlled response; May not experience; may think nurses are in tune
operations) and quantitative characteristics; Can relate to pain experienced by complain if given cues from other healthcare with their thoughts, so don’t need to tell
others providers nurse about their pain
Step 3: Family Dynamic Checkpoint
Step 3. Family Dynamic Checkpoint

• Who is with the patient?- family, caregiver, etc.

• Who is the legal guardian?
• Who actually cares for the patient?
• Who do you want at the bedside?
• Consider culture, past experiences, time
commitments, family personality, and family stress
level
 Step 4: Facility (Agency/Community) Checkpoint
Step 4. Facility Checkpoint

• Staffing and setting

• Community, rural, children’s hospital
• Provider experience, team capabilities and
expertise
• Existing hospital/agency pain or procedural
sedation policies
• Acuity and overcrowding of the ED, hospital or
clinic
• Other priorities- MCI, natural disaster, etc.
• Equipment, monitoring, backup
Step 5: Patient Assessment Checkpoint
Step 5. Patient Assessment Checkpoint

• Review history, assessment and risk factors

• Chronic illness-previous painful experiences, recent
surgery
• Psychiatric and mental considerations
• Injury severity, +/- contraindications to opioids or
sedation
• Body habitus
• Weight- ideal or real? Obesity?
 Step 6: Management Checkpoint:
Choose Your “Recipe”
Step 6. Management Checkpoint
• No magic recipe, must individualize and adjust “Ingredients”
• Pharmacologic “ingredients”
• Route: oral, nasal, IV, nebulized, topical, nerve blocks
• Type: sucrose, NSAID, opioids, anxiolytics, ketamine
• Nonpharmacologic “ingredients”
• Everyone needs a little child life 101- distraction, music, virtual reality, etc.
• Engage caregivers and parents- coaching, therapeutic language
Always consider nonpharmacologic options +/- medications:
Will pain duration be short (removal of FB, laceration repair), prolonged (burn) or
chronic (rheumatologic)?
Step 7: Monitoring And Discharge
Checkpoint
Step 7. Monitoring & Discharge Checkpoint
• Joint Commission standards
• Document reassessments
• Patient should be back to baseline and tolerating fluids at discharge
• Consider falls prevention and transportation- especially for patients on opioids or
sedating medications
• Discharge planning and instructions
• Pain plan

90
Pharmacologic and
Nonpharmacolgoic Management
 PAMI Pain Management and Dosing Guide
• The PAMI Pain Management and Dosing
Guide is a free tool for use by health care
providers in all settings and should be used as
general guide when managing pain in pediatric
and adult populations.
• The guide provides treatment options for
opioids, non-opioids, procedural sedation,
nerve blocks, and IV/IM/IN/topical
administration. It includes patient safety
considerations as well as nonpharmacologic
interventions. To take a tour of the dosing
guide, click here!
• A free downloadable pdf of the dosing guide
can be accessed on the PAMI website.
http://pami.emergency.med.jax.ufl.e
du/resources/dosing-guide/
92
 Opioid Prescribing and Equianalgesic Chart
Generic (Brand) Onset (O) and Duration (D) Approximate Recommended STARTING Recommended STARTING
Equianalgesic Dose dose for ADULTS dose for CHILDREN (> 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIR®) [CII] O: 30-60 min O: 5-10 min 30 mg 10 mg 15-30 mg q 2-10 mg q 0.3 mg/kg q 4 0.1 mg/kg
D: 3-6 h D: 3-6 h 2-4 h 2-4 h h q 2-4 h
Morphine extended release (MS O: 30-90 min — 30 mg 10 mg 15-30 mg q — 0.3-0.6 mg/kg q —
Contin®) [CII] D: 8-12 h 12 h 12 h
Hydromorphone (Dilaudid®) [CII] O: 15-30 min O: 15 min D: 7.5 mg 1.5 mg 2-4 mg q 4 0.5-2 mg q 0.06 mg/kg q 4 0.015 mg/kg
D: 4-6 h 4-6 h h 2-4 h h q4h
Hydrocodone/APAP 325 mg O: 30-60 min 5-10 mg q 0.1-0.2 mg/kg q
(Norco 5, 7.5, 10®) [CII] D: 4-6 h — 30 mg — 6h — 4-6 h —
Hycet (7.5 mg/325 mg per 15 mL)
Fentanyl [CII] Transdermal Transdermal Transdermal 1-2 mcg/kg
(Sublimaze® Duragesic®) O: 12-24 h O: immediate 100 mcg 12-25 mcg/h 50 mcg q 12-25 mcg/h q q 1-2 h
— (max 50
Patch for opioid tolerant patients D: 72 h per D: 30-60 min (0.1 mg) q 72 h 1-2 h 72 h
ONLY patch mcg/dose)
 Non-Opioid Analgesics
Generic (Brand) Adult Pediatric (<12 yo)
Acetaminophen 325-650 mg 15 mg/kg
(Tylenol®) PO q 4-6 h PO q 4-6 h
Max: 4 g/d or 1 g q 4 h Max: 90 mg/kg/d
Acetaminophen <50 kg
IV (Ofirmev®) 1 g IV q 6 h Max: 4 g/d or 650 15 mg/kg IV q 6 h or 12.5 mg/kg
Use only if not tolerating mg q 4 h prn pain IV q 4 h prn pain
PO Max: 75mg/kg/d
Celecoxib (Celebrex®) 100-200 mg >2 yo
PO daily to q 12 h 50 mg PO BID
Max: 400 mg/d
400-800 mg PO q 6 to 8 h 10 mg/kg
Ibuprofen (Motrin®) Max: 3200 mg/d PO q 6 to 8 h
Max: 40 mg/kg/d or 2400 mg/d
15-30 mg IV/IM q 6 h 0.5-1 mg/kg/ dose IM/IV q 6 h
Ketorolac (Toradol®)
Max: 120 mg/d x 5 d Max: 15-30 mg q 6 h x 5 d
Naproxen (Naprosyn®) 250-500 mg PO q 8 to 12 h 5 mg/kg PO q 12 h
Max: 1500 mg/d Max: 1000 mg/d
 Intranasal* and Nebulized Medications
Generic Dose Max Dose Comments
Fentanyl IN: 1.5-2 mcg/kg q 1-2 h 3 mcg/kg or 100 mcg Divide dose equally
Neb: 1.7-3 mcg/kg between each nostril
Midazolam IN: 0.3 mg/kg 10 mg or 1 mL per Divide dose equally
(5 mg/mL) nostril (total 2 mL) between each nostril
Ketamine See Ketamine table
Lidocaine Neb: 4% (40 mg/mL) 4.5 mg/kg total or 300 >5 mg/kg associated with
100-200 mg or 2.5-5 mL mg serious toxicity
Ketamine (Ketalar®) Indications and Dosing
Indications Starting Dose
Procedural Sedation IV: Adult 0.5-1.0 mg/kg; Ped 1-2mg/kg;
IM: 4- 5 mg/kg
Sub-dissociative Analgesia^ IV: 0.1 to 0.3 mg/kg;
IM: 0.5-1.0 mg/kg; *IN: 0.5-1.0 mg/kg
Excited Delirium Syndrome IV: 1 mg/kg; IM: 4- 5 mg/kg
 Intranasal Medications
• Use concentrated solution
• Ketamine 50 mg/ml*
• Fentanyl 50 mcg/ml*
• Midazolam 5mg/ml

• Use an atomizer
• If > 1ml divide between nares
• Aim spray toward turbinates/pinna

*Rapid CSF levels

96
 61

Ketamine Pharmacology
• Blockade of N-methyl D-aspartate (NMDA) receptors, peripheral Na+
channels and μ-opioid receptors providing sedation, amnesia, and
analgesia.
• High lipid solubility
• allows rapid crossing of the blood-brain barrier,
• quick onset of action (peak concentration at 1 minute-IV)
• Rapid recovery to baseline

97
Consensus Guidelines on the Use of Intravenous
Ketamine Infusions for Acute Pain Management
• From the American Society of Regional Anesthesia and Pain Medicine,
the American Academy of Pain Medicine, and the American Society of
Anesthesiologists (Reg Anesth Pain Med 2018;43: 456–466)
• Evidence supports the use of subanesthetic ketamine for acute pain in
a variety of contexts, including as a stand-alone treatment, as an
adjunct to opioids, and, to a lesser extent, as an intranasal
formulation.
New Emphasis on Nonpharmacologic
Methods of Treating Pain
• Nonpharmacologic pain management techniques should be
considered along with pharmacologic techniques and may:
• improve assessment
• decrease or avoid the use of opioids or anxiolytics
• decrease time and recovery for procedures
• decrease adverse events
New Emphasis on Nonpharmacologic
Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your “base coat” or “primer” before
applying additional coats of analgesic treatment. With the right base coat
foundation, you have a better chance of painting a patient’s symptoms a more
tolerable and long-lasting new color.
(PEM Playbook: http://pemplaybook.org/podcast/pediatric-pain/
 The Importance of Incorporating
Nonpharmacologic Methods When Treating Pain
In an effort to encourage multimodal approaches, hospitals are now required to
incorporate nonpharmacologic interventions in pain management plans.
These pain assessment and management requirements are designed to improve the
quality and safety of care provided by Joint Commission-accredited hospitals.

Click on the link to find out more!

https://www.jointcommission.org/assets/1/18/Joint_Commission_
Enhances_Pain_Assessment_and_Management_Requirements_for_
Accredited_Hospitals1.PDF

101
 Categorization of Nonpharmacologic Interventions
Cognitive-Behavioral Interventions
Psychologic preparation, education, information Physical (Sensory) Interventions
Distraction (passive or active): Video games, TV, Positioning
movies, phone, lighted or interactive toy, virtual
Cutaneous stimulation
reality
Nonnutritive sucking, sucrose
Relaxation techniques (breathing, meditation, etc.)
Pressure
Music
Hot or cold treatments
Guided imagery
Others
Training and coaching
Coping statements: “I can do this”
Adapted from: Murray KK, Hollman GA. Non-pharmacologic interventions in children during medical and surgical procedures. In: Tobias JD, Cravero JP, eds.
Procedural Sedation for Infants, children, and adolescents; Section on Anesthesiology and Pain Medicine. American Academy of Pediatrics ; 2016.
Nonpharmacologic Interventions
• Pain can sometimes be adequately managed using
nonpharmacologic interventions such as ice, splinting, distraction,
etc.

• These management options can be applied singly or as adjuncts

along with pharmacological options.
For additional information and resources refer to the website and the
Nonpharmacologic PAMI module.

Click here for more information on

nonpharmacologic management options.

103
 Develop Your Own
Distraction &
Nonpharmacologic Pain
Toolkit

Virtual Reality

Distraction &
Nonpharmacologic
Pain Toolkit
b. Re-assessment of Pain

105
Re-assessment of Pain
• Timely reassessment of pain is essential. One of the most common mistakes
made in pain management is failure of reassessment after an intervention
(pharmacologic or nonpharmacologic).

• Pain level should be reassessed after an intervention, such as medication

administration, and once the intervention has had time to exert its effect.

• The timeframe and frequency for re-assessment will depend on the setting.
 For example, re-assessments will be performed frequently and over a
shorter time course in acute care settings, like the ED, compared to
outpatient settings.
 In the acute care settings, consider reassessing pain level 30 minutes after
IV and 60 minutes after PO administration of a medication.
106
Re-assessment of Pain
• The same scale or scoring system used previously should be used on re-
assessment for consistency.

• All patients do not respond to identical management in the same manner due
to genetic and other factors.

• Appropriate monitoring for respiratory depression should be used especially

when using pain relievers with sedating effects (opioids).

• Pain should always be reassessed at time of discharge or within an appropriate

time interval in the outpatient setting.
The literature suggests that a 33% to 50% decrease in pain intensity is clinically
meaningful from a patient's perspective and represents a reasonable standard of
intervention efficacy for acute and chronic pain.
107
c. Consequences of Unrelieved Pain

108
 Consequences of unrelieved acute pain
Psychological Impacts
• The psychological impact of untreated pain can include post-traumatic stress disorder,
anxiety, catastrophizing, and depression.

Chronic pain syndromes

• Chronic pain syndromes can develop as a consequence of untreated acute pain mechanisms
including spinal cord hyper-excitability.

Mortality and Morbidity

• Increased mortality and morbidity can result from unrelieved acute pain. This can occur
through increased oxygen demand, increased metabolic rate, cardiovascular and pulmonary
complications, and impaired immune function.

109
Chronic Pain Syndrome
Chronic pain can affect sleep, mood, activity, and energy level. It has both
physical and psychological affects that can result in a detrimental cycle.

110
6. Discharge Planning and
Transitions of Care

111
Discharge Planning for Patients with Pain
• Appropriate discharge planning should take into account what interventions the patient
has received during the visit and transportation home.
• How will the patient safely arrive home? Consider patient transportation and driving precautions, especially
after receiving a sedating medication
• Are they ambulating at their baseline without assistance?
• Could the treatment or medication still be exerting its effects (i.e. lethargy as a side effect of morphine)?

• An important consideration during discharge planning is whether the patient will be able
to safely take the prescribed medications at home. Also consider if the patient will be
able to obtain the prescribed medications from their pharmacy? (ie cost, supply, etc.).
• Patients should be educated on the proper use of their prescribed medications with clear and easy
to understand instructions: potential side effects, interactions with other prescribed medications
and any adverse effects.
• Has the patient been advised to:
• Not drive while taking their prescribed opioid
• Not combine their medication with alcohol
• Not take more than prescribed especially for acetaminophen containing products
• Store medications safely and dispose of unused tablets properly

112
 Pain Management Transitions of Care
Sound management of pain during transitions of care is important
because:
 It reduces return visits
 Expedites return to normal activities and work
 Helps reduce risk of acute pain progressing to chronic pain
Patients often take 4-6 weeks to experience pain reduction after an acute
injury! Yet national guidelines support limiting opioid prescriptions to a
week or less.

This is why use of multimodal interventions and timely follow up is important.

113
 PAMI Discharge Planning Toolkit for Pain
Detailed discharge instructions are a key element of reducing risk and return visits
for ED patients with painful conditions and those discharged with
pain medication prescriptions.
See PAMI website for more information and to download the
Discharge Planning Toolkit for Pain

PAMI Discharge Planning Toolkit

114
 Discharge Planning
Toolkit for Pain
Algorithms
• Safe practices
• Screening for opioid use disorders
• Identification of pain “risk factors”

Patient discharge handouts and videos

• Tips for managing pain at home
without opioids
• Utilized by pain and other clinics
• Can be incorporated into EMR D/C
instructions
Remind patients in pain that they are like a
care with 4 flat tires
• Medications only pump up one of the tires
• How will they “pump” up the other tires?
• Review the “Car with 4 flat tires analogy” developed by the
American Chronic Pain Association
https://www.youtube.com/watch?v=5RIii6OUK2A
7. Patient Safety, Regulatory and
Legal Aspects of Pain Management

117
Institution, Local, State, and Federal
Regulations

Providers must be familiar with regulations regarding pain management at

their institution and at the local, state, and federal levels.

Most states now have PDMPs (prescription drug monitoring programs) and opioid
legislation.

118
8. Case Scenario
Discussion

119
Case Scenario 1 A 54 year-old non-English speaking male is brought to the ED by EMS after
sustaining a motorcycle collision approximately 20 minutes prior to arrival.
He has an obvious deformity to his left femur and multiple areas of “road
rash.” He received no pain medications prior to arrival. His left leg is
splinted. His eyes are closed and he appears to be praying. After physical
exam and x-rays, it is determined that he has a left femur fracture and
profuse areas of abrasions and denuded skin contaminated with dirt and
gravel.
A second patient arrives during your assessment of the first patient.
Patient number 2 is a 23 year-old female that was involved in the same
accident. She was the restrained backseat passenger in a pick-up truck,
reports “pain all over” and is crying hysterically. After a thorough exam she
is determined to have mild musculoskeletal strain and one small contusion
of her forehead.

 What factors account for the different reactions to pain in these two patients?
 What are the potential barriers to adequately assessing their pain?
120
Case Scenario 1 Discussion

• Patients respond to and express their degree of pain differently due

to a number of psychosocial factors. The severity of injury alone does
not always dictate the degree of a patient’s pain.
• In this case, patient 1 objectively has sustained more severe injuries.
However, patient 2 presents with a more intense and dramatic
response to her injury and situation.
• There are many barriers the treatment team faces when assessing
and treating these two patients, including language barriers (patient
1), lack of previous physician-patient relationship, simultaneous
evaluation of potentially critical patients, and lack of knowledge
regarding past pain experiences.

121
Case Scenario 2
A 3 year-old right-handed male presents to his pediatrician’s office with
his caregiver who reports that the child has complained of pain in his
right arm since yesterday. When questioned the child denies pain, but
cries and pulls away when any part of the right upper extremity is
touched. He has no obvious deformity or swelling to either arm.

 How would your approach to pain assessment

in this child differ from that of an adult? From
an adolescent?

122
 Case Scenario 2 Discussion
• Pediatric patients require a different pain • You hand him two toys and he attempts
assessment approach from adults as they to hold both toys using his left hand. As
often cannot adequately communicate their he is distracted with the toys, you are
pain symptoms or the severity. able to palpate his entire upper
• There are several resources clinicians can use extremity and determine that his pain is
in addition to patient report. These include localized to the elbow.
pediatric pain scales, observation of the
patient’s behavior, and question
• You notice the patient to be playful and
interactive, but not using his right arm.
Although the child is attempting his normal Through the use of observation, surrogate
behaviors (such as playing), he is doing so history provided by the caregiver, and
through compensation. This is confirmed via
his caregiver stating that he has been distraction you are able to localize the
favoring his left arm. patient’s pain.

123
Case Scenario 3
• A 53 year-old male with chronic back pain underwent knee
replacement one week ago. He presents to his primary care doctor
complaining of persistent post-op pain. The patient reports his
prescribed opioid is not controlling his pain. His pain has greatly
limited his ability to perform his daily living activities.

 How would you manage this patient’s pain? What important questions
regarding his history should be asked?

124
Case Scenario 3
• This patient suffers with chronic back pain which he treats with a
prescription opioid. It is important to ask the patient how long he has
been receiving prescription opioids and at what dose. Also if he was
prescribed any new medications after his surgery.

• Upon further inquiry, the patient indicates that he has been taking
the same opioid medication at the same dose for three years. It has
always controlled his pain until his knee surgery. He reports that he
was not given any new prescriptions for pain after his surgery. He was
told that he should take ibuprofen as needed for pain.

125
Case Scenario 3
• In this case, the patient is suffering with an increase in his baseline
pain due to his recent surgery. The prescription opioid which had
controlled his pain for years is no longer effective given this increase
in pain. It is important to recognize that patients who have taken the
same prescription opioids for significant period of time may need an
increase in dose. Additionally, this patient would likely benefit from a
multimodal approach utilizing other non-opioid pharmacologic and
nonpharmacologic adjuncts.

126
9. Summary

127
Summary
 Pain is complex and multifactorial.
 There are several different classifications of pain depending on location and
etiology.
 Successful management of pain relies on a thorough pain history and exam, a
stepwise approach, timely re-assessments, and appropriate selection of
pharmacological and nonpharmacologic management options.
 There is no test that can adequately identify or measure pain.
 Chronic pain is a potential outcome of untreated acute pain.
 Discharge planning must take into account several safety concerns and should
be centered on patient education.

128
 Strive to Obtain the Complete Picture!
It is difficult to gain a comprehensive understanding of all the factors associated
with a patient’s pain in one encounter. For example:
• The back pain patient who has called several times in one week to get an appointment with his
primary care doctor has an important project due for work. He sustained a back injury 1 week
ago in a motor vehicle accident. He was hit by a drunk driver with no insurance. His pain is
uncontrolled and is interfering with his ability to run his lawn maintenance business.
• The demanding patient in bed 10 wanting pain medication for her migraine may be anxious to
get home to her mother who has end-stage cancer. She has been overwhelmed balancing work,
childcare and her mother’s care and appointments and forgot to refill her own maintenance
medications.
• The “whiner” you are transporting to the ED with sickle cell pain is an honor student who has
never called 911 before for pain and accidently left his medications at his parent’s home while on
a weekend visit home from college.

129
 The PAMI website offers access to learning module handouts, PAMI Pain
Management and Dosing Guide, resources, nonpharmacologic and discharge
toolkits, best practices and recent pain news.

We welcome your feedback on all PAMI materials and are interested in how
you use them to improve patient safety, pain education and clinical care.
Please email [email protected].
For more information please visit http://pami.emergency.med.jax.ufl.edu/

Like Us on Facebook at https://goo.gl/4Yh1cB Follow Us on Twitter @pami_painmgmt 130