Pain Management: Introduction Painthe most common symptom that brings patients to see a physiciannearly always manifests a pathological

process. Any treatment plan must be directed at the underlying process as well as at controlling pain. Patients are generally referred for pain management by primary care practitioners or specialists once a diagnosis has been made and treatment of any underlying process has been initiated. Notable exceptions are patients with chronic pain in which the cause remains obscure after preliminary investigations; serious and life-threatening illnesses should, however, have been excluded.

The term "pain management" in a general sense applies to the entire discipline of anesthesiology, but its modern usage is restricted to management of pain outside the operating room. This type of practice may be broadly divided into acute and chronic pain management. The former primarily deals with patients recovering from surgery or with acute medical conditions in a hospital setting, whereas the latter includes diverse groups of patients in the outpatient setting. Unfortunately, this distinction is artificial because considerable overlap exists; a good example is the cancer patient who frequently requires short- and long-term pain management, both in and out of the hospital.

The practice of pain management is not just limited to anesthesiologists but includes other practitioners such as physicians (internists, oncologists, and neurologists) and nonphysicians (psychologists, chiropractors, acupuncturists, and hypnotists). Clearly, the most effective approach is multidisciplinary, in which the patient is evaluated by one physician (the case manager) who conducts the initial examination and formulates a treatment plan, and the services and resources of other specialists are readily available. Moreover, the case manager and the various consultants meet regularly in formal case conferences to discuss patients. Single specialty pain clinics tend to be either syndrome or modality oriented. The former specialize in chronic back pain, headache, and temporomandibular joint dysfunction, whereas the latter offer nerve block, acupuncture, hypnosis, and biofeedback.

Anesthesiologists trained in pain management are in a unique position to coordinate multidisciplinary pain management centers because of broad training in dealing with a wide diversity of patients from surgical, obstetric, pediatric, and medical subspecialties, as well as expertise in clinical pharmacology and applied neuroanatomy, including the use of peripheral and central nerve blocks (see Chapters 16 and 17).

Definitions & Classification of Pain

Like other conscious sensations, normal pain perception depends on specialized neurons that function as receptors, detecting the stimulus, and then transducing and conducting it into the central nervous system. Sensation is often described as either protopathic (noxious) or epicritic (nonnoxious). Epicritic sensation (light touch, pressure, proprioception, and temperature discrimination) is characterized by low-threshold receptors and is generally conducted by large myelinated nerve fibers (see Table 141). In contrast, protopathic sensation (pain) is subserved by high-threshold receptors and conducted by smaller, lightly myelinated (A) and unmyelinated (C) nerve fibers.

What Is Pain?

Pain is not just a sensory modality but is an experience. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." This definition recognizes the interplay between the objective, physiological sensory aspects of pain and its subjective, emotional, and psychological components. The response to pain can be highly variable among persons as well as in the same person at different times.

The term "nociception," which is derived from noci (Latin for harm or injury), is used to describe the neural response only to traumatic or noxious stimuli. All nociception produces pain, but not all pain results from nociception. Many patients experience pain in the absence of noxious stimuli. It is therefore clinically useful to divide pain into one of two categories: (1) acute pain, which is primarily due to nociception, and (2) chronic pain, which may be due to nociception but in which psychological and behavioral factors often play a major role. Table 181 lists terms frequently used in describing pain.

Table 181. Terms used in pain management.

Pain can also be classified according to pathophysiology (eg, nociceptive or neuropathic pain), etiology (eg, postoperative or cancer pain), or the affected area (eg, headache or low back pain). Such classifications are useful in the selection of treatment modalities and drug therapy. Nociceptive pain is caused by activation or sensitization of peripheral nociceptors, specialized receptors that transduce noxious stimuli. Neuropathic pain is the result of injury or acquired abnormalities of peripheral or central neural structures.

Acute Pain

Acute pain can be defined as pain that is caused by noxious stimulation due to injury, a disease process, or the abnormal function of muscle or viscera. It is usually nociceptive. Nociceptive pain serves to detect, localize, and limit tissue damage. Four physiological processes are involved: transduction, transmission, modulation, and perception. This type of pain is typically associated with a neuroendocrine stress that is proportional to intensity. Its most common forms include posttraumatic, postoperative, and obstetric pain as well as pain associated with acute medical illnesses, such as myocardial infarction, pancreatitis, and renal calculi. Most forms of acute pain are self-limited or resolve with treatment in a few days or weeks. When the pain fails to resolve because of either abnormal healing or inadequate treatment, the pain becomes chronic (below). Two types of acute (nociceptive) painsomatic and visceralare differentiated based on origin and features.

Somatic Pain

Somatic pain can be further classified as superficial or deep. Superficial somatic pain is due to nociceptive input arising from skin, subcutaneous tissues, and mucous membranes. It is characteristically well localized and described as a sharp, pricking, throbbing, or burning sensation.

Deep somatic pain arises from muscles, tendons, joints, or bones. In contrast to superficial somatic pain, it usually has a dull, aching quality and is less well-localized. An additional feature is that both the intensity and duration of the stimulus affect the degree of localization. For example, pain following brief minor trauma to the elbow joint is localized to the elbow, but severe or sustained trauma often causes pain in the whole arm.

Visceral Pain

The visceral form of acute pain is due to a disease process or abnormal function of an internal organ or its covering (eg, parietal pleura, pericardium, or peritoneum). Four subtypes are described: (1) true localized visceral pain, (2) localized parietal pain, (3) referred visceral pain, and (4) referred parietal pain. True visceral pain is dull, diffuse, and usually midline. It is frequently associated with either abnormal sympathetic or parasympathetic activity causing nausea, vomiting, sweating, and changes in blood pressure and heart rate. Parietal pain is typically sharp and often described as a stabbing sensation that is either localized to the area around the organ or referred to a distant site (Table 182). The phenomenon of visceral or parietal pain referred to cutaneous areas results from patterns of

embryological development and migration of tissues, and the convergence of visceral and somatic afferent input into the central nervous system. Thus, pain associated with disease processes involving the peritoneum or pleura over the central diaphragm is frequently referred to the neck and shoulder, whereas disease affecting the parietal surfaces of the peripheral diaphragm is referred to the chest or upper abdominal wall.

Table 182. Patterns of Referred Pain.

Chronic Pain

Chronic pain is defined as pain that persists beyond the usual course of an acute disease or after a reasonable time for healing to occur; this period can vary from 1 to 6 months. Chronic pain may be nociceptive, neuropathic, or mixed. A distinguishing feature is that psychological mechanisms or environmental factors frequently play a major role. Patients with chronic pain often have an attenuated or absent neuroendocrine stress response and have prominent sleep and affective (mood) disturbances. Neuropathic pain is classically paroxysmal and lancinating, has a burning quality, and is associated with hyperpathia. When it is also associated with loss of sensory input (eg, amputation) into the central nervous system, it is termed "deafferentation pain." When the sympathetic system plays a major role, it is often termed "sympathetically maintained pain."

The most common forms of chronic pain include those associated with musculoskeletal disorders, chronic visceral disorders, lesions of peripheral nerves, nerve roots, or dorsal root ganglia (including diabetic neuropathy, causalgia, phantom limb pain, and postherpetic neuralgia), lesions of the central nervous system (stroke, spinal cord injury, and multiple sclerosis), and cancer pain. The pain of most musculoskeletal disorders (eg, rheumatoid arthritis and osteoarthritis) is primarily nociceptive, whereas pain associated with peripheral or central neural disorders is primarily neuropathic. The pain associated with some disorders, eg, cancer and chronic back pain (particularly after surgery), is often mixed. Some clinicians use the term "chronic benign pain" when pain does not result from cancer. This is to be discouraged, because pain is never benign from the patient's point of view, regardless of its cause.

Systemic Responses to Pain

Acute Pain

Acute pain is typically associated with a neuroendocrine stress response that is proportional to pain intensity. The pain pathways mediating the afferent limb of this response are discussed above. The efferent limb is mediated by the sympathetic nervous and endocrine systems. Sympathetic activation increases efferent sympathetic tone to all viscera and releases catecholamines from the adrenal medulla. The hormonal response results from increased sympathetic tone and hypothalamically mediated reflexes.

Minor or superficial operations are associated with little or no stress, whereas major upper abdominal and thoracic procedures produce major stress. Pain following abdominal and thoracic operations or trauma additionally has direct effects on respiratory function. Immobilization or bed rest due to pain in peripheral sites can also indirectly affect respiratory as well as hematological function. Moderate to severe acute pain, regardless of site, can affect nearly every organ function and may adversely influence postoperative morbidity and mortality. The latter suggests that effective management of postoperative pain is not only humane but is a very important aspect of postoperative care.

Cardiovascular Effects

Cardiovascular effects are often prominent and include hypertension, tachycardia, enhanced myocardial irritability, and increased systemic vascular resistance. Cardiac output increases in most normal persons but may decrease in patients with compromised ventricular function. Because of the increase in myocardial oxygen demand, pain can aggravate or precipitate myocardial ischemia.

Respiratory Effects

An increase in total body oxygen consumption and carbon dioxide production necessitates a concomitant increase in minute ventilation. The latter increases the work of breathing, particularly in patients with underlying lung disease. Pain due to abdominal or thoracic incisions further compromises pulmonary function because of guarding (splinting). Decreased movement of the chest wall reduces tidal volume and functional residual capacity; this promotes atelectasis, intrapulmonary shunting,

hypoxemia, and, less commonly, hypoventilation. Reductions in vital capacity impair coughing and the clearing of secretions. Regardless of the pain's location, prolonged bed rest or immobilization can produce similar changes in pulmonary function.

Gastrointestinal and Urinary Effects

Enhanced sympathetic tone increases sphincter tone and decreases intestinal and urinary motility, promoting ileus and urinary retention, respectively. Hypersecretion of gastric acid can promote stress ulceration, and together with reduced motility, potentially predisposes patients to severe aspiration pneumonitis. Nausea, vomiting, and constipation are common. Abdominal distention further aggravates loss of lung volume and pulmonary dysfunction.

Endocrine Effects

The hormonal response to stress increases catabolic hormones (catecholamines, cortisol, and glucagon) and decreases anabolic hormones (insulin and testosterone). Patients develop a negative nitrogen balance, carbohydrate intolerance, and increased lipolysis. The increase in cortisol, together with increases in renin, aldosterone, angiotensin, and antidiuretic hormone, results in sodium retention, water retention, and secondary expansion of the extracellular space.

Hematological Effects

Stress-mediated increases in platelet adhesiveness, reduced fibrinolysis, and hypercoagulability have been reported.

Immune Effects

The stress response produces leukocytosis with lymphopenia and has been reported to depress the reticuloendothelial system. The latter predisposes patients to infection.

General Sense of Well-Being

The most common reaction to acute pain is anxiety. Sleep disturbances are also typical. When the duration of the pain becomes prolonged, depression is not unusual. Some patients react with anger that is frequently directed at the medical staff.

Chronic Pain

The neuroendocrine stress response is absent or attenuated in most patients with chronic pain. The stress response is generally observed only in patients with severe recurring pain due to peripheral (nociceptive) mechanisms and in patients with prominent central mechanisms such as pain associated with paraplegia. Sleep and affective disturbances, particularly depression, are often prominent. Many patients also experience significant changes in appetite (increase or decrease) and stresses on social relationships.