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1

Types of pain

Nociceptive
Neuropathic/functional

2

Nociceptive pain

Caused by damage to body tissue, secondary to noxious stimuli

3

Neuropathic/functional pain

Disengaged from noxious stimuli or healing; Described in terms of chronic pain, result of nerve damage or abnormal operation of nervous system

4

Postherpetic neuralgia - pain type?

Neuropathic/functional pain

5

Diabetic neuropathy - type of pain?

Neuropathic/functional

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Neuropathic pain

Result of nerve damage

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Pain regulated by -

Excitatory & inhibitory neurotransmitters in response to stimuli

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Perception of pain - 3 systems?

1. Afferent pathways
2. CNS
3. Efferent pathways

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Afferent pathway

send signals to spinal cord

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CNS system involvement in pain pathway

discriminate & localize pain, arouse & alert (fight/flight), motivational factors

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Efferent pathway

Modulate pain sensation

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Pathophysiology - 4 stages of pain

1. Stimulation
2. Transmission
3. Perception
4. Modulation

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Pain - Stimulation pathophysiology

Involves stimulation of free nerve endings - nociceptors

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Pain - Transmission pathophysiology

Afferent fibers synapse into various layers of the spinal cords dorsal horn - pain impulses transmitted to brain stem — thalamus via ascending pathways — then finally to CNS

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Ascending transmission pathway

Peripheral pain receptors to spinal cord to medulla to brain stem to midbrain to cortex

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Pain - perception pathophysiology

The point at which pain becomes a conscious experience

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Pain - modulation

Initiation of the anti-nociceptive system
Endogenous opiate system in CNS releases “endorphins”

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Location of pain modulation

Descending system - inhibits pain transmission at dorsal horn

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Neuropathic pain

Rewiring of pain circuits - anatomically and biochemically

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The goal of managing pain

Reduce peripheral sensation (the cause) and decrease central stimulation

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Pain severity vs. therapy measurement

Numerical assessment unless cognitive deficit or children - use face scale

22

Mild pain scale

1-3

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Mild pain treatment

APAP, aspirin, NSAID, COX-2 inhibitors

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Moderate pain scale

4-7

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Moderate pain treatment

NSAID, opioid + APAP, tramadol

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Severe pain scale

8-10

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Severe pain treatment

Opioids

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Reason for combination therapy (opioid + another Rx)

1. Take advantage of the synergistic effect on pain
2. To limit the dose

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Benefits of non-opioids

Availability, additive therapy when combined with opioids, inexpensive, low abuse

30

Only true “pain killers”

NSAIDs - decreasing inflammation (large cause of pain)