Do you know the different types of pain and how to treat them? Can you distinguish between acute and chronic pain and take appropriate action to help patients manage pain? Here at MORPh, we run regular FREE webinars to deliver pain management training to Primary Care and PCN pharmacists. In fact, MORPh Clinical Director Helen Liddell is a leading Advanced Pain Pharmacist. You will benefit from her expertise if you sign up for one of our free online pain management courses. This blog post takes you through a basic overview of pain and how to treat it, including reference to the pain management guidelines. For further information delivered by a leading pain expert, you can book onto one of our free online training sessions.
Pain management training: Types of pain
There are four distinct types of pain. The way we treat pain will depend on which of these is the dominant type for the patient.
- Nociceptive Pain: typically the result of a tissue injury
- Inflammatory Pain: abnormal inflammation caused by an inappropriate response by the immune system.
- Neuropathic pain–caused by nerve irritation
- Functional Pain–pain without obvious origin
When you cannot place pain into one of these four types, the result is complex pain. This is characterised by:
- Complex Regional Pain Syndrome
- Fibromyalgia – a particularly difficult pain condition to treat – an over sensitisation to pain in all areas with no known cause – diagnosed by exclusion when you can’t find a reason for the pain
- Chronic Primary (persistent) Pain
Chronic primary pain lasts over three months with no identifiable cause, or it’s out of proportion to the originating injury or disease. NICE Guidance 193 covers this.
Treating pain
We can divide the treatment of pain into different areas:
- In acute pain relief settings, we need to recognise when acute pain moves to chronic pain and avoid adding to the opiate addiction crisis. If we are prescribing opiates for acute pain, we need to be clear that this is short term only.
- Set expectations and support chronic and complex pain sufferers appropriately. They can be divided into those who are taking long term opiates and those who are not.
Pain management training: Chronic pain guidance
In April 2021, NICE issued guidelines for dealing with both primary and secondary chronic pain conditions. Secondary pain means that there is an identifiable cause of the pain. Treatment will usually be dealt with via that identifiable cause rather than following the chronic pain guidelines.
If the pain is out of proportion to the underlying condition or there is no underlying condition, we treat chronic primary pain or chronic primary pain co-existing with secondary pain. When treating chronic primary pain, the NICE guidelines say that pharmacological management is through SSRIs only. We should not treat with
- Morphine
- Non-steroidals
- Tramadol
The guidelines state that the options in treating chronic primary pain are:
- Exercise programmes
- Psychological therapy
- Acupuncture
- Pharmacological management
We can treat pain with exercise in some cases
Why do we treat chronic and acute pain differently?
There is often a mismatch between the expectations of the patient and those of the healthcare professionals treating them. People think that if you are in pain, you should take something to get rid of it. In fact, that is not the case with chronic pain because its origin is very different from that of acute pain.
- Acute pain is caused predominantly by tissue input. Thoughts and emotions do have an impact, but it is minimal.
- Chronic pain is caused predominantly by thoughts and emotions with very little if any tissue input.
Around 88.5% of chronic pain patients suffer from at least one other condition as well. One third of chronic pain patients have depression and even more than that have hypertension. The way we manage their comorbidities will also affect their pain.
There is a strong association between opioid prescribing and deprivation. We must be mindful of this when deprescribing opiates. Patients’ health, beliefs and social situation are very relevant when treating complex chronic pain.
Factors influencing chronic pain
The stages of behaviour in opiate use
- Intended therapeutic use
- Unintended use (misuse)
- Harmful use and dependence – addiction
When a person has been on an opiate for a long time, they are likely to become physically and psychologically dependent. The patient is likely to suffer from withdrawal syndrome when you remove the opiate because they are addicted to it. They may need a lot of support to withdraw.
Tolerance to a drug is different to dependence. Tolerance means that you need more of a drug to get the same effects. This leads to addiction as the amount you use increases. It is important when prescribing opiates for the first time to explain to people about tolerance. This is linked to managing expectations to ensure that people know it is only a short-term solution.
Things to bear in mind when deprescribing opiates
All cases are different. You will need to treat each patient individually when deprescribing opiates. Things to bear in mind include:
- Patient attitude and circumstances
- How long they have been on it
- Is there a driver to change?
- Have they tried to reduce before and what happened?
- What do they know about their pain?
- Are they ready for empowerment?
- Are they able to self-manage?
- What are their expectations?
Pain management training: Further information
Deprescribing opiates and other pain medicine is a complex area. Our free pain management training webinars cover pain assessment and deprescribing for chronic non-cancer pain. We use case studies to reinforce the learning so that students can go back to their own clinical setting and put it into practice. Every participant will receive a certificate and the webinars can be used as evidence for your Pharmacist CPD planned learning. We divide our webinars by both geographical area and therapy area. If you can’t find the right session for you on our list, please do get in touch.
