Addressing the Pain Issue

Abdus Salam Khan, MD FACP

Every day significant number of patients present to emergency department complaining about pain. Pain at times is a complain in itself and other times is part of another issue that needs to be identified.

It is utmost important to address pain in patients as soon as possible. Improving or addressing patient pain complaints, dramatically improves the perception of care given to patients and increase level of satisfaction.

The world started acknowledging pain quite recently and a comprehensive recommendation in the form of pain ladder was introduced by WHO in 1986. It was originally meant for cancer pain but later on was utilized in acute and chronic pains of non cancer origins.

Since 1986 a lot of work has been done on the pain issue and new treatment guidelines and strategies including non medical interventions have been put forth for physicians to address the pain issue.

When patients experience pain, they like to get a relief of their feeling one way or the other. They depend upon their physicians to make best suggestions and judgment for them. So it is duty of the physician to educate themselves on the different ways of addressing the pain. Sometimes it becomes necessary to treat the pain at the same time as trying to ascertain the reason for the pain.

Let me elaborate the WHO recommendations for the correct use of pain medication and it is recommended for both cancer as well as non cancer pain.

  1. Oral form of medication should be used as first line.
  2. Pain medicines should be given at regular intervals rather than only after pain gets worse. The dosage of medication should be adjusted until the patient is comfortable.
  3. The prescription should be given according to the level of pain described by the patients rather than the perception of the doctor. If the patients say he/she has pain it is important to believe him/her.
  4. Dosing of medication to relieve pain should be tailored for the individual. There is no set dosage that fits all. The physician should tailor the dose to find a balance between reliefs of pain and side effects due to medicine.
  5. Pain medicine should be prescribed with a constant concern for detail so the family and the patient himself should be aware of how and when to administrator the pain medicine.

Physicians have a difficult task of adequately addressing the pain, which at the same time be mindful to the side effects and addiction potential. A step wise approach to pain control gives a much needed guidelines on how to approach the pain but it become inadequate when physicians confront with acute and severe pain.

Medications used in acute pain control at times come with a price. Lack of awareness regarding side effects may cause more harm to patients. This practice of prescribing pain without regards to side effects is rampant in Pakistan. I have come across quite a few patients that endure kidney damage or have stomach bleeding from the pain medicines prescribed by doctors.

Especially the intravenous and intra muscular treatments can results into bigger problems like

  • renal failure
  • congestive cardiac failure
  • un controlled blood pressure
  • stomach bleeding

And so on and so forth.

In a lot of patients persistent pain is another issue. They suffer day in and day out and some of them become depressed due to persistent pain. In these patients other medications to address pain should be utilized, one of the approaches is to effectively utilize physical therapy. A mobile joint for example is less painful than a joint that does not move frequently. Similarly taking weight off while exercising will relieve pain better then weight bearing exercise.

As an emergency physician I do come across all spectrum of pain and my advice to patients and the treating physicians is that always address the pain adequately, but at the same time try to address the cause of the pain. If the cause is not appropriately addressed the pain will come back and the problem may get worse.

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