What Do We Need to Consider for Pain Management?

*Srini Chary*

## **Abstract**

Chronic pain in palliative care is viewed as an illness but remains as a subjective symptom. Hence, we must consider genetics, pain experience, coping skills, epigenetic effects, mental health, social determinants of health, interventions, and molecular biology. Acute pain transitions to chronic pain in some individuals following an injury, and there is poor evidence to stop such change. Acute, Chronic, and mixed pain can occur in patients with trauma, cancer, organ failure due to primary illness and other co-morbidities. The response to interventions may include biopsychosocial, non-pharmacological, surgery, radiation, chemotherapy, interventional radiology, pharmacological and depending upon survivorship, consider what is appropriate with peer reviewed medical evidence. Neurobiology is important in relation to physical and psychological issues; it affects an expression of pain. Manageable pain and relief are considered as being Human Right. Lack of adequate knowledge and treatment resources are common for care providers and patients. Cancer and noncancer pain ought to consider collaborating with interdisciplinary palliative approach, palliative care, and end of life care along with acute, chronic, and mixed pain management. Cancer patients with survivorship is increasing and risk management with chemicals, noncancer individuals appear similar. Barriers include health professional education, lack of treatment resources, medical, economic, ethical, and legal reasons. Pain management as an illness, care providers considers patient and family centered approach, useful to the community.

**Keywords:** pain taxonomy, genetics, epigenetic effects, biopsychosocial, molecular biology, interventions

#### **1. Introduction**

As a care provider, we must consider up to date pain management skills beneficial to individual patient. Valuing, dignity and hope along with better therapeutic relationship with the patient, allows us to return home happier at the end of the day. Relief of pain is not effective; health care professionals feel uncomfortable and complain around the world.

In 1967, the world's first purpose-built, St Christopher's Hospice in south London, England by Dame Cicely Saunders, who was a nurse, social worker and became a physician for "end of life care and clinical research" in the United Kingdom. Dr. Robert Twycross and from Canada Dr. Balfour Mount had worked with Dame Cicely Saunders and Dr. Mount came up with a term "Palliative Care" in 1973 which within a short time, the entire world accepted.

World Health Organization (WHO) present definition comprises: "Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual."

More recently "Palliative Approach, Palliative Care and End of Life Care" has been accepted internationally as well as also "Early, Integrated, Collaborative and Inter-professional Care". Advanced care planning, goals of care, and good communication with relevant language and words reduce distress of patient and family (**Figure 1**).

Now palliative care has patients with palliative approach, palliative care, end of life care and survivorship with cancer or organ failure. Dr. Pippa Hawley explained the value of a visual "Bow Tie Model" as a disease management and palliative care triangles can be adopted for cancer and non-cancer interventions [1].

At the end of last century, pain management and scientific research had improved but chronic pain and palliative care specialists with present knowledge were limited in Canada and other parts of the world.

The Gold Standards Framework from the UK has prognostic indicators; general, cancer, and organ failure trajectories, which are important and useful to consider, before treatment plan [2].

In 2007, Boulanger et al., did a study whether chronic non-cancer pain has improved, though more patients were receiving medical analgesics, the changes were minor and could be better in Canada [3].

Genetics play a major role with physical, psychological health or illness and our knowledge and management is improving [4, 5]. Nutrition has a role in pain management and requires learning care providers, patients, and families [6].

Optimal pain management requires history, physical examination, investigations, and appropriate interventions. In the past four to five years "opioid crisis" increased deaths due to the use of illicit fentanyl [7]. "Pain crisis" is an experience of a patient relating to pain and requires immediate interventions, whereas "opioid crisis" relates to substance use disorder or an error with medication or illicit drug use.

IASP, pain and palliative care societies across the world are encouraging physicians and interprofessional team members to consider interventions for pain management, clinical research and in the past three decades, several peer reviewed manuscripts have been published for pain management with such evidence and knowledge, can reduce pain in an individual and community can prosper.

#### **Figure 1.**

*Bow Tie Model: Bow Tie Model: Palliative care is an interdisciplinary coordination at the time of diagnosis and the timelines can vary in an individual head towards survivorship with cure or illness is controlled and requires supportive care or some individuals can be at the end of life.*

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*What Do We Need to Consider for Pain Management? DOI: http://dx.doi.org/10.5772/intechopen.93640*

International Association for the study of pain (IASP) has revised, 1979 definition of pain in 2020 considering concepts, challenges and compromises and stated "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage" and is relevant for pain

Pain perception and expression is associated with molecular biology which includes transmission of signals from an injury, transmitting through spinothalamic tract to thalamus in the brain, in nanoseconds, the signals move to limbic system. Alteration in the limbic system, changes in neurotransmitters, tissue receptors lead

Acute pain like "stubbed toe or a needlestick" disappears in a few minutes secondary to the antinociceptive nervous system triggered and the pain stimuli release endorphins within the brain, and enkephalins in the brain stem, which block the transmission of pain signals at different levels and the ion channels are

However, the acute pain secondary to cell injury caused by pressure, heat, chemicals, or physical stimulus; damaged cells release lysosomes which causes inflammation within hours and magnifies the pain signals through the release of signaling chemicals such as prostaglandins, arachidonic acid and leukotrienes in the nervous system and involves glutamate at low levels. Ion channels may not function

Acute nerve injury associated with acute neuropathic pain, e.g., broken bone,

Acute, nociceptive, and inflammatory pain can transition to chronic pain, if the pain persists more than 3 months in an individual. In this period of transition, the ion channel function may not be normal, and endorphins may not be

Following an acute injury; infection, crush or nerve injury, degeneration of tissues, micro, macro vascular insufficiency, and cancer the recovery is low, and healing is slower, leading to chronic pain associated with poor quality of life. Palliative and end of life care, some patients who are dependent, frail and require extensive nursing care may have pain crisis along with delirium. Identifying the difference between the symptoms, pain and delirium, using appropriate pharmacological interventions are useful. Refractory symptoms like delirium, respiratory distress, seizures may need palliative sedation. Patients with pain and agitation

Advanced cancer trajectory leads to end of life, pain crisis or delirium and other co-morbidities need to be considered. However, if patient responds to intervention, almost 50% of them are in survivorship and not end of life, requiring long-term pain and symptom management. Cancer pain is often a "mixed pain" as inflamma-

may require analgesic and intermittent or palliative sedation [10].

tion around primary or metastasis is common [11].

to high expression of pain, anxiety, frustration, and major depression.

appropriately thus endorphins may not be active [9].

**2. Optimal pain management**

management [8].

**2.1 Acute pain**

functioning.

amputation.

active.

**2.2 Chronic pain**

**2.3 Cancer and pain**
