Pain:

Dealing with Pain and Latin. poena = punishment

Fever in the Pharmacy (reflects the deleterious effects that can be inflicted upon the body)

unpleasant sensory and emotional

experience associated with actual or
potential tissue damage, or described in
terms of such damage
International Association for the Study of Pain

Mechanism of Perception Mechanism of Perception

of Pain: of Pain:
Through the dorsal dorsal
The sensory Afferent pain impulses route ganglion horn of
component of pain spinal cord
Synapse with
results from
transmission of
Ascending fibres
peripheral pain to the brain Efferent fibres to the
impulses to the CNS periphery- complete
the circle
by nociceptors and
nociceptive nerve Many substances involved
fibers. e.g. Substance P, bradykinin, histamine, prostaglandins

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 Mechanism of Perception of
Pain:

normally a balance exists between Pain

excitatory and inhibitory due to

neurotransmissions
Perceived pain, either acute or chronic Noxious stimuli
(e.g.mechanical, thermal)
Ongoing tissue
damage/diseases
occurs when this balance changes,
resulting in exaggerated responses and Release of pain-facilitating
sensitization Acute
fight-or-flight mediators: prostaglandins,
histamine, bradykinen
epinephrine
(immediate)
release
Chronic

Pain Classifications
Acute exacerbation of a recurring painful
Acute: condition:
Duration of 0 to 7 days.
The cause may be known or unknown.
usually occurs as part of a single and treatable event. Pain can occur over any duration of time.
a result of traumatic injury, surgical procedure, or a Pain is due to chronic organic
medical disorder. nonmalignant pathology. Examples of
often (not always) associated with autonomic nervous diagnoses that include acute exacerbation
system responses (tachycardia, hypertension, diaphoresis).
decreases with time.
of a recurring painful condition are the
Examples of diagnoses that are associated with acute pain following: sickle cell pain episodes and
include: fractured femur, appendicitis, burns, procedural migraine headache. There are pain-free
pain. episodes between the exacerbations.
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Management of Pain:
Chronic/persistent pain: Chronic (persistent) pain is pain that lasts
longer than the expected time of healing. There is continuous pain
or the pain recurs at intervals for months or years. In some cases,
Acute and chronic malignant:
there are acute exacerbations of chronic pain problems. The cause is
often unknown. Examples of chronic/persistent pain include the
- indications for aggressive drug therapy.
following: low back pain, diabetic neuropathy, post herpetic
neuralgia, multiple sclerosis, and phantom pain.
- Take analgesics on a regular basis to
prevent the recurrence of pain not as
needed > i-e after the pain recurs
Cancer pain: Pain caused by conditions that are potentially life- - Sometimes additional mechanisms are
threatening. The causes of cancer pain are: cancer itself, treatment
of cancer and concurrent disease. Examples of cancer pain include involved- inflammation > NSAID
the following: cancer of the pancreas, spinal cord compression
caused by tumor infiltration, postsurgical pain associated with cancer
treatment, post mastectomy syndrome.
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Management of Pain: Types of Pain
Chronic non-malignant pain: Somatic
Pain of all three
- Analgesics: NOT the primary treatment, only
adjuncts. types can be
Visceral
- The underlying disorder should be treated, either acute or
not just the presenting symptom chronic.
- Multi-modal approach: a doctor with pain expertise Neuropathic
(anaesthiologist, neurologist), rehabilitation specialist
(physiotherapist), mental health professional (psychologist) and
a pharmacist.

Pain-associated conditions
responsive to OTC analgesics: Headache: A symptom: primary or
secondary

Headache Results from dysfunction, injury or

displacement of pain-sensitive cranial
Myalgia
structures.
Periarticular pain
Headache Muscle contraction.Tension HA

Arthralgia Vascular HA / Migraine

Vascular/ Muscle Contraction HA

Other Types of HA Traction HA
e.g. Side effect, sinus HA,
eye strain, dental pain Chronic daily HA (medication
overuse)

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Headache:
1. Muscle Contraction / Tension HA:
- Results from tight muscles at upper back, neck, occiput
or scalp.
- Bilateral, diffuse- at top of head- extend. Aching tight
pressing- gradual in onset, worsens through the day.
- Associated with emotional stress/anxiety- may last
several days (Acute or chronic)
- OTC analgesics for acute types
- Chronic types: physical therapy + relaxation

NOTE
Recently, neurological research has
isolated the temporalis muscle as the
primary center of tension headache
pain and possibly common migraine
pain (Boyd, 2005)

2. Migraine HA (vascular HA)

- Mainly women (3 times more)
- Attack: 3 hrs--- up to 3 days (av. 24 hrs)
- Migraine: recurrent, hemicranial, throbbing
- Triggers: stress, fatigue, oversleeping,
fasting, vasoactive substances in food,
caffeine, alcohol. Menses and changes in BP;
- Maybe caused by medications: nitrates, OCPs,
indomethacin, HRTs)
- IHS: recognises 7 types of migraine BUT for
practicality classical OR common

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Classic Migraine (with aura) Common Migraine (without aura)
Accounts for < 25% of migraine cases 75% of sufferers
visual or neurological aura
No aura
over 5-20 minutes and can last for up to 1
hour All other symptoms the same
Within 60 min of aura ending HA starts
Pain unilateral, throbbing, moderate to
severe, sometimes generalized and diffuse.
Physical activity and movement intensify
pain. Nausea (1/3 sickness). Photophobia,
Phonophobia, fatigue, concentrating difficulty.

3. Cluster headache
Predominantly affects men aged 40-60
HA occurs same time each day, last 10 min-3h
50% of patients: night-time
Woken 2-3 h after sleep with steady intense unilateral
orbital pain.
Conjunctivitis and nasal congestion (watery) is
experienced at same side of head as HA
Ch.ch: periods of acute attack, typically a number of
weeks- few months (1-3 attacks per week)
Nausea is usually absent and family history uncommon

Referral to the doctor. OTC unlikely to be effective

4. Vascular- Muscle contraction HA:

- Patients with daily tension headaches and occasional
migraines
- Either type can precipitate the other

5. Other Causes of HA
**Sinus Headache:
- infection/blockage of the paranasal sinuses >
inflammation/distension of the sensitive sinus walls.
- Localised: peri-orbital, forehead area
- with stooping, blowing nose. Upon awakening,
subside after a while
- OTC analgesics + decongestants
- Persistent > bacterial infection> Dr.

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Headache: Secondary HA:
- All secondary causes of HA except sinusitis Glucoma: frontal HA with pain in the
need to be referred.
eye. Sometimes, but not often, the eye
- Fever, hangover, some NSAIDS (like what?) appears red and is painful. Vision is
- eye strain, infection (e.g. meningitis), blurred and the cornea can look cloudy.
depression, anxiety, glucoma > OTC not In addition, the patient may notice
effective
halos around the vision.
- Temporal arteritis, raised ICP
- weekendHA

Meningitis
Meningitis: severe generalized HA associated
with fever, an obviously ill patient, neck
stiffness, a positive kernigs sign (pain behind
both knees when extended) and latterly a
pupuric rash all classically associated with
meningitis

Meningitis is notoriously difficult to diagnose. Any child has a

difficulty in placing the chin on the chest, has a headache and is
running a temperature over 38.9 Referred urgently

When to Refer? Myalgia

Dull, constant diffuse pain of the muscles cause by:
HA unresponsive to analgesics
HA in children < 12 y/o with stiff neck or skin rash
HA occurs after recent (1-3 months) trauma injury Systemic infection Strenous exersion Prolonged tonic contraction
HA that lasted for > 2 weeks
(e.g. infuenza, measles) (e.g. exercise, poor posture)
Nausea and/or vomiting in the absence of migraine OTC analgesics should be started soon after the injury.
symptoms Adjunctive: heat, massage.
Neurological symptoms (in absence of migrain) Remobilisation after injury healed is important,
especially change in conciousness otherwise: weak, tight, overly contracted muscles, trigger
New or severe HA in patients over 50 points may arise
Symptoms indicative of cluster HA R.I.C.E: beneficial. ice, vapo-coolant spray, trigger point
Very sudden or severe onset of HA injections (= Local anaesthetic to facilitate mobilisation)

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 Periarticular Pain:
injury or inflammation to the tissues
surrounding the joint ( joint capsule,
ligaments, tendons, bursae)
Localised tenderness, pain associated with
movement of structure. knee, shoulder, elbow
Responds well to OTC analgesics
and limitation of movement

Arthralgia: Pain
Joint pain often caused by synovitis
Assess the patient's level of pain or
(inflammation of synovial membrane). Cartilage
loss may occur (e.g. in DJD, RA).
discomfort.
Doctor/Pharmacist should enquire
Osteoarthritis (DJD) Reumatoid Arthritis (RA)
about:
-In wt bearing joints: -mainly: multiple joints, fingers, - Aetiology
hips, knee, lumbar spine hands, wrist and feet
- Duration
-Paracetamol is analgesic - joints warm, red, swollen, - Location
of choice, wt loss motion limited > deformity
- Severity
-For acute flares: NSAIDs, -more than OTC (NSAIDs): - Factors that or pain
local heat education, physical therapy,

Acute Pain Measuring Acute Pain

Adults
Verbal Rating Scales
The Patients Pain None Mild Moderate Severe
Is What They Say It Is
Numerical Rating Scales
0 = no pain 10 = worst pain ever

Visual Analogue Scales

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Measuring Acute Pain Assessment of Pain:
Children 3-7 yrs It is important to use validated scales
for pain assessment:

Visual Analogue Verbal numerical

Scale (VAS): rating scale
marking on a 10cm
line distance that 0----------10
represents pain,
measure then record
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Treatment of Pain Fever

Fever is defined as a body temperature
that is higher than the normal core
temperature of 37.8C (average 36.4 C
37.2 C )
Rectal > 38.8 C
Oral >37.8 C
Axillary > 37.2 C

Complications of Fever: Febrile Seizures:

Serious complications are rare
Harmful effects: dehydration,
delirium, seizures, irreversible
neurologic/muscular damage and coma
seizures associated with fever in the
absence of another cause (e.g. acute
If metabolic syndrome, CNS inflammation)
> 41.1C
in 2-4% of children (6mths-5 years)

Simple
However, even lower temp can be life-
threatening: infants, people with heart D, brain tumor or -No longer than 15 mins
haemorrhage, CNS infections, preexisting neurologic disorder - do not recur during single
>> febrile seizures episode
- no focal features
-No neurologic sequelae
Complex
-> 15 mins
- repetitive during the episode
- exhibit focal features/signs
- in children of
preexisiting/latent epilepsy

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focal seizure
<neurology> A brief temporary alteration in movement,
sensation or autonomic nerve function caused by
abnormal electrical activity in a localized area of the
brain.
Focal seizures (i.e. Partial or Jacksonian seizures)
usually cause no change in awareness or alertness. An
example of a focal (partial) seizure would be rhythmic
muscle contractions in one area of the body: lip
smacking, mouth movements, drooling, head turning,
eye movements or seemingly purposeful movements
(for example picking at clothes).
Other presentations may be strictly sensory with
abnormal numbness, tingling or a crawling sensation to
the skin. More unusual symptoms include changes in
speech, thought, personality, mood, sensation of deja
vu or hallucinations
Measurement of body temperature
Types of thermometers:
oral ~ bulb: thin, long to reach well
under tongue
rectal ~ bulb: short, thick, permit
insertion with little risk of breakage
rectal ~ can be used orally
Never the opposite (why?)
Never use the same thermometer for
both oral and rectal measurements
Febrile Seizures:
although magnitude and rate of temp are
determinants of febrile seizures, however, the
temp at which the child will seize is
unpredictable.
high risk: previous seizure, family Hx,
documented CNS disorder.
Prophylaxis: antiepileptics (DOC: valproate,
diazepam) are reserved for those at high risk.
Prevalence of epilepsy may be higher after a
febrile seizure.
Measurement of body temperature
Axillary, tympanic, oral, rectal
During the course of illness > use same thermometer
wash hands thoroughly before and after
Types of thermometers:
- Mercury-in-glass
- Electronic thermometer
- Tympanic thermometer
- Skin thermometer
Treatment of Fever:
Fever is a sign of an underlying process
Treatment should focus on the underlying
cause instead of temperature reading
no correlation between magnitude/pattern of
temp elevation (persistent, intermittent, recurrent,
prolonged) and the aetiology or severity of the
disease
Thus, it is difficult to determine the cause of
fever based solely on temperature elevation
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The main indication for treatment
of fever is:
Patient discomfort
Arguments against treatment of
fever:
An evidence: fever is an adaptive
response & elevated body
temperature maybe beneficial:
A. certain microbes may be thermolabile,
growth is impaired by higher-than-normal
temperature
Clinical evidence: treatment of chickenpox
with paracetamol, or rhinovirus with ASA:
resulted in longer duration of symptoms
than no treatment
Treatment Goals
The major goal of self-treatment is to
alleviate the discomfort of fever by
reducing the body temperature to a
normal level
General Approach: antipyretic
around the clock and continued for at
least 24 hours + nonpharmacologic
measures
Arguments against treatment of
fever:
1. The benign and self-limited course of fever
2. The possible elimination of a diagnostic or
prognostic sign
3. The untoward effects of antipyretic drugs
4. Fever is not associated with harmful effects
unless temperature exceeds 41.1 C
5. The attenuation of enhanced host defenses
(i.e. possible therapeutic effects of fever)
B. Low grade fever may also have
beneficial effects on host defense
mechanisms
(e.g. antigen recognition, T-helper
lymphocyte function, leukocyte motility)
- But these effects have not been shown to
favorably alter the course of infectious
diseases
Exclusions for self-treatment of
fever:
1. patients > 3 months old with rectal temperature
40 C
2. children < 3 months old
3. Symptoms of infection
4. impaired O2 utilization (e.g. severe COPD,
respiratory distress, heart failure)
5. Impaired immune function (e.g. cancer, HIV)
6. CNS damage (e.g. head trauma, stroke)
7. Children with Hx of febrile seizures or seizures
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Non-pharmacologic:
- light clothing, remove blankets, room
temp (25.6 C)
- increase fluid supply (by at least
1oz/hour)
- if > 40 C- sponging with tepid water, 1
hour after antipyretic intake
Not recommended in children < 40 C (why?)
Treatment of Fever:
children predisposed to seizure:
- The doctor should be contacted at the 1st
sign of fever
- Antipyretic should be given every 4 hours
with one dose during the night
- Anticonvulsants given by the doctor
- If febrile-seizure occurred sponge with
tepid water
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