ACUTE PAIN

Acute pain is pain that is of recent origin, is related to specific injury or illness, is of short duration, and is accompanied by limited disability, if any is present. Acute pain is an important indicator that tells us to stop using the injured body part to allow healing, while alerting us to the presence of a problem. It is caused by normal activation of pain nerve receptors, known as nociceptors. These specialized nerve endings are embedded throughout our bodies and respond to penetrating wounds, chemical irritations or burns, heat, cold, pressure, nerve injury, inflammation, muscle spasm, fractures, infections, edema, expansion or rupture of a viscous tissue, ischemia, overuse, erosion and degeneration. This covers almost all of the conditions that present medically, and, in fact, pain is the most common presenting medical complaint, covering up to 70% of patient complaints to a physician's practice.

Pain is often the symptom that helps us pinpoint the pathology, or at least helps us to begin to come up with a differential diagnosis. At the same time pain can be quite confounding both for diagnosis and treatment. It is not an uncommon experience to find the underlying pathology, treat it effectively and still be left with residual pain complaints. This occurs less frequently with acute pain, and more often when that pain is becoming chronic. Although most acute pain clears up with treatment of the underlying condition, it is important to treat the pain concomitantly with the healing of the pathology. Additionally, when the pain does not clear up, more aggressive means should be employed, to prevent that pain from becoming chronic. Once chronicity sets in, the pain is much more difficult to treat.

The treatment ladder approach can be used for acute pain, with some modifications:

1. Rest, ice, compression and elevation
2. Non-opioids (Tylenol, Ultram, aspirin, NSAIDs. Ambien for sleep)
3. Short acting opioids (Weak: Propoxyphene, Codeine; Intermediate: Hydrocodone; Strong: Oxycodone, Morphine, Hydromorphone)
4. Blocks
5. Surgery

Obviously, this ladder is not always right or proper to follow, but it is a reasonable general guideline. A more effective approach is to assess the degree of pain between mild, moderate and severe and to look at the available treatment as more of a wheel than a ladder. This way appropriate treatment from each category can be applied as clinically indicated. Again it is important to stress that pain should be treated concomitantly with the underlying disorder, to avoid precipitation of chronic pain. Moderate to severe levels of pain should jump to step 3 of the ladder immediately. It is also important to note that chronicity can occur even in the face of the most outstanding treatment of acute pain. If it does occur than treatment should follow the guidelines for diagnosing and managing chronic painful disorders.

An area of special importance is postoperative pain. More often we are seeing the immediate postoperative care in the hospital setting being addressed with strong opioid analgesic medications, epidural analgesia, and patient controlled methods of delivery of analgesia. This has led to vast improvements. Often, however, patients with complaints of pain beyond that usually seen are dismissed as being overly sensitive. It is important to take the complaints at face value and treat the pain. Of course their are times when patients are drug seeking, but this is usually restricted to people with significant drug dependency histories and even in those cases requires post operative treatment of pain. When this is suspected a referral to a local addictionologist or pain specialist can be quite helpful. It is most important to note that physical dependency upon an opioid medication is not addiction. The disease of addiction is one that involves the use of a substance for the purpose of attaining a high and despite the considerable damage it causes to the patient's biological, psychological and social well-being. Although patients with pain, who are not addicts, may act like they have this illness, it is most often due to inadequate pain control.

When patients leave the hospital, it is also important to send them home with adequate pain medication. This is especially important in conditions that have prolonged recovery times and are predictably going to be experienced as painful. Intermediate and weak strength opioids are often inadequate and dependency can be dealt with by a slow time contingent taper, when the pain begins to subside. Often it is better to use a long acting opioid, such as sustained release morphine or Oxycodone to treat complicated painful conditions, as tapering off these doses can occur in a smoother fashion than short acting opioids. These shorter acting medications can throw the patient into withdrawal symptoms, between doses, during downward taper. This is less likely to happen with longer acting opioids. Sleep is also improved with these types of medications and sleep is extremely important for healing and avoidance of chronic pain.