University College London Hospitals. Understanding pain. Information for adult inpatients

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1 University College London Hospitals Understanding pain Information for adult inpatients

2 Table of Contents 1. Introduction 2 2. Understanding pain 3 3. What can be done to manage pain? 6 4. Summary Resources Contact us Introduction We are all likely to experience pain during our lives and particularly so when we are unwell or in hospital. Pain is a common reason for seeking medical help. It is an unpleasant experience that can cause fear and anxiety. It can be helpful to understand the complex links between body and emotions, which make the experience of pain very personal. We hope that this booklet will help explain the different ways in which pain can be managed in hospital. It will also describe things you can do yourself to control pain. 2 Your healthcare team will aim to control your pain using drugs and other techniques. They will also want to help you keep active, as this will help you feel better and reduces serious risks

3 like chest infections, blood clots and pressure sores. If your pain is well controlled, it may enable you to get home and back to your normal activities safely and sooner. 2. Understanding pain What is pain? Pain can arise from an obvious injury, for example a cut or a bruise, or from an unseen, internal source like appendicitis. Pain is no less real if you can t see the cause. Short-term pain is sometimes called acute pain. This is often the type of pain you get after an injury or surgery. Acute pain can be a useful warning sign telling us to protect the injured area and stopping us from disrupting the healing process. This pain generally gets better as healing occurs. In some cases pain continues beyond injury and becomes persistent or chronic. It is no longer serving the useful purpose of letting us know that we are injured. The original tissue damage may have healed but the experience of pain remains. The nervous system is oversensitive and continues to behave as though there are pain signals so the person still experiences pain. This can be shown in research laboratories, but hospital tests and investigations are not sophisticated enough to show these changes. This does not mean the experience of pain is not real. 3

4 Chronic pain can have a very negative impact on people s lives and can be difficult to manage. Referral to a specialist chronic pain service may be necessary. Treatment may focus on coping with the pain and living a full life despite the pain, rather than getting rid of the pain. How do we feel pain? Pain is a complicated and very personal experience. Everyone feels pain differently and some people are more sensitive than others. Pain signals can start in most parts of the body from the skin on the surface to the deeper tissues such as muscles, bones, joints and internal organs. These signals travel along nerves first to the spinal cord and on to the brain. It is in the brain that we feel or experience pain. Pain messages being sent to the brain are affected by other parts of the brain relating to mood, anxiety, thoughts, memory, sleep and appetite. Pain is therefore unique to each individual. The brain sends signals back to the spinal cord which can either increase or reduce the pain further. Pain can be turned up or turned down by messages from the brain and spinal cord, rather like a volume control. Pain management tries to turn down the volume of pain at any stage of the pathway. 4

5 Pain is a complex mix of signals from the body and how the brain interprets and alters them. 5

6 3. What can be done to manage pain? Pain can be managed in different ways and often a combination of approaches is most effective. As pain is very individual, a trial and error approach may be necessary to see what works best for you. Drugs and medicines are often used for painful conditions but there are lots of other things which can be very helpful. Techniques other than medicines Because your thoughts and feelings affect the way you experience pain, things that help you to relax, lift your mood or distract you, may lessen pain. You might find it useful to listen to music, watch a film, talk to someone or do an activity you enjoy. When we re feeling anxious or worried, pain is worse. Always raise any concerns or questions you might have with the doctors and nurses looking after you. They may be able to explain or resolve a problem. 6

7 Movement and gentle exercise It s natural to be hesitant if you are feeling pain but activity helps to stretch muscles, ligaments and joints which can lessen pain. Moving will help your overall recovery. Distract yourself Shifting your attention onto something else so the pain isn t the only thing on your mind can really help. Talking, listening to music, reading, watching TV may all help. Mindfulness and meditation can help with relaxation and the acceptance of pain. Breathe well Concentrating on your breathing when you re in pain can help. When the pain is intense it s very easy to start taking shallow, rapid breaths which can make you feel dizzy, anxious or panicked. Instead, breathe slowly and deeply. You may find this simple exercise helpful: Breathe in to a count of five, then breathe out with your lips pursed (as if you were blowing out a candle) to a count of ten, repeat for a few minutes. Breathing well can help you to feel more in control of the situation, keep you relaxed and can prevent muscle tension or anxiety from worsening your pain. 7

8 Support Talking to friends and family, other patients and staff can make you feel much better. Relax Relaxation exercises can help reduce pain. There are many types of relaxation techniques, varying from breathing exercises to types of meditation. These are freely available as internet downloads (see Resources and further information at the end of this booklet). Other therapies sometimes called complementary therapies for example acupuncture can be helpful in some cases. Drugs and medicines There are 3 main groups of pain relief medicines: 1. Paracetamol Paracetamol has very few side effects and works very well for mild pain. If the pain is moderate or severe it is still very useful as it helps reduce the required dose of other medicines. 2. Anti-inflammatory medicines These painkillers are very effective but can have side effects, such as stomach irritation and may worsen asthma in some patients. 8

9 3. Opioid (morphine-based) medicines Tramadol, morphine, fentanyl, oxycodone. These strong painkillers are more likely to have side effects than paracetamol or antiinflammatory drugs. (See the table later in this booklet). Other drugs such as gabapentin and amitriptyline (sometimes called neuropathic pain medicines) are occasionally used to manage certain types of pain. Pain medicines can be taken by various routes; by mouth, or by suppository, injection into the muscle or under the skin, through a cannula in your vein (intravenous) or through a patch on your skin. Doctors will often start by prescribing simple medications such as paracetamol. You may think that because you have them at home they are not effective, but in fact they are very useful and safe medicines. Doctors may gradually increase doses or move on to stronger medications if needed in a stepwise manner. If you are able to eat and drink, it is always better to give pain relief as tablets. This stepwise approach to pain relief is known as the analgesic ladder. Decisions will be based on how you report or score your pain, your medical condition(s), your medication history and any allergies you might have. 9

10 In hospital we use a pain score to describe levels of pain. Pain scores 0 No pain comfortable 1 Mild pain uncomfortable, aching, niggling 2 Moderate pain painful, sore, really hurting 3 Severe pain very painful, very sore 4 Worst pain possible extremely painful, horrible pain 10 Using painkillers that work in different ways, in combination, can lead to more effective pain relief. Tackling pain from different angles can mean less reliance on one family of drugs and reduced doses of some of the stronger drugs, which have unwanted side effects. Side effects of morphine like drugs (opioids) Nausea and vomiting Constipation Drowsiness Hallucinations Breathing problems Side effects are usually related to the amount of the drug you are taking, though some people can be more sensitive than others. Your medical team will often prescribe other medications (like laxatives or anti-sickness medication) alongside morphine-like drugs (opioids) to try Itch and counteract any side effects. Regular analgesia including paracetamol helps to maintain background pain relief while faster-acting top-up doses (eg. oral

11 morphine oramorph ) can be used to manage breakthrough pain or help you do things like get involved with physiotherapy, move and cough. Patient Controlled Analgesia PCA stands for Patient Controlled Analgesia. This is a way of giving opioid pain medicines through a pump into a cannula in your vein. You will be given a button that when pressed gives a small safe dose of the drug. If you don t press the button you will not get any medication. You have control over how often you press the button depending on your degree of pain. Safety settings on the pump mean you cannot overdose, however you should tell someone if you feel drowsy or unwell while using a PCA. Because the pump will not give you more than one dose every five minutes, if you 11

12 12 anticipate activity, you can press the button frequently (every five minutes) in the fifteen minutes beforehand, to boost the amount of medicine in your system in advance. Knowing that you can have some control over your pain can make you feel more confident and reduce understandable anxiety. Regional anaesthesia: Nerve blocks, epidurals, spinals and injections of local anaesthetics For certain operations, injuries or chronic pain conditions, doctors sometimes use regional anaesthetic techniques. Examples include nerve blocks, epidurals and spinal injections. These injections can make a particular part of the body feel numb or heavy for some time. The benefits and risks of these interventions will always be discussed with you so that you can decide whether you want to go ahead. You should also be given information about what to expect before and after the local anaesthetic is injected, how long it should last and how to manage your pain as it wears off. Electrical techniques for pain control Some people may be familiar with Transcutaneous Electrical Nerve Stimulation (TENS) machines which are available from high street chemists. Gentle electrical signals pass through pads on the skin and interrupt the passage of pain messages at the spinal cord so fewer pain signals reach the brain. TENS

13 machines work in a similar way to rubbing the sore area better. What if I am already taking painkillers before coming into hospital? It is always important to let your medical team know what medications you are already taking, as this may affect which medicines and doses you are given when in hospital. If your body is used to strong painkillers it may be dangerous to stop them suddenly and you may require higher doses to manage your pain compared to someone who has never taken opioids. Can I become addicted to painkillers? If you are taking painkillers for a relatively brief period of time, the short answer is no, you can t become addicted. Over a period of weeks to months, your body may become adapted to opioid medications so that you develop a physical dependence on them or require higher doses to get the same pain relieving effect (tolerance). If you have become used to morphine-like painkillers it can be dangerous to stop them suddenly as you may experience withdrawal symptoms. Addiction is when there is an additional psychological dependence which leads to craving and use of the drug even if it is causing harm. If you are taking painkillers in the short term for an injury or following surgery, you are very unlikely to become dependent, tolerant or addicted to them. Talk to your doctors and nurses if you have any worries about these issues. 13

14 4. Summary Pain is a very important issue for patients and healthcare teams. Our pledge is to acknowledge and help you manage your pain. Good pain management requires teamwork between you and the healthcare professionals. You may be given medications or receive interventions as part of your pain management, and developing activities that you can do yourself to reduce the impact of pain is also very important. Do not hesitate to ask any questions or raise any concerns you may have about your pain or your care. 5. Resources and further information 14 Websites The British Pain Society ( Reading Publications are available from The British Pain Society website ( Living with Pain: NHS Choices ( Painhome.aspx)

15 Living Well with Pain and Illness: The Mindful Way to Free Yourself from Suffering (V Burch, 2011) Pain relief after surgery Epidurals for pain relief after surgery ( Pain Relief at Home Pain relief at home booklet ( document-store/pain-relief-home) Spinal anaesthetic Your spinal anaesthetic ( Brachial Plexus Block ( Wellbeing podcasts Podcasts from the Mental Health Foundation ( Stress and Relaxation: Quick Fix Breathing Exercise Wellbeing and Sleep: Quick Fix Relaxation Exercise What is Mindfulness? Mindfulness - 10 Minute Practice Exercise Podcast Podcasts also available from Breathworks for Mindfulness ( 15

16 Contact details If you need help managing your pain, please ask the nurses or doctors who are looking after you. Main hospital address: 235 Euston Road London NW1 2BU Telephone: / Website: If you would like this document in another language or format, or require the services of an interpreter, contact us on We will do our best to meet your needs. First published: May 2014 Date last reviewed: May 2014 Date next review due: May 2016 Leaflet code: UCLH/CS/UP-AIP/1 University College London Hospitals NHS Foundation Trust 16

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