Common Misconceptions About Pain • Physical or behavioral signs of pain (e.g., abnormal vital signs, grimacing, limping) are more reliable indicators of pain than patient self-report. • Elderly or cognitively impaired patients cannot use pain intensity rating scales. • Pain does not exist in the absence of physical or behavioral signs or detectable tissue damage. • Pain without an obvious physical cause, or that is more severe than expected based on findings, is usually psychogenic. • Comparable stimuli produce the same level of pain in all individuals (i.e., a uniform pain threshold exists). • Prior experience with pain teaches a person to be more tolerant of pain. • Analgesics should be withheld until the cause of the pain is established. • Noncancer pain is not as severe as cancer pain. • Patients who are knowledgeable about pain medications, are frequent emergency department patrons, or have been taking opioids for a long time are necessarily addicts or “drug seekers.” • Use of opioids in patients with pain will cause them to become addicted. • Patients who respond to a placebo drug are malingering. • Neonates, infants, and young children have decreased pain sensation. Sources: Sources: Jacox AK, Carr DB, Chapman CR, et al. Acute Pain Management: Operative or Medical Procedures and Trauma Clinical Practice Guideline No. 1. Rockville, MD: US Department of Health and Human Services, Agency for Health Care Policy and Research; 1992. AHCPR publication 92-003, McCaffery M, Pasero C. Assessment: underlying complexities, misconceptions, and practical tools. In: McCaffery M, Pasero C, eds. Pain Clinical Manual. 2nd ed. St. Louis, MO: Mosby Inc; 1999:35-102. . Examples of Chronic Noncancer Pain • Osteoarthritis • Low back pain • Myofascial pain • Fibromyalgia • Headaches (e.g., migraine, tension-type, cluster) • “Central pain” (e.g., spinal cord injury, stroke, MS) • Chronic abdominal pain (e.g., chronic pancreatitis, chronic PUD, IBS(Irritable bowel syndrome) • Sickle cell diseasea • CRPS(complex regional pain syndrome), Types I and II • Phantom limb pain • Peripheral neuropathy • Neuralgia (e.g., post-herpetic, trigeminal) Sources: MacDonald RL, Kelly KM. Mechanisms of action of currently prescribed and newly developed antiepileptic drugs. Epilepsia. 1994;35(suppl 4):S41-50. 100. Weinberger J, Nicklas WJ, Berl S. Mechanism of action of anticonvulsants. Neurology (Minneap). 1976;26:162-173. Migraines and sickle cell disease may be more accurately classified as intermittent pain but are treated as chronic noncancer pain for purposes of this discussion.     Acute pain Pain usually concordant with degree of tissue damage, which remits with resolution of the injury Reflects activation of nociceptors and/or sensitized central neurons Often associated with ANS (autonomic nervous system) and other protective reflex responses (e.g., muscle spasm, “splinting”) Chronic pain  Low levels of identified underlying pathology that do not explain the presence and/or extent of the pain Perpetuated by factors remote from the cause Continuous or intermittent with or without acute exacerbations Symptoms of ANS hyperactivity less common Irritability, social withdrawal, depressed mood and vegetative symptoms (e.g., changes in sleep, appetite, libido), disruption of work, and social relationships Cancer pain  Strong relationship between tissue pathology and levels of pain Limited time frame that permits aggressive pain management Rarely involves medical-legal or disability issues CNCP (Chronic noncancer pain) Weak relationship between tissue pathology and pain levels Prolonged, potentially life-long, pain May involve medical, legal, disability issues/conflicts, work or relationship problems, physical deconditioning, psychological symptoms (see chronic pain above) May progress to CPS CPS (chronic pain syndrome) Preoccupation with somatic functioning Lifestyle centered on seeking immediate pain relief, with excessive, nonproductive, and often harmful use of health care services Repeated attempts to obtain pain-related financial compensation (e.g., Social Security, Veterans’ benefits) Numerous symptoms and signs of psychosocial dysfunction that the patient attributes to the pain (e.g., anger, depression, anxiety, substance abuse, disrupted work or personal relationships) Sources: References 88 and 98-100. 2009 Pain Management Directory