Pain Management

Pain  Management


Dr. Supakorn Rojananin

Deputy Dean of Public Relation and Special Affairs,

Faculty of Medicine Siriraj Hospital


            Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It is a self defense mechanism to protect ourselves from being damaged or injured by some form of internal or external stimulus, such as thermal, mechanical or chemical stimuli. Pain may be initiated from stimulus at any parts of the body (skin, musculoskeletal structures, nerve, visceral organs, etc.). Injury to tissue from stimulus causes cells to breakdown and releases various tissue by-products.  These substances activate sensory receptors that are preferentially sensitive to tissue trauma or a stimulus that would damage tissue if prolonged. These receptors will generate electrical impulses that transmit to brain where the signals are interpreted as pain to acknowledge and take rapid reflexes against the external stimulus or to know that something bad has happened or is going on. Most pains persist if the causes had not been getting rid of.


            Pain may be classified as acute and chronic pain in term of duration. Chronic pain is subdivided into cancer and non-cancer pain. Common sources of acute pain include trauma, surgery, labor, medical procedures, and acute disease state. It may further contribute to develop chronic pain if it is not properly treated. Cancer itself does not cause pain. Pain arises only when cancer presses on nerve, bone and body organs. For example, a small tumor located near a nerve or the spinal cord may be very painful while a large cancer elsewhere such as a breast cancer will not cause pain at all. Chronic non-cancer pain includes back and neck pain, muscle and joint pain, headache, and neuropathic pain.


            According to Associate Professor, Doctor Pongparadee Chaudakshetrin, Chief of the Pain Clinic, Department of Anesthesiologist, Faculty of Medicine Siriraj Hospital, half of million Thai people suffered from chronic pain as surveyed by Thailand Development Research Institute in 1991.  About one third of the sufferers were not received any treatment and nearly half were treated by non physicians such as monks, paramedics and fortune tellers. Therefore, most people suffering from pain were not properly treated or under-treated. They do not have their pain under control. Inadequate pain management has adverse consequences. Poorly managed acute pain may cause serious medical complications from delayed ambulation (e.g., pneumonia, deep vein thrombosis), impair recovery from injury or procedure, or progress to chronic pain. Under-treated chronic pain can impair an individual’s ability to carry out their daily activities and diminish quality of life. It may cause significant suffering which leads the patients to have anxiety, fear, anger, or depression. Pain is also the major cause of work absenteeism, underemployment, and unemployment.


            Dr. Pongparadee discloses that pain is best relieved when treated early so people do not wait until it gets worse. No one feel pain in the same way and does not feel ashamed if you have more pain than others in the same kind of disease. Telling the doctor or nurse about the pain is not a sign of weakness.


             Pain is subjective symptom, unique individually and varied between persons. Its severity and characteristics does not correlate well with the severity of the disease. One major problem of the under-treatment of pain is the failure of physicians to assess pain and pain relief or ignore the patients’ complaints. Be remembering that the most reliable indicator of pain is the patient’s self- report and most pains have the underlying causes, therefore, physician should afford ample time to let the patient tells the story in his or her words. Thorough taking present and past history and physical examination are mandatory during the initial assessment of pain.


            Pain rating scale is a simple mean for the patients to rate their pain intensity. Patients can rate their pain on a 0-to-10 or a 0-to-5 scale, with 0 representing “no pain at all” and 5 or 10 representing “the worst imaginable pain”. Dr. Pongparadee reiterates   the physicians not to forget to treat the pain along with the disease.


            Today, we consider pain as the fifth vital sign and review our patients’ pain management needs as often as we take their pulse, blood pressure, respiration rate and temperature. We work to find the best combination of pain controlling treatments so that our patients can experience the best possible quality of life. 


             Acetaminophen (paracetamol), aspirin, and ibuprofen are the most popular pain medicines used worldwide to relief mild to moderate pain. They have minimal side effect if properly used and are available in all drug stores. Aspirin may cause stomach ulcer and bleeding disorder which may cause harmful if it is not discontinued before surgery. Therefore, one should inform your doctor for the use. Morphine and its derivatives is the most potent moderate to severe pain killer especially for controlling the cancer pain. Although it is a narcotic drug and can be used under prescription only, it rarely causes the patient to become addicted. Constipation, nausea and vomiting, sleepiness and slow breathing are the most common side effects especially at the beginning of use. Other groups of pain killers include antidepressants, anti-epileptics and steroid. Today we advise to take pain medicine on a regular schedule (by the clock) and do not skip a dose of medicine or wait for the pain to get worse before taking it. The goal is to prevent the pain, Once you feel the pain, it is harder to get it under control, In severe postoperative pain or some chronic pain patients, interventional techniques may be added including epidural medication, intrathecal injection, nerve block, patient-controlled analgesis (PCA). PCA is becoming popular in which the patient oneself can control the amount and timing of the release of the medication by pressing a button on a computerized pump that releases a preset amount of the medication into the body. Other non-drug treatments of pain may also introduce to supplement your pain medication including acupuncture, biofeedback, breathing and relaxation exercise, hot or cold packs, hypnosis, imagery, massage and vibration, electrical nerve stimulation and rest. All of these remedies in combination can improve tremendously for people who are suffering with pain.


            After years of neglect, issues of pain assessment and management have captured the attention of both health care professionals and public. Most university hospitals have set up the pain clinic cored by anesthesiologists for service and research development of pain control. Consequently, pain free diseases are not out of reach in the near future.