Are you a medical student interested in pain medicine and pain management? Or, perhaps, want to learn more about the pharmacology or interventional procedures of pain medicine? Then, you’ve come to the right place to learn about the basics of pain management! In this succinct, easy-to-understand lesson, we learn about pain medicine, pain management for both acute and chronic pain, as well as pharmacology and interventional pain management. All on aboard!

Medical School: Pain Management on Acute and Chronic Pain

Pain can occur acutely or chronically, and adequate pain management is important for patients because it has been found to reduce risk of adverse outcomes, enhance quality of life, improve physical and psychological functionality, as well as shorten hospital stay. Adverse outcomes can include both circulatory and respiratory depression, nausea and vomiting, sedation, among many. If undertreated, patients can suffer thromboembolic complications, with increased stress, blood pressure, and the increased development of chronic pain. There are 3 main goals of pain therapy: including pain management offered around the clock, providing continuous pain relief, and assessing and reassessing patient for adequate pain relief.

3 main goals of pain therapy include 1) offering pain management around the clock, 2) providing continuous pain relief, and 3) assessing and reassessing for adequate pain relief!

Pain Management for Medical School: Acute Pain

There are two pillars of managing acute pain: 1) pharmacologic and 2) interventional. Pharmacologically, physicians can either alter nerve conduction with local anesthetics or modify transmission in the spinal column with opioids or antidepressants. One interventional technique is called the TAP (transverse abdominis plane) block that anesthetizes the peripheral nerves supplying the anterior abdominal wall (T6 to L1). For opioid analgesics like morphine, it is important to note the route of transmission, where oral of 300 is equivalent to parenteral 100, epidural of 10, and intrathecal of 1.

Always remember the dosage equivalents for opioid analgesics

Especially in NY State, healthcare providers monitor the use of opioids in patients. Patients can only get opioids from one MD, and often physicians check the ISTOP website to ensure patient is not getting opioids from another physician. For inpatient patients, a common pain management is patient-controlled analgesia or PCA. The patient has an IV where they can administer small doses of analgesic like opioids. PCA, however, is controlled and over dosage is prevented by the set limit of amount, number of boluses during a time period. What about ambulatory surgery? Compared to inpatient, ambulatory surgery patients do not use PCA and are often discharged within a few hours after surgery. Their pain is usually controlled with PO analgesics.

Inpatient Pain Management vs Ambulatory Surgery Pain Management?: PCA (inpatient) vs PO analgesics (ambulatory and discharge)

Pain Management for Medical School: Non-opioid Analgesics

Non-opioid analgesics are effective as well for treating patients in pain. Acetaminophen and NSAIDS such as aspirin, ibuprofen, ketorolac, COX-2 inhibitors, and Lidoderm are common non-opioids. NSAIDS are for mild to moderate relief but do have side effects including GI bleeding, nephrotoxicity, and inhibition of platelet aggregation which can potentially impact post-op bleeding. Ketorolac or Toradol is a potent analgesic and given parenterally including IV or IM; the typical dosage of ketorolac is 15-30 mg q6 hours with fewer side effects including minimal respiratory depression, no nausea/vomiting, and no pruritis. Cox-2 inhibitors include celecoxib (100-200 mg PO BID), rofecoxib, valdecoxib, or parecoxib.

NSAIDS: mild-to-moderate relief < Ketorolac or Toradol: moderate-enhanced relief

Pain Management for Medical School: Interventional Pain Management and Regional Nerve Block Anesthesia

Interventional management includes 1) epidural analgesia, 2) spinal analgesia, and 3) peripheral nerve block. Epidural anesthesia can involve lumbar, thoracic, or caudal. Compared to general anesthesia, regional anesthesia has superior pain relief and fewer systemic side effects with lower incidence of DVT/PE and rapid recovery. However, there are absolute contraindications to be noted, including increased intracranial pressure, skin infection, coagulopathy.

During your inpatient clinical rotations or surgeries, you may see patients receiving epidural analgesia, which is commonly seen especially for mothers in labor and delivery! OBGYN ALERT! Remember, epidural analgesia for labor and delivery C-sections usually occur at L3-L4 or L4-L5.

Here is a diagram of epidural analgesia in action:

Regional anesthesia or nerve blocks are helpful for managing pain for patients in certain locations of their body, such as their back, lower legs, shoulders, etc. For example, before a patient goes for an orthopedic surgery to fix his or her broken bone, anesthesiologists or pain management interventionalists come in to perform a nerve block. They use an ultrasound to look at the anatomical structures underneath, finding the nerve and then use a needle to insert at the location and give regional anesthesia. This numbs the pain in that specific regional location and reduces systemic side effects.

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