University College London Hospitals

Understanding pain

Information for adult inpatients

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Contents

1. Introduction 3

2. Understanding pain 4

3. How can I manage my pain? 7

4. Summary 16

5. Further information 17

6. Contact details 19

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Introduction

We are all likely to experience pain during our lives and particu-larly 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 manage pain.

Your healthcare team will aim to manage 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 like chest infections, blood clots and pressure sores. If your pain is well managed, it may help you to get home and back to your normal activities safely and sooner.

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Understanding pain

What is pain?

Pain can occur after an obvious injury, for example a cut or a bruise, or from an unseen, internal source like appendicitis.

Even if you can’t see the cause, pain is still real. 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 feeling of pain remains. The nervous system which is involved in producing pain can become sensitive and continues to behave as though there is still damage so the person still feels pain. This process can be shown in research laboratories, but hospital tests and investigations are not able to show these changes. This does not mean the experience of pain is not real.

Chronic pain can have a 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 living well with the pain and living a full life despite the pain, rather than getting rid of the pain.

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How do we feel pain?

Pain is complicated, it is a very personal experience and everyone feels pain differently.

Danger signals in the nervous system 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. These messages sent to the brain are affected by other parts of the brain relating to mood, anxiety, thoughts, memory, sleep and appetite. The brain uses all this information to decide if the signal is dangerous and due to injury. If the conclusion is that, yes, the signal is dangerous, pain is produced to motivate us to take action.

Pain is 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, a bit like a volume control. Pain management tries to turn down the volume of pain at any stage of the pathway.

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Pain emerges from a complex mix of different types of signals e.g. from the body, the environment, from experiences, from social situations.

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How can I manage my pain?

We can manage pain 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 are 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 help with a problem.

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Breathe well Concentrating on your breathing when you are in pain can help. When the pain is intense, it is 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, and 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.

Movement and gentle exercise

It is 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. It is important to balance activity and rest to improve function over time and return to activity that is important to you.

Distract yourself Shifting your attention onto something else so the pain is not 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.

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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 aromatherapy can be helpful in some cases.

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Drugs and medicines There are three 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.

3. Opioid (morphine-based) medicines Tramadol, morphine, fentanyl, oxycodone. These strong painkillers are more likely to have side effects than paracetamol or anti-inflammatory 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.

You can take pain medicines in different ways ; 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. Your healthcare professional 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 they are very useful and safe medicines.

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Your healthcare professional 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’. We will make decisions based on how you report or score your pain, your medical condition(s), your medication history and any allergies you might have.

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’

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.

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Side effects are usually related to the amount of the drug you are taking, though some people can be more sensitive than others can. Your medical team will often prescribe other medications (like laxatives or anti-sickness medication) alongside morphine-like drugs (opioids) to try to counteract any side effects. Regular analgesia including paracetamol helps to maintain background pain relief while faster-acting top-up doses (e.g. Oral morphine ‘oramorph’) can be used to manage breakthrough pain or help you do things like get involved with physiotherapy exercises, move and cough.

Side effects of morphine like drugs (opioids) Nausea and vomiting

Constipation

Drowsiness

Hallucinations

Breathing problems

Itch

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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 anticipate activity, you can press the button frequently (every five minutes) in the fifteen minutes beforehand. This is to boost the amount of medicine in your system in advance.

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Knowing that you can have some control over your pain can make you feel more confident and reduce anxiety.

Regional anaesthesia: Nerve blocks, epidurals, spinals and injections of local anaesthetics

Doctors sometimes use regional anaesthetic techniques for some operations, injuries or chronic pain conditions. 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. We will always discuss the benefits and risks of these interventions with you so that you can decide whether you want to go ahead. You should also receive information about the following:

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 machines work in a similar way to rubbing the sore area better.

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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 taking, as this may affect which medicines and doses we give you in hospital. If your body is used to strong painkillers it may be dangerous to stop them suddenly. You may need 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 brief period, 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 need 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.

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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.

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Further information

Websites The British Pain Society http://www.britishpainsociety.org/ Reading Publications are available from The British Pain Society website https://www.britishpainsociety.org/british-pain-society-publications/patient-publications/ Living with Pain: NHS Choices

http://www.nhs.uk/livewell/pain/Pages/Painhome.aspx

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 http://www.rcoa.ac.uk/document-store/epidurals-pain-relief-after-surgery Spinal anaesthetic Your spinal anaesthetic http://www.rcoa.ac.uk/document-store/your-spinal-anaesthetic

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Brachial Plexus Block https://www.rcoa.ac.uk/system/files/10-BrachialPlexusBlock.pdf Wellbeing podcasts Podcasts from the Mental Health Foundation https://www.mentalhealth.org.uk/podcasts-and-videos/podcasts-for-your-wellbeing

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 Bangor University for Mindfulness

https://www.bangor.ac.uk/mindfulness/audio/index.php.en UCLH cannot accept responsibility for information provided by

external organisations.

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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 Switchboard: 020 3456 7890

Website: www.uclh.nhs.uk

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First published: May 2014 Date last reviewed: November 2018

Date next review due: November 2020

Leaflet code: UCLH/CS/UP-AIP/2

© University College London Hospitals NHS Foundation Trust