KIRSTIE GALBRAITH: Meet Ari Contos. He’s going to be our case study this week as we learn about management of pain, with a particular focus on morphine. Ari’s a married, 50-year-old gentleman with ongoing back problems resulting from a car accident. He’s seen a variety of health practitioners about his back, including his GP, a physiotherapist, and a chiropractor. He takes a range of medication to manage his pain. In the following short video, Ari talks about his back pain.
ARI: I’m all right now, you know, if I’m good, if I walk regularly, and if I do my physio exercises.
ARI’S WIFE: You should do your exercises.
ARI: Yeah, but look, a few weeks ago, I twisted my back playing with [INAUDIBLE], you know.
ARI’S WIFE: He’s our four-year-old.
ARI: Yeah, yeah, and the doctor said to take it easy, you know. I had a lot of time off work. I have to take a regular morphine for the back pain.
LYN CLEARIHAN: Managing pain is a common problem in modern medical practise. In Ari’s situation, that of chronic pain following an acute incident, presents one of the most challenging problem areas in practise. In this context, chronic refers to pain that persists beyond its expected clinical course. To maximise patient quality of life and minimise drug interactions and side effects, pain management requires a team based approach to care. Pain is a very subjective symptom, by which I mean people may describe a different intensity of pain, even if they experience exactly the same event. So it’s helpful to use tools that assist practitioners to understand the patient’s perception of their pain.
These tools can be descriptive, such as using a happy face or a sad face. Or they can be numerical, where the patient rates their pain out of 10. Managing a patient whose prime concern is pain requires a whole person approach. For chronic pain, it’s essential to understand the meaning of the pain for the particular person, and how the pain affects all aspects of their life. When reviewing a patient with chronic pain, the general practitioner will usually take a very thorough medical history and examine the patient very carefully, although there may be few physical findings.
But this process gives the doctor the opportunity to explore the patient’s beliefs about the cause of the pain, their fears, their the expectations about managing the pain, and what the outcome of the treatment might be. Taking a detailed pain history also helps us determine what sort of pain the patient is experiencing, which assists when selection of pain medication. Pain can be described as being either neuropathic or nociceptive. Or it may have features of both. The quality of the pain and the patient’s ability to localise it helps us to differentiate between these two causes. Once the pain is characterised, an appropriate medication for the pain type can be chosen.
For example, neuropathic pain is very unlikely to respond effectively to opioid based medications, such as morphine. However, it can respond quite well to anti-seizure and antidepressant medications, as they often have pain relieving properties. Different medical conditions are often associated with particular types of pain. Nociceptive pain is often due to inflammation such as that caused by sprains, bruises, fractures, infections, as well as a number of arthritic conditions. Diabetes is the most common cause of neuropathic pain. Pain in the lower leg or feet, which doctors call peripheral neuropathy, candidate be the first indication that diabetes is present. A number of other conditions can cause neuropathic pain, for example, the persistent pain that can follow shingles.
Often, however, the initial cause of the pain may no longer be present, although the patient may still be experiencing significant levels of pain. This can have a profound impact on their life. So coming back to our patient, Ari, he may now be experiencing chronic pain. And once this occurs, the original injury is less problematic in treatment than the pain itself. Trying to prevent chronic pain by managing the acute condition when it occurs may be one of our best approaches to management.
KIRSTIE GALBRAITH: Ari’s currently taking a range of medications to treat his back pain. He takes slow release morphine tablets, 60 milligrammes twice a day. He also takes a combination ibuprofen and codeine tablet. And he takes two of these three times a day, only when he needs to for pain. And finally, he takes diclofenac tablets. He takes them twice daily, again just when he needs to for pain. For managing his pain. We’ll talk more about this as we learn about the science of pain medication, in particular the science of morphine. During this week, we’ll also be learning more about the different types of pain and how the body feels pain.
We’ll discuss the different sorts of pain medication available, and how they work in the body. You’ll hear the story of morphine, and how the chemistry of the opium poppy is used to give strong pain relief to patients like Ari. You’ll also learn more about how morphine is formulated into slow release tablets, which give 12 hours of continuous pain relief. We’ll come back to Ari at the end of this week’s material and find out about some of the side effects which morphine can cause.