Pain management consists of many options to help people deal with pain. One of the first steps in pain management is usually medical interventions. They are aimed at fixing any physical damage that has been done. Other treatments may be tried as pain becomes more severe, bothersome, or chronic. Good communication with medical providers is important for the best care.
Medicinal (pharmacologic) therapy for pain can be given orally, intravenously (through the veins), intramusculaly (shot in a muscle), locally (directly into the site of injury), or into the space surrounding spinal cord. Each method has benefits and risks.
The oral route provides a means to give long-lasting therapy (several hours). Medications given by this route are usually acetaminophen, NSAIDs (non-steroidal anti-inflammatory drugs), narcotics, or a combination of these agents. The limitation of this route is the delay to onset of effect which can be up to 30 minutes. Furthermore, the patient must be able to digest the medication without vomiting.
The intravenous route of administration is the preferred route on the time of initial arrival to the hospital. Medications that can be delivered intravenously are narcotics and NSAIDs. This route has the quickest onset of action but requires i.v. access. Furthermore, depending on the agent administered, the effect may not last as long as a medication administered orally. Often, a PCA (patient controlled analgesia) pump is used when prescribing intravenous narcotic (e.g. morphine) medications to a patient who is awake and alert. This system involves giving a patient a button which is connected to a pump that delivers a pre-set dose of medicine when pushed. The pump’s settings are customized to the patient to prevent accidental overdose. It is imperative that ONLY the patient push the button since it is possible to receive an overdose if others (such as family) push the button for the patient. The purpose of this system is to prevent the delay associated with asking nursing staff to obtain and administer pain medication.
Intramuscular administration of pain medication is rarely used today. This method involves giving single doses of a drug (usually a narcotic) into a muscle – most often the arm. Drawbacks of this modality are: pain associated with the shot, the possibility of causing bleeding in the muscle, and slower onset of action relative to the intravenous route. However, the administered medication’s effect will last longer than the intravenous method.
Local administration of pain medication is also rarely used following injury. When needed, this is most often used to washout and suture a wound. Other uses include numbing broken ribs to improve the pain associated with breathing. However, this approach has fallen out of favor because the effect is short lived, the lung can be injured during administration of local anesthetic to the area of the broken ribs, and each dose requires the expertise of an anesthesiologist.
Spinal-based analgesia is most often delivered via an epidural catheter, but a spinal catheter can also be used. The spine is surrounded by a sac called the dura mater. Epidural medications are placed just outside of this sac whereas spinal analgesia is administered using a catheter placed just inside this sac. Both methods require that a catheter be introduced through the back. The catheter is left in place and can be used to give a continuous infusion or intermittent doses of medications or both (continuous rate augmented with a larger dose for pain flare episodes). As with a PCA, a PCEA (patient controlled epidural analgesia) can also be prescribed to allow a patient to give a supplemental dose to themselves using a button attached to the pump. Medications given by this route include narcotics and/or local anesthetic agents. This method numbs a broad region of the body associated with the area of the spinal cord which is bathed with the medication. Advantages of this modality include: a decrease in side-effects associated with intravenous narcotic administration, quick onset of pain relief, and ability to control pain in large areas of the body. Disadvantages of this method include the need to access the area around the spinal cord and introduce infection. Rarely, bleeding can also be problematic if the epidural catheter punctures the dura mater and enters the peri-spinal space. This may manifest as a severe headache or weakness/tingling in the extremities when the catheter is removed.