Tag Archives: Acute Pain

Doctors must balance pain relief, fear of addiction

Some doctors won’t prescribe them.

But even for those who do, the decision to write a prescription for a potentially addictive, high-powered pain killer like oxycodone is never without some trepidation, according to several doctors who attended a lecture on “Addiction Risk Assessment” at Holyoke Medical Center Sept. 14.

While drugs like oxycodone, morphine or fentanyl are necessary to relieve very real chronic and acute pain in patients, law enforcement has found the potent medicines are also readily abused, particularly among the young. The 2003 National Survey on Drug Use and Health found a 15-percent rise in prescription drug abuse by people 18 to 25.

“You are in a precarious situation,” she said. “You need to make sure that people do not suffer in pain as well as make sure the medicine does not get into the wrong hands … It is a challenge.”


CT- Connecticut Pain Care


Connecticut Pain Care opened its doors on May 30th 1995 in Danbury, CT. Since that time we have opened offices in Waterbury, Bridgeport and Norwalk, New Milford, Hartford, and Port Chester, NY.

Dr. David Kloth is founder and Medical Director of Connecticut Pain Care. His previous experience includes Medical Director of the Danbury Hospital Anesthesia Pain Center and Co-Director of the Acute Pain Management Service at Danbury Hospital. Dr. Kloth is a Diplomate and Board Certified with the American Academy of Pain Management and the American Board of Anesthesiology with Subspecialty Certification in Pain Management. He completed his anesthesia training at the University of Philadelphia. He is a graduate of the New York University School of Medicine.


Founder, Medical Director of Connecticut Pain Care
Diplomate of the American Board of Anesthesiology (ABA) with Board Certification and Subspecialty Certification in Pain Management
Diplomate of the American Academy of Pain Management (AAPM) ABA and AAPM Board Certified in Pain Management
President, Connecticut Pain Society
Executive Vice President, American Society of Interventional Pain Physicians.
Member: American Pain Society American Academy of Pain Medicine New England Pain Association International Spinal Injection Society


Joined Connecticut Pain Care September, 2000.
Fellowship in Pain Management at Stanford University Hospital, Stanford, California.
ABA Board Certified in Anesthesiology
ABA Board Eligible for Added Qualifications in Pain Management
Member: American Society of Interventional Pain Management, American Society of Anesthesiology, American Pain Society, Connecticut Pain Society


Joined Connecticut Pain Care July, 2002
Fellowship in Pain Management at University of Chicago Hospitals, Chicago, Illinois
ABA Board Certified in Anesthesia
ABA Board Certified for Subspecialty Qualifications in Pain Management
Member: ASIPP, Connecticut Pain Society

Main Office:

109 Newtown Road
Danbury, CT 06810

Satellite Offices:

1389 West Main Street
Tower 2, Suite 123
Waterbury, CT 06708

4920 Main Street
Suite 308
Bridgeport, CT 06606

148 East Avenue
Suite 3D
Norwalk, CT 06851

131 Kent Road, Bldg A
New Milford, CT 06776

81 Gillett Street
Hartford, CT 06105

Facility Privileges

Danbury Hospital

New Milford Hospital

St. Mary’s Hospital, Waterbury

Hospital of Saint Raphael

Healthsouth Surgery Center of Danbury

Healthsouth Surgery Center of Bridgeport

Naugatuck Valley Surgical Center

Connecticut Surgery Center, Hartford

Physiotherapy, chiropractic techniques, acupuncture and TENS.

Whilst this has usually been attempted by the time a patient reaches a Pain Clinic, appropriate physiotherapy in the form of an exercise programme is almost always of benefit. A great deal of work needs to be done to validate conventional physiotherapy techniques; usage in acute pain appears to bring little benefit over the natural history of the condition, whilst in chronic pain it can often be of only short-term efficacy. However, functional rehabilitation programmes aimed at restoration of suppleness and muscle function do appear to be of very real benefit in the long term. Chiropractic manipulation has been shown to be effective in some studies, whilst ineffective in others. Again, patient selection and the technique of the manipulator are markedly variable and will alter efficacy a great deal.

Both acupuncture and TENS are exciting great controversy at the present time in the Western world; their long standing use for chronic pain is being questioned because (again) of the lack of evidence. This remains a controversial field, but both techniques appear to be relatively simple, fairly safe in appropriate hands and reasonably cheap. Acupuncture again is said to work on descending inhibitory pain pathways and also to stimulate endorphins (as well as the body’s natural cortisone). Both positive and negative results have been shown in a bewildering variety of trials. There is certainly a powerful placebo effect, but there also seems to be a significant analgesic component, albeit this might last for only a very short period, and the benefits seen with many patients may be due to a reduction in distress and disability engendered by their interaction with the therapist.

Again it is difficult to find a wealth of hard evidence as to the efficacy of TENS, but a limited, albeit significant number of patients appear to get good benefit, and this appears in some studies to be better than placebo.

Dorsal column stimulation continues to excite interest. Clearly, this can be a useful therapy for moderate pain, especially if it encourages entry into a pain management programme-type approach.




Morphine sulfate is a strong analgesic used to relieve severe, acute pain or moderate to severe, chronic pain (e.g., in terminally ill patients). The drug is also used parenterally for preoperative sedation, as a supplement to anesthesia, and for analgesia during labor. Morphine sulfate is also available as a preservative-free injection (AstramorphÆ PF, DuramorphÆ PF, InfumorphÆ) that can be injected epidurally or intrathecally for relief of severe pain (neuraxial analgesia); administration of the drugby these routes reportedly provides pain relief for prolonged periods without attendant loss of motor, sensory, or sympathetic function.

Acute Pain

Acute pain is the symptom of a larger disease process, and is usually nocioceptive in nature. This means that a noxious (unpleasant) event stimulates the intact nervous system to produce the sensation of pain. Examples of this noxious event include a surgical incision, labor pain, acute pancreatitis or a myocardial infarction.

Acute pain can be somatic or visceral or neuropathic in origin. Somatic pain is sharp and well localized in nature, usually to an external site. Visceral pain tends to be dull and vaguely localized to a deep site, and is frequently associated with nausea. Acute pain is self-limiting, and resolves when the noxious stimulus ceases.

Physiological and psychological responses to acute pain are directed toward escape from the painful situation. Acute pain usually triggers a neuroendocrine stress response, which is proportional to the intensity of the pain. This is a variant of the fight-or-flight response. Catecholamines are released, increasing heart rate, blood pressure, and systemic vascular resistance. Other effects of this catecholamine release may include urinary retention, ileus, stress ulcers, increased work of breathing, nausea, and constipation.

The predominant emotional response to acute pain is anxiety, although anger toward caretakers may also be expressed. These emotional responses indicate that the patient believes the pain to be temporary and “fixable”, and represent an attempt to escape from the painful stimulus.

Acute pain usually responds well to non-steroidal pain relievers and/or narcotics. Frequently, neural blockade can effectively relieve acute pain and de-
crease the likelihood of developing a chronic pain syndrome.

Classification of Pain

Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” (International Association for the Study of Pain)

Pain can be separated into two broad categories: acute pain and chronic pain. This distinction is not perfect- cancer pain, for example, may have components of both. Nevertheless, it remains a useful way to classify pain.

Assessment of Pain

One of the main problems in assessing patients with chronic pain is that the physical examination and laboratory tests often do not provide the information necessary to gauge severity and assess outcomes. Various survey instruments and visual analogue scales that allow precise measurements of pain are available but used only rarely. Pain is generally assessed indirectly, which why it is so important to listen to–and believe–patients when they say that they are in pain.

Some physicians apparently have difficulty with that. Many of my patients with chronic pain have been refused treatment by previous caregivers who apparently believed that their pain was not real. Even after undergoing painful procedures and surgeries that failed to bring relief, some of these patients were labeled as drug-seekers when they continued to ask for help. They had to contend not only with the pain but also with feelings of frustration, isolation, and abandonment by those on whom they had most relied.

In some cases, physicians may be well informed about pain mechanisms but lack an organized approach to the individual assessment of pain. A comprehensive evaluation of patients with chronic pain syndromes can be time-consuming and often requires more data than can be obtained in a few brief clinic visits. I have found the following operational format to be particularly useful, both in gauging the severity of pain and in determining the degree of disability:

1) The patient’s perception. Asking the patient to keep a pain diary that includes numerical scales can help to objectify the pain. If it is understood that the physician will review the diary carefully, the patient will not have to act out a month’s worth of pain at every appointment. The diary can also be an important aid in identifying exacerbating or ameliorating factors and developing more effective strategies to cope with the pain such as behavioral changes or the preemptive use of analgesics in certain situations.

2) The patient’s emotional state and somatic preoccupation. This relates to the degree to which the patient remains focused on bodily symptoms to the exclusion of other issues and often can be best assessed by interviewing a close family member.

3) Functional status at home. The first things that many patients in pain stop doing are usually non-work-related activities such as going out with family and friends, attending church, or engaging in hobbies. Some patients continue to report pain or discomfort even though their condition has improved. By keeping track of daily activities, both patient and physician have some measure of how disabling the pain actually is.

4) Functional status at work. The number of work days missed and the specific work activities curtailed because of pain are also useful indices of pain severity. Since these variables can be expected to change with analgesic treatment, they provide a way to gauge the patient’s response to different therapies.

5) Use of analgesic medications. If the patient is given an adequate supply of effective short-acting rescue medications and told to take them as needed, the number consumed can be a measure of pain. It can also be a way to assess whether the patient is benefiting from other medications or nonpharmacologic treatments. The physician should make it plain that the other treatments are not designed to get the patient to stop using the pain medication but to stop needing it.