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Clinical Care Pain Management

According to a 1994 study, more than 65% of the people suffering with chronic wounds (leg ulcers, in particular) experience severe pain. An additional 20% experience some degree of pain less than severe.⁸⁷ Just as there are specific protocols for the treatment of the different categories of chronic wounds, there should be individualized protocols for the management of pain associated with each type of wound.

In all cases, determination of the pain protocol will be based upon the pathogenesis of the wound. There are three major categories of pain etiology in any given chronic wound:

Ischemia
Neuropathy
Tissue damage

The following table summarizes the various types of chronic wounds, the pathogenesis specifically related to the associated pain, and the suggested treatment protocol for pain.

A critical consideration in pain management is the measurement of pain as the treatment regimen is administered over time. Pain should be assessed using a standard form devised for determining pain levels.⁸⁸ Additionally, removing local infection is critical to reducing pain; typically this is done through surgical debridement. Opioid analgesics may be administered to those patients who can tolerate their action, depending on pathogenesis of the wound and the underlying cause of pain.

Chronic Wound	Patho-Genesis of Pain	Pain Management Treatment	Mechanism of Action	Result of Treatment
Ischemic (Arterial insufficiency) ulcer	Ischemia	Regional sympathetic blockade	Dilation of smooth muscles in venules and arterioles	Decrease in peripheral resistance, increase in capillary blood flow
Ischemic ulcer		Lumbar sympathetic blockade	Percutaneous block of lumbar sympathetic chain	Similar to regional blockade
Ischemic ulcer		Spinal cord stimulation	Placement of electrodes in epidural space for spinal cord dorsal column stimulation	Increased local blood flow
Sickle cell ulcer	Micro-circulatory occlusion	Opioids	Patient-controlled analgesia (PCA)	Pain relief
Sickle cell ulcer			Epidural analgesia (for patients not responding to PCA)	Pain relief
Diabetic foot ulcer	Neuropathy, caused by nervous system deterioration (specifically axonal degeneration and segmental demyelination	Tricyclic antidepressants (TCA): amitryptiline, desipramine	Inhibition of reuptake of serontonin and norepinephrine	Relief of neuropathic pain
Diabetic foot ulcer		Anticonvulsants: phenytoin, carbamazepine, gabapentin		Relief of neuropathic pain
Diabetic foot ulcer		Mexilitene	Analgesic effect	Relief of neuropathic pain
Venous ulcer	Venous reflux causing increased capillary permeability and extravasation of fluids and proteins	EMLA® (eutectic mix of local anesthetics: lidocaine and prilocaine)	Topical application, facilitating debridement	Relief of associated pain
Venous ulcer		Systemic analgesics: Level 1, TCAs, tramadol and acetaminophen; Level 2, codeine, oxycodone, and hydrocodone; Level 3, stronger opioids	Analgesic effect	Relief of associated pain
Pressure ulcer	Constant pressure to the skin and muscle	Non-opioid analgesics: ketorolac	Intravenous administration; analgesic effect	Relief of associated pain