Download 2. Pain Management Overview - 263 KB

Pain Management
Elizabeth Whiteman, M.D.
Goals and Objectives
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Pathophysiology of pain
Classification of pain
Assessment of pain
Treatment
▫ Analgesics
▫ Non Pharmacological
▫ Specialty
Four Components of Pain
• Physical pain
▫ Can be multifactorial
• Emotional pain
▫ Anxiety, depression, fear
• Social or interpersonal pain
▫ Not working, family, friends
• Spiritual or existential
Consequences of pain
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Depression
Decreased socialization
Impaired ambulation
Sleep disturbance
Malnutrition
Polypharmacy
Suffering
Other chronic causes of pain, in
addition to current illness
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Osteoarthritis
Constipation
Pressure ulcers
Headaches (migraine etc)
Muscle strain, deconditioned
Post surgical
Classification of
pain
Nociceptive Pain
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stimulation of pain receptors
visceral or somatic
tissue injury, inflammation, mechanical
Described as “tender” or “deep and aching”
Responds to opioids and also adjuvant pain
medication if needed
Neuropathic pain
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peripheral or central nervous system
often respond to non conventional analgesics
Described as “burning” or “shooting”
Light touch may be severe pain sensation
(allodynia)
▫ Usually adjuvant drugs more helpful
Pain Assessment
Assessment
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Most reliable indicator is patient’s report
Reliable pain scales
Cognitively impaired persons
Use of proxies
Non verbal assessment
Full history and physical exam
Reasons patients may not report
pain
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Fear of pain
Fear of testing
Fear of medications
Believe nothing can be done
Worry physician is too busy
Worry complaining may effect care
Don’t want to be a burden
Assessment
• Pain history and medical history
• Physical exam
▫ Good neurologic and orthopedic exam
• Functional status
▫ ADL’s (activities of daily living) , Gait, activities,
use of assist device
• Psychological assessment
• Cognitive function
Pain Scales
Pain
Management
Management
• Analgesic ladder
▫ treat according to intensity of pain
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Routes of administration
Around the clock
Breakthrough pain
Short vs. long acting
WHO Analgesic Ladder
Pain
1
Non Opioid
+/Adjuvant
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3
Opioid
Moderate-Severe Pain
Opioid
+/Mild to moderate pain
Non Opioid
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+/Non Opioid
Adjuvant
+/Adjuvant
Dosing
• Around the clock
▫ Need routine dosing
▫ Long acting preparations
• Breakthrough pain
▫ Short acting preparations
▫ Monitor needs and episodic pain
Pharmacologic
Treatments
Analgesics
• Acetaminophen
• Non steroidal Anti-inflammatory
 Non Specific COX inhibitors (COX 1 and 2)
 COX 2 inhibitors
• Opioids
▫ useful in moderate and severe pain
▫ tolerance to cognitive side effects,
respiratory depression and nausea
▫ Constipation should be prevented
NSAID’s
▫ Beneficial in inflammation
▫ Used alone or in combination
• Nonspecific (Ibuprofen, Naproxen)
▫ GI ulcers, gastritis, GERD
▫ Renal effects
• Cox 2 inhibitors (Celecoxib, Meloxicam)
▫ Less GI side effect, still use with
caution)
▫ Renal effects the same
▫ Cardiac risk factors
NSAID’s
• Patient’s should be taking with food
• If GI upset or pain, reassess
• GI Prophylaxis
▫ Carafate, H2 Blockers, proton pump inhibitor
• Caution in use with patient with platelet
disorders
Opioids
Long acting and short acting
• Long acting drugs
▫ Morphine sulfate, Oxycodone
▫ Should be used routinely
▫ Monitor for side effects
• Short acting
▫ Breakthrough pain
▫ Episodic pain
Starting Opioids
• Opioids naive patient start slow
• Oral first line if patient can swallow
• Short acting prn, or around the clock if constant
pain
• Can then calculate long acting needs
• IV or Subcutaneous infusion if need rapid
titration or unable to take other route
Special populations
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Frail elderly
Liver patients
Dementia
Renal failure
Drug users
Adjuvant
medications
Adjuvant medications
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Antidepressants
Anti seizure medication
Anticholinergics
Local anesthetics
Corticosteroids
Other: calcitonin, bisphosphonates
Muscle relaxants
NMDA inhibitors
Antidepressants
• Tricyclic Antidepressants
▫ For neuropathic pain
▫ High side effects- Anticholinergic
▫ Use with caution in elderly
• SSRI’s, SNRI’s
▫ Can be used as adjuvant medication
▫ Duloxetine is approved for diabetic
neuropathy (off label for post herpetic
neuralgia)
• Anti seizure medications
▫ Carbamazepine, phenytoin
 Monitor LFT
 Risk for sedation
▫ Pregabalin (lyrica)
 Approved for diabetic neuropathy and post herpetic
neuralgia
 25-100mg tid dosing
 Need to renal dose
Gabapentin
• Good results for neuropathic pain
▫ Sharp shooting pain, numbness, burning
• Usual effective dose 900-3600mg/day in 3
divided doses
• Slow and gradual dose increase
▫ 100mg QD to start, increase by 100mg every 3-5
days as tolerated
▫ 100mg bid-100mg tid etc…
Topical anesthetics
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Ice, heat ,massage
Heated rubs (BenGay, icy hot etc.)
topical NSAID creams
Lidocaine Patch
Capsaicin cream
Bone Pain
• NSAID’s
▫ Alone or in combination with Opioids
• Corticosteroids
▫ Metastatic bone pain
• Calcitonin (studies vary on effectiveness)
▫ Osteoporosis and fractures
• Bisphosphonates
▫ Paget’s Disease
• Radiation therapy
▫ Bone metastasis
Non
Pharmacologic
Non drug Strategies
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Patient education
Relaxation techniques, cognitive therapy
Physical exercise, therapy
Ice, heat, massage
Biofeedback (TENS unit)
Acupuncture, acupressure
Other types of pain
• Physical
• Emotional
• Social
• Spiritual
• Use team: from the start !!!
Social workers, chaplain, home health
aide, physical therapy, family/ friends
included
Other treatments
• Refer to pain specialist
▫ Epidural
▫ Nerve block
▫ Nerve stimulator
• Surgery
▫ Minimally invasive surgery
▫ Joint replacement or spine
• Radiation therapy
• Palliative Chemotherapy
▫ If possible help shrink tumor size,
relieve pain
Summary
• Patients may have atypical presentation
• Need to fully assess pain and be able to monitor
symptoms
• Assess type of pain
• Pain medication treatment
• Avoid side effects
• Non pharmacologic treatment
• Remember specialists if appropriate
• Involve other team input
References
• Hanks,G, Cherney,N et al, eds., Oxford Textbook
of Palliative Medicine, pages 299-421, Oxford
University Press, New York, 2011.
• Jacox,A, Carr,D, Payne,R, New Clinical Practice
guidelines for the Management of Pain in
Patients with Cancer, New England Journal of
Medicine, Vol 330, No 9, 1994.
• Whitecar,P, Jonas,P Clasen,M, Managing Pain in
the dying patient, American Family Physician,
Feb 1;61(3):755-764, 2011.