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Pain Management Elizabeth Whiteman, M.D. Goals and Objectives • • • • 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 • • • • • • • Depression Decreased socialization Impaired ambulation Sleep disturbance Malnutrition Polypharmacy Suffering Other chronic causes of pain, in addition to current illness • • • • • • Osteoarthritis Constipation Pressure ulcers Headaches (migraine etc) Muscle strain, deconditioned Post surgical Classification of pain Nociceptive Pain ▫ ▫ ▫ ▫ ▫ 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 ▫ ▫ ▫ ▫ 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 • • • • • • 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 • • • • • • • 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 • • • • Routes of administration Around the clock Breakthrough pain Short vs. long acting WHO Analgesic Ladder Pain 1 Non Opioid +/Adjuvant 2 3 Opioid Moderate-Severe Pain Opioid +/Mild to moderate pain Non Opioid + +/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 • • • • • Frail elderly Liver patients Dementia Renal failure Drug users Adjuvant medications Adjuvant medications ▫ ▫ ▫ ▫ ▫ ▫ ▫ ▫ 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 • • • • • 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 • • • • • • 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.
