Download Managing chronic pain

Pain
Management
Pain Management
Role of GPs in Pain Management
GPs can:
• improve assessment and treatment
of pain
• offer early intervention and treatment
• prevent chronic pain.
Pain Management
General Principles of
Pain Management
• Unrelieved pain has adverse severe physiological /
psychological side effects
• Proper assessment and control requires patient
involvement
• Effective pain relief requires flexible, individually
tailored treatment
• Pain is best treated early. Established severe pain is
more difficult to treat
• Whilst it is not always possible to alleviate all pain,
it can be reduced to a tolerable or comfortable level.
NHMRC (1999)
Pain Management
Categories of Pain
• Acute monophasic pain
• Recurrent acute non-malignant pain
• Chronic malignant pain
• Chronic pain associated with non-malignancy
disease – identifiable pathology
• Chronic non-malignant pain syndrome.
Pain Management
WHO 3-step Pain Relief Ladder
Freedom
from Pain
Pain persisting
or increasing
Pain persisting
or increasing
Treat with Opioid for
moderate–severe pain +/non-opioid +/- adjuvant
Treat with Opioid for mildmoderate pain +/- non-opioid +/adjuvant
Treat with non-opioid +/- adjuvant
Gill (1997)
3
Mild Pain
2
1
Pain Management
Pain Cycle
Injury / Insult
(Chronic)
Pain
Dependence
Treatment
Reliance on Medication
Failure of Treatment
Loss of Control
Adapted from Gill (1997)
Psychological
& Social
Consequences
Pain Management
Pain Rating Scales
• Most reliable indicator of pain severity is patient
self-report
• Categorical rating scales: use descriptors such
as ‘no pain’ / ‘mild pain’ / … ‘worst possible pain’
• Visual analogue scales:
no pain
worst possible pain
• Verbal analogue scales:
rate from 0 (no pain) to 10 (worst possible).
Pain Management
The GP–Patient Relationship
Successful management depends on:
• patient trust & confidence in GP
• complete physical and psychosocial history – this is
essential so allow adequate time
• supportive & clear explanations of the pain issues
• ability to discuss strategies openly to reduce potential
for ‘self-medicating’
• case management – for consistency in management,
commence treatment with consultation between patient
and treating staff
• trust – avoid placebos at all costs
• adequate relief – achieving relief / reducing pain level
is paramount.
Pain Management
A Shared Care / Team Approach
• A team-based, holistic approach tends to
be most effective for pain management,
involving:
– nurses
– psychologists & psychiatrists
– physiotherapists
– pain specialists.
Pain Management
Acute Pain Management and
High-risk Drug Use
Key Principles
• Unless patient uses opioids, treat as ‘normal’ patient
with pain
• ‘First do no harm’ – shortest dose, shortest duration
with minimal side effects, with aim to reduce pain to a
tolerable level
• Maintain clear communication (prevent anxiety,
reassure patient)
• Do not withhold analgesia unless medically indicated
• Avoid Pethidine
• Allow adequate time for assessment – impossible in
Pain Management
10 minute consultation.
Acute Pain Management:
People who Inject Opioids
Consider:
• tolerance to opioid analgesics
– e.g., if already on regular prescribed opioid
medication (iatrogenic dependence), on
methadone, opioid-dependent, or regularly taking
liver enzyme-inducing drugs
• real and perceived legal constraints for prescribers
• potential adverse interactions with other CNS
depressants
• difficulties / misunderstandings which arise in
communications between clinicians and patients.
Pain Management
Assessment of Chronic Pain in
Drug-dependent Patients (1)
Comprehensive assessment required of:
• organic pathology and psychosocial history / supports
• past / present drug use (+alcohol and prescribed drugs)
• drug tolerance & dependence
• contribution of pain & drug use to mood & lifestyle?
• whether the pain predates the drug(s) problem or
reverse?
• psychiatric comorbidity; chronic pain and depression
often coincide, but difficult to disentangle cause & effect
• stressors and coping strategies.
Pain Management
Assessment of Chronic Pain in
Drug-dependent Patients (2)
• Obtain information from other sources (p.r.n.)
– e.g., previous GP, other doctors, family,
with patient’s consent
• 1/3 or more of patients with chronic pain have
no obvious organic disease but may feel
genuine and debilitating pain
If in doubt, err on the side of the patient’s report.
Pain Management
Opioids and Pain Management
• A true ‘opioid allergy’ is very uncommon
• There is no evidence that use of opioids for
treatment of severe acute pain leads to
dependence / addiction
• When opioids provide no relief, the pain may be
neuropathic in nature
• Opioids for pain relief are most effective when:
– tailored to the individual
– used in conjunction with NSAIDS.
Pain Management
Prescribing Opioids and
Drug-dependent Patients (1)
Use opioids with caution:
• if opioid-dependent, high tolerance is likely, and
therefore need higher doses (not lower doses)
• potential for adverse events /excessive sedation
• avoid injections and Pethidine (poor clinical outcomes)
• aim for regular fixed doses (better, cheaper response
compared with ‘on-demand’)
• consider sustained-release forms.
Pain Management
Prescribing Opioids and
Drug-dependent Patients (2)
• Controversy re prescribing methadone for the opioiddependent
• Separate prescribing for dependence from pain
management issues (e.g., via shared care) so that:
– patients are not confused about dose, types &
purpose of prescribed drugs
– drug doses can be adjusted to accommodate the
separate problems
– staff fears of malingering can be allayed
• Analgesics are just part of an effective management plan
for chronic pain.
Pain Management
Chronic Pain and
Iatrogenic Dependence
Definition:
• dependence on medication following a period of
medically-initiated pain management
• true extent of the problem is difficult to gauge
• treatment: dose tapering or methadone
• prevention:
– close supervision and monitoring of pain patients
– review medication frequently
– encourage alternative (non-drug) treatments to
complement medication.
Pain Management
Chronic Pain Patients and
Risk of Drug Dependence
Risk indicators may include:
•
personal / family history of high-risk patterns, problems or therapy
(including receiving MMT)
•
demonstrating abnormal illness behaviour, low frustration tolerance,
premorbid personality problems, or poor coping skills
•
history of childhood abuse
•
patients who describe euphoric effect from prescribed opiates
•
current stressors
•
complex compensable patients
•
young patients with obscure pathology.
Pain Management
Chronic Pain Patients and
Suspected Drug Dependence
The following signs should alert you:
• tolerance to prescribed opiates +/- BZDs and;
– intoxication, deterioration in function,  pain-associated
distress
• requesting scripts early
• withdrawal symptoms and signs medication(s) not being taken
• increased use of alcohol (increases sedation)
• requesting opiate-based analgesics (rather than NSAIDS)
• preoccupation with obtaining opioids despite analgesia
• evidence of ‘doctor shopping’, visits to E.D., hoarding supplies.
Pain Management
Non-drug Complementary
Strategies (1)
• Medications
– Other analgesics, antidepressants, anxiolytics,
tranquillisers and hypnotics, muscle relaxants,
antispasmodics, antihistamines, corticosteriods,
local anaesthetics etc.
• Lifestyle adjustment
– exercise
– ergonomic work stations / change in tasks / roles
– relaxation / meditation
• Physiotherapy / hydrotherapy / radiotherapy
• Supportive counselling/CBT.
Pain Management
Non-drug Complementary
Strategies (2)
• Cognitive therapy
– changing beliefs / expectations, blocking negative
thinking
• Behaviour therapy
– goal setting / problem-solving
– self-reinforcement
– diversion techniques
• Stimulation to relieve pain
– Transcutaneous Electrical Nerve Stimulation (TENS)
– acupuncture
– vibration / massage.
Pain Management
Pain Relief is the Overriding
Consideration
• For the very elderly
• The terminally ill with a short life
expectancy
Concerns of exacerbating drug dependence
in these situations are secondary
Pain Management
10 Tips for Managing Patients
with Chronic Pain (1)
1. Define pain syndrome and treat cause
(where evident)
2. Ensure Mx by single practitioner
3. Validate and accept patient’s pain
experience
4. Establish clear, honest, open relationship
5. Make, and agree on, a clear treatment
contract
(cont…)
Pain Management
10 Tips for Managing Patients
with Chronic Pain cont. (2)
6. Educate and inform about your approach to
pain Mx
7. Treat comorbidity with shared care team
8. Encourage alternatives to pharmacotherapy
9. Medication Mx – one doctor, close
monitoring
10. Monitor progress, compliance and symptoms
and maintain vigilance for evidence of
dependence.
Pain Management
Strategies for Managing
Aberrant Behaviour
• Re-assess medication, expectations, underlying cause
• Consider changing drugs /  interval between supply
• Reinforce discussions / contract
• Consider urine testing / warn of consequences of
continued behaviour
• Wean or cease opioid use
• Notify health department / joint management with drug
treatment agency
• Consider very frequent medication supply / MMT.
Pain Management