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A FREE CONTINUING EDUCATION LESSON
OBJECTIVES
Upon successful completion of this
lesson, the pharmacist will be able to:
1. assess whether patients require referral
to another health-care professional for
acute pain management.
2. compare and contrast medications
currently indicated for acute pain
management.
3. recommend appropriate acute pain
management strategies.
4. discuss the role of the newly approved
combination tramadol/acetaminophen
in the treatment of acute pain.
5. counsel patients about benefits/risks
associated with analgesics for the relief
of acute pain.
INSTRUCTIONS
1. After carefully reading this lesson,
study each question and select the
one answer you believe to be correct.
Circle the appropriate letter on the
attached reply card.
2. To pass this lesson, a grade of 70%
(14 out of 20) is required. If you pass,
your CEU(s) will be recorded with the
relevant provincial authority(ies).
(Note: some provinces require individual pharmacists to notify them.)
ANSWERING OPTIONS
A. For immediate results, answer online
at www.pharmacygateway.ca.
B. Mail or fax the printed answer card to
(416) 764-3937. Your reply card will
be marked and you will be advised of
your results within six to eight weeks
in a letter from Rogers Publishing.
THIS FREE LESSON
IS APPROVED FOR
Acute Pain Management
— A Practical Update for
Community Pharmacists
By Tom Smiley, BSc Phm, Pharm D
Tom Smiley is a pharmacist consultant and a community pharmacist in Brantford, ON. In addition to
his clinical experience with patients and pain management over the last 25 years, Tom has developed
and presented many CE lessons and workshops for pharmacists on the topic. He has also written many
patient brochures and web postings about acute and chronic pain management principles and integration into practice. Tom currently sits on the executive committee of the Ontario Pharmacists Association
board of directors and serves on the Family Health Team Action Group and Chronic Disease
Management subcommittee of the Ontario Ministry of Health.
The author, expert reviewers and Pharmacy Practice magazine have each declared that there is no real
or potential conflict of interest with the sponsor of this lesson.
INTRODUCTION
It is often difficult to distinguish acute
from chronic pain because these phenomena likely represent a continuum rather
than distinct entities.1 Acute pain has been
defined as “pain of recent onset and probable limited duration.”1 Cause of acute
pain is usually associated with an isolated
injury or disease process. Pain is an individual experience that is influenced by culture, previous pain events, beliefs, mood
and ability to cope. Therefore, pain management strategies must be individualized
to the circumstances and personal experiences of the specific patient, and selfreporting of pain should be employed as a
monitoring parameter whenever possible.1
It is extremely important that acute pain
be treated appropriately and in a timely
fashion. In addition to the obvious associated quality-of-life implications, untreated or
inadequately treated pain may cause physiologic hormonal responses that alter circulation and tissue metabolism and can produce
significant psychological stress responses.
1.25 CE UNITS
The body’s immune system may be compromised by release of endogenous corticosteroids provoked by pain.2 Certain acute
pain states, including postoperative and
post-traumatic pain, acute back pain and
acute zoster, may progress to chronic pain if
not managed appropriately.1 Pharmacists are
frequently the first health professional a
patient turns to when seeking relief from
acute pain. For this reason, it is extremely
important for pharmacists to clearly understand the principles of individualized acute
pain management with respect to options
available and associated benefits and risks of
treatment. This lesson has been designed to
refresh and update the community pharmacist’s knowledge in the area of acute pain
management.
ORIGINS AND TYPES OF PAIN
Pain may be nociceptive or neuropathic in
nature. Nociceptive pain can be further
subdivided into somatic and visceral pain.
• Somatic pain is often described as
sharp, hot or stinging, and is generally
SUPPORTED BY AN EDUCATIONAL GRANT FROM
Approved for 1.25 CE units
by the Canadian Council
on Continuing Education in
Pharmacy. File #432-0606.
Not valid for CE credits
after June 26, 2009.
September 2006 | Answer online at www.pharmacygateway.ca
Acute Pain Management — A Practical Update for Community Pharmacists |
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localized with surrounding tenderness.
• Visceral pain is often described as
dull, cramping, or colicky, and is often
poorly localized. Visceral pain may be associated with tenderness locally or distally in
the form of referred pain, and may illicit
symptoms such as nausea, sweating and
cardiovascular changes.
Neuropathic pain is more common in
chronic pain syndromes but may also be a
component of acute pain.1 Patients suffering from this type of pain often describe it
as burning, shooting or stabbing. The pain
may be paroxysmal or spontaneous in
nature. Additional experiences associated
with neuropathic pain may include:3
• dysaesthesias (spontaneous unpleasant abnormal sensations)
• hyperalgesia (increased response to
normally painful stimulus)
• allodynia (pain due to a stimulus that
does not normally evoke pain)
• regional autonomic features (changes
in colour, temperature and perspiration)
• phantom pain.
PAIN ASSESSMENT
In order to appropriately assess pain, a structured approach should be applied, including
identification of the components that contribute to the patient’s perception of pain.
A useful tool that may be adapted for such
an approach is illustrated in Appendix A.
Evidence suggests that regular assessment of pain leads to improved acute pain
management.1 The pain assessment tool
chosen should be appropriate to the individual patient.
Numerical Rating Scales (NRS) or
Verbal Rating Scale (VRS) and Visual
Analogue Scales (VAS) are the two most
common and simple pain assessment tools
available (see Appendix B). The NRS has
patients assess their pain on a scale of 0 to
10, where 0 represents no pain and 10 represents the worst pain imaginable. The
scale can also be used to determine the
effectiveness of pain medications where 0
would represent no relief and 10 would
represent complete relief.4
The VAS consists of a 100 millimeter
(mm) horizontal line with the left side
marked no pain and the right side marked
the worst pain possible. Various authors
have suggested the following interpretation
of Numerical Rating Scales (NRS) and
VAS ratings:2,5,6
• 7-10 (NRS) or >70 mm (VAS) =
severe pain
• 4-6 (NRS) or 45-74 mm (VAS) =
moderate pain
• 1-3 (NRS) or 4-44 mm (VAS) = mild
pain
2
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FIGURE 1:
Soft Tissue Injury Acute Pain Assessment Algorithm
Soft tissue injury
Are any of the following present?
• Severe pain
• Obvious fracture (bone sticks out or
makes grating sound)
• Joint deformity
• Inability to weight-bear on an injured limb
Refer to
physician
at once
How long since injury occurred?
<2 days
RICE regimen
± oral analgesic
2-14 days
NO
Has initial swelling
subsided?
YES
When swelling subsides
and 48 hours have passed
since acute injury, begin
therapy listed for 2-14 days
Heat therapy.
Consider oral or external analgesics
>14 days
Refer to physician.
Consider heat therapy
± analgesics while
waiting for appointment.
NO
Are symptoms resolved
in 14 days?
Adapted from Reference 9
• 0 (NRS) or 0-3 mm (VAS) = no pain
The VAS is unsuitable for children
under five years because of the need for
concentration and coordination to use
effectively.1 Tools such as the Wong-Baker
Faces Pain Rating Scale, where children
choose faces ranging from happy to sad
based on how they are feeling, have been
validated for use in children aged 3-8 years
(see Appendix B).7
The McGill Pain Questionnaire assesses sensory, affective and evaluative dimensions of pain (see Appendix C).8 This type
of tool is more appropriate for pain that is
neuropathic in nature and allows the
patient to be more descriptive with regard
to other factors affecting their quality of
life which may also influence their
response to pain.1
The tools discussed above and presented in the appendices are easily administered and may be utilized by pharmacists
to help assess their patient’s pain and effectiveness of their therapies.
GENERAL APPROACH TO ACUTE
PAIN CAUSED BY SOFT TISSUE
INJURY
Pharmacists are often the first point of care
for patients who have sustained a soft tissue
injury either at home or through sports. A
regimen referred to by the acronym RICE is
often recommended for initial management
| Acute Pain Management — A Practical Update for Community Pharmacists
of these types of injuries:9
• Rest – immobilize the affected area for
at least the first 24 hours to avoid aggravation of the injury. Continue to exercise
unaffected joints where possible to prevent
tissue atrophy and loss of coordination.
• Ice – Apply cold to injury for reduction of local blood flow. Apply cold therapy every few hours until swelling subsides.
Apply for 10-30 minutes at a time depending on body area. Areas with little body fat
(e.g., bony areas such as knees, elbows)
should be kept to the lower end of time.
• Compression – Use an elasticized
bandage for at least the first 24 hours to
reduce swelling and support a weak joint.
• Elevation – Raise the injured area
above the level of the heart to help drain
fluid and reduce swelling.
Figure 1 offers an algorithm for helping
patients with acute soft tissue injuries associated with acute pain.9
CONSIDERATIONS IN
PHARMACOLOGICAL
MANAGEMENT OF ACUTE PAIN
Pain is a very individual experience and the
selection of pharmacological agents must
also be individualized. Factors influencing
the choice of medication(s) include:
patient’s age, concomitant medical conditions, allergies and sensitivities, patient’s
preference for dosage form and dosing
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FIGURE 2:
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Pharmacological Choices According to Severity of Acute Pain11
Assess and determine source of pain. Refer to physician for diagnosis
where appropriate (e.g., chest pain, migraine, dyspepsia)
Minor Pain
1. Acetaminophen
2. If ineffective or not
effective for at least 4 hrs,
consider NSAID (unless
contraindicated)
Moderate Pain
1. Codeine ±
Acetaminophen*
2. If ineffective or not
effective for at least 4 hrs,
consider NSAID (unless
contraindicated)
Severe Pain+
1. Morphine (unless contraindicated)
2. If ineffective or not
effective for at least 2
hours, titrate and consider
infusion (or more frequent
dosing interval)1
*Tramadol/acetaminophen was not available when this algorithm was originally created and may be considered an
alternative to codeine ± acetaminophen (see “Tramadol/Acetaminophen — a new option…”).
+ It is assumed that most patients with severe acute pain will be treated in hospital.
Algorithm refers to patients with somatic pain (most common). Visceral pain and neuropathic pain may require alternative strategies specific to cause of pain and patient symptoms.
interval, history of pain management and
details of pain. The pharmacist should
obtain the following specifics regarding the
patient’s pain:10
• Type of pain
• Onset and frequency of pain
• Description of pain
• Location of pain, including radiating
patterns
• Intensity of pain at rest and with
activity
• Factors that induce and/or exacerbate
pain and associated signs and symptoms
• Factors that relieve the pain, including non-pharmacological and pharmacological interventions
• Side effects of interventions along
with side effect management and their
effectiveness
• Degree of pain relief or intensity of
pain after a pain relieving treatment or
intervention
Figure 2 suggests an approach to pharmacological management of acute pain.
ACUTE PAIN MANAGEMENT
IN LIGHT OF RECENT NSAID
CONCERNS
With the recent withdrawals of the COX2 inhibitors rofecoxib and valdecoxib from
the Canadian market and warnings related
to the balance of available NSAIDs, acute
pain management has become somewhat
more complicated.
More specifically, evidence from the
APPROVe trial indicated that patients treated with rofecoxib had a risk of stroke or
myocardial infarction of 1.5 per 100 patient
years versus 0.78 per 100 patient years in
the placebo group17. Valdecoxib was found
in manufacturer studies to be associated
with increased risk for cardiovascular events
versus placebo and increased risk for potentially serious rash.18 The only clinical trial
demonstrating a dose-related increase in
serious cardiovascular events with celecoxib
compared to placebo (mainly myocardial
infarction) employed the drug at a dose of
200 mg twice daily or more (highest recommended dose is 200 mg twice daily for
rheumatoid arthritis).15 As a result, celecoxib
is currently the only COX-2 inhibitor available in Canada.
All NSAIDs, COX-2 or otherwise, are
now required by Health Canada to indicate the following statement on their
monograph:
“Caution should be exercised in prescribing (name of NSAID) to patients with risk
factors for cardiovascular disease, cerebrovascular disease or renal disease, such as any of
the following (not an exhaustive list):”14
• hypertension
• dyslipidemia/hyperlipidemia
• diabetes mellitus
• congestive heart failure (NYHA 1)
• coronary artery disease (atherosclerosis)
• peripheral arterial disease
• smoking
• creatinine clearance <50 mL/min
The following strategies have been recommended in light of recent warnings
associated with the use of NSAIDs:19
• Use NSAIDs preferentially for
patients at low risk of thrombotic events
(e.g., no history of ischemic heart disease
or stroke; low risk-factor profile for vascular disease).
• Initially use drugs with lowest risk of
thrombotic events (e.g., acetaminophen);
if symptoms are not adequately controlled,
assess risk-to-benefit ratio before moving
to drugs with a higher risk of thrombotic
events (relative degree of COX-2 selectivity cannot be used to assess comparative
risks of drugs).
• Minimize duration of treatment with
NSAIDs to decrease period of risk.
September 2006 | Answer online at www.pharmacygateway.ca
• Use the lowest dose of NSAID to
control symptoms.
• If clinical circumstances necessitate
NSAIDs be prescribed to patients at
increased risk of thrombotic events and/or
for extended periods, add ASA 81 mg
(enteric-coated) in combination. The
antithrombotic effects of low-dose ASA
may be helpful but do not necessarily completely neutralize the risks of other
NSAIDs. When ASA is used in combination with another NSAID, consider a proton pump inhibitor or misoprostol to
reduce risk of gastrointestinal bleeding.
• During the period of treatment with
an NSAID, the patient should be monitored for increases in blood pressure, development of edema, deterioration of renal
function, or development of gastrointestinal bleeding.
Where NSAIDs are contraindicated, or
risks outweigh benefits, recommendations
regarding therapy that will relieve pain to
acceptable levels are extremely important.
Pharmacists have a critical role to play in
helping patients make truly informed decisions regarding pain control.
MODERATE TO SEVERE ACUTE
PAIN – ASSESSING THE OPTIONS
Moderate acute pain is most appropriately
treated with a combination opioid/acetaminophen analgesic. One of the most
commonly prescribed medications in
Canada is acetaminophen with codeine.
Codeine is defined as a weak opioid.1 The
molecule itself does not have any analgesic
activity, but is partially metabolized to
morphine (approximately 10% of dose
given).1 The enzyme responsible for the
conversion to morphine is cytochrome
P450 2D6 (CYP2D6). Approximately 9%
of Caucasians are lacking in this enzyme
and therefore may receive minimal pain
relief with codeine and 2% of Asian people
due to inefficiency of the CYP2D6
enzyme.1
When it is deemed that severe acute
pain is best treated parenterally (due to fast
onset of action), the most appropriate
choice is intravenous morphine due to
less painful administration and more predictable onset of action compared with
subcutaneous or intramuscular route. (See
Figure 2).11 When possible, pharmacists
should refer patients with severe pain to a
physician capable of administering this
type of treatment (i.e., emergency department or urgent care centre).
In circumstances where oral opioids are
appropriate, those that are immediaterelease dosage form are the agents of choice
for acute pain. All full opioid agonists
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TABLE 1:
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Overview of Analgesics Recommended for Treatment of Acute Pain in Adults
Medication
Dose
Adverse Effects (ADRs), Precautions
& Drug Interactions*
Role in Acute Pain Management
Acetaminophen Adults: 325-650 mg po or pr q4h
Max: 4 g daily
Pediatric: 10-15 mg/kg/dose po q4h;
15-20 mg/kg/dose pr q4h
Max: 5 doses/day
ADRs: Hepatotoxicity11
Pregnancy and Nursing: Analgesic of choice in
pregnancy (category B).12 May be used in nursing
mothers.13
Drug interactions: Warfarin11 Monitor more
frequently at doses of acetaminophen 2000 mg
(2 g) daily or above.
- Used for mild to moderate pain.
- Analgesic and antipyretic activity
equal to ASA and fewer adverse
reactions and drug interactions than
NSAIDs but no anti-inflammatory
action.
- Use with opioid analgesics for
additive analgesic effect.11
NSAIDs
Adults (unless otherwise stated)
ASA 325 mg - 650 mg po q4h
Max: 4 g/day
Ibuprofen 200-400 mg po q 6-8 h
Max: 1.2 g/day
Pediatric: Ibuprofen 10 mg/kg/dose
po q 6-8 h
Max: 40 mg/kg/day, not to exceed
adult dose
Naproxen 500 mg initially, then
250 mg po q 6-8 h
Max: 1,250 mg/day
Celecoxib 400 mg as single dose first
day followed by 200 mg /day to a
max 7 days. Patients may take up to
400 mg/day as instructed by
physician.14
Ketorolac 10 mg PO q 4-6 hrs prn
(max 40 mg daily) - not to exceed
5 days for post-surgical patients or
7 days for musculoskeletal pain
10-30 mg IM or IV q 4-6 h
Max: 120 mg/day
Not to exceed 2 days therapy.
Total combined IV/IM plus oral
therapy not to exceed 5 days.
ADRs:
Common (>10%)
Dyspepsia, nausea/vomiting, diarrhea, dizziness,
headache, antiplatelet effect
Uncommon (1-10%)
Gastric and duodenal ulcers, fluid retention/
edema, tinnitus, loss of hearing, disorientation,
confusion (seniors), increased liver enzymes
Rare (<1%)
Gastric hemorrhage, perforation, small bowel
ulceration, renal insufficiency, skin rashes,
hypersensitivity reaction, thrombocytopenia,
asthma (in patients with ASA hypersensitivity).
Pregnancy and Nursing: Contraindicated during
3rd trimester of pregnancy and while nursing.14
Exception: Ibuprofen is considered compatible
with nursing by American Academy of Pediatrics.
Category: B (D in 3rd trimester)
Drug Interactions: warfarin diuretics, betablockers, ACE inhibitors, alpha-blockers, lithium11
- Indicated for short-term
(≤7 days) management of
moderate to severe acute pain
- COX-2 selective inhibitors
(e.g., celecoxib) and nonselective
NSAIDs have similar efficacy for
acute pain.1
- Usual doses of celecoxib do not
appear to have antiplatelet effect
but monitoring with warfarin
therapy still recommended.14
Opioids
Adults (unless otherwise stated)
Codeine 15-60 mg q 4-6 h (alone or
in combination with acetaminophen)
Max: 60 mg/dose
Pediatric: Codeine 0.5-1 mg/kg/dose
po q 4-6 h
Max: 60 mg/dose
Morphine (immediate-release)
5-20 mg PO q 4-6 h prn
Morphine intermittent iv: 2.5 - 10 mg
IM or IV q 2-4 h prn (use lower dosing
range for narcotic naïve patients)
Morphine (continuous infusion)
1-10 mg/h
Breakthrough pain during infusion:
2.5-5 mg/dose
Oxycodone immediate-release
(alone or in combination with
acetaminophen) 5-10 mg PO q6h prn
Hydromorphone (immediate release)
2-4 mg PO q 4-6 hrs prn.
Meperidine 50-150 mg PO q 3-4 hrs prn
50-100 mg IV q 3-4 hrs prn
ADRs: Sedation, constipation, respiratory depression (dose related)1
Pregnancy and Nursing: Category: C (D in
prolonged doses) Weigh benefits versus risks
for pregnancy and nursing.15
Codeine considered compatible with nursing by
American Academy of Pediatrics.
Drug Interactions: All opioid CNS depressants
Codeine: somatostatin, rifampin, celecoxib,
cimetidine, desipramine, fluoxetine, paroxetine,
quinidine.
- For short-term use in the treatment of acute moderate to severe
pain associated with medical
conditions such as trauma
and myocardial infarction.15
- Oral opioids, preferably shortacting agents at regular intervals
may be necessary to relieve severe
acute musculoskeletal pain;
ongoing need for such treatment
requires reassessment.1
Opioid/
serotonin,
norepinephrine
reuptake
inhibitor16
Adults (over 18 years)
Tramadol (37.5 mg)/acetaminophen
(325 mg) per tablet: 1-2 tablets every
4-6 hours to a maximum of 8 tablets
per day.
Dose adjustment required for patients
with impaired renal function:
CrCl <30 ml/min: Max 2 tablets q12h.
ADRs: sedation, constipation, respiratory depression (higher dose), increased risk for seizures
Pregnancy and Nursing: Risk category C
Nursing not recommended as safety not known.
Drug Interactions: CNS depressants
Carbamazepine (should not be used together)
MAOIs (great caution) SSRIs (caution)
increased risk of serotonin syndrome, seizures
Warfarin - rare interaction - monitor regularly
- For the short-term management
of acute pain (5 days or less)16.
- Tramadol may cause less constipation as compared to codeine
at equi-analgesic doses.1
- Tramadol may be useful in
neuropathic pain.1
*Please refer to product monographs for more detailed description of drug interactions
4
| Acute Pain Management — A Practical Update for Community Pharmacists
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given in equianalgesic doses produce the
same analgesic effect.1 Choices include
codeine, morphine, hydromorphone and
oxycodone. The combination of oxycodone/acetaminophen is also commonly
prescribed for moderate to severe pain.
Ketorolac is an NSAID that can be
given IM or IV or orally. When used parenterally, a dose of 30 mg is comparable in
pain relief potential to approximately 12
mg of morphine.11 This treatment is appropriate for pain that would otherwise be
treated with parenteral opioids but contraindications exist.11
TRAMADOL/ACETAMINOPHEN
– A NEW OPTION FOR ACUTE PAIN
MANAGEMENT
Recently, a combination product containing tramadol/acetaminophen was introduced on the Canadian market. The following section is intended to help pharmacists understand how this product compares to other currently available acute
pain analgesics.
Tramadol/acetaminophen (37.5 mg/325
mg) was approved for use in Canada in
July 2005 for the short-term management
(5 days or less) of acute pain and is marketed under the brand name Tramacet®.20
Unlike other products containing an
opioid, Health Canada has designated
tramadol/acetaminophen as a Schedule F
drug.21 This decision was made based on
reports from other jurisdictions, notably
the United States, that tramadol abuse
occurs at a level of 0.5 - 1.0 case per
100,000 patients who are prescribed the
analgesic.22 Furthermore, release of a less
expensive generic brand in the United
States did not result in an increase in the
rate of abuse.22 Although similar studies of
the rates of abuse of opiates such as morphine and oxycodone were not undertaken, reports based on prescription drug
plan use reveal that therapeutic use of pain
relievers seldom leads to dependence.22
Suspicion of patients seeking pain relief
remains an inappropriate obstacle to the
appropriate use of pain relievers.22
The tramadol component of tramadol/acetaminophen is unique from
other opioid agents in that it appears to
have at least two complementary mechanisms of action; the binding of parent and
a metabolite to µ-opioid receptors and
weak inhibition of reuptake of norepinephrine and serotonin.16 When the combination of tramadol/acetaminophen is
administered with food, the time to peak
plasma concentration is delayed. It is not
known whether this delay is clinically significant. Excretion of tramadol is reduced
Page 5
in patients with renal impairment and dose
adjustments are required for patients with
creatinine clearance of less than 30
mL/minute.
In
these
patients
tramadol/acetaminophen dosing should
not exceed 2 tablets every 12 hours.20
Studies suggest that tramadol has low
dependence potential for a period of treatment less than 6 months, but the possibility of dependence with long-term use cannot be ruled out.2 To this end, the manufacturer of tramadol/acetaminophen in
Canada has initiated a “risk management
strategy” to support the safe and effective
use of the analgesic combination product.
Appendix A:
The components of the risk management
strategy include:16
• Commitment to not emphasize or
highlight the scheduling of tramadol/acetaminophen in advertising or promotional
activities.
• Inclusion of an approved fair balance
statement in all tramadol/acetaminophen
advertising and promotional materials.
• Provision of progress reports to
Therapeutic
Products
Directorate,
Marketed Health Products Directorate and
the Health Environments and Consumer
Safety Branch of Health Canada from an
ongoing drug abuse surveillance program,
Recommended Information to be Assessed During Pain History4
Nature of Pain • Onset and duration
• Location(s) and radiation
• Quality
• Intensity
• Associated symptoms
• Factors that exacerbate or alleviate pain, including medical intervention
Attempted
• Ask about current and prior attempts to manage the pain. For prior
Management
attempts, ascertain why intervention was discontinued.
Strategies
• Medications (prescription, nonprescription, supplements)
• Nonpharmacologic treatments (physical therapy, etc.)
• Complementary and alternative treatments (chiropractic, acupuncture)
• Other coping strategies (distraction, relaxation)
Medical
• Prior and coexisting illnesses (including mental comorbidities, substanceHistory
abuse disorders)
• History of accidents and surgeries
• Allergies and/or intolerances to medications
• Medical conditions affecting choice of medication
Family History • Health status of family members
• Family history of pain or illness, including depression
Psychosocial • Developmental, marital or vocational problems
History
• Stressors or depressive symptoms
• Compensation/litigation issues
Functional
Impact of pain on the patient’s:
Impact of
• Work
Pain
• Other daily activities (e.g., ability to care for house and family members,
ability to participate in sports or hobbies)
• Personal relationships
• Sleep, appetite, emotions
Expectations What the patient hopes to achieve with regard to:
and Goals
• Intensity of pain
• Functional abilities
• Quality of life
Appendix B:
Pain Assessment Tools
Numerical Rating Scale
Rate your pain on a scale of 0 to 10 where 0 is “no pain” and 10 is “the worst pain ever”
Visual Analogue Scale
Mark the line below to indicate the current level of your pain
NO PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PAIN AS BAD AS IT CAN BE
Wong-Baker FACES Pain Rating Scale*
0
No
hurt
September 2006 | Answer online at www.pharmacygateway.ca
1
Hurts
little bit
2
Hurts
little more
3
Hurts
even more
4
Hurts
whole lot
5
Hurts
worst
*Adapted from Wong D, Daley L. (1986) Clinical
Handbook of Pediatric Nursing, 2nd ed. p. 373;
St. Louis. C.V. Mosby Company. Available online at:
http://painconsortium.nih.gov/pain_scales/Wong
-Baker_Faces.pdf.
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Appendix C:
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Page 6
The McGill Short-Form Pain Questionnaire24
Patient’s Name ___________________________________ Date: _______________
None
Mild
Moderate
Severe
1.Throbbing
0) ______
1) _______
2) ______
3) ______
2.Shooting
0) ______
1) _______
2) ______
3) ______
3. Stabbing
0) ______
1) _______
2) ______
3) ______
4. Sharp
0) ______
1) _______
2) ______
3) ______
5. Cramping
0) ______
1) _______
2) ______
3) ______
6. Gnawing
0) ______
1) _______
2) ______
3) ______
7. Hot-Burning
0) ______
1) _______
2) ______
3) ______
8. Aching
0) ______
1) _______
2) ______
3) ______
9. Heavy
0) ______
1) _______
2) ______
3) ______
10. Tender
0) ______
1) _______
2) ______
3) ______
11. Splitting
0) ______
1) _______
2) ______
3) ______
12. Tiring-Exhausting
0) ______
1) _______
2) ______
3) ______
13. Sickening
0) ______
1) _______
2) ______
3) ______
14. Fearful
0) ______
1) _______
2) ______
3) ______
15. Punishing-Cruel
0) ______
1) _______
2) ______
3) ______
Total Score = Pain Rating Index (PRI) = ___________
Visual Analogue Scale (VAS)
No pain |--------------------------------------------------------------------------------| Worst possible pain
Present Pain Index (PPI)
0 No pain ______
1 Mild
______
2 Discomforting ______
3 Distressing ______
4 Horrible
______
5 Excruciating ______
Descriptors 1-11 represent the sensory dimension of pain experience and 12-15 represent the affective
dimension (qualitative descriptors). Each descriptor is ranked on an intensity scale of 0=none, 1=mild,
2=moderate, 3=severe. The PPI and VAS are included to provide overall pain intensity scores.
Appendix D:
1.
2.
3.
4.
5.
The Screening Instrument for Substance Abuse Potential25
If you drink alcohol, how many drinks do you have on a typical day?
How many drinks do you have in a typical week?
Have you used marijuana or hashish in the past year?
Have you ever smoked cigarettes?
What is your age?
The SISAP screening tool suggests to doctors that caution should be used when prescribing
opioids for: men who exceed four drinks per day or 16 drinks per week, women who exceed
three drinks per day or 12 drinks per week, patients who admit recreational marijuana or
hashish use in the past year and patients under 40 who smoke.
* For additional addiction screening tools see reference 25
Appendix E:
Possible Indicators of Drug-Seeking Behaviour26
• Patient is from out of town
• Hurried manner
• Allergic to weak opioid analgesics or non-opioid drugs such as NSAIDs
• Conversant with clinical terms
• Knows street nicknames for prescription drugs
• Reluctant to present identification
• Offers to pay cash instead of presenting identification or prescription drug plan
including data from 4 key informant
Canadian sites in the program.
• Reassessment of the success of the risk
management strategy two years post-product launch.
6
This risk program was modelled after a
similar very successful program that was
launched in the United States in 1995
along with the release of tramadol in that
country.22 Substance abuse and drug diver-
| Acute Pain Management — A Practical Update for Community Pharmacists
sion are important issues for pharmacists.
Appendix E overviews patient characteristics that may indicate drug-seeking behaviour, while the Screening Instrument For
Substance Abuse Potential (SISAP) is presented in Appendix D. Although these
tools can be used in a general approach to
assessing the likelihood of someone seeking
drugs, they should not be used to stereotype. Prescriptions from doctors who are
not known to the pharmacist should always
be verified regardless of the circumstances.
The risk of respiratory depression with
tramadol is significantly lower at equianalgesic doses in comparison with other
opioids.1 Tramadol is also associated with
less constipation and has less effect on gastric emptying and postoperative bowel
recovery than morphine. Nausea and vomiting occur at rates that are similar to other
opioids. Tramadol may increase incidence
of seizures with increasing risk at higher
doses (above recommended range) and
when used together with selective serotonin re-uptake inhibitors, tricyclic antidpressants, other opioids, monoamine oxidase inhibitors, neuroleptics or other drugs
that reduce the seizure threshold.1,16
Two studies comparing tramadol/acetaminophen to other currently available
agents have been conducted. Tramadol/
acetaminophen has been found to work as
well as acetaminophen with codeine 30 mg
for chronic back pain and osteoarthritis
pain.2 Tramadol 37.5 mg/acetaminophen
325 mg was recently compared to codeine
30 mg/acetaminophen 300 mg or placebo
(2 tablets initially, then 1 to 2 tablets every
4 to 6 hours as needed) in 305 patients
with postsurgical orthopedic or abdominal
pain.20 Tramadol/acetaminophen was superior to placebo for average daily pain relief
and average daily pain intensity while
codeine/acetaminophen was found to be
not statistically different in these categories
from placebo. Tramadol/acetaminophen
was found to be superior to placebo but
was not significantly different than acetaminophen/codeine for total pain relief,
sum of pain intensity differences, and sum
of pain relief and pain intensity differences.
Adverse events were similar for both treatment groups except for constipation (4.1%
for tramadol/acetaminophen versus 10.1%
for codeine/acetaminophen) and vomiting
(9.2% for tramadol/acetaminophen and
14.7% for codeine/acetaminophen).20
In a study comparing tramadol 37.5
mg/acetaminophen 325 mg tablets with
hydrocodone bitartrate 10 mg/acetaminophen 650 mg tablets for treatment of postoperative dental pain, the tramadol/acetaminophen combination (2 tablets) was
Answer online at www.pharmacygateway.ca | September 2006
JO_CE_AcutePain_0906_E
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3:20 PM
found to provide equivalent analgesia to
the comparator (one tablet) with a better
tolerability profile.23
Tramadol/acetaminophen offers an alternative to codeine/acetaminophen for treatment of moderate acute pain in those who
find codeine ineffective or who cannot tolerate constipation associated with codeine.
THE PHARMACIST’S ROLE IN
ACUTE PAIN MANAGEMENT
Pharmacists are often the first health professional consulted by patients with acute
pain. It is extremely important for health
professionals to gather appropriate information and make individualized recommendations regarding the best therapeutic
approach. Open communication with the
patient is a vital component in the
approach to effective pain management.
Assessment of pain type, level, duration
and compounding factors are critical for
identifying those patients in need of emergency or physician care. Assessment tools
presented in the appendices will help with
patient assessment.
Rest, application of cold, compression
and elevation of injured limb are often
appropriate recommendations for self-limiting soft tissue injuries that have occurred
within the last 48 hours. Recommendation
of appropriate analgesia (based on benefitto-risk considerations), and ongoing care
as outlined in Figure 1 are also important
roles for the pharmacist.
Pain control is a patient’s right, and it is
tremendously important for pharmacists
Page 7
to help their patients make educated and
well-informed decisions. For example,
some patients may fear taking opioids due
to addiction concerns, or NSAIDs because
of the recent reports of cardiovascular
events associated with their use.
Pharmacists need to take individual
patient concerns into account when recommending the most appropriate therapy
for managing pain effectively.
11. Bailey B. Acute Pain. In: Gray J, editor. Therapeutic Choices.
Ottawa: Canadian Pharmacists Association, 2003: 116-27.
12. Black RA, Hill DA. Over-the-counter medications in pregnancy.
Am Fam Physician 2003; 67(12):2517-24.
13. Medline Plus. Acetaminophen (Systemic). Available online at
http://www nlm nih gov/medlineplus/druginfo/uspdi/202001 html.
Accessed March 23, 2006.
14. Celebrex product monograph. Pfizer Canada 2006.
15. Opioids Product Monograph. Compendium of Pharmaceuticals and Specialties 2006.
16. Tramacet Product Monograph. Janssen-Ortho Inc 2006.
17. Bresalier RS, Sandler RS, Quan H, Bolognese JA, Oxenius B, Horgan
K et al. Cardiovascular events associated with rofecoxib in a colorectal ade-
REFERENCES
noma chemoprevention trial. N Engl J Med 2005; 352(11):1092-102.
1. Australian and New Zealand College of Anaesthetists and
18. Health Canada. Bextra: Important Safety information.
Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence.
Available online at http://www.pfizer.ca/english/newsroom/press%
Available online at http://www anzca edu au/publications/acutepain
20releases/default.asp?s=1&year=2004&releaseID=146.2006.
pdf. Accessed March 21, 2006.
Accessed March 21, 2006.
2. Reisner LKPJS. Pain and its Management. In: Koda-Kimble M,
Young L, Kradjan WA, et al, editors. Applied Therapeutics: The Clinical Use
of Drugs. Philadelphia: Lippincott, Williams & Wilkins, 2005: 9.1-9.40.
3. Hobbs GJ, Hodgkinson V. Assessment, measurement, history
and examination. In: Rowbotham D, Macintyre PE, editors. Clinical Pain
Management; Acute Pain. London: Arnold Publishers, 2003.
4. American Pharmacists Association. A Pharmacist’s Guide to the
Clinical Assessment and Management of Pain. Available online at
http://www pharmacist com/pdf/pain/pharmacists-guide pdf 2004.
19. Antman EM, DeMets D, Loscalzo J. Cyclooxygenase inhibition
and cardiovascular risk. Circulation 2005; 112(5):759-70.
20. PMPRB Canada. Report on New Patented Drugs - Tramacet.
Available online at http://www.pmprb-cepmb.gc.ca/English/View
asp?x=561&mp=117. Accessed March 23, 2006.
21. Health Canada. Notice of Decision for Tramacet. Available
online at http://www.hc-sc.gc.ca/dhp-mps/prodpharma/activit/
proj/sbd-smd/nd_ad_2005_tramacet_095167 _e html. Accessed
March 26, 2006.
Accessed March 21, 2006:1-39.
5. Aubrun F, Langeron O, Quesnel C, Coriat P, Riou B. Relationships
between measurement of pain using visual analog score and morphine
requirements during postoperative intravenous morphine titration.
Anesthesiology 2003; 98(6):1415-21.
22. Cicero TJ, Inciardi JA, Adams EH, Geller A, Senay EC, Woody GE
et al. Rates of abuse of tramadol remain unchanged with the introduction
of new branded and generic products: Results of an abuse monitoring
system, 1994-2004. Pharmacoepidemiol Drug Saf 2005; 14(12):851-9.
6. Jensen MP, Chen C, Brugger AM. Interpretation of visual analog
23. Fricke JR, Jr., Karim R, Jordan D, Rosenthal N. A double-blind,
scale ratings and change scores: A reanalysis of two clinical trials of
single-dose comparison of the analgesic efficacy of tramadol/acetamin-
postoperative pain. J Pain 2003; 4(7):407-14.
ophen combination tablets, hydrocodone/acetaminophen combination
7. Wong DL, Baker CM. Pain in children: Comparison of assessment scales. Pediatr Nurs 1988; 14(1):9-17.
8. Melzack R. The McGill Pain Questionnaire: Major properties and
scoring methods. Pain 1975; 1(3):277-99.
9. Lum L. Sports Injuries. In: Repchinsky C, editor. Patient SelfCare. Ottawa: Canadian Pharmacists Association, 2002: 439-46.
10. The Canadian Pain Society. Accreditation Pain Standard:
Making it Happen! Available online at http://www.canadianpainsociety.ca/
accreditation_manual.pdf. Accessed March 21, 2006.
tablets, and placebo after oral surgery. Clin Ther 2002; 24(6):953-68.
24. Melzack R. The short-form McGill Pain Questionnaire. Pain
1987; 30(2):191-7.
25. The Canadian Pain Society Task Force. Use of opioid analgesics for the treatment of chronic noncancer pain - A consensus statement and guidelines from the Canadian Pain Society. Pain and
Research Management 1998;1-19.
26. Goldman B. Drug-Seeking Behaviour. Managing Pain - The
Canadian Health Professional’s Reference 2002;77-86.
QUESTIONS
1. Which of the following best describes the
type of pain that John is experiencing?
a) Neuropathic
c) Somatic
b) Visceral
d) Allodynia
3. Which recommendation(s) would be
most appropriate for John?
a) Immobilize and rest the ankle for at least
24 hours and apply cold therapy every
few hours until swelling subsides.
b) Try walking on the injured ankle every
few hours for the first 24 hours to prevent
tissue atrophy and apply ice after each
round of exercise.
c) Sit with the heel on the floor and keep
the ankle joint flexed.
d) a and c
2. You ask John what his pain is on a scale of
0 to 10 where 0 is no pain and 10 is the
worst pain imaginable. He says it is about
a 6. Which of the following would best
describe the level of his pain according
to the Numerical Rating Scale?
a) Mild pain
c) Severe pain
b) Moderate pain
d) Very severe pain
4. Which situation(s) should prompt a
referral to a physician as soon as
possible?
a) Severe pain
b) Obvious fracture
c) Inability to bear weight on the injured
ankle.
d) All of the above
CASE 1: John H is a 20-year-old male who
has just twisted his ankle while playing intramural basketball at university. He has come
into the pharmacy and describes his pain as
sharp and stinging, with tenderness around
the ankle. He is not currently taking any
medication and is generally healthy.
September 2006 | Answer online at www.pharmacygateway.ca
5. If John’s physician prescribed celecoxib
for him, which protocol would be most
appropriate for acute pain management?
a) 100 mg bid for maximum 14 days
b) 200 mg bid for maximum 7 days
c) 400 mg first day, followed by 200 mg
daily for 7 days maximum
d) 400 mg once daily for maximum 7 days
CASE 2: Sonya is an otherwise healthy 4year-old who has just had a tonsillectomy.
She weighs 22 kg. The physician has recommended ibuprofen for pain.
6. Which dose of ibuprofen would be most
appropriate for Sonya?
a) 200 mg every 6-8 hours prn
b) 100 mg every 4 hours prn
c) 50 mg every 4 hours prn
d) 100 mg every 6-8 hours prn
Acute Pain Management — A Practical Update for Community Pharmacists |
7
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Page 8
QUESTIONS continued
7. If the doctor had prescribed acetaminophen suppositories, which statement
would apply?
a) Give double dose as recommended for
oral acetaminophen products in the suppository dosage form.
b) She should receive 325 mg pr q4h with a
maximum of 5 doses per day.
c) She should receive 480 mg pr per day
divided into 4 doses (i.e., 120 mg qid prn).
d) She should receive 650 mg pr q6h with a
maximum of 4 doses daily.
CASE 3: Joan is a 30-year-old female who
has been given a prescription for acetaminophen 300 mg with codeine 15 mg, 1-2
tablets q4h prn pain for one week.
Additional medications include docusate
sodium 100 mg at bedtime. She is currently
nursing her infant baby.
8. Which statement about codeine is TRUE?
a) About 9% of the Caucasian population
lacks the enzyme to metabolize codeine
to morphine.
b) Codeine is not compatible with breast
feeding according to the American
Academy of Pediatrics
c) Acetaminophen with codeine is a primary
choice for minor pain.
d) None of the above.
9. Would celecoxib be considered an
appropriate alternative for Joan?
a) Yes, if acetaminophen with codeine is
ineffective.
b) Yes, NSAIDs should actually be used
before acetaminophen with codeine for
moderate acute pain.
c) No, because Joan is nursing.
d) No, because Joan is taking docusate
sodium.
CASE 4: Fred is a 58-year-old man with Type
2 diabetes. Fred currently takes metformin
500 mg bid, ramipril 10 mg once daily, and
coated ASA 81 mg daily. He has a prescription from his doctor for diclofenac 25 mg
three times daily for acute pain.
10. Which statement(s) about NSAIDs
is/are TRUE?
a) COX-2 selective inhibitors are considered
by Health Canada to be associated with
greater cardiovascular risk than traditional
NSAIDs.
b) Patients who smoke are at increased risk
of cardiovascular events while using
NSAIDs than the general population.
c) Valdecoxib has been associated with
increased risk for serious rash.
d) b and c
8
11. Which statement(s) about Fred’s
circumstances is/are TRUE?
a) Fred should stop taking his coated ASA
while taking diclofenac.
b) Fred does not have any risk factors that
increase his risk for cardiovascular
adverse effects with NSAIDs.
c) Fred should continue to take his coated
ASA while taking diclofenac as its
antithrombotic effect may be helpful.
d) None of the above.
CASE 5: Millie is a 48-year-old woman who
has just had dental surgery. She rates pain
at 6 out of 10 on the numerical rating scale.
The doctor calls and says Millie can’t take
NSAIDs, and codeine tends to constipate
her. You ask if he has considered Tramacet®
(tramadol/acetaminophen).
12. Which of the following are included in
the indications for use of tramadol/
acetaminophen for acute pain?
a) Use for not longer than 5 days.
b) Use for not longer than 7 days.
c) Use for not longer than 14 days.
d) Use for not longer than one month.
13. Which of the following is TRUE of
tramadol/acetaminophen compared
with acetaminophen/codeine?
a) Less constipation at equi-analgesic doses.
b) Increased risk for respiratory depression
at equi-analgesic doses.
c) Increased risk for interaction with CYP2D6
inhibitors.
d) a and c
14. Which drugs should not be used with
tramadol/acetaminophen but may be
used with other opioids?
a) Amlodipine
b) Verapamil
c) Carbamazepine
d) Clonazepam
15. If Millie has a creatinine clearance of
25 mL/min, what is the maximum
daily dose of tramadol/acetaminophen
(37.5/325 mg) tablets allowed?
a) 2
c) 6
b) 4
d) 8
16. Which description makes
tramadol/acetaminophen unique
among opioid analgesics?
a) It is associated with a very low abuse
potential.
b) It is a Schedule F product.
c) The manufacturer has implemented a
post-marketing “risk management strategy.”
d) All of the above
| Acute Pain Management — A Practical Update for Community Pharmacists
17. Which result was found in a study
comparing 2 tablets tramadol/acetaminophen (37.5/325 mg) with
hydrocodone bitrartrate/acetaminophen (10/650 mg) for treatment of
postoperative dental pain?
a) Tramadol/acetaminophen provided better
analgesia with better tolerability.
b) Tramadol/acetaminophen provided less
analgesia with better tolerability.
c) Tramadol/acetaminophen provided equivalent analgesia with better tolerability.
d) Tramadol/acetaminophen provided better
analgesia with worse tolerability.
18. Which situation would lead you to suspect drug-seeking behaviour or someone at high risk for substance abuse?
a) A man hands you the prescription, says
immediately that he will pay cash and
that he is in a bit of a hurry.
b) When asked, a 58-year-old woman tells
you she smokes one-half pack of cigarettes a day.
c) A 40-year-old man tells you he has a
glass of wine with dinner every day.
d) All of the above would lead you to suspect drug-seeking behaviour or substance
abuse potential.
19. Which patient would be most appropriate to ask to fill out a short-form
McGill Pain Questionnaire?
a) A patient who complains of pain symptoms that are burning, shooting and
stabbing in nature.
b) A patient whose pain is generally welllocalized.
c) A patient who marks their pain at 10 mm
on a standard Visual Analogue Scale.
d) None of the above
20. Which statement is TRUE concerning
acetaminophen and warfarin use?
a) Acetaminophen and warfarin do not
interact.
b) Acetaminophen may increase the effects
of warfarin at a dose of approximately
650 mg daily in most individuals.
c) Acetaminophen may increase the effects
of warfarin at a dose of approximately 2
g daily in most individuals.
d) One should begin monitoring INR more
closely when acetaminophen doses reach
4 g daily.
Answer online at www.pharmacygateway.ca | September 2006
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