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بسم هللا الرحمن الرحيم PAIN MANAGEMENT 1. PHARMACOTHERAPY Salah N A El-Tallawy Prof. of Anesthesia and Pain Management, Faculty of Medicine, Minia University & NCI, Cairo University, Egypt Associate Prof. KSU, KSA Objectives Introduction. Pain control strategies. Special painful conditions. Rules for pharmacotherapy. Algorithms for pain management. What’s the definition of pain? “Pain is a Sensory and Emotional experience, associated with actual or potential tissue damage or described in terms of such damage” (IASP) Pain is under-treated ??? Lack of Knowledge Barriers: in the health care in the regulatory systems with the patients The “Costs” of Uncontrolled Pain Stress response Hypothalamo-Pituitary-Adrenal axis: Disturbed cytokine cascade. Impairment of immune function. Increased catabolism. Negative nitrogen balance. Pain Chronicity. Cardiovascular Respiratory GIT Neuro-psychiatric Impairment of mobility, Gait disturbances. Peripheral sensitization • Tissue damage Central Sensitization • Nociceptive input • Inflammatory soap • Excitability of DHN • Sympathetic stimulation • Mechanical allodynia 1ry Hyperalgesia 2ry Hyperalgesia Causes of Acute Pain Post-operative Obstetric - Labor Burns Trauma Infective / Inflammatory conditions Ischaemic pain Visceral pain Causes of Post-Operative Pain Incisional skin and subcutaneous tissue Deep Positional IV site Tubes Respiratory Rehab Surgical Others cutting, coagulation, trauma nerve compression, traction & bed sore. needle trauma, extravasation, venous irritation drains, nasogastric tube, ETT from ETT, coughing, deep breathing physiotherapy, movement, ambulation complication of surgery cast, dressing too tight, urinary retention Causes of Chronic Pain Cancer pain Cancer related From cancer therapy Cancer unrelated Non-cancer Nociceptive Neuropathic Idiopathic Pain Assessment S R N Good assessment = Successful management Pain Assessment • Subjective: • Pain Scores: • Unidimentional Acute pain • • • Multidimentional Chronic pain • • VRS, VAS & NRS. Facial expression. McGill & Pain Inventory. Objective: – – – – Behavioral: refusal to move, cough & deep breath Physiological: PR, RR, ABP, sweatiness & dilated pupils Neuro-endocrinal: RBS, Stress hormones Algometry. Pain Scores Visual Analogue Scale (VAS) 0 10 Numeric Rating Scale (NRS) Verbal scale No Pain Mild Moderate Severe Pain Wong-Baker “Faces Scale” Questions to Ask about Pain P A I N Pattern: onset, course & duration Area: location Intensity Nature: burning, colic, … Questions to Ask about Pain P Q R S T (ECG format) Provocation Quality - characters of pain Referred / Radiating Severity Timing Questions to Ask about Pain LO CATE S L – Location. O – Other Symptoms. C – Character: deep, burning, throbbing… A – Aggravating and Alleviating factors. T – Timing. E – Effect: your daily routine? S – Severity. Personal opinion # Patient self report ? Pain Control Strategies –Pharmacotherapy – – – – – – – Anesthetic approaches Implantable devices Neurostimulation approaches Alternative approaches Surgical approaches Rehabilitative approaches Lifestyle changes – Psychological approaches Non Opioid Analgesics: – NSAA – NSAIDs • Non-selective COX inhibitors • Selective COX-2 inhibitors Opioids – Weak Opioids. – Strong opioids. – Mixed agonist – antagonists Adjuvants – – – – – – – – Antidepressants Anticonvulsants Substance P inhibitors NMDA inhibitors LA Drugs for Headache Drugs for Bone pain Others . Drug Strategies Non-Drug Strategies Alternative medicine: – – – – Acupuncture TENS Cupping Chiropractice Physical Therapy – ice, heat, massage Exercise Psychological therapy – – – – Cognitive-behavioral therapy Relaxation techniques Biofeedback Hypnosis WHO step Ladder 3 severe Morphine 2 moderate Codeine Hydrocodone 1 mild Oxycodone Dihydrocodeine ASA Acetaminophen NSAIDs ± Adjuvants Tramadol ± Adjuvants Hydromorphone Methadone Pethidine Fentanyl Oxycodone ± Adjuvants 1. Drug Therapy 1) Non Opioid Analgesics: – NSAAs – Analgesic /Antipyretic e.g. – Acetaminophen (COX-3 ---) & Antipyrine – Analgesic/Anti-inflammatory/Antipyretic e.g. – Salicylic acid – NSAIDs • Non-selective COX inhibitors • Selective COX-2 inhibitors Commonly Used NSAIDs Drug Name Usual Adult Oral Dose (mg) Usual dose interval (Hrs) Pediatric Dose (Mg/Kg) Maximal Daily Dose (Mg/Day) Other Comments Aspirin 325-1000 4-6 10-15 g 4-6 4000 Not for use in children younger than 12 with possible viral illness due to Reye’s syndrome Acetaminophen 500-1000 4-6 10-15 q 4-6 4000 Significant liver toxicity in overdose. May increase INR in patients taking warfarin. Choline Magnesium Trisalicylate 1000-1500 12 25 bid 2000-3000 No effect on platelet function. Avoid in children younger than 12 with possible viral illness. Ibuprofen 200-800 6 10 q 6-8 2400-3200 Relatively infrequent GI side effects Naproxen 250-500 6-12 5 bid 750-1250 May be beneficial for headaches of migraines Ketoprofen 12.5-50 6-8 Not recommended 300 Slightly increased GI side effects Flurbiprofen 50-100 Bid-tid Not recommended 300 Potent anti-inflammatory properties Oxaprozin 1200 24 Not recommended 1800 Onset delayed for 3-6 hours Sulindac 150-200 Bid Not recommended 400 Prodrug with decreased GI side effects Etodolac 200-400 6-12 Not recommended 1000 Balanced COX-1/COX-2 with decreased GI side effects Indomethacin 25-50 8-12 Not recommended 100 Limit use to 2 weeks if possible Ketorolac 30 mg IV/IM 6 None 120, except 150 first day Efficacy similar to 4 mg morphine. Not for use for more than 5 days Piroxicam 20 24 Not recommended 20 About half of patients intolerant of GI effects Nabumetone 500-1000 12 Not recommended 2000 Low incidence of GI effects Celecoxib 100-200 12-24 Not recommended 400 Primarily COX-2 inhibitor Rofecoxib 12.5-50 24 Not recommended 50 Primarily COX-2 inhibitor. Increased incidence of cardiac events in VIGOR trial 1.a.) NSAA - Acetaminophen • Acetaminophen blocks prostaglandin synthesis centrally antipyretic effect. • However, it does not act on prostaglandins peripherally so it cannot block local inflammation. • Clinical use: • • • • • • Fever and mild pain Can be used in children Can be used during pregnancy & breast-feeding May be used in combination with caffeine or propoxyphen IV forms are available for post-op pain. Side effects: • Long-term or large doses are both hepatotoxic and nephrotoxic. NSAA – Acetaminophen COX-3 inhibitor Recently, COX-3 activity is selectively inhibited by analgesic/antipyretic drugs such as acetaminophen, phenacetin and Inhibition of COX -3 could represent a primary central mechanism by which these drugs decrease pain and possibly fever Salicylates (e.g. aspirin) • Aspirine has: • Antipyretic and analgesic, • Anti-inflammatory actions (> 3 gm/d), • Anticoagulant. • These actions result from the anti-PGs activity, • Centrally and Peripherally. • Unfortunately, these additional actions • GIT problems: gastritis, bleeding ulcer. 1.b.) NSAIDs NSAIDs NSAIDs Blocks the production of Prostaglandin Very effective in mild – moderate pain Effective in other types of pain e.g. – Musculoskeletal pain – OR & RA – Cancer Pain May be used alone or in combination with opioids Practical guide for NSAID’s In Postoperative sitting: Pre-op administration post-op pain. – e.g. Leroxicam 8-16 mg IV or Celebrex 400mg, P.O. pre-op Ketorolac & Leroxicam are effective in acute pain (IV) Precautions: – Gastric effects: • PPI are the drugs of choice to treat gastric complications. • H2 blockers only mask the disease – Check the renal function routinely prior to administration – COX2 inhibitors doesn’t affect the platelet function Practical guide for NSAID’s Usage (Contin) All specific or non-specific NSAID’s may cause: Water retention and edema Hypertension Renal dysfunction May delay bony fusion in chronic usage Practical guide for NSAID’s Usage (Contin) Mechanism of Renal dysfunction: PGE2 and PGI2 are medullary VD. TXA2 is: – cortical VC, – regulate the renal vascular resistance and Renin secretion. Both can influence: – The action of ADH. – Loss of local renal Haemo-regulation (e.g. in hypotension) – Reduction of GFR. Electrolyte and Na imbalance. PGDs depletion can result in: – Acute tubular necrosis & papillary necrosis, – Interstitial nephritis Choice of NSAIDs 1. NSAIDs with Low Potency & Short t½ e.g. Ibuprofen • Acute pain: 200 – 800 mg • Chronic pain: 2 – 3 gm/day Choice of NSAIDs 2. NSAIDs with High Potency & Short t½ e.g. Diclofenac • Less against COX-1 compared to COX-2 – Less GIT side effects. • 1st pass metabolism – oral bioavailability 50% – Liver toxicity. – Other drugs: • • Indomethacin Ketoprofen Choice of NSAIDs 3. NSAIDs with Intermittent Potency & t½ e.g. Naproxen – Clinical use in: • Migraine • Musculoskeletal pain Choice of NSAIDs 4. NSAIDs with High Potency & Long t½ e.g. Oxicams (melo-, piro- & teno-xicam). – They are not recommended in: • Acute pain, • Pain of short duration – Recommended in: • Inflammatory pain that persist for longer duration – Arthritis & bone pain & cancer pain – The High Potency & Long t½ of side effects • GIT & renal. Selective COX-2 Inhibitors Examples T-maz t½ Bioavail. Daily dose Celecoxib 2-4 hs 9-15 hs 100 200 – 400 mg Rofecoxib 2-4 hs 12 hs 100 25 mg They are poor candidate for acute pain Effective in chronic pain e.g. OA & RA They are comparable to non specific NSAIDs More safe in elderly, GIT pts. More safe with other medications e.g. steroids & anticoagulants Less GIT toxicity ~ risk of CV events in pt at risk. Selective COX-2 Inhibitors COX-2 inh. & GIT: – COX-1 confer cytoprotection in the GIT – COX-2 inhibitors improve risk/benefit regarding GIT safety COX-2 inh. & Kidney: – they do not spare kidney ~ edema & HP COX-2 inh. & CVS: – – – – prostacyclin ++ Do not – platelet COX-1 ~ -- throm. /prost. balance thrombogenic risk Some studies reported IHD in some pts received celecoxib. Drug Therapy 2. Opioids - Weak Opioids. - Strong opioids. - Mixed agonist – antagonists Weak Opioids e.g. Tramadol hydrochloride – Potency: 100 mg equivalent to 100 mg pethidine. – Dose 200 – 400 mg/d. – Advantages: • • • • Less postoperative respiratory depression. Efficient in reduction of postoperative shivering. Acute & Chronic pain Cancer & non cancer pain – Side effects: Nausea and vomiting. Strong Opioids e.g. Morphine, Pethidine and Fentanyl. Duration of action is: – Morphine: (10 mg) 3-4 hours. – Pethidine: (100 mg) 3-4 hours. – Fentanyl: (100 g) 45- 60 minutes. Main side effects: – Nausea and vomiting. – Respiratory depression. – Extrapyramidal rigidity. Agonist Antagonist Opioids Members are: – Butorphanol “Stadol” (2 mg) – Nalbuphine “Nubain” (10 mg) Duration of action is very short ( 2 hours). Suitable to be used in infusion pumps and PCA. Side effects: Hallucination is a famous one. Opioid / Local Anesthetic Mixture Epidural Marcaine and fentanyl is a useful mixture: – Used epidurally – Can be used in pediatrics. – High quality of pain relief. – Potentiation for action and duration. Positioning of Opioid Therapy Opioid therapy is the mainstay approach for • Acute pain • Cancer pain • Pain in advanced illnesses • Moderate - Severe non cancer pain • AIDS pain Opioid Therapy in Chronic Non-Cancer Pain Under-treatment is a major problem because: • Published experience of multidisciplinary pain programs showed that opioids associated with: • Poor function • Psychiatric disorders • Poor outcome Consider the following: • Are opioids likely to work well? • Are there reasonable alternatives? • Are drug-related behaviors likely to be used? Opioid Therapy: Prescribing Principles Prescribing principles 1. Drug selection 2. Dosing to optimize effects 3. Route of administration 4. Treating side effects 5. Managing the poorly responsive patient Opioid Therapy: 1. Drug Selection Immediate-release preparations – Used mainly • For acute pain • For stabilization phase • For “rescue” dosing – Can be used for long-term management in select patients Opioid Therapy: Drug Selection Immediate-release preparations – Single-entity drugs e.g. • Tramadol • Morphine – Combination products • Codeine + ASA • Propoxene + Acetaminophen. Opioid Therapy: Drug Selection Extended-release preparations – Preferred because of improved pt’s compliance. – Morphine, oxycodone, hydromorphone, codeine, tramadol, buprenorphine Fentanyl-TTS (72 hs). 2. Dose adjustments for opioids Increase the dose (not the number of opioids) until: – pain relief is adequate or – intolerable side effects occur Only one long acting opioid should be ordered at any given time. – (e.g. Oramorph, Oxycontin, Duragesic) Only one opioid combination should be ordered at any given time. 3. Poor Opioid Responsiveness If dose escalation adverse effects – Strategy to lower opioid requirement • + Add non-opioid analgesic • + Adjuvant analgesic • + Non-pharmacologic strategy. – Changes of opioid therapy: • Change the route: e.g. Spinal opioids • “Opioid rotation” 4. Opioid Rotation Based on inter individual variation in response to different opioids Reduce equianalgesic dose by 25%–50%: – Reduce less if pain is severe – Reduce less if same drug by different route – Reduce less fentanyl – Reduce more methadone (75%–90%) 5. The Equianalgesia • The amount (mg) required to deliver the same degree of analgesia varies from one opioid to another Drug Oral IV Duration morphine 30mg 10mg 3-4h hydromorphone 7.5mg 1.5mg 3-4h codeine 200mg 130mg 3-4h oxycodone 30mg - 3-4h hydrocodone 30mg - 3-4h meperidine 300mg 100mg 2-3h TTS-Fentanyl dose based on oral morphine dose Oral Morphine (mg/day) 45 - 134 135 - 224 225 - 314 315 - 404 405 - 494 495 - 584 585 - 674 675 -764 765 - 854 855 - 944 945 - 1034 1035 - 1124 TTS Fentanyl Patch 25 g / hour 50 g / hour 75 g / hour 100 g / hour 125 g / hour 150 g / hour 175 g / hour 200 g / hour 225 g / hour 250 g / hour 275 g / hour 300 g / hour 6. Opioid Therapy: Side Effects Common – Constipation – Somnolence, mental clouding Less common – – – – N/V Myoclonus Itch Urinary retention – Sweating – Amenorrhea – Sexual dysfunction – Headache Prevention # management of constipation “The hand that writes the “opioid order” also writes the bowel regimen” In every patient receiving opioids – Increase fluids and fibers – Scheduled stool softeners/stimulant laxatives Addiction • It is associated with: • • Genetic, psychosocial, and environmental factors. It is characterized by behavioral changes: • impaired control over drug use, • compulsive use, • continued use despite harm & craving. • Quality of life is not improved Tolerance Tolerance is a state of adaptation; in which exposure to a drug results in a diminution of the drug's effects over time. - 1st in duration of action; - 2nd in overall effectiveness. Pseudotolerance Pseudotolerance is the need to increase due to other factors such as: • disease progression, • new disease, • increased physical activity, • lack of compliance, • change in medication formulation, • drug interaction. Physical Dependence Physical dependence is a state of adaptation that is manifested specific withdrawal syndrome that can be produced: • by abrupt withdrawal, • rapid dose reduction, • decreasing blood level of the drug, • or administration of an antagonist. Opioid Pseudoaddiction An iatrogenic syndrome in which patients develop certain behavioral characteristics of psychological dependence as a consequence of inadequate pain treatment. Drug Therapy 3. Adjuvant's Therapy 3. Adjuvant Therapy Clonidine Anxiolytic drugs Anticonvulsants Antidepressants Ketamine LA Corticosteroids Others Clonidine Alpha-2 agonist. Routes of adminstration: Oral, neuraxial & TTS Pain control properties by itself Excellent adjuvant for opioid dependent patients Decrease the requirement of opioids Decrease tolerance Effective control for neuropathic pain Caudal block for children 1g/kg pain relief / 24h Ketamine NMDA receptors antagonist Neuropathic pain Potent analgesic effect Small doses in combination of opioids pain control Post-op in chronic opioid users: – Bolus dose of 100 g/kg followed by a continuous drip of 1-3 g/kg/min. Anti-Convulsant Drugs in Pain Gabapentin Carbamazipine Phenytoin Depakine Mechanisms of Anti-Convulsant Drugs in Pain Usage of Anti-Convulsants Drugs in Acute Pain Gabapentin: Mainly for neuropathic pain Studies showed that: – giving 600-1200 mg of Gabapentin 1 h pre-op.: • decreases the opioids requirement post-op & • better pain relief without increased sedation – Combining Gabapentin + opioids is ideal for: • re-do back surgery cases • with chronic opioids usage These class of drugs are also mode stabilizers Antidepressant Drugs in Pain Managements This type of drug may be divided into 4 categories: 1. Drugs that inhibit synaptic neurotransmitter reuptake. 2. Drugs that have direct receptor stimulation. 3. Drugs that produce receptor blockade. 4. Drugs that inhibit the activity of enzymes such as monoamine oxidase. Mechanism of Action of Antidepressants Name Dosage Presynaptic Mechanism of Action Fluoxetine (Prozac) “SSRI” 20–80 mg Inhibits serotonin reuptake Paroxetine (Paxil) SSRI 20–50 mg Inhibits serotonin reuptake Mirtazapine (Remeron) 15–45 mg Stimulates norepinephrine and serotonin release Tricyclic antidepressant 10 – 50 mg inhibiting reuptake of catecholamines, as well as indolamines Postsynaptic Mechanism of Action Blocks 5-HT2 and 5HT3 receptors Adjuvant Analgesics for Musculoskeletal Pain “Muscle relaxants” Refers to numerous drugs: e.g. cyclobenzaprine, orphenadrine, methocarbamol. Centrally-acting analgesics. Adjuvant Analgesics for Cancer Pain For bone pain – Bisphosphonates (e.g. pamidronate, clodronate), – Calcitonin, – Radiopharmaceuticals (e.g. Sr89, Sm153) For bowel obstruction pain – Anticholinergics, octreotide Adjuvant Analgesics for Chronic Headache Beta blockers Anticonvulsants Antidepressants Alpha-2 adrenergic agonists Vasoactive drugs Triptans Mimic 5-HT involved in migraine Only indicated for migraine pain Other Adjuvant Analgesics Miscellaneous drugs Calcitonin – RCTs in CRPS and phantom pain – Bone pain Baclofen – RCT in trigeminal neuralgia – 30–200 mg/d or higher – Taper before discontinuation Other Adjuvant Analgesics NMDA-receptor antagonists N-methyl-D-aspartate receptor involved in neuropathic pain Commercially-available drugs are analgesic: ketamine, amantadine, dextromethorpan. Topical Adjuvant Analgesics For neuropathic pain - Local anesthetics • Lidocaine patch • Cream: lidocaine 5%, EMLA - Capsaicin For musculoskeletal pains • NSAIDs Routes of Drug Administration Oral Rectal SQ IM IV TTS Neuraxial. Others Routes of Administrations Use the oral route whenever possible – Except e.g. post op period, – Try other routes e.g. • buccal, sublingual, or rectal routes before initiating parenteral routes Parenteral: – SQ and IV preferred & – feasible for short-term therapy Always avoid IM. Oral and transdermal: preferred Routes of Administrations I.M. not recommended but it is commonly used: – Painful – Serum levels are unpredictable. Rectal route: – For pediatric patients. – Simple procedures. – Slow absorption: longer duration. Neuraxial: – Intrathecal generally preferred for long-term use – Epidural for a shorter periods. Routes of Administrations Intravenous Route Desired. Easy titrated. Serum level is controllable. Can be used in: – drip form , – by pumps , – best is by PCA. Routes of Administrations - PCA Used for IV, SC & Epidural. Pre-set by the physician. Activated by the patient. Programming modalities include: 1. 2. 3. 4. 5. Loading dose or infusion. Demand bolus dose. Constant background infusion rate. Lock-out interval. Maximum hourly dose. } Safety Routes of Administrations - PCA Advantages: – Patients can titrate their own analgesia – Improved: • Pain relief • Pulmonary function. – Decreased: • Total daily dose. • Over sedation. • Postoperative complications. Transdermal Therapeutic System TTS “Fentanyl-TTS” Non-permeable protective cover Drug Reservoir - Alcohol is added - Hydroxy-ethyl cellulose matrix Rate controlling membrane Adhesive layer Protective Liner TTS- Fentanyl Character of the patch: Dose Patch size Cmax Tmax ng/ml Range in hours 25g/hour 10 cm2 0.3-1.2 26-78 50g/hour 20 cm2 0.6-1.8 24-72 75 g/hour 30 cm2 1.1-2.6 24-48 100g/hour 40 cm2 1.9-3.8 25-72 • The composition of the patch/unit area is fixed (2.5 mg/10 cm2). • The dose is dependent upon the patch size. Advantages of the TTS route 1. Reduction in the variability of in the plasma levels. 2. Avoidance of 1st pass metabolism. 3. Bioavailability: 92 % 4. Prolonged duration of action: 72 hrs. 5. Improved compliance. 6. Less side effects e.g. constipation. Disadvantages of TTS-fentanyl - It has a delayed onset of action (12-17 hours). - The time to reach Cmax. is ranged from 26-72 hours. - Followed by residual effects after removal of the patch up to 17 hours. Pain Management Algorithm Algorithm for Management of Neuropathic Pain Initial Assessment History • • • • • • • • • Quality of pain. Distribution of pain Course. Sleep disturbances Mental changes Drugs, toxins. Alcoholism Systemic illness Trigger points Physical / Neurologic examination • Sensory examination: Pin prick, pain, T, Position, vibration. • Allodynia or Hyperalgesia • Motor examination: Strength, atrophy, fascisulations • Reflexes • Vasomotor changes Investigations • EMG & NC study • Blood: CBC, FBS, ESR, B12, folate, heavy metals, immune fixation, • Electrophoresis. • Radiological. • Lumbar puncture • Nerve biopsy. Algorithm for Management of Neuropathic Pain Central Pain Trigeminal Neuralgia Other Neuropathies 1st line therapy 1st line therapy 1st line therapy • Amitryptiline 2nd line therapy • Mexiletine 3rd line therapy Anticonvusants: • Carbamazepine • Gapapentine • Valporate • Carbamazepine 2nd line therapy • Baclofen • Gabapentin • Lamotrigine • Valporate • Phenytoin • Gabapentin/TCA 2nd line therapy • Carbamazepine • Tramadol • Capsaicin,lidocain 3rd line therapy • Mexiletine • SSRIs • Phenytoin • Lamotrigine 4th line therapy El-Tallawy • Opioids Trauma pain management Algorithm HeadInjury injury Head patients Clear mental status Unclear mental status Treat with any modalities Small doses of opioids(codeine) or/with Ketorolac Trauma pain management Algorithm Extremity Injury Extremity injury Bone injury Peripheral nerve or vascular injury Epidural analgesia opioids or local anesthetics Nerve function monitoring yes Epidural analgesia Opioids only No PCA Epidural opioids with or without local anesthetics Peripheral nerve block Trauma pain management Algorithm Abdominal Abdominal Injury injury Surgery required Surgery not rquired Epidural analgesia PCA Trauma pain management Algorithm Neurologic Injury Neurologic injuries Spinal cord injury Neuropathic nerve injury PCA CRPS I CRPS II Epidural analgesia with local anesthetics (Very effective) PO/IV Narcotics Antidepressants Anticonvulsants Trauma pain management Algorithm Thoracic Injury Thoracic trauma Intubated patients IV narcotics PCA Not Intubated patients Thoracic epidural analgesia Ready for extubation Thoracic epidural analgesia Intercostal nerve block PCA Intercostal nerve block PCA Summary of Pain Management …the basics Do Not Use Placebos! Unethical They don’t work Not helpful in diagnosis Effect is short lived Destroys trust Match the therapy to the type of pain Intensity of pain – Mild, moderate or severe. Type of pain e.g. – Somatic & Visceral pain # Neuropathic pain Duration of pain – Continuous # intermittent pain. Acute # chronic Drug combinations – Never order more than one SR preparation at a time – Only one combination analgesic should be ordered at a time Basics of Pain Management 1st step: is the good pain assessment. Pain medications must be taken: when the pain is first perceived. Doses of opioids are increased: with the patient’s report of pain Adjuvant medications are used for: opioid non-responsive & neuropathic pain. Non-pharmacologic approaches are always a part of any pain management protocol. Pain Management in the late 18th century “By any reasonable code, freedom from pain should be a basic human right, limited only by our knowledge to achieve it ...” Wall P & Melzack R 1987