APSA/SIA PAIN MANAGEMENT Project
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Transcript APSA/SIA PAIN MANAGEMENT Project
Pain Consultations 101
Melissa Durham, Pharm.D.
September 14th, 2011
Acute vs. Chronic Pain
Characteristic
Acute Pain
Chronic Pain
(No Self-Treatment)
Relief of Pain
Highly Desirable
Highly Desirable
Dependence & Tolerance Unusual
to Medication
Common
Psychological
Component
Usually Not Present
Often a Major Problem
Organic Cause
Common
Often Not Present
Environmental
Contributions & Family
Involvement
Small
Significant
Insomnia
Unusual
Common Component
Treatment Goal
Cure
Functionality
Assessment of Pain
SCHOLAR
• Symptoms
– Describe the symptoms you are experiencing
• Characteristics/Course
– Is the pain throbbing, sharp, dull, tingling? Rate the pain on a scale of 1-10
• History
– How does it compare to other pain experienced? Has it gotten worse over
time?
• Onset
– When did the pain start?
• Location
– Where is the pain located? Does it stay localized to one area or does it
spread?
• Aggravating factors
– What makes the pain worse?
• Relieving factors
– What makes the pain better?
Temporary relief of minor aches and pain
associated with the common cold
Reduction of fever
Sore throat
Headache (Episodic Tension, Migraine, Sinus)
Muscle aches
Minor aches and pains of arthritis
Acute back pain
Menstrual pain
Acetaminophen, AKA APAP (Tylenol)
Mild-moderate pain, fever, headaches
NSAIDs
Ibuprofen (Motrin, Advil)
Naproxen sodium (Aleve)
Mild-moderate pain, headaches, muscle pain, menstrual
pain
Salicylates
Aspirin AKA ASA (Ecotrin, Bayer)
Mild-moderate pain, muscle pain, menstrual pain,
cardioprotection
Topicals
(IcyHot, Bengay)
Muscle soreness, muscle pain, osteoarthritis
Brand Name – Tylenol®, FeverAll®
Class – Analgesic/Antipyretic
◦ Not effective as an anti-inflammatory
Very few side effects
◦ Liver toxicity a major concern with chronic high
doses
Very few drug interactions
◦ Warfarin, alcohol
DOC in pregnancy/breastfeeding
Used mostly for primary and secondary
prevention of thrombotic events
◦ Ex. Aspirin 81mg/day
Has anti-inflammatory properties, but only at
high doses
Major side effects are bleeding, GI ulcers,
bronchospasm in patients with asthma
More DDIs than APAP
NOT for use in pregnancy/breastfeeding
Counseling point: TAKE WITH FOOD
Ibuprofen, naproxen sodium
More effective than APAP and ASA for most
pain conditions
Analgesic and anti-inflammatory effects
Major side effects are bleeding, GI ulcers,
bronchospasm in patients with asthma,
increased blood pressure, fluid retention
Generally avoid in pregnancy but OK in
breastfeeding
Counseling point: TAKE WITH FOOD
Used for minor aches and pains of muscles and
joints, muscle soreness, osteoarthritis, lower back
pain, neuropathy
Ben-gay, Icy-hot, Salonpas
Methyl salicylate, camphor, menthol,
capsaicin
Combinations
Apply 3-4 times daily for a max of 7 days
Do not apply immediately after a hot shower
or bath, do not use with a heating pad
Wash hands after applying
Types of Headache
Stress
Anxiety
Depression
Emotional conflicts
Fatigue
Repressed hostility
Excedrin® Tension Headache
◦ 500mg Acetaminophen + 65mg caffeine
APAP
Ibuprofen
Naproxen
Other combo products
Physical
therapy
Relaxation exercises
Massage
Topical Peppermint oil
◦ Applied to forehead and temples
Stress
Fatigue
Oversleeping
Fasting, missing a
meal
Alcohol
Changes in
barometric pressure
or altitude
Menses
Hormone changes
Magnesium
deficiency
Foods with nitrites,
tyramine,
phenylalanine, MSG,
caffeine
Excedrin® Migraine
Advil® Migraine
Other analgesics will work, NSAIDs probably best
Initiate NSAIDS 2 days before menses for menstrual
migraine
Self-treatment is only for patients who have been
diagnosed with migraine by a physician
◦ Acetaminophen 250mg/Aspirin 250mg/Caffeine 65mg
◦ 2 tabs at onset, no more than 2 tabs per 24 hours
◦ Ibuprofen 200mg (liquid filled)
◦ 2 caps at onset, no more than 2 tabs per 24 hours
Regular sleeping & eating schedule
Avoidance of triggers (food, stress)
Cold packs + pressure
Lie in a dark, quiet room
Keep a headache journal
Symptoms of cluster headache
Symptoms of migraine headache with no formal
diagnosis
Chronic tension headache (>15 days/month for > 6
months)
Severe pain (pain score 8-10)
Signs of infection (fever, purulent discharge, altered
mental status)
Headache that
Lasts more than 10 days
Occurs more than 3 times a week
Not managed by NonRx dosing
Acute Low Back Pain
Possible causes
Inactive lifestyle
Poor posture
Improper shoes
Excess body weight
Poor mattress
Poor sleeping posture
Improper lifting techniques
•
•
Most back pain disappears with home
treatment and self-care
Treatment options
• NSAIDs
• Topical analgesics
• Alternating heat/cold
• Massage
• Chiropractic manipulation
• Moderate physical activity when not
acutely injured
•
Chronic low back pain ( > 4 weeks) Refer
Sprains – injury to ligaments
Strains – injury to muscle or tendons
◦ Overextension of the joint
◦ Ankle inversion most common
◦ Overuse or improper use
Symptoms: Pain, bruising, loss of some
function, stiffening
Treatment
◦ RICE Therapy
◦ NonRx NSAIDS
Rest the injured area.
Ice the area in 10 minute intervals, 3 – 4 times
a day for 1 – 2 days.
Compress the area with elastic support.
Elevate the area above the heart for 48-72
hours to decrease swelling and pain.
Delayed-onset muscle soreness most
common and is self-treatable
Other types - Refer
NonRx treatment:
◦ NSAIDS ATC
◦ Topical Preparations (Salicylates,
Camphor, Menthol)
Nonpharmacologic Therapies
NonRx Therapies
◦
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Low-impact exercise
Weight-loss
Shock-absorbing shoes
Physical and occupational therapy
Acupuncture
◦ Tylenol is drug of choice
◦ NSAIDS
◦ Glucosamine & Chondroitin: Not for people
with shellfish allergy, may raise blood sugar in
diabetics, may increase the effect of warfarin
◦ Topical analgesics/counterirritants
OTC treatment options:
Midol® Menstrual Complete:
(Acetaminophen 500mg/Caffeine 60mg/Pyrilamine 15mg)
Midol® Extended Relief
(Naproxen sodium 220mg)
Midol® Cramps and Body Aches
(Ibuprofen 200mg)
Midol® Teen Formula
(APAP 500mg/Pamabrom 25mg)
NonRx NSAIDs are the treatment of choice at MAX OTC doses
Heating
pads
Regular exercise
Loose clothing
Massage
Smoking cessation
Do
Give advice and make suggestions
Determine if nonprescription medications will help
Provide resources
Suggest options and let people know their pain may
be managed
◦ Use common sense
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Don’t
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Say something you are not sure about
Diagnose or suggest specific prescription therapy
Recommend self-treatment when not appropriate
Give false hope
Community Resources
Referral Sources:
◦ American Chronic Pain Association (www.theacpa.org)
◦ American Pain Foundation (www.painfoundation.org)
◦ American Headache Society (www.americanheadachesociety.org)
◦ Arthritis Foundation (www.arthritis.org)
Referral for pain management:
◦ American Chronic Pain Association at 800-533-3231
◦ Local hospice or cancer center often know good pain specialists
◦ USC/Norris Comprehensive Cancer Center (323) 865-3000, ask for referral
to pain specialist
◦ USC pain center: 323-442-6202
For those without a doctor or insurance:
◦ Local hospital’s social services department or local health department
LA Social Services Info Line at 800-339-6993
LAC/USC Referral Line at 323-226-4970
◦ Patient Advocate Foundation at 800-532-5274
Poison Control: 1-800-222-1222
Questions?