Pain - University of Alabama at Birmingham
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Transcript Pain - University of Alabama at Birmingham
Elizabeth Kvale, MD
Assistant Professor of Medicine
University of Alabama at Birmingham
Unpleasant sensory and emotional
experience associated with actual or
potential tissue damage.
Physical pathology does not need to be
present
Pain is one of the most common reasons
Americans 18+ seek medical attentions.
25-50% community-dwelling older adult
have pain
45-80% nursing home residents have pain
Sensory-Discriminative
Pain Perception
Affective-Motivational
Noxious Stimulus
Autonomic & Motor Responses
Commons Myths Regarding Pain
In the presence of tissue damage there must
be pain, and vice versa.
It is useful to classify pain as either organic
(biological) or functional (psychogenic)
A placebo response verifies that pain is
psychological in origin
BIOPSYCHOSOCIAL MODEL OF
PAIN (and symptoms)
BIOMEDICAL
- Pathology
- Injury
- Nociception
SOCIOCULTURAL
- Age, Sex, Race
- Income, Education
- Social Milieau
PSYCHOLOGICAL
- Anxiety, Depression
- Cognitive Factors
- Behavioral Factors
Pain Behavior
Suffering
Pain
Nociception
Acute pain
◦ identified event,
resolves days–weeks
◦ usually nociceptive
Chronic pain
◦ cause often not easily
identified, multifactorial
◦ indeterminate duration
◦ nociceptive and / or
neuropathic
Nociceptive – Arthritis,
fracture, laceration
Visceral – Pancreatitis,
M.I., Constipation
Neuropathic – Herpes
zoster, diabetic
neuropathy,
Complex Regional
Pain Syndromes – RSD
Central Pain
Pain is a subjective experience – the patient is
the best source of information about their pain
Pain History – site(s), intensity, temporality,
character, exacerbating and alleviating factors
Comprehensive and ongoing
assessment.
Medical history
Physical exam
Psychosocial
Family and culture
Pain history (including previous
treatment)
Comprehensive medication history
The nature and intensity of the pain.
Current and past treatments for the pain.
Underlying or coexisting diseases or
conditions.
The effect of the pain on the physical and
psychological function.
Documentation of a history of substance
abuse.
Documentation of one or more recognized
medical indications for the use of a
controlled substance.
American Academy of Pain Medicine, Long-term
Controlled Substances Therapy for Chronic Pain, July 2004
The use of an instrument to assess pain
allows you to know and document
whether you have helped the patient
Grimace, Groan, Rub, Guard, Brace
Can be observed and quantified
Don’t delay for investigations or disease
treatment
Unmanaged pain nervous system
changes
› permanent damage
amplify pain
Treat underlying cause (eg, radiation for
a neoplasm)
74 yo with multiple medical issues, many
of which contribute to pain
Multiple medications
Declining functional ability
Recent Falls
Lives alone, but with supportive family
near
Routine assessment and documentation
Patient and family education
Non-pharmacologic strategies
Serial Trial Intervention
Documentation
Heat
Cold
Positioning
Distraction
Relaxation
Massage
Controlled breathing and guided
imagery
Music
Regular use of acetaminophen
Consider nonsteroidal anti-inflammatory
› For intermittent pain
› Many medical contraindications
Consider low dose pain medications
› Oxycodone, morphine, hydromorphone
› ? Use of combination medications
Re-evaluate
Match the medication to the amount of discomfort
the patient is having
severe
WHO 3-step
Ladder
3
2 moderate
A/Codeine
1 mild
A/Hydrocodone
A/Oxycodone
ASA
Acetaminophen
NSAIDs
± Adjuvants
A/Dihydrocodeine
Tramadol
± Adjuvants
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
± Adjuvants
A structured approach to “let’s try it and
see what happens”
Patients and caregivers are essential
team members in evaluating and
managing pain
Caregiver resistance to pain
management strategies ensures failure
Explore areas of concern or resistance to
tailor education efforts most effectively
Use a
standard
scale to
track the
course of
pain
Identify objectives that will be used to
determine treatment success including but not
limited to pain relief, improved physical
function, and improved psychological function.
Documentation of the need for further
diagnostic evaluations or other treatments
which may be planned.
Adjustment of drug therapy based on the
individual medical needs of each patient.
Consideration of other treatment modalities or
rehabilitation programs depending on the
extent and etiology of the pain.
Encourage activity and self-care
Employ physical modalities: heat, cold,
massage, acupuncture, transcutaneous
electrical nerve stimulation
Recommend cognitive-behavioral
interventions: relaxation and imagery,
psychotherapy, structured support
Educate the patient
The
risk of under treating pain is a
greater concern than the risk of
worsening delirium with medications
None systemic therapies, intraarticular steroid injections, lidocaine
patches, topical preparations
Opioids are first-line therapy for severe
acute pain and chronic moderate to
severe persistent pain due to cancer, AIDS,
and other advanced illnesses.
Consider the individual’s risk of drug abuse
and addiction and provide appropriate
and structured therapy.
Opioids are metabolized by the liver and
excreted by the kidney
Peak plasma concentration is reached:
60-90 minutes after oral dosing
30 minutes after SC or IM dosing
6 minutes after IV injection
Effective half-lives of 3–4 hours with normal
renal clearance
Steady state achieved in 24 hours
Extended-release forms release over 8, 12, or
24 hours; fentanyl patch provides continuous
relief for 48–72 hours
Use short-acting opioids to determine opioid
requirements over 24 hours
If pain remains uncontrolled, increase doses
by 25% to 50% for mild to moderate pain and
by 50% to 100% for severe pain
Provide “rescue” analgesia for breakthrough
pain or acute pain flares
5% to 15% of the 24-hr dose
Offer every 1 hr orally; 30 min SC/IM; 10 min IV
Urine drug screening (UDS) is
recommended on initiation of therapy
and randomly at subsequent visits
Implement as a global policy rather than
a targeted policy
Evaluate for aberrant drug use and
adherence to therapy you are providing
Interpretation of UDS results can be
challenging
Provides a report of all schedule 2
prescriptions filled by patient in state of
Alabama
Results of report can be shared with
patient, but you cannot give a copy of
the report to the patient
Reports should not be placed in the
medical record
http://pdmp.alabama.gov/index.html
Reduce pain severity
Improved and or restore function
Improve mood and sleep patterns
Reduce misuse or overuse of medication
Return to productive activity
Increase ability to manage pain
Effective treatment should be as costeffective as possible