Pain Management

What are some examples for acute types of pain?

injury (strains, sprains), trauma (fractures, falls), surgery (amputations), spasm (MS), disease (sickle cell crisis), inflammation

what are the signs/symptoms of inflammation?

rubor (redness), tumor (swelling), calor (heat), dolor (pain)

What is chronic pain?

pain that occurs for > 6 months and there is usually no acute event

What are some examples of chronic pain?

cancer (tumor, metastasis, treatment), neuropathic (post herpetic neuralgia, diabetic neuropathy, trigeminal neuralgia, phantom), musculoskeletal (arthritis, OP, gout), vascular (PVD, venous ulcers)

What are the broad types/mechanisms of pain?

nociceptive and neuropathic

What are the types of nociceptive pain?

somatic and visceral

what is somatic pain?

originates from skin, muscles, bones, or joints (e.g., sharp or localized)

what is visceral pain?

originates from internal organs (e.g., dull, cramping, or hard to localize)

What are the steps in nociceptive pain?

stimulation, conduction, transmission, perception, modulation

What is spontaneous transmission?

pain signals that occur without any external stimulus or injury (nerves are sending pain messages to the brain on their own)

What types of pain mechanisms are seen in neuropathic pain?

spontaneous transmission, hyperalgesia, and allodynia

what is hyperalgesia

an exaggerated pain response to a normally painful stimulus (more painful than it usually is)

what is allodynia?

a painful response to a normally non-painful stimulus (e.g., a light touch or gentle breeze causing pain)

how does neuropathic pain differ from nociceptive pain?

pain is initiated or caused by a primary lesion or dysfunction in the nervous system (either peripheral or central nervous system)

how does nociceptive pain differ from neuropathic pain?

pain is caused by injury to body tissues (musculoskeletal, cutaneous, or visceral)

What is mixed pain?

pain with neuropathic and nociceptive components

examples of neuropathic pains:

painful diabetic neuropathy, postherpetic neuralgia, trigeminal neuralgia, postsurgical neuropathic pain, posttraumatic neuropathy, central poststroke pain

What are some of the common descriptors for neuropathic pain?

burning, tingling, hypersensitivity to touch or cold

examples of mixed pain:

low back pain with radiculopathy, cervical radiculopathy, cancer pain, carpal tunnel syndrome

examples of nociceptive pain:

pain d/t inflammation, limb pain after a fracture, joint pain in osteoarthritis, postoperative visceral pain

What are the common descriptors of nociceptive pain?

aching, sharp, throbbing

What are the appropriate patient selection considerations for acute pain?

This pain has rapid onset and high intensity of pain, so it often requires immediate relief. 

Opioids may be appropriate for moderate to severe pain

Can consider multimodal analgesia (e.g., NSAIDS, APAP, regional anesthesia)

Monitor for side effects especially in elderly (e.g., sedation, respiratory depression)

Short-term use with clear goals and reassessment

What are the appropriate patient selection considerations for chronic noncancer pain?

Should emphasize functional improvement over complete pain relief.

Non-opioid therapies are preferred (e.g., PT, CBT, SNRIs, gabapentinoids), and opioids should only be used if benefits outweigh risks and after other options fail. Risk of tolerance, dependence, and side effects increases with long-term use.

Regular reassessment and clear treatment goals should be established.

Consider adjunctive agents for neuropathic or musculoskeletal components.

What does PQRSTU stand for?

Palliative/Provocative

Quality

Region/Radiation

Severity

Temporal

You

What is involved in patient assessment of pain?

patient interview (PQRSTU), pain scales, pain diaries, and ongoing functional assessment

What are the common pain behaviors seen in cognitively impaired elderly persons:

facial expressions, verbalizations/vocalizations, body movements, changes in interpersonal interactions, changes in activity patterns or routines, mental status changes.

what facial expressions may be seen in cognitively impaired patients (experiencing pain)

slight frown, sad, frightened face, grimacing, wrinkled forehead, closed or tightened eyes, any distorted expression, rapid blinking

what verbalization/vocalizations may be seen in cognitively impaired patients (experiencing pain)

sighing, moaning, groaning, grunting, chanting, calling out, noisy breathing, asking for help, verbally abusive

what body movements may be seen in cognitively impaired patients (experiencing pain)

rigid/tense body posture, guarding, fidgeting, increased pacing, rocking, restricted movement, gait or mobility changes.

what changes in interpersonal interactions may be seen in cognitively impaired patients (experiencing pain)

aggressive, combative, resisting care, decreased social interactions, socially inappropriate, disruptive, withdrawn

what changes in activity patterns or routines may be seen in cognitively impaired patients (experiencing pain)

refusing foods, appetite changes, increase in rest periods, sleep or rest pattern changes, sudden cessation of common routines, increased wandering

what mental status changes may be seen in cognitively impaired patients (experiencing pain)

crying or tears, increased confusion, irritability or distress

what is the assessment of discomfort in dementia (ADD) protocol?

assess history for likely cause of pain, apply non-pharmacologic intervention (APAP), administer non-opioid prn if effective then routine, no effect gives opioid analgesic or psychotropic (if response, then use routinely)

when is assessment of pain in cognitively impaired patients triggered?

when a patient displays signs or symptoms of possible physical or affective discomfort

what are the barriers to recognition of pain?

no objective biological markers for the presence of pain, blunted response, cognitive and communication, cultural and social concerns, co-morbidities/multiple meds, staff training and access to tools, system barriers, practitioner/caregiver (recognition and diagnosis, management priority)

What are the problems with a failure to use multimodal approaches for pain management?

miss the benefits of physical, behavioral, and psychological approaches to train the nervous system and maximize functional recovery

What are the problems with a failure to target the mechanism of pain?

suboptimal pain control and increased costs when pain control not effective

What are the problems with a failure to treat neuropathic pain with adjuvant medications?

worsening hypersensitivity of nervous system and suboptimal pain control

What are the problems with heavy use of short-acting opioids instead of long-acting opioids

increased breakthrough pain, disturbed sleep, development of opioid tolerance, APAP toxicity with combination opioid/APAP combinations

what are the common misconceptions about what chronic pain is/means?

Is a sign of personal weakness, is a part of aging, punishment (misspent youth), death is near, indicates serious illness

what are the common misconceptions that prevent proper chronic pain management/assessment?

elderly patients have a higher pain tolerance, reporting pain means losing independence, acknowledging pain will lead to intrusive/painful medical tests, patients with cognitive impairment cannot be assessed for pain, in LTC patients only report pain to get attention, and if a patient takes pain medication they are likely to become addicted.

What are some of the physical non-pharm approaches for persistent pain in older adults?

exercise and PT, assistive devices, thermal modalities.

What are some of the behavioral/psychological non-pharm approaches for persistent pain in older adults?

cognitive-behavioral therapy (CBT), relaxation techniques, biofeedback

What are some of the complementary and alternative non-pharm approaches for persistent pain in older adults?

massage therapy, acupuncture, transcutaneous electrical nerve stimulation (TENS)

What are some of the social and environmental interventions for persistent pain in older adults?

patient education, caregiver involvement, environmental modifications

What are some of the non-pharm comfort intervention categories for persistent pain in older adults?

soothing/supportive verbal communication, music therapy, sensory stimulation, rummaging, “busy” hand activities, soothing/supportive touch, therapeutic massage, physical exercise/movement, cold or heat therapy

what is the first step for mild-moderate pain that is persisting or increasing?

non-opioid options ± adjuvant

what is the second step for mild-moderate pain that is persisting or increasing?

opioids for mild-moderate pain ± non-opioid ± adjuvant

what is the “third step” for moderate-severe pain treatment

opioids for mod-severe pain ± non-opioid ± adjuvant

How is mild pain treated?

APAP and/or NSAIDs when risk does not outweigh benefits; always consider around-the-clock regimens; use as-needed regimens for breakthrough pain or when pain displays great variability or has greatly subsided; titrate to max dose; adjuvant analgesics as appropriate

How is moderate pain treated?

Combination of opioid and APAP or NSAID; always consider around-the-clock regimens; use as-needed regimes for breakthrough pain or when pain displays greater variability or has greatly subsided; may use NSAIDs around the clock with an opioid as needed when risk does not outweigh benefits; ± adjuvant analgesics as appropriate

How is severe pain treated?

Opioid analgesics; always consider around-the-clock regimens; use as-needed regimes for breakthrough pain or when pain displays great variability or has greatly subsided; use of route of administration to fit needs of patient; avoid excessive sedation when risks do not outweigh benefits; ± adjuvant analgesics as appropriate

What should be done if a patient’s pain relief is not adequate after first trial medication/treatment?

use pain assessment tools and titrate to relief & monitor patient

What are the general rules for using analgesics/opioids?

recognize the side effects of all analgesics, properly titrate (assess and re-assess) the dose for each individual patient and administer for an adequate duration, use the most effective analgesic with the fewest side effects that best fits the clinical situation, use the oral route whenever possible

What are the general principles for prescribing pain-control medications in the long-term care setting?

administer medication routinely not PRN (if persistent pain give persistent analgesia), use the least invasive route of administration first, begin with a low dose and titrate carefully until comfort is achieved, reassess and adjust dose frequently to optimize pain relief while monitoring and managing side effects

What changes occur to Vd in older patients?

potential increases in Vd of fat-soluble drugs such as antidepressants and NSAIDs (drugs stay in body longer)

What changes occur to albumin in older patients?

decreases which can lead to more free (active) drug in the bloodstream

Which medications are highly bound to albumin?

NSAIDs, anticonvulsants, TCA, opioids (morphine, meperidine)

What changes occur to a-1 acid glycoproteins in older adults

increases (affects protein binding of certain highly-bound meds like methadone), more med would become protein-bound and lead to less “free” medication in bloodstream

What happens to phase I metabolism in older adults?

decreases - which leads to reduced metabolism and elimination of medications such as celecoxib, tramadol, and anticonvulsants

Which medication needs transformation to be converted to morphine?

codeine (older adults may have less conversion and decreased pain relief)

What happens to renal elimination in older adults?

decreased which can lead to accumulation of renally cleared drugs/active metabolites (important for opioid metabolites)

What are the pros of using acetaminophen for pain?

is useful for mild-mod pain, is elder “safe,” can be used adjunctively, is a starting point for initial and ongoing pharmacotherapy

what are the cons of using APAP for pain

Very few! Patient perception and failure to complete adequate trial. Should not be used in patients with hepatic failure, alcohol use, hepatic insufficiency, or taking warfarin (DDI). Watch for total APAP use to not go over max of 4 g/day.

what are the pros of using NSAIDs and COX-II for pain

effective for mild-mod pain, useful for musculoskeletal pain and inflammation, topical options available (e.g., diclofenac), may reduce opioid need

what are the cons of using NSAIDs and COX-II for pain

Has ceiling effect (limits efficacy), GI toxicity (ulcer & bleeding), renal and cardiac risks (CKD, CHF, MI), increased coagulation risk, DDIs (e.g., aspirin prophylaxis), contraindications with PUD, CKD, and HF

Facts regarding NSAIDs and elders:

evaluate for risk vs benefit, use the lowest possible effective dose (avoid multiple agents, analgesic vs anti-inflammatory), COX-2 may be safer (use PPI or misoprostol), GI prophylaxis for pts at risk

brand of suzetrigine

Journavx

what is Journavx FDA approved for?

short term (14 days) of acute moderate-severe pain (non-opioid)

MOA of suzetrigine

selective blocker of the NaV1.8 voltage-gated sodium channels

PKPD of suzetrigine

Has a less potent active metabolite M6-SUZ, highly protein bound. Half-life is 23.6 hours while metabolites is 33 hours. Both are CYP3A4 substrates

ADRs of suzetrigine

decreased eGFR, N/V, and rare but serious side effect of arrhythmia exacerbation

dosing of suzetrigine

100 mg initially, then 50 mg a day

What are the pros of using opioid analgesics in elders?

good for mod-severe pain, no ceiling dose, many routes of administration, long-acting agents available

T/F: all patients with mod-severe pain, pain-related functional impairment or diminished quality of life d/t pain should be considered for opioid therapy

true

What did the SPACE randomized clinical trial demonstrate?

Opioids are not superior to non-opioids for pain. The results did not support initiation of opioid therapy for mod-severe chronic pain or hip or knee osteoarthritis pain. 

What are the SIDE EFFECTS of opioids?

respiratory depression (concomitant disease of asthma, COPD, or sleep apnea), lethargy/sedation, pre-existing cognitive impairment, dysphoria, delirium, hallucinations, miosis, constipation, N/V, orthostasis, urinary incontinence

What are the signs of opioid TOXICITY?

severe respiratory depression or apnea, loss of consciousness, unarousable, pinpoint pupils (fixed; no accommodation to light)

How are opioids available (formulations)?

PO/SL/transbuccal, inhaled, intranasal, rectal (ostomy), topicals (fentanyl, buprenorphine), parenteral (IM, SQ/IV, continuous infusion, PCA), ATC ER vs IR, PRN

what are the specific considerations for transdermal opioids?

active ingredients may still be present after therapeutic obsolescence, improper disposal (e.g., household trash container) could lead to accidental/unintended exposure (e.g., children, pets), external heat/fever/exertion could impact rate of absorption and adverse effect profile, products with metal foil backing preclude use if an MRI is necessary

what is the CDC’s CPF for prescribing opioids not applicable to?

pain related to sickle cell disease, management of cancer-related pain, or palliative care or end-of-life care.

what does the CDC say about determining whether or not to initiate opioids for pain?

Utilize and optimize nonpharmacologic and nonopioid pharmacologic therapies. Opioids for acute pain on if benefits > risks. Discuss realistic benefits vs. known risks of opioids.

Nonopioid therapies are preferred for subacute and chronic pain. Establish treatment goals for pain and function and should consider how opioid therapy will be discontinued if benefits do not outweigh risks.

What does the CDC say about selecting opioids and doses for opioid-naive pts?

When starting opioid treatment, immediate-release formulations are preferred. In opioid-naïve patients start with lowest effective dosage. If continued for subacute or chronic pain.

Use caution when prescribing opioids at any dosage. Carefully evaluate individual benefits and risks when considering increasing dosage. Avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients

What does the CDC say about opioid experienced patients and the benefits vs risks in changing?

If benefits > risks; optimize nonopioid therapies while continuing opioid therapy.

If benefits < risks; optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted, appropriately taper and discontinue opioids.

Unless life-threatening issues such as impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosage

what does the CDC say regarding opioids needed for acute pain?

Clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids

When should clinicians evaluate the benefits and risks (of opioids) in patiens?

Within 1-4 weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Clinicians should regularly reevaluate benefits and risks of continued opioid therapy with patients

what does the CDC say about assessing risk and addressing potential harms of opioid use?

Before & during opioid therapy, evaluate risk for opioid-related harms and discuss risk with patients. Incorporate strategies to mitigate risk, including offering naloxone.

Clinicians should review history of CRx when initiating opioid Rx therapy to determine whether the patient is receiving opioid dosages or combos that put the patient at high risk for overdose.

Opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other controlled substances.

Caution when opioids and benzos used concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other CNS depressants. Offer treatments for patients with opioid use disorder

what are adjuvant analgesics?

Drugs developed for other indications that may be useful for chronic pain. Older patients with chronic pain should be assessed to determine whether any of the multipurpose adjuvant analgesics, or any of those drugs used selectively for neuropathic pain, musculoskeletal pain or cancer pain, should be recommended.

T/F: most adjuvant analgesics are centrally acting and must be used cautiously in older adults

true

Adjuvants in older adults should be initiated at ________________________________________________________

A low dose and dose titration should involve small increments at intervals adequate to monitor response. Ineffective drugs should be discontinued

T/F: multipurpose adjuvant analgesics may be considered for any type of chronic pain

true

What are the preferred adjuvant analgesics?

Antidepressants (SNRIs, particularly duloxetine, and the secondary amine tricyclic drugs desipramine and nortriptyline).

When should topical analgesics be considered?

whenever pain is focal or regional

What is the preferred adjuvant for neuropathic pains?

treatment with an analgesic antidepressant or a gabapentinoid, and concurrent use of a topical agent if appropriate

How should musculoskeletal pain disorders be addressed?

with several of the multipurpose adjuvant analgesics, such as the antidepressants and tizanidine, and topical agents. The so-called “muscle relaxants” are not preferred for chronic pain

T/F: adjuvant analgesics may be useful in opioid-refractory cancer pain syndromes

true

Bone pain is commonly treated with:

osteoclast inhibitors and pain related to bowel obstruction may be addressed by a combination of drugs, including a glucocorticoid and anti-secretory drugs

What is a main counseling point for adjuvant analgesics?

use of these drugs is a trial-and-error process that requires time and careful monitoring

recommendation for APAP use

mild-moderate pain

what are the safety concerns for APAP

liver toxicity is a concern at higher doses, particularly from unintentional overdose