Pain Management

75% of Patients report insufficient pain relief.

Types of Pain

• 2 Types of Pain:

  • Nociceptive Pain

    • Somatic: Musculoskeletal

      • Localized, easily located

    • Visceral: Organs

      • Generalized, accompanied by nausea

  • Neuropathic Pain

    • Peripheral: Spinal cord and periphery

      • burning, electric

      • Ex: phantom limb pain

    • Central: spinal cord and brain

      • Tingly, pins and needles

      • spinal cord injury

    • Response to prolonged nociceptive pain

      • CNS becomes sensitized

      • Hyperalgesia: increased response to pain

      • Allodynia: increased pain sensitivity to non-painful touch

      • Less responsive to opioids

Classifications based on duration

• Acute: Less than 6 months

  • Easiest to treat

  • Easily identifiable

    • Objective indicators: tachycardia, inc. BP, sweating, anxiety

  • Major issues:

    • Tissues healing > thoughts, emotions

• Chronic Pain: Longer duration beyond healing time

  • Not always evident

  • Sometimes caused by flares from chronic disease

    • Not always objective indicators: Depression

  • Major Issues:

    • Thoughts > Tissue Input > Emotions

• Acute-on-chronic pain

  • Someone who has chronic pain then gets injured with acute pain

  • Issues: Tolerance to pain medicine

    • 1/3 US has chronic pain

Pain Assessment

• Pain Self Report is the Gold Standard

  • OPQRSTU: Like when we did our shift assessment

    • Assessment should never only be based on 1-10 rating

• Patient Can’t Self Report?

  • Can assume if condition or procedure is present

  • Get info from caregivers of patient

  • Observe behaviors and expression

    • Be careful of agitation: can be a cause of hypoxia

  • Attempt an analgesic trial (give a little bit)

-Many Factors Affecting Pain-

Populations with Under-Treatment of Pain

• Elderly

• Pediatric

• Confused

• Non-english speaking

• Ethnicities different from the caregivers

• History of substance abuse

  • Worse if meds are put off till excruciating pain because they will have to take a higher dose

• Chronic Pain patients with acute pain

  • tolerance to pain meds

  • providors acuse patients of med seeking

Terminology

• Tolerance: Pain medication doesn’t work as well, so higher doeses are needed

  • Can happen as little as a week

• Dependance: Physical dependance that causes withdrawl symptoms to a drug

  • Can happen if doses lower

  • Normal physical process

• Addiction: Psychological dependance from the alternative effects of pain meds

  • “4 Cs”

    • Lack of Control

    • Craving for drug

    • Compulsive use

    • Continued use despite consequences

  • Addictioned people also have pain

• Pseudo-addiction: demanding, manipulative behaviors used to get appropriate doses

  • truly need it for pain

  • behaviors will go away when pain is releived

• Diversion: Trying to get meds to give to other people

Multi-Modal Analgesia

• non-pharm

  • distracting, heat, cool, ect.

• complementary therapies

• opioid and non-opioid analgesics

• WHO Ladder

  • Start with non-opioids, then opioids, then invasive

Non-Opioids

• Acetaminophen (tylenol)

  • Max dose <4000 mg in 24 hours

  • Avoid pts w/liver disease

  • Beware other drugs with it: vicodin, perocet

• NSAIDs

Adjuvants

• meds that help with pain, but do not primarily treat pain

• Antidepressants

• Alpha-adrenergic blockers

  • ex: clonidine (helpful for withdrawals)

• Anticonvulsants

• NMDA inhibitors

• corticosteroids

• muscle relaxants

Opioid Analgesics

• morphine

• hydromorphone

• fentanyl

• Demerol

• oxycodone

• methadone

  • long half-life

• ADE:

  • Respiratory depression

    • >6 breaths/min → Narcan (naloxone) → uncontrolled pain → Cardiac issues

  • constipation

  • nausea/vomiting

  • pruritus

  • urinary retention

  • sedation

Regiments

• Baseline Pain

  • even at rest

• Breakthrough pain

  • End of dose failure,

• Activity related pain

• Procedural Pain

  • Wound care

• Anticipatory pain (anxiety)

Problems with PRN-only dosing

• Inconsistent timing = inconsistent blood levels

• Larger analgesic peaks

• Difficulty to catch up

• Solutions:

  • Control with pain at rest and background pain

    • Sustained release

    • Continuous IV infusion

    • Scheduled dosing of oral or IV pain

    • Fent patches (transdermal and systemic), lidocaine patches (topical), Tylenol

  • Breakthrough pain (pain spikes)

    • Incremental doses of IV opioids

    • IV bolus (morphine or dilaudid)

    • Oral immediate release (oxycodone IR, morphine IR, Dilaudid)

  • Acute on Chronic pain

    • know what they already take, then give them something stronger

• Know the onset, peak, and duration of pain meds

Patient Controlled Analgesia (PCA)

• Small doses administered by patient only

  • NOT for family/friends

• Overdose is avoided by limiting the size and number of boluses

• Used mostly for postop patients and in palliative care

IV or PO?

• PO don’t work as fast as IV

• IV

  • Can’t tolerate PO, can’t eat

  • intolerable current pain

• PO

  • Tolerable pain

  • Rectal admin

  • Ready for discharge

Intervention

• Epidurals

• Peripheral Nerve Blocks

• Implanted intrathecal pumps

• single shot intrathecal morphine

• subcutaneous infusions (On-Q pumps): local anesthetic

• Steroid injections: outpatient

• trigger point injections: outpatient

Complementary and Alternative Therapies

• acupuncture

• therapeutic massage

• guided imagery

• music therapy

• reiki (touch)

• hypnosis

• meditation