Presentations
An Interdisciplinary approach to pain management
What is Pain?
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” International Association for the Study of Pain (Merskey, 1979)
Pain is always subjective.
- The patient’s self-report of pain is the single most reliable indicator of pain
- It is NB that the clinician accepts this
Pain Management Policy at the Cape Town Pain Clinic
Optimal acute pain management is essential to prevent chronic pain
- Appropriate screening and pain assessment
- Documentation
- Care and treatment
- Pain education
Pain Management Policy at the Cape Town Pain Clinic
Putting the pieces of the puzzle together
The Pain Cycle
Facts about Chronic Pain
Acute Pain VS
Presents most often with a clear cause, relatively brief in duration and subsides as healing takes place.
Acute pain is often accompanied by observable objective signs of pain
- increased pulse rate
- increased blood pressure
- Non-verbal signs and symptoms
such as facial expressions and tense muscles.
Chronic Pain
- Pain that is persistent and recurrent
- When pain persists, it serves no useful purpose and may dramatically decrease the quality of life and
function
- Chronic pain rarely has any observable or behavioral signs although persons may appear anxious or depressed
Chronic Pain Disorders
Modalities
Pain that is associated with cancer or cancer treatment may be attributed to
- Tumor location
- Chemotherapy
- Radiation therapy
- Surgical treatment
Pain Assessment
Initial Pain Assessment should include:
- Location(s)
- Intensity
- Sensory quality
- Alleviating and aggravating factors
Any new onset of pain requires a new comprehensive pain assessment.
Modalities to objectively assess pain
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Pain Reassessment
- Every 8 hours minimally
- Following the administration of pain medications to determine the
effectiveness of the medication and/or need for further intervention
- IV within 15 mins of administration PO/IM/SC within 1 hour of
administration
Pain Management Approach
Should be interdisciplinary and multimodal
Care is individualized and may depend on:
- Pain source and intensity
- Patient’s age
- Developmental, physical, emotional and cognitive status
- Cultural beliefs
- Treatment preferences
- Concurrent medical conditions
- Treat concurrent mood disorders, especially depression
Physical Therapy
- A good baseline
- Obesity/increased adiposity results
in endothelial dysfunction
- Decreases inflammatory markers
- Improves Insulin sensitivity
- Improves mental health
Exercise is a physiological stressor:
- Lower intensity
- Shorter duration
Exercise induced hypoalgesia:
- Increases sensitivity to opioids –
by Beta endorphin release
- Assists with Noxious Inhibitory Control
- Can assist with weaning or dose reduction
of opioids
Psychotherapy
- Reduction in Brain Derived Neurotropic factor (BDNF)
- Reduction in brain regional grey matter by 4.6 % for every 1 year of pain
- Recovers with treatment
- Central sensitization
- Upregulation of noxious signaling
- Endogenous signaling
Dietetics
Multimodal Analgesia
This term describes the use of multiple modalities that are used to provide pain relief with various parts of the pain pathway targeted
Decreased dependence on a single modality agents decreases the risk of side effects:
May include
- Pharmacological (opioids, NSAIDS, gabapentanoids)
- Relaxation techniques (biofeedback, deep breathing)
- Regional analgesia (nerve blocks, epidural catheters)
It allows for opioid sparing !! Reduces polypharmacy !!
Treatments May Include
Non-pharmacologic Methods
- Heat/cold
- Relaxation
- Distraction
- Graded motor imagery
- Acupressure/acupuncture
- Repositioning
Pharmacologic Methods
- NSAIDS
- Anti-seizure
medications
- Anti-depressants
- Opioid analgesics
- Local anesthetics
- Neurolytics
- Cannabinoids
Acute vs. Chronic Pain Management
Acute Pain
Most often treated with:
- NSAIDS
- Opioids
- Local anesthetics
- Splinting
- Positioning changes
- Ice
Chronic Pain
Most often treated with:
- Combinations of paracetamol and opioids such as tramadol
- Opioids (oxycodone and tapentanol, combinations of opioid and naloxone)
- Anti-seizure medications Carbamazepine
- Anti-depressant medications
- NSAIDS
- Implantable devices
- Psychological therapy
- Acupuncture
Undertreatment of Chronic Pain
- > 40 -50 % of patients in the routine practice settings
- In a recent study of 805 Chronic Pain sufferers, > 50 % had to change physicians to establish pain control
Why???
- Unwillingness to treat pain aggressively
- Lack of empathy or belief in the patient’s perception of pain
- Inadequate knowledge
American Pain Society 2001, Gjachen
Click here to download An Interdisciplinary approach to pain management
Responsible Opioid Prescribing
Assess risk for opioid abuse
Risk factors for misuse or abuse of opioids include the following
- Males between 18 and 45.
- A personal history of substance abuse
- A family history of substance abuse
- A personal history of preadolescent sexual abuse
- A personal history of psychological disease (depression, anxiety, obsessivecompulsive
disorder
Patient and Family Education
Patients and family are given specific instructions prior to discharge regarding
- Pain control
- Pain medications
- Management of potential side effects
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