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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

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

Our pain policy

The Pain Cycle

Pain cycle

Facts about Chronic Pain

Pain cycle

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

Disorders

Modalities

WHOS Pain relief ladder

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

Click here to view

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