EXAM - Pain Flashcards
Jackie, cis female age 45 recent day surgery for ankle fracture. Comorbidities of dyslipidemia on atorvastatin 10mg po daily. Sent home with 3 days of T-3s and told to follow up in community. Presents to primary care on day 5 reporting pain 2/10 at rest and 7/10 with the ambulation recommended by the surgeon. Jackie says she doesn’t think she needs to take anything for pain since it doesn’t hurt very much if she doesn’t walk on it and she doesn’t want to get addicted to anything. What teaching should be done with Jackie?
I would teach about the importance of mobilization and movement and the need to treat pain to allow this to happen.
Also teaching about the benefits of non-opioid drugs which are not addicting
As per Susan, what would you recommend that Jackie takes to manage her pain?
Scheduled acetaminophen and ibuprofen
Acetaminophen 1000 mg q6 hours
Ibuprofen 600 mg po q8 hours
(RxFiles p. 126 and 128)
What are some non-pharmacological considerations for Jackie?
Reassurance and encouragement to verbalize pain
Cold or heat as indicated – more cold for Jackie
Relaxation, imagery, distraction
PT
(CPS – Acute Pain – Therapeutic Choices)
Charles (age 64) has chronic back pain associated with a distant work injury. He has had workups done including imaging and there is no surgical intervention indicated. Previous care providers have prescribed Charles oral NSAIDS and advised him to take acetaminophen regularly as well. Charles is new to our care and comes to your office expressing frustration and anger that no one seems to believe him that he has pain and that it is decreasing his quality of life. Charles states that the NSAIDS/tylenol combo just doesn’t work. Where do you start in your management of Charles – what are some useful general principles to consider?
Important principles for treating chronic pain: empathy, setting goals, using non-pharm therapy, prescribing artfully, individualizing therapy, team approach
Treat pain holistically – consider biological, psychological, social and spiritual aspects
RxFiles p.123
What are some non-pharm approaches to consider in chronic pain management?
Psychological – CBT, mindfulness, support groups, etc
Physical/rehab - yoga, tai chi, exercise, PT, etc
Device/Procedure - low level lasers, TENS, heat/cold, trigger point injections, etc
Practitioner-based – RMT, acupuncture, chiro, hypnosis
Self-management – sleep hygiene, music therapy, relaxation, breathing, meditation, weight loss
(p. 123)
Explore what Charles has already tried, what has and has not worked, what he is open to trying and what he can afford/access
Non-opioid therapy is ideal for chronic pain, according to Sue acetaminophen and ibuprofen can be very effective. Charles has told you these drugs do not work. What might your next step be?
Ask about how the medications were taken – what dose and frequency and for how long? Assess if medications were taken at sufficient amounts. If not, may recommend a trial of specific dosing of these medications in addition to non-pharmacological options
Charles assures you that he has been taking both medications as prescribed at full doses for months. They have not been effective at relieving his pain and he is experiencing depressive symptoms which he attributes to his pain. What are some additional options for prescribing to Charles.
Need to assess his pain thoroughly. Treatment really depends on the type of pain– also better assess his depressive symptoms and ask about suicidality.
An SNRI or TCA could be worth trialing – Duloxetine or if the pain seems neuropathic perhaps amitriptyline, nortriptyline or Venlafaxine
Also could consider opioids, short term muscle relaxants – see page 127
“Oh wait! I was told that my pain is from osteoarthritis in my back.” remembers Charles. You find an old note supporting this. Looking at your RxFiles you see that there is some evidence supporting the use of opioids to treat chronic pain related to OA. What are some important steps to take before prescribing an opioid to Charles?
Ensuring optimization of non-opioid pharmacotherapy and non-pharm therapy
Ensure no current or past substance use disorder – recommend against opioid use
(2017 Canadian Opioid prescribing guidelines)
Checklist from “opioid manager”:
Stable psychiatric disorder/mental illness
Current or past substance use disorder
Cannabis use
Thorough baseline assessment
Explained potential benefits/adverse effects/opioid safety
Obtained informed consent
Provided information handout
As needed – signed treatment agreement, urine drug screening, naloxone prescription
You determine that a trial of opioid pain control is acceptable for Charles. What do you prescribe?
RxFiles recommends an average dose of approx 60 MED/day to treat pain for OA. Tramadol is also mentioned but may increase mortality. (p. 127)
I THINK maybe Hydromorphone 0.5mg po q6h for the first week… titrate up to 1mg doses after 1 week and then continue to increase dose by 1 mg per week. Follow up each week to reassess pain, side effects, functional ability etc.
Once acceptable pain control is reached I would want to transition to a CR formulation. Apparently 50 MED = 10 mg daily dilaudid. So it may be appropriate to end up on Hydromorphone CR 4mg q12h.. Depending on a lot of factors.
Be sure to prescribe bowel care!!
(Opioid manager, p.2 - suggested initial dose and titration)
What will you want to be sure to assess at each visit?
Review prescription drug monitoring program records for new/double prescriptions – give urine drug screen as needed
Calculate current MED per day – little additional benefit above 50-90 MED
Ensure non-opioid interventions are still optimized
Is the opioid still providing benefit?
Adverse effects?
Are there any warning signs of aberrant drug use?
Is the risk of OD still low?
(RxFiles p. 132)
You see a new patient in your clinic. Ashley, age 47 has been taking opioids to manage her fibromyalgia pain for the past 2 years. Ashley has been transferred to your practice and has presented to you requesting refills for her regularly scheduled oxycodone. Upon assessment it is clear that Ashley’s pain is not well managed and that she is experiencing significant side effects associated with her plan of care. What would you do with the opioid?
Per RxFiles (p. 127) opioids are not beneficial in fibromyalgia. I would recommend tapering the opioid and prescribing something more indicated for this condition
What would be your approach to tapering Ashley’s opioid?
Decrease dose by 5-10% every 2-4 weeks, going slower as the taper comes to an end. Consider rotating to a lower dose of a different opioid
more details on p.133
(RxFiles, p. 132)
What might be a better analgesic option for Ashley?
For fibromyalgia, RxFiles recommends Amitriptyline, duloxetine and possibly tramadol
(p. 127)
Although Ashley’s pain is not well-controlled, she is resistant to the plan to taper her opioids and fears that she will suffer more without them. What are some strategies to support Ashley in this transition?
Be supportive, nonjudgmental, flexible and accessible to build trust
Share the benefits of improvement on overall quality of life after tapering – focus on this instead of on issues of addiction/OD
Offer non-opioid alternatives
Encourage and facilitate helpful social support
Address fear of withdrawal – many symptoms can be avoided if taper slow enough
(RxFiles, p. 134)
Which patients may be a good candidate for gabapentinoids?
patients with neuropathic pain and fibromyalgia
(p.127)
