Lecture 75 - Non-Malignant Pain Part 1 Flashcards
What is pain?
Why Does Pain Matter?
1 reason that patients seek
medical care
*75 - 100 million in US have chronic pain (~30% of Americans)
*40 million adults experience severe pain
Interferes with quality of life and productivity
*half of patients with low back pain report interference with basic and complex activities
Annual cost in the US exceeds 500 billion dollars Opioid epidemic
*Need for increased safety due to elevated opioid related deaths
Role of Pharmacists
Assessment of pain
Recommend OTC medications
Refer patients to prescribers
Recommend initial prescription analgesics to providers
Educate patients on analgesic therapy
Evaluate safe and effective use (abuse, side effects, etc.)
Adjust medication therapy based on response
Assessment of Pain
What questions would you want to ask to subjectively assess a patient’s pain?:
“PQRSTU” Mnemonic
Palliative or Precipitating factors
Quality of pain
Region of pain location
Severity (pain assessment instruments)
Time-related nature of pain
U Impact of pain on yoU
What have you tried to control the pain?
Assessment of Pain
Objective information to assess pain
Behavioral changes
Physiological changes: Dilated pupils (mydriasis); Paleness (pallor); Sweating (diaphoresis); Tachycardia; Tachypnea
Pain intensity scales: Verbal; Numeric; Visual; Wong-Baker
Classifying Pain
Pain:
acute - <3 months
chronic - >3 months –> nociceptive (tissue), neuropathic (nerve), mixed (tissue and nerve)
malignant
Guidelines
Center for Disease Control (CDC) Guideline for Prescribing Opioids for Pain (US, 2022): Outpatients aged ≥18 years with acute (duration of <1 month), subacute (duration of 1–3 months), or chronic (duration of >3 months) pain; Excludes pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care.
Society of Critical Care Medicine (SCCM) Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (US, 2018): Referred to as PADIS Guideline
National Institute for Health and Care Excellence (NICE) Neuropathic pain in adults (UK, 2020)
Management of Acute Pain From Non–Low Back, Musculoskeletal Injuries in Adults: Academy of Family Physicians (AAFP) (US, 2020)
Goals of Therapy
Correct: Correct underlying cause of pain if possible
Minimize: Minimize pain and symptoms from pain/injury (May not be possible to be free of pain)
Improve: Improve quality of life (QOL) and activities of daily living (ADLs)
Limit: Limit pharmacotherapy side effects
Selecting an Analgesic - patient factors
Hepatic/renal function
Past medical history
Previous analgesic therapy
Routes for medication administration
Type of pain (neuropathic vs. nociceptive
Severity of pain
Selecting an Analgesic - medications factors
Allergies
Cost
Drug-drug interactions
Duration of action/dosing frequency
Potency
Route of administration
Side effects
Non-Pharmacologic Therapy
Can be used in combination with analgesics
Physical manipulation
Heat or ice
Massage
Acupuncture
Exercise
Correct the underlying cause (surgery, avoidance)
Treatment approach
step 1: non-opioid +/- adjuvant analgesic
step 2: opioid for mild-moderate pain + non-opiod +/- adjuvant analgesic
step 3: opioid for moderate-severe pain + non-opioid +/- adjuvant analagesic
step up if pain is persisting or increasing
step down if pain is resolving or toxicity occurs
Step 1: Non-opioid Analgesics
Non-opioids
* Acetaminophen
* Non-steroidal anti-inflammatory drugs (NSAIDS)
Adjuvant therapies
* Gabapentinoids
* Serotonin norepinephrine reuptake inhibitors (SNRIs)
* Tricyclic antidepressants (TCAs)
* Skeletal muscle relaxants
* Antiepileptics
* Topical agents
Acetaminophen (Tylenol)
Analgesic and antipyretic
Available formulations: Tablet (regular strength = 325mg, extra strength = 500mg, arthritis = 650mg ER tablet); Capsule; Chewable tablet (80mg or 160mg); Liquid/gel; IV solution; Suppository
Recommended dosing: Adults: 325 -1000mg PO Q4-6H PRN (max dose ≤3-4
g/day); In liver disease, decrease max ≤2 g/day); Pediatrics: 10-15 mg/kg PO Q4H PRN (max dose 75mg/kg/day or ≤3-4 g/day)
Side effects: Hepatotoxicity (acute liver failure most likely with ≥10g dose)
Acetaminophen clinical pearls
Gold standard for osteoarthritis due to fewer side effects in geriatric patients than NSAIDs
Educate patients about max daily doses, including combination products
Injection is expensive (often restricted use)