Management of Pain

Question 1

Pain: quick history? (4)

Answer 1

How bad is it? Baseline and now

What is exercise tolerance

Impact on work, sleep, relationships

Red flags: weight loss, fever, point tenderness, night pain, sensory changes (including bladder/bowel function), high CRP.

Question 2

Differential diagnosis in general for Pain (5)

Answer 2

MIN-FE (민폐)

Mechanical (bone #, OP, OA, disc degeneration, herniated disc…etc)

Inflammatory (and Infection)

Neuropathic (Neoplastic)

Fibromylagia / Functional

Extraordinary: Complex-Regional Pain Syndrome

Question 3

How would you approach to manage this patient’s pain?

Answer 3

Goals: minimize symptoms, improve function and prevent complications

C & A: screen & treat depression, obesity (weight loss), rule out organic causes first (inflammatory markers, radiology - e.g. discitis, abscess, OM)

Non-pharm

• Buzz words: difficult Mx issue that require continuous support and MDT approach
• Educate to ensure that patient has realistic expectations - that we will not cure but improve function and tolerance
• Motivate, encourage, Praise
• RICE: rest, ice/heat packs, compression, elevation
• Exercise: increased activity leads to improved pain and ADLs
• Physiotherapy: set goals - muscle strengthening, flexibility & aerobic fitness - Massage, hydrotherapy, graded exercise therapy so we don’t over do it
• Mind-body interventions: Yoga & Tai Chi
• TENS (transcutaneous Electrical Nerve Stimulation) - mild improvement according to 2015 Cochrane meta-analysis
• Cognitive behaviour therapy - with specific aim of getting rid of idea of “cure” via surgical intervention

Pharmacological

• WHO analgesic ladder
• Start regular + PRN (1/12^th to 1/6^th of total daily dose fractionated) - try and avoid PRN use (high risk of misuse)
• Joint steroid injections - symptomatic benefit for 2-3 months
• Regular Panadol, SNRI/TCAs (2nd line for back pain), consider centrally acting drugs as a last resort in general (e.g. tramadol, tapentadol, targin, buprenorphine patch), neuropathic agents

Involve: family, educate on common side effects and how to deal with them (e.g. constipation)

Ensure follow-up and monitor for complication

• Opioids: falls, confusion, constipation, abuse/dependency
• Tramadol & Tapentadol: serotonin syndrome with TCA/SSRIs

Question 4

You would avoid NSAIDs because (3 - basically never say you will use it in long case)

Answer 4

1. Increased CV risk: e.g. HF
2. Renal impairment
3. PUD

Question 5

Meloxicam?

Answer 5

Is NSAID

Question 6

Why give targin over oxycodone?

Answer 6

Naloxone component: reduces opioid induced constipation (NNT = 4 to 14) but often loperiens still needed.

Oral naloxone has a low systemic bioavailability but once it reaches maximum dose (Targin 80/40mg then can reach systemic circulation)

Dose reduce if renal or hepatic impairment.

Question 7

Buprenorphine (Norspan) vs. Fentanyl (Durogesic) patch? in what situations would you use them over another?

Answer 7

These are Not suitable for acute pain. Patches not suitable for patients that are very slim

Buprenorphine patches

• Suitable for people who require low doses of opioids for persistent pain
• Given as weekly patch
• Buprenorphine patch 5mcg/hour – MS Contin 5mg BD
• Largest patch available in Australia 20mcg/hour

Fentanyl patches are an option

• for stable severe chornic pain and established opioid needs
• Start 12mcg/hr patch applied every 72hrs
• Fentanyl patch 25mcg/hour = Morphine 90mg orally daily
• Not appropriate for opioid naive patients – risk of fatal opioid overdose

Question 8

Patches are, as a whole not suitable for 2 occasions - when?

Answer 8

These are Not suitable for acute pain. Patches not suitable for patients that are very slim

Question 9

Initial & max dose of Tapentadol? Important fact to remember about Tapentadol metabolism?

Answer 9

50mg BD to 250mg BD

It is metabolism (Extensively) by cytochrome p450 so be aware of interactions

Question 10

Neuropathic pain pharmacologic options? (5)

Answer 10

1. Gabapentin
2. Pregabaline
3. TCAs
4. SNRI (Duloxetine 30mg OD)
5. Anti-epileptics (Valproate 200mg OD-BD to 1500mg daily max)

Question 11

Are there any further options for palliative intent malignant pain? (3)

Answer 11

1. Ablation (e.g. RFA, phenol injection) - spinal nerve, coeliac plexus (pancreatic Ca), trigeminal nerve
2. Long-term epidural infusions (<2 months)
3. Deep brain stimulation

Question 12

Options for Obese people needing exercise for pain Mx?

Answer 12

Still possible

Physiotherapy - hydrotherapy and Graded resistance training

Question 14

Why would you prefer TCAs/SNRI (Duloxetine) instead of opioids for management of back pain?

Answer 14

1. Equally effective (no benefit of opioid when compared in trials)
2. Effects only short term
3. Potential for harm, abuse, dependency, complications