Pain Management Flashcards
Chronic Pain can be one of these two categories
Neuropathic or Nociceptive
Neuropathic pain
Seconday to a disease or a dysfunction of the nervous system. Either peripheral like PHN, Diabetic neuropathy or central like post stroke pain or MS.
Nocicpetive pain
Musculoskeletal (back, ankle) , Inflammatory (arthropathies, infection) or Mechanical/Compressive (kidney stone, tumor) Caveat – multifactorial causes of chronic pain are not uncommon
Hyperalgesia
increased response to a stimulus that is normally painful
Hypoalgeisa
Diminished response to a normally painful stimulus
Analgesia
Absence of pain in response to stimulation that normally is painful
Hyperesthesia
Increased sensitivity to stimulation, excluding the special senses
Hypoesthesia
Diminished sensitivity to stimulation, excluding the special senses
Dysesthesia
An unpleasant abnormal sensation, whether spontaneous or evoked
Paresthesia
An abnormal sensation, whether spontaneous or evoked
Allodynia
Pain resulting from a stimulus (such as light touch) that does not normally elicit pain
Myelinated nociceptors
relatively fast- conducting A-delta fibers
Nociceptors
highly- specialized subset of primary sensory neurons that respond only to pain stimuli. Their signals sum to produce the nociceptive input, leading to the subjective sense of pain.
Sciatica pain
Pain typically found in posterior part of lower extremity and follows dermatomal pattern.
Digital Gangrene
Arterial ulcers are intensely painful and occur on the distal portions of the extremities. They may result in tissue necrosis.
Herpes Simplex Infection in HIV Infection
In patients with HIV disease, herpes simplex may appear as painful, nonhealing shallow ulcers.
Transduction
conversion of a noxious stimulus (thermal, mechanical, or chemical) into electrical activity in the peripheral terminals of nociceptor sensory fibers
Transmission
he passage of action potentials from the peripheral terminal along axons to the central terminal of nociceptors in the central nervous system
Conduction
is the synaptic transfer of input from one neuron to another
Modulation
alteration (eg, augmentation or suppression) of sensory input
Perception
the “decoding”/interpretation of afferent input in the brain that gives rise to the individual’s specific sensory experience- the ouch experience
The International Association for the Study of Pain (IASP)
Axis I: Anatomic regions
Axis II: Organ systems
Axis III: Temporal characteristics, pattern of occurrence
Axis IV: Intensity, time since onset of pain
Axis V: Etiology
Caveat Number #2: compatible with the International Classification of Diseases (ICD 9 and ICD 10) but provides for more detailed identification of various chronic pain syndromes and major acute pain syndromes
Axis I: Anatomic regions
Need Specifics to Accurately bill ex R10.1 pain localized to upper abdomen
Treatment options for chronic pain generally fall into six major categories
- pharmacologic;
- physical medicine;
- behavioral medicine; 4. neuromodulation;
- interventional, and 6. surgical approaches.
Opioids in chronic pain mgmt
Opioids should not be considered first- line or routine therapy for chronic pain. This does not mean that patients should be required to sequentially “fail” nonpharmacologic and nonopioid pharmacologic therapy before proceeding to opioid therapy - benefits should be weighed against the risk
Adaptive pain
Adaptive pain contributes to survival by protecting the organism from injury and/or promoting healing when injury has occurred.
Maladaptive pain
Chronic pain- aka – maladaptive - is pain as disease itself, and represents pathologic functioning of the nervous system.
Sympathetically Mediated Pain
pain arising from a peripheral nerve lesion and associated with autonomic chances (e.g. complex regional pain syndrome I and II)
Peripheral Neuropathic Pain
is due to damage to a peripheral nerve without autonomic change (e.g. post-herpetic neuralgia)
Central Pain
arises from abnormal CNS activity (e.g. phantom limb pain)
Nociceptive Pain
A nociceptor is a nerve fiber sensitive to a noxious stimulus or a stimulus that would become noxious if prolonged (e.g. operative incisions) Nociceptive pain is the perception of nociceptor input arising from tissue injury, inflammation or mechanical deformation.
Somatic Pain
arises from injury to body tissues, well localized, variable in description and experience
Visceral Pain
arises from the viscera mediated by stretch receptor, poorly localized, deep, dull and cramping.
Examples of Nocioceptive pain
Examples: trauma, burns, infections, arthritis, ischemia and tissue distortion
Examples of neuropathic pain
diabetic neuralgia, trigeminal neuralgia, thalamic pain syndrome
Nociceptive Somatic pain described as
“ache”, “throb”, “sharp” May worsens with movement
Nociceptive Visceral described as
“colickly”, “vague”, “diffuse” May worsen with meals
Neuropathic described as
“burning”, “sharp”, “tingling” May worsen with touch
Chronic neck pain
Constant dull pain, occasionally shooting pain, pain does not follow nerve distribution. No trigger points, poor ROM in involved muscle
Fibromyalgia
Diffuse muscular pain, stiffness, fatigue, sleep disturbance, Diffuse muscle tenderness, >11 trigger points
Chronic back pain
Constant dull pain, occasionally shooting pain, pain does not follow nerve distribution, NO trigger points, poor ROM in involved muscle
Myofascial back pain syndrome
Constant dull pain, occasionally shooting pain, pain does not typically follow nerve distribution, TRIGGER points in area of pain, usually no muscle atrophy, poor ROM in involved muscle
When to use opiods
Opioids are generally recommended to reduce the level of moderate to severe pain, Opioids should be considered if reasonable, conservative therapy has failed
Nonopiod analgesics
acetaminophen and nonsteroidal anti- inflammatory drugs (nonselective agents and selective COX-2 inhibitors).
Adjuvants
specific medications for neuropathic pain (antidepressants, anticonvulsants, miscellaneous agents), specific medications for cancer-related pain (bisphosphonates, radioisotopes, steroids), and medications for bowel spasms
fibromyalgia cardinal symptom
Chronic widespread pain
Documentation with opiod treatment
Documentation is critical and should include the initial evaluation, substance abuse history, psychosocial issues, pain/pain relief, side effects, functional outcomes, and continuing monitoring- with each visit. The medical record should document the nature and intensity of the pain, current and past treatments for pain, underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function, and history of substance abuse- WITH EACH VISIT- Now Being Done Monthly.
When to refer
- Previous failure with opioids or other analgesics • Significant psychosocial issues
- Conviction of a drug-related crime
- Current use of illicit drugs
- Regular contact with drug high-risk groups
- History of substance abuse
- Be careful- you cannot quickly abandon the patient
Bio/Physical Approaches
- pharmacologic and/or nonpharmacologic therapies
- physical rehabilitation
- physical/ occupational therapy
- homeexercise program
Psychological Intervention
- mood disturbances • coping skills
* sleep disturbance
Social Issues
- family/social relations
* work issues
Psychologicalintervention
integralpartoftheroutinemanagement→improvespatients’coping skills and their ability to relax and sleep without interruption
Alternatives to Opioid Therapy
- adjuvant analgesics
- nonpharmacologic modalities
- CAM (e.g. Acupuncture/massage)
- Anticonvulsants
- Tricyclic antidepressants
- Topical medications
Interventional treatments
- Neuralblockade
* Stimulatory techniques (spinal cord stimulation; peripheral nerve stimulation)
Nonpharmacological therapies
- Biofeedback
- Relaxation therapy
- Cognitive/behavioralstrategies • Acupuncture
Antispasmodics
can be useful in treating this aspect of the patient’s symptoms, but their action may be more the result of sedation rather than muscle relaxation.
Benefits of high-dose opioids for chronic pain
these are not established
ER/LA opioids
methadone, transdermal fentanyl, and extended-release versions of opioids such as oxycodone, oxymorphone, hydrocodone, and morphine. reserved for “management of pain severe enough to require daily, around-the-clock, long-term opioid treatment” when “alternative treatment options (e.g., nonopioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain” and not used as “as needed” pain relievers
limiting days of opioids
Because physical dependence on opioids is an expected physiologic response in patients exposed to opioids for more than a few days (contextual evidence review), limiting days of opioids prescribed also should minimize the need to taper opioids. Each day of unnecessary opioid use increases likelihood of physical dependence without adding benefit
Initiating Opioid Therapy
- Consider cost, tolerability, ease of administration, compliance
- Develop and document an Exit Strategy
- Should regularly reassess all patients receiving long-term opioid therapy, including patients who are new to the clinician but on long- term opioid therapy, at least every 3 months.
Moderate to Severe pain
Morphine, Fentanyl, oxycodone, hydromorphone
Mild to Moderate
Codeine, Tramadol, hydrocodone, propoxyphene
Mild pain
nonopiod, Tylenol, Asa, Nsaids, Corticosteroids Tricyclic antidepressants Anticonvulsants Topical Preparations
Factors That Influence Analgesic Selection
- Type of pain
- Severity
- Duration
- Patient-specific factors:::
- age
- pain and analgesic history
- concomitant diseases, organ function
- psychosocial issues
Create an Exit Strategy
Upon initiating opioid therapy, agree with patient on criteria for failure of the trial. Common failure criteria include: • lack of significant pain reduction
• lack of improvement in function • persistent side effects
• persistent noncompliance
The “Four A’s of Pain”
Analgesia Activities of daily living Adverse effects Aberrant drug-taking behaviors Important to remember two other “A’s” Assessment Action (treatment plan)
Prescribe naloxone when factors that increase risk for opioid overdose, such as:
- History of overdose
* history of substance use disorder, higher opioid dosages
Review the patient’s history of controlled substance prescriptions
the state prescription drug monitoring program
Urine drug testing
–before starting opioid therapy –consider urine drug testing at least annually to assess –Recommend 3 negative test per 12 months for prescribed medications as well as other controlled prescription drugs and illicit drugs
Nausea and vomiting s/e
Switch opioids; anti-emetics
Sedation s/e
Lower dose (if possible); add co-analgesics; add stimulants
Constipation s/e
Treat prophylactically with stool softeners, bowel stimulants; non-pharmacological measures; switch opioids
Itching s/e
Switch opioids; antihistamines
Endocrine dysfunction/reduced libido s/e
Endocrine monitoring; testosterone replacement; endocrine consultation
Edema and sweating s/e
switch opioids
Dizziness s/e
Antivertiginous agents (eg, scopolamine)
Confusion s/e
Titrate dose; switch opioids
Opioid treatment may lead to the development of
- pharmacological tolerance
- opioid-induced pain through similar cellular mechanisms Both may contribute to the clinical manifestation of apparent opioid tolerance with a demand of opioid dose escalation. Opioid dose escalation may feed back into the cellular mechanisms of pharmacological tolerance
Opioid-induced pain sensitivity
further escalating the opioid demand
Continue Opioid Therapy
An option if there is • effective pain relief
• improvement in ADLs
• improvement in psychosocial functioning • management of side effects
Relevant regulations of the CDC include
- federal (DEA)
- state policies
- Your scope of practice
- Your prescribing habits
- Your collaborative agreement
Exit Strategy
Start on Day one. Documentation of lack of pain reduction and/or lack of functional improvement
• criteria for tapering emphasized in the initial patient agreement • This is Huge: Distinguish between abandoning opioid therapy, abandoning pain management, and abandoning patient • Taper off opioid therapy, with or without specialty assistance
preferred treatment for chronic pain
Nonpharmacologic therapy and nonopioid
pharmacologic therapy
Clinicians should consider opioid therapy only if
expected benefits for both pain and function are
anticipated to outweigh risks to the patient.
If opioids are used you need to combine them with what?
nonpharmacologic therapy and nonopioid
pharmacologic therapy, as appropriate.
Before starting opioid therapy for chronic pain,
clinicians should establish
treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks.
Clinicians should continue opioid therapy only if there is
clinically meaningful improvement in pain and function that outweighs risks to patient safety.
Before starting and periodically during opioid therapy, clinicians should discuss with patients
known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.
When starting opioid therapy for chronic pain, clinicians should prescribe
immediate-release opioids instead of
extended-release/long-acting (ER/LA) opioids.
When opioids are started, clinicians should prescribe
the lowest effective dosage.
Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to
≥50 morphine milligram equivalents (MME)/day
We should avoid increasing dosage to
≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.
Long-term opioid use often begins with treatment of
acute pain
When opioids are used for acute pain, clinicians should prescribe
the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.
Clinicians should evaluate benefits and harms of continued therapy with patients every
3 months or more frequently (many places do this monthly)
If benefits do not outweigh harms of continued opioid therapy, clinicians should
optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.
Before starting and periodically during continuation of opioid therapy, clinicians should
evaluate risk factors for opioid-related harms.
Clinicians should incorporate into the management plan strategies to mitigate risk, including
considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present.
Clinicians should review the patient’s history of controlled substance prescriptions using
state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose.
Clinicians should review PDMP data when
starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.
When prescribing opioids for chronic pain, clinicians should use urine drug testing
before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
Clinicians should avoid prescribing opioid pain medication and
benzos
Clinicians should offer or arrange evidence-based treatment for patients with opioid use disorder
usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies
Can improve pain in diabetic
neuropathy and post-herpetic neuralgia
Lyrica and Neurontin
FDA approved adjuvant therapy for fibromyalgia
Lyrica and Tricyclic and SNRI antidepressants
Effective analgesia for neuropathic pain conditions
tricyclic antidepressants and SNRIs (Cymbalta) often at lower dosages and with a shorter time to onset of effect than for treatment of depression
Situations in which opioids will be discontinued or doses tapered
if treatment goals are not met, opioids are no longer needed, or adverse events put the patient at risk
Scale to track patient oucomes
PEG - Pain assessment, Enjoyment of life, interfere with General activity
Clinically meaningful improvement has been defined as a
30% improvement in scores for both pain and function
assessment of functional improvement
assess functional goals like walking around the block
If they do not receive benefit in both pain and function
taper of stop the opiod and use nonpharm and nonopiod forms of pain management (NSAIDS, SNRI, pt/ot, etc)
common effects of opioids,
constipation, dry mouth, nausea, vomiting, drowsiness, confusion, tolerance, physical dependence, and withdrawal symptoms when stopping opioids.
ER/LA opioids
methadone, transdermal fentanyl,extended-release versions of opioids such as oxycodone, oxymorphone, hydrocodone, and morphine – higher risk of overdose
ER/LA opioids be reserved for
management of pain severe enough to require daily, around-the-clock, long-term opioid treatment” when “alternative treatment options (e.g., nonopioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain” and not used as “as needed” pain relievers
opioid-tolerant patients
patients who have received certain dosages of opioids (e.g., 60 mg daily of oral morphine, 30 mg daily of oral oxycodone, or equianalgesic dosages of other opioids) for at least 1 week. ER/LA opioids should be reserved for severe, continuous pain and should be considered only for patients who have received immediate-release opioids daily for at least 1 week
Methadone risk
Prolonged respiratory despression, QT prolonged
transdermal fentanyl risk
absorption properties differ widely from patient to patient
higher opioid dosages areassociated with increased risks for
motor vehicle injury, opioiduse disorder, and overdose
although there is not a single dosage threshold below which overdose risk is eliminated, holding dosages < This Dose of MME/day would likely reduce risk among a large proportion of patients who would experience fatal overdose at higher prescribed dosages
50 MME/Day, increasing dosages to 50 or more MME/day increases overdose risk without necessarily adding benefits for pain control or function and that clinicians should carefully reassess evidence of individual benefits and risks when considering increasing opioid dosages to ≥50 MME/day. If > 50 need increased follow up monitoring and narcan education
opioid dosages should not be increased to ≥ this dose MME/day without careful justification based on diagnosis and on individualized assessment of benefits and risks
90 MME/day
Wait how long before increasing a dosage
5 half lives or usually one week - especially with methadone
Consult pain mgmt if
do not experience improvement in pain and function at ≥90 MME/day, or if there are escalating dosage requirements
early warning signs of serious adverse events, signs of opioid use disorder
difficulty controlling use, work or family problems related to opioid use
exposed to greater risk of opioid use disorder or overdose
patients with depression or other mental health conditions, a history of substance use disorder, a histor of overdose, taking ≥50 MME/day, or taking other central nervous system depressants with opioids
Tapering opiods
10-50% of original dose over 2-3 weeks. If taking for years it may need to be done by 10 percent per month.
signs of opioid withdrawal
drug craving, anxiety, insomnia, abdominal pain, vomiting, diarrhea, diaphoresis, mydriasis, tremor, tachycardia, or piloerection – need to taper slow enough to avoid these symptoms
factors that increase risk for harm
history of overdose, history of substance use disorder, higher dosages of opioids (≥50 MME/day), and concurrent use of benzodiazepines with opioids
If clinicians suspect their patient might be sharing or selling opioids and not taking them, clinicians should
consider urine drug testing to assist in determining whether opioids can be discontinued without causing withdrawal. A negative drug test for prescribed opioids might indicate the patient is not taking prescribed opioids,
