Pain Management Presentation for Pgy1- By Dr. Abdelal

PAIN MANAGEMENT Randa Yehia-Abdelal Pharm D Clinical Pharmacist Muhlenberg Regional Medical Center

Physicians Have a Moral Obligation to Provide Comfort and Pain Management

Pain is the most feared complication of illness

Pain is the second leading complaint in physicians’ offices

Often under-diagnosed and under-treated

Effects on mood, functional status, and quality of life

Associated with increased health service use

18% of Elderly Persons Take Analgesic Medications Regularly (daily or more than 3 times a week)

71 % take prescription analgesics

63% for more than 6 months

72% take OTC analgesics

Median duration more than 5 years

26% report side-effects

10% were hospitalized

41% take medications for side-effects

ELDERLY PATIENTS TAKING PAIN MEDICATIONS FOR CHRONIC PAIN WHO HAD SEEN A DOCTOR IN THE PAST YEAR

79% had seen a primary care physician

17% had seen a orthopedist

9% had seen a rheumatologist

6% had seen a neurologist

5% had seen a pain specialist

5% had seen a chiropractor

20% had seen more than 5 doctors

Common Causes of Pain

Osteoarthritis

back, knee, hip

Night-time leg cramps

Claudication

Neuropathies

idiopathic, traumatic, diabetic, herpetic

Cancer

Sickle Cell Anemia

MISCONCEPTIONS ABOUT PAIN Myth : Pain is expected with aging. Fact : Pain is not normal with aging.

MISCONCEPTIONS ABOUT PAIN Myth : If they don’t complain, they don’t have pain Fact : There are many reasons patients may be reluctant to complain, despite pain that significantly effects their functional status and mood.

REASONS PATIENTS MAY NOT REPORT PAIN

Fear of diagnostic tests

Fear of medications

Fear meaning of pain

Perceive physicians and nurses too busy

Complaining may effect quality of care

Believe nothing can or will be done

The most reliable indicator of the existence pain and its intensity is the patient’s description.

There is a lot we can do to relieve pain!

Analgesic drugs

Non-drug strategies

Specialized pain treatment centers

Patient and caregiver education and support

Analgesic Drugs

Acetaminophen

NSAIDs

Non-selective COX inhibitors

Selective COX-2 inhibitors

Opioids

Others

Antidepressants

Anticonvulsants

Others

Usage Breakdown

Mild to moderate pain :-

Acetaminophen; Codeine

Severe pain :-

Morphine; Hydromorphone, Oxycodone; Transdermal Fentanyl; Methadone

Adjuvant analgesics :-

NSAIDS; Tricyclic antidepressants, anticonvulsants, steroids, oral local anesthetics

Acetaminophen: 1 gram per dose and 4 grams daily is the maximum recommended quantity for adults under 65 years of age.

Consistently exceeding the daily recommended dosage can cause liver damage by formation of a toxic metabolite .

Can have synergistic effect when

used adjunctively

Acetaminophen

Nonselective nonsteroidal anti-inflammatory drugs {NSAIDS}

Nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) have a role in postoperative pain management, but concerns about increased bleeding and inhibited wound healing and bone fusion have limited their use.

used adjunctively

Ex: Ibuprofen; naproxen

Selective COX-2 inhibitors

Cyclooxygenase (COX)-2-selective inhibitors (coxibs) offer the peripheral pain-relieving benefits of nonselective NSAIDs but with fewer adverse GI effects; they also may have a role in central sensitization.

used adjunctively

Ex: Celecoxib (Celebrex)

Opioids

Common opioids

Morphine

Hydromorphone

Oxycodone

Fentanyl

Methadone

Buprenorphine

Meperidine (not recommended)

Main Opioid Side Effects

Fear of inducing respiratory depression is often cited as a factor that requires careful dosing & usage for opioids in pain management, especially for opioid naive patients.

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Side Effects

Constipation is a side-effect of all opioids, and is opioid-receptor mediated with both central and peripheral mechanisms; tolerance to this effect develops slowly if at all.

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Side Effects

Sedation and nausea, possible early side effects, usually dissipate with continued use.

Addiction

CAUTION

Meperidine (Demerol)

Accumulation of normeperidine, the toxic primary metabolite, can occur because of the drug's long half-life (20 hours in young, healthy patients), high first pass metabolism, and because it is renally excreted.

Patients with compromised renal function, those taking multiple dosages within a short period of time, and those with comorbidities have a higher risk of accumulation of the toxic metabolite.

Normeperidine toxicity can cause tremors, myoclonus, seizures, and excessive delirium, which are not reversed by naloxone.

The duration of analgesia is only 2-3 hours (shorter than most alternatives).

Demerol has a potentially fatal drug interaction with MAO Inhibitors. Alternative opiates or delivery systems (morphine, hydromorphone, fentanyl, oxycodone) may be superior to meperidine if dosed equivalently, regardless of the cause of the pain.

Non-Drug Strategies

Exercise

PT, OT, stretching, strengthening

general conditioning

Physical methods

ice, heat, massage

Cognitive-behavioral therapy

Chiropracty

Acupuncture

Alternative therapies

relaxation, imagery

herbals

PATIENT AND CAREGIVER EDUCATION

Diagnosis, prognosis, natural history of underlying disease

Communication and assessment of pain

Explanation of drug strategies

Management of potential side-effects

Explanation of non-drug strategies

MRMC PAIN TEAM

Pain Team consulting services is offered to inpatients at Muhlenberg Regional Medical Center. This service is primarily focused on managing acute/chronic pain through pharmacologic therapy.

Non-pharmacological therapy is also offered to inpatients in conjunction with pharmacologic management. Non-pharmacologic mode of therapy can include music, guided imagery, journaling, humor, prayer, and relaxation.