Managing Acute Pain


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Managing Acute Pain

  1. 1. Management Strategies for Acute and Subacute Pain Julio A. Martinez-Silvestrini, MD Medical Director Baystate Physical Medicine and Rehabilitation
  2. 2. Objectives <ul><li>Compare analgesic management options for acute and subacute pain </li></ul>
  3. 3. Pain <ul><li>Defined as localized sensation of discomfort, distress or agony, resulting from the stimulation of specialized nerve endings after tissue damage. </li></ul><ul><ul><li>C fibers and A delta fibers </li></ul></ul><ul><ul><li>Release of histamine, peptides, prostaglandins and serotonin </li></ul></ul>
  4. 4. Pain generators may be: <ul><li>Muscular </li></ul><ul><li>Vascular </li></ul><ul><li>Cutaneous </li></ul><ul><li>Visceral </li></ul><ul><li>Osseous </li></ul><ul><li>Ligamentous </li></ul><ul><li>Neuropathic </li></ul><ul><li>Combination of the above </li></ul>
  5. 5. Acute pain <ul><li>Arises from: </li></ul><ul><ul><li>Acute macrotrauma </li></ul></ul><ul><ul><li>Chronic repetitive microtrauma </li></ul></ul><ul><ul><li>Acute exacerbation of a chronic injury </li></ul></ul>
  6. 6. Inflammation <ul><li>Localized protective response </li></ul><ul><li>Elicited by injury or destruction of tissues </li></ul><ul><li>The first step of tissue healing </li></ul><ul><ul><li>Characterized by: </li></ul></ul><ul><ul><ul><li>Pain (dolor) </li></ul></ul></ul><ul><ul><ul><li>Increased temperature (calor) </li></ul></ul></ul><ul><ul><ul><li>Erythema (rubor) </li></ul></ul></ul><ul><ul><ul><li>Swelling </li></ul></ul></ul>
  7. 7. Why? <ul><li>Coupled with pain, the inflammatory response limits the use of the injured structure </li></ul><ul><li>Avoiding the possibility of further injury to the affected tissue. </li></ul>
  8. 8. Medications <ul><li>Considerations </li></ul><ul><ul><li>Compliance </li></ul></ul><ul><ul><ul><li>59% in TID medications </li></ul></ul></ul><ul><ul><ul><li>84% in Once a day medications </li></ul></ul></ul>
  9. 9. Compliance <ul><li>Significant side effects </li></ul><ul><li>Complexity and organization of the treatment regimen </li></ul><ul><ul><li>Multiple doses or agents </li></ul></ul><ul><li>Cost </li></ul><ul><li>Low perceived benefits </li></ul>
  10. 10. Leadbetter “ If pain and signs of inflammation are persistent, repeated efforts to turn off the body’s alarm is not a substitute for finding the cause of the fire.”
  11. 11. Pain Ladder <ul><li>The World Health Organization (WHO) designed a three-step ‘ladder’ for pain relief in cancer patients </li></ul><ul><li>More recently validated for </li></ul><ul><ul><li>Nonmalignant pain </li></ul></ul><ul><ul><li>Musculoskeletal pain </li></ul></ul><ul><ul><li>Pediatric population </li></ul></ul>
  12. 13. Pain Ladder <ul><li>The administration of medications to control pain consists of scheduled, ‘by the clock’ rather than ‘as needed’ or ‘on demand’ doses. </li></ul><ul><li>Considered to be relatively inexpensive and 80 to 90% effective </li></ul>
  13. 14. Non-steroidal Anti-inflammatories (NSAIDs) <ul><li>~30 million people take NSAIDs daily </li></ul><ul><li>20 million of prescriptions in the UK yearly </li></ul><ul><li>May contribute to 2,600 deaths annually </li></ul><ul><li>Anti-inflammatory, antipyretic and analgesic effects </li></ul>
  14. 16. NSAIDs classes Meclofenamate Fenamates Ibuprofen, Naproxen, Oxaprosin Propionic Acids Nabumetone Napthylkanones Meloxicam, Piroxicam Enolic Acids Celecoxib Cox-2 Inhibitors Aspirin, Salsalate Carboxilic Acids Diclofenac, Sulindac, Indomethacin Acetic Acids Selected NSAID Class
  15. 17. Acetaminophen <ul><li>N-acetyl-P-aminophenol (APAP) </li></ul><ul><li>No anti-inflammatory effects </li></ul><ul><li>First line of treatment </li></ul><ul><ul><li>Patients allergic to aspirin or NSAIDS </li></ul></ul><ul><ul><li>Inflammation is not a predominant component of the pain complex </li></ul></ul>
  16. 18. Acetaminophen <ul><li>Poorly understood mechanism of action </li></ul><ul><li>Central inhibition of prostaglandins </li></ul>
  17. 19. Ceiling effect <ul><li>Doses above a certain level produce no additional analgesia </li></ul><ul><ul><li>but may incur additional toxicity </li></ul></ul>
  18. 20. Opiates <ul><li>Gold standard for pain control. </li></ul><ul><li>High potency and risk of physical dependence </li></ul><ul><li>Potential for abuse </li></ul><ul><ul><li>Should be limited to moderate to severe pain levels </li></ul></ul><ul><ul><li>Used for short periods of time </li></ul></ul>
  19. 21. Opiates <ul><li>If a patient requires opiates for more than 3-4 weeks, long acting opiates for pain control should be considered. </li></ul><ul><li>Short acting opiates for chronic pain control </li></ul><ul><li>Inferior for continuous pain control </li></ul><ul><li>Promote “pain behavior” </li></ul>
  20. 22. Opiates <ul><li>The primary objective is to achieve an acceptable balance between analgesia and adverse effects. </li></ul><ul><li>In opiate-naive patients: </li></ul><ul><ul><li>Short acting, low potency agents </li></ul></ul><ul><ul><li>Advanced gradually. </li></ul></ul><ul><li>Prescribing stool softeners and antiemetics to minimize adverse effects </li></ul><ul><ul><li>May jeopardize compliance. </li></ul></ul>
  21. 23. Compounded agents <ul><li>Second step agents in the “pain ladder” are available in combination with APAP or NSAIDs </li></ul><ul><li>Often over the counter cold remedies contain APAP </li></ul><ul><li>High risk for surpassing the ceiling level. </li></ul>
  22. 24. Tramadol <ul><li>Central analgesic with binary action </li></ul><ul><ul><li>Weak opioid mu receptor agonist </li></ul></ul><ul><ul><li>Reuptake inhibitor of norepinephrine and serotonin. </li></ul></ul><ul><li>Indicated for moderate to severe pain. </li></ul><ul><li>It is considered to be more appropriate than NSAIDS for patients with gastrointestinal or renal disease. </li></ul>