Powerpoint/PDF interdisciplinary approach to the management of pain

1. MP 0686328 | Practice No 0687359 Office: 021 975 7093 | Email: drcventer@mweb.co.za | reception@paincapetown.com | Suite 6, 2 Somerset Crescent, Durbanville
An Interdisciplinary approach
to pain management
Dr. Ché Venter
Neurorehabilitation and Pain Practitioner
Medico legal and RAF4 Independent medical
Examiner
MBChB (UCT) CIME
© Dr Ché Venter
CapeTownPainClinic

2. Disclosures
© Dr Ché Venter
None

3. What is Pain?
© Dr Ché Venter
An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described
in terms of such damage.”
International Association for the
Study of Pain (Merskey, 1979)
Pain is always subjective.
• The patient’s self-report of pain is
the single most reliable indicator of
pain
• It is NB that the clinician accepts
this

4. Pain Management Policy at the Cape
Town Pain Clinic
© Dr Ché Venter
Optimal acute pain management is essential to
prevent chronic pain
• Appropriate screening and pain assessment
• Documentation
• Care and treatment
• Pain education

5. Pain Management Policy at the Cape Town
Pain Clinic
© Dr Ché Venter
Putting the pieces of the
puzzle together

6. The Pain Cycle
© Dr Ché Venter

7. © Dr Ché Venter

8. Acute Pain VS
Presents most often with a clear cause,
relatively brief in duration and subsides as
healing takes place.
Acute pain is often accompanied by
observable objective signs of pain
• increased pulse rate
• increased blood pressure
• Non-verbal signs and symptoms
such as facial expressions and
tense muscles.
Chronic Pain
• Pain that is persistent and recurrent
• When pain persists, it serves no
useful purpose and may dramatically
decrease the quality of life and
function
• Chronic pain rarely has any
observable or behavioral signs
although persons may appear
anxious or depressed
© Dr Ché Venter

9. Chronic Pain Disorders
© Dr Ché Venter

10. Cancer Pain
© Dr Ché Venter
Pain that is associated with cancer or cancer
treatment
May be attributed to
• Tumor location
• Chemotherapy
• Radiation therapy
• Surgical treatment

11. Pain Assessment
© Dr Ché Venter
Initial Pain Assessment should include:
• Location(s)
• Intensity
• Sensory quality
• Alleviating and aggravating factors
Any new onset of pain requires a new comprehensive pain assessment.

12. Modalities to objectively assess pain
© Dr Ché Venter
Patient self report of pain must be a source of assessment

13. Modalities to objectively assess pain
© Dr Ché Venter

14. Pain Reassessment
© Dr Ché Venter
• Every 8 hours minimally
• Following the administration of pain medications to determine the
effectiveness of the medication and/or need for further intervention
• IV within 15 mins of administration PO/IM/SC within 1 hour of
administration

15. Pain Management Approach
© Dr Ché Venter
Should be interdisciplinary and multimodal
Care is individualized and may depend on:
• Pain source and intensity
• Patient’s age
• Developmental, physical, emotional and cognitive status
• Cultural beliefs
• Treatment preferences
• Concurrent medical conditions
• Treat concurrent mood disorders, especially depression

16. Physical Therapy
© Dr Ché Venter
• A good baseline
• Obesity/increased adiposity results
in endothelial dysfunction
• Decreases inflammatory markers
• Improves Insulin sensitivity
• Improves mental health
Exercise is a physiological stressor:
• Lower intensity
• Shorter duration
Exercise induced hypoalgesia:
• Increases sensitivity to opioids –
by Beta endorphin release
• Assists with Noxious Inhibitory Control
• Can assist with weaning or dose reduction
of opioids

17. Psychotherapy
© Dr Ché Venter
• Reduction in Brain Derived Neurotropic factor (BDNF)
• Reduction in brain regional grey matter by 4.6 % for every 1 year of pain
• Recovers with treatment
• Central sensitization
- Upregulation of noxious signaling
- Endogenous signaling
More efficient transmission of nociception
Faciliatory Inhibitory
CCK Serotonin
Nitrous Oxide Noradrenalin
Excitatory amino acids Dopamine
GABA

18. Dietetics
© Dr Ché Venter

19. Multimodal Analgesia
© Dr Ché Venter
This term describes the use of multiple modalities that are used to provide pain relief
with various parts of the pain pathway targeted
Decreased dependence on a single modality agents decreases the risk of side effects:
May include
• Pharmacological (opioids, NSAIDS, gabapentanoids)
• Relaxation techniques (biofeedback, deep breathing)
• Regional analgesia (nerve blocks, epidural catheters)
It allows for opioid sparing !!
Reduces polypharmacy !!

20. Treatments May Include
© Dr Ché Venter
Non-pharmacologic Methods
• Heat/cold
• Relaxation
• Distraction
• Graded motor
imagery
• Acupressure/acupu
ncture
• Repositioning
Pharmacologic Methods
• NSAIDS
• Anti-seizure
medications
• Anti-depressants
• Opioid analgesics
• Local anesthetics
• Neurolytics
• Cannabinoids

21. Acute vs. Chronic Pain Management
© Dr Ché Venter
Acute Pain Chronic Pain
Most often treated with:
• NSAIDS
• Opioids
• Local anesthetics
• Splinting
• Positioning changes
• Ice
Most often treated with:
• Combinations of
paracetamol and opioids such as
tramadol
• Opioids (oxycodone and
tapentanol, combinations of
opioid and naloxone)
• Anti-seizure medications
(Carbamazepine
• Anti-depressant medications
• NSAIDS
• Implantable devices
• Psychological therapy
• Acupuncture

22. Undertreatment of Chronic Pain
© Dr Ché Venter
American Pain Society 2001, Gjachen
• > 40 -50 % of patients in the routine practice settings
• In a recent study of 805 Chronic Pain sufferers, > 50 % had to change
physicians to establish pain control
??
- Unwillingness to treat pain aggressively
- Lack of empathy or belief in the patient’s perception of pain
- Inadequate knowledge

23. © Dr Ché Venter

24. Responsible Opioid Prescribing
© Dr Ché Venter
Assess risk for opioid abuse
Risk factors for misuse or abuse of opioids include the following
• Males between 18 and 45.
• A personal history of substance abuse
• A family history of substance abuse
• A personal history of preadolescent sexual abuse
• A personal history of psychological disease (depression, anxiety, obsessive-
compulsive disorder

25. Patient and Family Education
© Dr Ché Venter
Patients and family are given specific instructions prior to discharge regarding
• Pain control
• Pain medications
• Management of potential side effects

26. Thank You
© Dr Ché Venter

27. Questions ?
© Dr Ché Venter