Pain Management- It’s Everyone’s Business!
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Transcript of Pain Management- It’s Everyone’s Business!
Pain Management- It’s Everyone’s Business!
Dr. Joel Loiselle BSc. MD FRCPCStaff Anesthesiologist SBGH (General OR and OBS.)
Director Acute Pain Service (SBGH)
Palliative Care Consultant
Chronic Pain Consultant
Assistant Professor U of M
April 12, 2010.
CPG- opioids are only one part of a multi-modal/multi-disciplinary pain
approach.
…although I am going to talk
about opioids a fair bit today!
Objectives
Discuss some general pain definitions.
Why pain is like an onion! Some short case vignettes- why pain is important to _______.
Take home pearls- look for the important concept slides.
Definition of Pain
“…an unpleasant sensory and emotional experience associated with actual or potential tissue
damage or described in terms of such damage.”
Merskey H, Bogduk N. 2nd ed Seattle, WA: IASP Press; 1994.
Acute Pain: Adverse Consequences
“Stress hormone response” Suffering Neuronal remodeling Chronic Pain
Peripheral and central sensitization
De-conditioning: excessive bed rest
Associated behaviors
Prevention and aggressive treatment of acute pain may help prevent the development of
chronic pain
Chronic Pain
Definition: pain that lasts beyond the period of healing or is associated with chronic disease (arbitrarily 2-6 months).
Ceases to serve protective function or adaptive purpose.
Identified pathology may not explain the presence and/or severity of pain.
May be perpetuated by factors unrelated to the cause.
Associated with irritability, social withdrawal, depressed affect and vegetative symptoms.
Symptoms of catecholamine hyperactivity (tachycardia and sweating) less common.
Jacobsen L.. Bonica’s Management of Pain, 3rd ed. Baltimore, MD, Lippincott Williams & Wilkins; 2001;241-254.
Injury-induced Pain: Patient Factors
McQuay H. BMJ 1997;314:1531.
Individual variation in
response to injury:physiological,behavioural,and cultural
Individual variation in
response to treatment
Context:battlefield orlonely bed
Injury
Pain improveswith time
Complaint of pain
Pain Management: Pathophysiology of Pain and Pain Assessment. AMA, December, 2003
Three Hierarchical Levels of Pain
Sensory-Discriminatory ComponentsLocation, intensity, quality
Motivational-Affective ComponentDepression, anxiety
Cognitive-Evaluation ComponentThoughts concerning the cause
and significance of the pain
Pain Pathways
SUFFERINGSUFFERINGEMOTIONALPSYCHOSOCIAL
PHYSICAL
SPIRITUAL
A not so pretty picture
The steps:-GLU excess-NMDA receptor loses Mg2+
-Ca2+ moves in and stimul. PKC-NO is produced and stimul. guanyl syn. (K+ conduc. decreased) and Sub. P is released-Sub. P stimul. NK-1 receptor which causes c-fos activation-c-fos activation signals pain is entrenched
Chronic pain as a disease?
Pain has outlived its utility. It is typically much more difficult to identify the source of ongoing pain
The earlier chronic pain is treated, the less likely the physiological changes that occur will become firmly entrenched.
It is no longer the symptom but the disease…
Important concept #1
Pain is not a diagnosis but it may be a disease.
How common is Chronic Pain
in our society?
29%
22%
29%
39%
27%
31%
75%
59%
69%
66%
3%
3%
4%
3%
4%
3%
67%
67%Total (n=2012)
18-34 yrs (n=620)
35-54 yrs (n=890)
55+ yrs (n=473)
Male (n=1005)
Female (n=1007)
6 Months or more Less than 6 Months No Chronic Pain
Canadian National Pain Study, 2002Prevalence of Chronic Pain – (>6 Months) (n=2012)
Moulin D., PR&M, 2002
20%
10%
3%
12%
5%
3%
2%
2%
2%
2%
34%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%
ALL ARTHRITIS
Osteoarthritis
Rheumatoid arthritis
Arthritis (other mentions)
Migraines/headaches
Fibromyalgia
Degenerative discs
Angina
Osteoporosis
Sciatica
MS
Those over 55 years of age are significantly more likely to cite arthritis and osteoarthritis particularly
Canadian National Pain Study, 2002Condition Causing The Most Pain (n=340)
Moulin D., PR&M, 2002
Canadian Survey of
Post-surgical Pain 305 Canadian patients – surgery in past 3 years Both inpatient and day surgery Severe or extreme pain – 47% inpts; 15% outpts Still in pain 2 wks afterwards – 79% inpts; 74%
outpts Good relief from pain medications in 54 - 72%
Conclusion: improvements could be made
Rocchi A. Can J Anaesth, 2002
Canadian Pain SocietyPosition Statement on Pain Relief
“Almost all acute and cancer pain
can be relieved, and many people
with nonmalignant pain can be helped.”
Patients have the right to the best pain relief possible.
1. Unrelieved acute pain complicates recovery.
2. Routine assessment is essential for effective management.
3. The best pain management involves patients, families, and health professionals.
Canadian Pain Society, Patient Pain Manifesto, 2001
Treatment options for pain
Many more options outside of drug choices!!!
Opioids are accepted therapy for….
Acute Pain But for how long should you treat?Cancer PainAddiction/diversion is still a concern in this population.Chronic Non Cancer Pain
(CNCP)Most controversial area!
Case vignette # 1 Why pain is important to the surgeon… 50 y/o female
Cholecystectomy (Day surgery) for biliary colic.
Healthy. Previous surgery: ACL repair- was given Acetaminophen/Codeine Tabs and states they did not help to relieve her pain at all. She asks for Oxycodone specifically. Is this a problem?
Case vignette #2Why pain is important to the nurse/ward staff… 38 y/o female
Post op TAH for menorrhagia (endometriosis)
Chronic Pelvic Pain (HMC 6mg tid).
Refuses Epidural. PCA HM instituted: 0.2 mg/h with a bolus of 0.4- 0.6 mg LO of 5 min (usual adjuvants of Acetaminophen and NSAID’s given)
Thirty min. after getting to the ward (1730), the pt received dimenhydrinate 25 mg iv. Three hours later (2030) got an
additional 50 mg of dimenhydrinate po.
Pt transferred to stepdown unit at 0100 b/c of somnolence.
Important concept #2
Caution with other sedating drugs- common examples include
BZD’s and dimenhydrinate.
Analgesia is important but safety is paramount!
Case vignette # 3Why pain is important to the surgeon (again)… Urology slate;
Pt #1: 68 y/o male for a lap. nephrectomy
Pt #2: 42 y/o male for a lap. nephrectomy
Pt #1- requires a total of 10 mg iv Morphine in PARR. (PCA morphine use was as expected).
Pt #2- requires a total of 30 mg iv Morphine in PARR. (Used 100 mg of iv HM in the first 24h!)
What is going on???
Chronic Post surgical Pain (CPSP)
Risk factors: Genetic susceptibility? Preceding pain? Psychosocial factors? Age and sex? Type of procedure?
Strategies to decrease CPSP:
-Multi-modal analgesia?
-NMDA antagonist?
-Analgesia for a longer period of time?
-Surgical technique?
Important concept # 3
Individualize therapy and recognize early chronic
post surgical pain syndromes (NeP).
Case vignette # 4Why pain is important to the family physician/geriatrician… 72 y/o female with post polio syndrome and transverse myelitis (recovered). Also suspected to suffer from fibromyalgia (rheumatology opinion).
Consult reads: “Patient has chronic pain and is also insane. Continuously returning for opioid prescriptions (Codeine). Suggestions please.”
Assesment: Consistent with NeP pain syn. and FM. Pt settled very nicely with TCA and MSC
(no aberrant behavior over 5 yrs of care).
Guidelines from AGS: http://www.americangeriatrics.org/education/pharm_management.shtml
…”the longevity revolution” or “..the silver tsunami…”
- Over 50% of pts in nursing home patients suffer from pain and 80% could benefit from palliative care.
Case vignette # 5Why pain is important to the family physician… 81 y/o male with a RC Tear and Spinal Stenosis. Minimal activity b/c of pain. Fragile- numerous co-morbid conditions.Tx:
Lumbar ED steroid.
Surgical consult- disability minimal with RC.
Tramadol XL 200 mg OD and Tramacet 1-2 tabs per day.
Function re-established- stable for 2 yrs.
Treatment Goals in
Patients with Chronic Pain
Decrease pain
FunctionADLSleepSocialization
Minimize adverse effects
Quotes from this paper:
- CNCP 15-25% at any given time.
- …increases to 50% in pt’s older than 65.
- 18% of American respondents did not seek care as they felt their complaints would be ignored.
- Worldwide 10 million new cases CA/yr.
- 80% of pts with CA experience pain (may be more with advanced disease).
-By 2020- figure will double with 70% occurring in third world countries.
- 60-80% of pts suffering from HIV will have pain.
Why pain is important to health advocates, policy makers and world leaders….
Case vignette # 6Why pain is important to personal care home staff (including pharmacy)… 85 y/o female with IHD and PVD. Neither issue is amenable to surgical correction. Pt also suffers from extreme anxiety. Many medications have been tried without success (somnolence). Pt is frustrated and chooses a “palliative care approach”.
Ischemic pain is both nociceptive and NeP (many times difficult to treat).
Pain stabilized on methadone and increased dose of oxycodone for B/T. Using clonazepam for anxiety- reasonably stable symptoms but more titration has and will be required.
Palliative Care
Cure/Life-prolongingCure/Life-prolongingIntentIntent
Palliative/Palliative/Comfort IntentComfort Intent
BereavementBereavementDEATH
“Active Treatment”
PalliativePalliativeCareCare
DEATH
EVOLVING MODEL OF PALLIATIVE CAREEVOLVING MODEL OF PALLIATIVE CARE
-Courtesy of Dr. Mike Harlos-Medical Director -Palliative Care Program, Wpg., Mb.
Pain control
Case vignette # 7- Why pain is important to the ER staff…
35 y/o female- 6 mo. Hx of vague abd pain. Previous gastric bypass procedure- remains moderately
obese. Admits to excess ETOH. Pt has numerous tattoos covering her body. Presents several times to
ER over months to have abd pain assessed.
Presents Friday nt with abd pain - thought to be drug seeking- therefore sent home.
Presents Saturday with perf’ed viscus. Laparotomy reveals widespread gastric cancer.
Pt declines further tx and PC is consulted. Symptoms controlled- pts dies 3d after
transfer to PC ward.
The Seven Stages of Opioid PrescribingCredit for idea: Dr.Allan Gordon MDNeurologist and DirectorWasser Pain Management CentreMount Sinai Hospital
Stage 1- Opioid Naive
Stage 2- Opiophobic
Stage 3- Opioiphillic
Stage 4- Opioid Expert
Stage 5- Opioid Disaster
Stage 6- Acquired Opioiphobia
Stage 7- Opioid Balance
Dr. Gordon’s messages: Do not fall into the trap of treating all pain the same (ie. opioids).
Appropriate diagnosis and targeted therapy according to the etiology of the pain is key.
A multimodal/comprehensive approach to pain management is essential (and this also involves the patient/family).
Universal Precautions in Pain Medicine Diagnosis with appropriate differential Psychological assessment including risk of
addictive disorders Informed consent (verbal v. written/signed) Treatment agreement (verbal v. written/signed) Pre trial assessment of pain/function Appropriate trial of opioid therapy +/- adjuvants Reassessment of pain score and level of function Regular assess the “Four A’s” of pain medicine Periodically review Pain Diagnosis and co- morbid
conditions including addictive disorders DOCUMENT, DOCUMENT, DOCUMENT
Essential Follow-up Documentation: The “6 A s”
1. Analgesia (pain relief)2. Activities (physical and psychosocial
functioning)3. Adverse Effects (and your advice)4. Ambiguous Drug Taking Behaviour
(and your response)5. Accurate medication record6. Affect
Jovey R. et al. Managing Pain. 2002 p. 121Gourlay DL, Heit HA, Almahrezi A. Universal precautions in
pain medicine: A rational approach to the treatment of chronic pain. Pain Medicine 2005;6:107-112.
Take the time- assess and listen!
Important concepts:1- Pain is not a diagnosis but it may be a disease.2-Caution with other sedating drugs- common examples include
BZD’s and gravol.3- Individualize therapy and recognize early chronic post
surgical pain syndromes (NeP).4- As it relates to chronic pain, fxn may be a more important
outcome than pain relief.5- Don’t get caught in the trap and treat all types of pain
the same (at the same time do not be afraid to use opioids if indicated).
Why pain is important to……the surgeon.…the family physician.…the nurse.…entire paramedical team.…the ER team.…the politician and global advocates.
Education is where it starts.
Link: http://www.medschoolforyou.com/Subjects.aspx
Comments and Questions?