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PAIN MANAGEMENT

A branch of medicine employing an interdisciplinary approach for


easing the suffering and improving the life of those in pain
(Wikipedia, 2014).
Pain:
Defined as an unpleasant sensory and emotional experience
associated with actual or potential tissue damage or described in
terms of such damage.
Modulation Pain:
Different individuals have variability in pain felt even in injuries of
similar magnitude.
Suggestions that a treatment will relieve pain can have a
significant analysis effect (placebo effect) suggests that pain will
worsen following administration of an insert substance can
increase its perceive intensity (nocebo effect).
Pain Classification:
Referred pain spatial displacement of pain sensation from the site
of injuries that produces it.
Neuropathic Pain:
Lesions of the peripheral or central nociceptive pathway typically
result in lose or impairment of pain sensation and can also
produce pain.
- Severe and resistant to standard treatment for pain.
- Usually burning, tingling, pulsating or of electric shock-like
quality.
- May be triggered by very light touch .Pains by which can be
called neuropathic.
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- Damage s to peripheral nerves e.g. diabetic


neuropathy,continued pain continued experienced from a
limb which has been amputated.
- Damages to primary afferents e.g. herps zoster.
- Damages to CNS e.g. Cerebrovascular injuries to spinal cord,
brain stem.
Sympathetically maintained pain:
Spontaneous pain that occur in patients with peripheral nerve
injury.
- Begins after a delay of hours to days or even weeks.
- Accompanied by swelling of the extremilies periarticular
bone loss and arthritic changes.
- CRPSL (reflex sympathetic dystrophy) occurs without obvious
nerve injury and resolves with symptomatic treatment. Signs
and symptoms suggest over activity of the sympathetic
CRPS II (Post traumatic neuralgia or if severe (causalgia).
Occurs with an identifiable nerve injury.
Nocieptive Pain:
-

Pains associated with sprain ankle.


crowding other body parts near the cancer site.
Pains in diseases such as arthritis
Dunded in to two types radicular or sematic.

Goals of pains management


To remove all the pain (if possible).
To remove the cause of the pain.
To minimize side effects of pain reliever.
To cause the patients would once more be able to carry out
activities that was hindered by the pain.
Pain Management Team:
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*Pharmacists
-

Medical practitioners.
Clinical psychologists.
Physiotherapists.
Occupational therapists.
Clinical nurse specialists.

Approaches for treatment (management)


1. Non pharmacological.
A. Physical approach:
TENS (Transcutaneous electrical nerve stimulation)
Acupuncture
Light therapy.
B. Psychological Approach:
- Cognitive behavioral therapy (relationship between ones
physiology and pain. This involves life style changes.
- Hypnosis
- Mindful meditation.
2. Pharmacological approach
Acute pain:
*Cox 2

inhibitor: Aspirin, Acetaminophen, NSADS.

- Inhibit cyclooxygenase.
- Have anti-inflammatory action (expect acetaminophen).
- Effective for mild to moderate headache.
- Usually available without prescription.
Side effects:

- Cox2 selective e.g. Celecoxib has les gastric irritation but


increases cardiovascular risk contraindicated in patients in
the immediate diet period after coronary bypass.
- Acetaminophen (paracetamol) in a high does is toxic to the
live.
- Aspirin has high GIT irritability and also causes GIT bleeding.
NSAIDS have nepherotoxicity and can also increase blood
pressure.
Ketorolac is a parenteral form of NSAIDs.
*Opoid analgesics:
- Most potent pain relieving drugs currently available.
- Do not usually provide complete analgesia weather pain is acute
or chromic in origin.
- Drugs tolerance, chemical dependency, diversion and addiction
may occur.
Side effects include vomiting pruritus, constipation with
respiratory depression (uncommon).
Normeperidene a metabolite of meperidire produes hyper
excitability and seizures that are not reversible with anti opoids.
Examples includes oxycoddore, hydromorphore, methadone
bicarbonate, pentazocine pethidine (meperdine) Normeperdine is
a metabolite of mependine produces hyper excitability and
seizures that are not reversible with anti opiods.
- Opiods can be given intrathecally eg. (o-o.3)mg morphine
(used in cancer paheab) intravenorslly (E.g. 5-10mg
morphine ) reactively transdermally (fentanyl)
- 2nd and 3rd line in pain management.
Patients controlled Analgesia (PCA) - New?
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- A microprocessor controlled infusion device that can deliver


a baseline continues dose of opiod doing as well as
preprogrammed additional doses when the patient pushes a
button.
- To prevent overdosing, PCA are programmed with a lack out
period of one hour.
- Used for post-operative pain.
- Should be used for short-term home care of patients with
intractable pain such as metastatic cancer.
*Note it is important to assess the patients for the risk of
substance abuse, misuse or addition before during are
administered.
Chronic Pain:
This is caused by
- Disease e.g. Arthritis, Cancer, Chronic daily headaches,
fibromyalgia, diabetic neuropathy etc.
- Secondary, perpetuating factors initiated by diseases and
present after that disease has resolved e.g. damage sensory
nerves, sympathetic efferent activities, and painful reflux
muscle contraction.
- Psychological Condition
Drugs used include:
Anti-depressant medications
TCAS e.g. norhyptytine and desiproamine
Although the mechanism is unknown, analgesic effects of TCAs
has a more rapid onset and occurs at a lower dose than in
typically required for the treatment of depression.
- Selective serotonin reuptake inhibitors (SSRIs) e.g.
Fluoxetine (Prozac). These groups have fewer and less
serious side effects than TCAs.
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Non tricyclic antidepressants.


Blocks both serotonin and norepinephrine reuptake.
Appears to retain most of the pain reliving effects of TCAs.
Side effect profile more like that of SSRs.
Particularly useful in patients who cannot tolerate the effects
of TCA,s
- The first drug of choice in chronic pain management.
2. Anticonvulsants:
- For neuropathic pains mainly.
-

Phenytoin (Dilartin) and carbamazepine (Tegretol) 1 st used

Newer drugs e.g. Gabapentin (neurotin) and pregabatin


(Lyrica) have a broad range for neuropathic pain.

Newer drugs are first line (in the use of anticonvulsants)


because of favorable side effect profile.

3. Antairrythmics:
- Lidocaine & mxiletene are examples.
- Less likely to be effective as even the intravenous effects
wane
off hours soon after administration.
Drug-Drug Interaction.
*Opioid and COX inhibitor combination.
-

Additive inhibitor analgesic effect.

- severity Side effects are non-additive therefore combinations


are used to
lower the of dose related side effects.
- Fixed ratio combination of opioid + paracetamol can become
a problem since every increase in dose would cause an
increase of paracetamol which could lead to toxicity .
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- Pentazocine and butorphenol have mixed against


antagonist properties.
*Opioids and TCAs.
- TCAs potentiate opioid analgesics and are additive also in
their side effects.
*Cimetidine, Gabapentin & grapefruit juice potentiates opiates
by inhibitory
cytochrome 450 enzymes in the liver.
Drug-Herb interactions:
NSAIDs e.g. Aspirin, interact with ginkgo, garlic, ginger, bulberry,
dongqual, feverfew, ginseng, tumeric, meadow sweet.
paracetamol + ginko -increased bleeding.
Paracetamol + Echinacea and /or kava s - increased
hepatotoxicity.
Paracetamol + herbs contarnury selicyelate glues an increase in
nephrotoxicity.
Opioid analgesic + valerein, kava and chamomille cause an
increase central nervous system depression.
Opioid analgesic + finsery___Inhabits effect.
Reasons for deficiencies in patient pain management:
- Physicians usually prescribe inadequate dose of opioids in
managing severe pain for fear of being accused of over
prescribing .
- Misconception that pain is a normal peart of eging .
- Inadequate training.
- Personal bias.
- Poor assessment.
Note that

Intrathecal drug delivery system for severe and persistent


pain.
Epidural injection of glucocorticoids.

CONCLUSION
Psychological pain is all around us (emotional, physical, etc)
but if measures are taken to assess properly the aspect of
pain that is most central in the life of any individual, usually
almost all other pains are taken care of.
REFERENCES
www.medtronicneuro.con. Au/chronic pain-common type &
html.
www. power over your pain.com/understand/chronic /pain
types.
www. Medicienent. Com/ pain-management /page 2.html
www.help for pain .com/articles / understand-neurpathinpain/ understanding.html.
www.webmd. Com/pain-management/fuide /painmanagement-symptoms-types.
www.annies remedy .com/chart/php.
Kumar and chart (2002) clinical medicine. Edition. w.b
sunder.Longo etal (2012).
Harrisons principles of internal medicine 18th edition.
http: llen. Wikipedia.org/wiki/ pain management.