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PAIN MANAGEMENT

Pain is a symptom
Pain is subjective
Pain is influenced by many factors
Localised pain may have different source
Nature and causes of pain are heterogenous
Other therapy outside of analgesia may be
required

Transmission of pain stimulus

Pain receptor (Nociceptor)at site of pain


Receptors translate to electrical impulse
Transmitted via nerve to spinal cord
Transmitted to pain centre of brain
Action produced by CNS depends on type
of nerve

Nerves
MYELINATED NERVES
Reflex action - quick response
UNMYELINATED NERVES
Secondary pain
Chronic pain - no response

Persistent pain may be due to


Ongoing tissue damage
Chemical irritants
Inflammatory mediators

ANALGESIA
Non-opioids - paracetamol, compound
preps and NSAIDs including aspirin
Opioids (narcotics)

Drug binds to opioid recs


Reduce release of inflam mediators
reduce electrical transmission of impulses
Affect levels of GABA in brain

Opioids - Side effects


Dependence and tolerance with long term
use
Constipation
Nausea
Pyschiatric effects
Respiratory depression
In overdose naltrexone used as antidote
(Naloxone)

Examples of opioids

Codeine
Dihydrocodeine
Alfentanil, fentanyl and remifentanil
Morphine, diamorphine
Pethidine
As narcotics they have to be locked and
registered

Acute pain
Arises from injury, trauma, disease or
spasm
involve both types of nerves
intensity proportional to damage
Limited duration
Intensity dec with healing

Types of acute pain


Superficial pain
throbbing, burning, picking

Visceral pain
Diffuse, dull, aching
Usual at onset/early disease stage

Treating acute pain


Aims
Reduce symptoms till healing
Enhance comfort

Post-surgical pain - opiates


NSAIDs in other causes

Chronic pain
Persists beyond injury
Usually malignancy OR non-malignant ex.
Neuropathic
Not always an objective cause
Pyshological damage
Dosing - 24 hour demands

Chronic pain
Selection of drug depends on nature of pain
Evaluation of pain - PQRST model:

Palliative pain?
Quality of pain?
Region of pain?
Severity of pain?
Time-related?

Treating different types of pain

Post-operative pain
Palliative care and cancer pain
Headache
Migraine

Post-operative pain

Pain will fluctuate hourly and daily


Analgesia not prn but continous
opioids first line
Addiction not a problem
Avoid delayed onset of action initially
If first dose not adequate - adm another 5
mins after IV, 1 hour after IM/SC and 90
mins after oral adm

Post-operative pain
Avoid pethidine repeated adm esp with
renal dysfunction
Post-op pain started before or at onset of
pain? Controversial
Intravenous analgesia - bolus opioid,
continous inf opioid or Patient Controlled
Analgesia (PCA)

Post-operative pain
Bolus administration opioid
Theatre and recovery rooms
Small boli till controlled
Constant supervision needed - not practical

Intravenous infusion opioid


Continous delivery via pump
Lag period - give initial bolus
Differing response- monitor

Post-operative pain
Patient controlled analgesia (PCA)

Give patient responsibility to control pain


Pump connected to patient with IV line
Patient controls dosing
Lock-out time for safety
Selective patients

Post-operative pain
Oral dosing opioids
Not immed post-op because
Dose req too large
Post-op nausea
GI Surgery

To be considered as soon as possible

Sublingual/buccal route - not used locally


V. fast onset
No FPE so lower dose needed

Cancer pain
Pain assessment:
Initially and regularly
Change in nature of pain
Pharmacological intervals

Cancer pain includes bone pain, neuropathic


pain, oral ulceration
Apart from analgesia, chemo, radiotherapy,
surgery

Cancer pain
WHO analgesic ladder:
Step 1: non-opioid analgesia
Step 2: Weak opioid + non-opioid
Step 3: Strong opioid +/- non-opioid

Adjuvant analgesia may be added at any


step
Choose simplest dosage schedules
Try other drugs in same category before
moving up

Cancer pain
Long term - consider break through pain
Step1: non-opioids
paracetamol, NSAIDs esp bone pain, tendons,
muscle pain, visceral pain.
No relief after 1 week try other NSAID before
moving up ladder

Cancer pain
Step 2: weak opioids
Codeine and dihydrocodeine and
dextropropoxyphene
Convenient non-opioid plus weak opioid
formulations - Co-proxamol
Inc. doses of weak opioids before moving up
ladder if combination prods used
Tramadol

Cancer pain
Step 3: Opioids
Oral morphine
Dependence not an issue in these patients
Initially start with syrup, start inc dose by 50%
daily till total pain control
Then calculate daily dose and give as Oral
Morphine Sustained release tablets twice dly
Keep oral syrup for breakthrough pain

Cancer pain
Consider other routes of adm if:
Severe dysphagia
Intractable nausea and vomiting
Head and neck cancer
Intestinal obstruction
Comatose or semiconscious patient
Rapid onset is required due to acute pain

SC pref to IM
Continous IV may be req - maybe PCA
Fentanyl transdermal patch

Cancer pain
Adjuvant analgesia
Corticosteroids - mood elevation, anti emetic
Anti-epileptic - lancinating/stabbing pain,
carbamazepine, gabapentin
Tricyclic antidepressants - Burning discomfort
used at lower doses ex. amitriptyline

Migraine
Phases of migraine headache involve:
Prodromal phase 1-2 days before
Auras 1-2 hours before - visual changes,
dizziness, drowsiness
Post-dromal phase - after headache subsided for
a day or two

Migraine
Trigger Factors:

Hormonal changes - HRT, OCs, Pregnancy


Environmental factors
Foods
Exercise or exertion

First line management is to avoid trigger


factors

Management of Migraine
Avoid triggers
Analgesia
GI S/E major concern
Larger doses than normal
Often combined with metoclopramide

Triptans
Mimic 5-HT involved in migraine
Only indicated for migraine pain