Published on December 12, 2007
Managing PainPharmacologic and Non-Pharmacologic Approaches: Managing Pain Pharmacologic and Non-Pharmacologic Approaches Pain Definition: Pain Definition Pain refers to any type of physical pain or discomfort in any part of the body Pain may be localized or more generalized Pain may be acute, chronic, continuous, intermittent, occur at rest or with movement Factors Associated With Chronic Pain In The Elderly: Factors Associated With Chronic Pain In The Elderly DJD Rheumatoid Arthritis Low back disorder Osteoporosis Neuropathic pain Headaches Pressure ulcers Oral or dental pathology Chronic leg cramps Peripheral vascular disease Post-stroke syndrome Immobility, contractures Amputations Total Pain: The Complex and Interrelated Dimensions of Pain: Total Pain: The Complex and Interrelated Dimensions of Pain The ABCs of Pain Management: The ABCs of Pain Management Always ask the patient Assess the pain and side effects systematically. Believe the patient and family Choose appropriate pain control Deliver medication in timely manor Empower and Educate patients and their families Enable patients to help control their treatment Pharmacologic Approach to Pain Management: Pharmacologic Approach to Pain Management Pharmacologic TreatmentWorld Health Organization (WHO): Pharmacologic Treatment World Health Organization (WHO) WHO Approach: WHO Approach Five Concepts By mouth By the clock By the ladder For the individual Pay attention to detail STEP 1Mild to Moderate Pain: STEP 1 Mild to Moderate Pain Acetaminophen (2.5-3.5 grams) NSAIDS (no prolonged use) Motrin, Relafin, Trilisate Adjuvant medications Cox-2 Inhibitors Vioxx, Celebrex COX-2 Inhibitors: COX-2 Inhibitors Advantages Better safety profile Selective inhibitor Fewer side effects Fewer drug interactions Disadvantages Allergies GI disturbances Asthma Elevated LFT Renal function Heart failure/fluid retention Requires monitoring of Renal & Liver functions and CBC STEP 2Moderate to Severe Pain: STEP 2 Moderate to Severe Pain Addition of combination opiate to Step 1 drug Vicodin or Lortab, Vicoprofen Percocet Tylox; Tylenol 3 Be aware of the total daily Tylenol dosage Tramadol (Ultram) Morphine, Oxycodone STEP 3Severe Pain: STEP 3 Severe Pain Substitution of Step 2 agent Morphine or Oxycontin preparation Oxycodone, Dilaudid Fentanyl patch (2nd line) Use of short and long acting preparation Combine with adjuvant Opioids: Opioids Long acting opioids Methadone-Sustained release products Transdermal fentanyl Meperidine Metabolic accumulation Fentanyl patch Ease of administration Difficult to titrate- slow onset Absorption affected by muscle mass Adjuvant Analgesic in Pain Management: Achieves a more favorable balance between side effects and pain relief of: Neuropathic pain Visceral pain Bone pain Adjuvant Analgesic in Pain Management Adjuvant Analgesics: Adjuvant Analgesics Steroids Antidepressants Anticonvulsants Antispasmodics Proactive Pain Management: Proactive Pain Management Anticipate painful events Avoid PRN dosing (<3 PRN QD) Use long/short acting combination Timing of administration of one has no relation to timing of administration of the other Treat pain early and aggressively Anticipate swallowing problems Recognition and Prevention of Side Effects: Recognition and Prevention of Side Effects Constipation Nausea/vomiting Sedation/confusion Respiratory depression Drug accumulation Myoclonus General Recommendations: General Recommendations Initiate pain management with immediate release form- adjust as needed Once at optimal dose - switch to extended release preparations Breakthrough medication on board 2-4 days for dose titration (long-half life) Chronic pain –Around the Clock Acute pain -PRN General Recommendations: General Recommendations Reassess pain if opioid needs are changed Determine need for adjuvant therapy Employ oral route of administration Avoid IM route of administration Avoid Meperidine and Propoxyphene Use preventive bowel regimen Case Study: Customer is 82 years old with prostate cancer, dementia, incontinence, and admitted after pneumonia. He is complaining of severe pain, mostly in legs and back. Demerol/Vistaril ordered in hospital. What type of pain syndrome is likely? What would be your approach? Case Study Non-Pharmacologic Approach To Pain Management: Non-Pharmacologic Approach To Pain Management The Pain Cycle: The Pain Cycle DEPRESSION LIMITED/LOST ABILITIES PAIN STRESS ACTIVITY… ACTIVITY…: ACTIVITY… ACTIVITY… Non-Pharmacologic Approaches: Non-Pharmacologic Approaches Exercise and mobility training Heat, cold, massage, ultrasound, paraffin, and/or TENS Positioning and/or splinting Education Stress management techniques: Biofeedback, relaxation, stress reduction Other techniques Who can provide these techniques?: Who can provide these techniques? Rehabilitation department (Skilled facility) Activities department/Recreation Therapy (Skilled facility) Nursing Physicians Therapists Therapeutic Exercise: Therapeutic Exercise Range of motion Strengthening Endurance training Aquatic therapy Functional mobility training Modalities: Modalities Heat: warm compress, hot packs and/or K-pads Cold: ice pack, cold pack or ice massage Massage Ultrasound Paraffin TENS Positioning and/or Splints: Positioning and/or Splints Bed positioning Wheelchair positioning Splinting Upper extremity Lower extremity Spinal EDUCATION Patient/Caregiver Education: Patient/Caregiver Education Posture Body mechanics Benefits of rest Joint protection Energy conservation Other Techniques: Other Techniques Biofeedback Relaxation techniques Stress reduction Aromatherapy Pet Therapy Other Techniques : Other Techniques Hypnosis Acupuncture Meditation Yoga Team Approach : Team Approach Communication Coordinate pain management with functional activities Questions?: Questions? Slide34: This material was prepared by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization for Pennsylvania, under contract with the Centers for Medicare & Medicaid Services (CMS). The views presented do not necessarily reflect those of CMS. Publication number 7SOW-PA-NH05.309.