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~ International Association ofthe Study of Pain, 1994

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Chronic Pain

100 million

Diabetes

25.8 million

Heart Disease

16.3 million

Cancer

11.9 million

IOM, 2011

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CDC, 2016

CDC, 2016

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(CDC, 2016)

Source of Opioid Prescriptionsfor Medical Users Percent

Own prescriptions 27%

From friends or relatives for free 26%

Buying from friends or relatives 23%

Buying from drug dealer 15%

outside of active cancer treatment, palliative care, and end-of-life care.

CDC, March 2016

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CDC Opioid Guidelines are here to stay!

1. Visible signs always accompany pain & can verify pain existence & severity.

False: Even with severe pain, adaptation occurs, leading to periods of minimal or no signs of pain. Lack of pain expression does not necessarily mean lack of pain.

2. Sleep equals pain relief.

False: People may sleep as a means to cope with unrelieved pain.

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3. Everyone who takes an opioid will become addicted.

• False: Depends on their personal risk of addiction.

• Even without addiction, long-term opioid use will create dependence

Addiction is often confused with tolerance & physical dependence.

Tolerance: An increased dose is required to reach effect

Physical dependence: S/Sx of withdrawal (sweating, diarrhea, agitation)

Addiction: Psychological dependence on a drug with or without physical dependence.

4. There is an upper limit to the dose of opioid medication that can be given.

• False: Opioid pain relievers can be given in whatever amount is needed to achieve pain relief

• But start low & go slow.

5. It’s unsafe to give opioids to children or the elderly.

• False: Opioids are safe as long as they are adjusted to past history of opioid use. Children will also need dose adjusted to their size & weight.

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6. Opioids are frequently associated with respiratory depression.

False: Respiratory depression can occur. However, in long term stable dosing, this will not occur.

• With short term or acute pain, titrate up based on history of opioid use

• Sedation will ALWAYS precede respiratory depression

7. Nausea and vomiting is an allergy symptom.

False: Nausea may occur initially but tolerance develops rapidly. If present, provide an anti-emetic for the first 3 to 4 days.

• Sedation & cognitive impairment may also occur initially(first 24 – 48 hours) but patients should become tolerant to this effect.

8. If a person doesn’t ask for pain medication, then they don’t have pain.

False: Some cultures consider asking for pain medication a sign of weakness, however, if asked, they will admit they need pain relief.

Some patients don’t want to be viewed as a “pest” or “complainer” and won’t volunteer information.

Others fear being seen as a drug seeker.

9. Opioids should be avoided unless actively dying

• False: Opioids are VERY effective for relieving acute pain• Shortens recovery time

• Improves functioning

• Improves quality of life

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1. Nociceptive Pain

2. Neuropathic Pain

Nociceptive Pain: Somatic and Visceral

Location

Cause

Quality

Example

Adapted from: APS. Pain: Current Understanding of Assessment, Management, and Treatments. Glenview, IL: American Pain Society; 2006.

Superficial Somatic Pain Deep Somatic Pain Visceral Pain

Skin, subcutaneous tissue, mucous membranes

External mechanical, chemical, thermal events

Sharp pricking, burning

Chemical burn,cuts, skin contusions,

post-op incision, mucositis

Muscles, tendons, joints, bones

Overuse, strain, injury, cramping,

inflammation

Dull aching, cramping

Arthritis, tendonitis, bone fracture

Gastrointestinal tract, heart, lungs, kidneys, pancreas, gallbladder, liver, bladder

Organ distention, muscle spasm, traction, ischemia,

inflammation

Deep aching, sharp stabbing; referred to cutaneous sites

Appendicitis, pancreatitis, liver disease, bladder

distention

Neuropathic Pain: Peripheral and Central

Definition

Cause

Quality

Examples

Peripheral PainMono/poly-

neuropathies Deafferentation PainSympathetically Maintained Pain Central Pain

Along distribution of one or multiple peripheral nerves

Metabolic disorders, toxins, infection, trauma, compression,

autoimmune/hereditary diseases

Continuous, deep, burning, aching, paroxysmal

lancinating

Diabetic neuropathy, postherpetic neuralgia, carpal tunnel syndrome

Due to loss ofafferent input

Damage to a peripheral nerve, ganglion, or plexus,

CNS disease or injury

Burning, cramping, crushing, aching, stabbing,

shooting, hyperalgesia, hyperpathia, dysethesia

Phantom limb pain, post-mastectomy pain

Maintained by sympathetic nervous system activity

Peripheral nerve damage, sympathetic efferent

innervation

Burning, throbbing, pressing, shooting,

allodynia, hyperalgesia,

Complex regional pain syndrome, phantom limb pain, postherpetic neuralgia, some

metabolic neuropathies

Caused by a primary lesions or dysfunction of

the CNS

Ischemia, trauma, syrinx, demyelination

Burning, numbing, tingling, shooting, allodynia,

hyperalgesia

Post-stroke pain, some cancer pain, pain associated

with multiple sclerosis

Adapted from: APS. Pain: Current Understanding of Assessment, Management, and Treatments. Glenview, IL: American Pain Society; 2006.

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Body’s Natural Pain Fighters

The body has neurohormones that naturally suppress pain conduction.

• Enkephalins (works at the spinal cord)

• Endorphins (works at the brain stem)

• Bind to opioid receptors on nerve endings

• Inhibit transmission of pain by preventing transmission of impulses to brain via spinal cord

Strategies for Managing Pain &

Associated Disability

Pharmacotherapy

APAP, NSAIDs, SNRIs, TCAs, opioids, topical agents

Interventional Approaches

Injections, neuro-stimulation

Psychological Support

Psychotherapy, group support, relaxation,

meditation, CBTLifestyle Change

Exercise, weight loss, anti-inflammatory diet

Complementary & Alternative Medicine

massage, herbals, acupuncture, heat/cold,

music, essential oils

Physical Medicine & Rehabilitation

Assistive devices, TENS,

Physical Therapy, exercises

Multimodal Treatment Best

How Can Pain Be Treated?

Main Classifications of Pain Medications

• NSAID

• Acetaminophen

• Opioid Medications

• Adjuvant Medications

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Pain Rating

(Scale of 0-10)Primary Medications Adjunct Medications

Mild pain or a rating of

1 to 3

Nonopioid, such as an NSAID

or acetaminophen

Antidepressant or

anticonvulsant

Moderate pain or a

rating of 4 to 6Weak opioid, such as codeine

or hydrocodone

NSAID, acetaminophen,

cyclooxygenase-2 inhibitors,

antidepressant, or

anticonvulsant

Severe pain or a rating

of 7 to 10

Strong opioid, such as

morphine, oxycodone, or

fentanyl

NSAID, acetaminophen,

antidepressant, or

anticonvulsant

Pharmacotherapy

NSAIDsAction: analgesic, antipyretic, anti-inflammatory, anti –thrombic

How do they work?

• Interfere with prostaglandin production.

• Metabolized by the liver, excreted by kidneys.

NSAIDS can give relief from mild to moderate pain, but are also extremely helpful in managing pain from bone metastasis.

Consider starting a medication for stomach protection if taking NSAID routinely.

NSAIDs & the COX Pathways

COX-1

• Continuously stimulated by the body

• Concentration in the body remains stable

• Creates prostaglandins

• Prostaglandins stimulate normal body functions

• stomach mucous production

• regulation of gastric acid

• kidney water excretion

COX-2

• Induced, not constant

• Built only in special cells

• Signals pain and inflammation

• Produces prostaglandins for inflammatory response

• Production is stimulated by inflammatory cytokines and growth factors

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Acetaminophen

Action: analgesic, antipyretic.

How does it work? • True mechanism of action is not fully known.

• Thought is that it weakly prohibits prostaglandin.

• Excreted through kidney’s and can be liver toxic.

Maximum daily dose? • 3000mg/day acute dosing

• 2000mg/day routine dosing

Combination Products Containing Acetaminophen

OPIOID Combination Drug

Hydrocodone Vicodin (5mg + 300mg Acetaminophen)

Vicodin ES (7.5mg + 300mg Acetaminophen)

Vicodin HP (10mg + 300mg Acetaminophen

Norco / Lortab (5mg +325mg Acetaminophen)

Norco / Lortab (7.5mg + 325mg Acetaminophen)

Norco / Lortab (10mg + 325mg Acetaminophen)

Lortab Elixer (10mg + 325mg Acetaminophen/15 ml)

Hycet (7.5mg + 325mg Acetaminophen/15ml)

Oxycodone Percodan (5mg + 325mg ASA)

Percocet (multiple Doses)

Roxicet (5mg + 325mg Acetaminophen)

Codeine Tylenol #2 (15mg + 325mg Acetaminophen)

Tylenol #3 (30mg + 325mg Acetaminophen)

Tylenol #4 (60mg + 325mg Acetaminophen)

Corticosteroids

• Action: Analgesic, anti-inflammation, Bone Pain

• How do they work?

• Decrease inflammation by limiting neutrophils and macrophages to the inflammation site.

• Suppress hypersensitivity and the immune response.

• Suppress redness, edema, heat and pain.

• Don’t need both Steroid and an NSAID as they have similar actions. Use one or the other.

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OPIOIDSAction: Analgesia

How do they work?

• Bind to receptors in the brain, spinal cord and periphery.

• Stimulate opiate receptors, giving the effects of endorphins.

• Can be given via any route.

• Metabolized by the liver but metabolites are excreted by the kidneys.

• Morphine is the “Gold Standard” drug of choice for moderate to severe pain.

Side effects of Opiates

• Sedation – ALWAYS comes before respiratory depression

• Dizziness• Nausea / Vomiting• Constipation• Itching• Respiratory depression• Myoclonic movements

Most side effects will subside after a few days of continued use.

Exception . . . CONSTIPATION!Unless otherwise indicated, all patients on an opioid should have a bowel regimen.

Adjuvant Analgesics

Medications that have indications for other diagnosis.

• Given alone or in combination with opiates to treat neuropathic and chronic pain.

Drug Classes Used As Adjuvant Analgesics

Muscle Relaxers (use with caution)

Steroids

Antipsychotics

SNRIs

Tricyclic Antidepressants

Anticonvulsants

Local anesthetics

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Pain Standards

• Everyone has the right to have their pain relieved.

• Self-report is what we base our interventions on.

• Fear of addiction or history of addiction shouldn’t be a barrier.

• Tolerance and physical dependence are consequences of opioid analgesic and are not addiction.

• An interdisciplinary / multimodal approach to treatment is best.

• If procedure / injury would be painful to you then it is painful to them (dementia or non-verbal pts).

• Educate, EDUCATE, EDUCATE!