MP 0686328 | Practice No 0687359 Office: 021 975 7093 | Email: drcventer@mweb.co.za | reception@paincapetown.com | Suite 6, 2 Somerset Crescent, Durbanville

An Interdisciplinary approach to pain management

Dr. Ché VenterNeurorehabilitation and Pain PractitionerMedico legal and RAF4 Independent medicalExaminerMBChB (UCT) CIME

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Cape Town Pain Clinic

Disclosures

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None

What is Pain?

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An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

International Association for the Study of Pain (Merskey, 1979)

Pain is always subjective.• The patient’s self-report of pain is

the single most reliable indicator of pain

• It is NB that the clinician accepts this

Pain Management Policy at the Cape Town Pain Clinic

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Optimal acute pain management is essential to prevent chronic pain

• Appropriate screening and pain assessment• Documentation• Care and treatment• Pain education

Pain Management Policy at the Cape Town Pain Clinic

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Putting the pieces of the puzzle together

The Pain Cycle

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Acute Pain VS

Presents most often with a clear cause, relatively brief in duration and subsides as healing takes place.

Acute pain is often accompanied by observable objective signs of pain

• increased pulse rate• increased blood pressure• Non-verbal signs and symptoms

such as facial expressions and tense muscles.

Chronic Pain

• Pain that is persistent and recurrent

• When pain persists, it serves no useful purpose and may dramatically decrease the quality of life and function

• Chronic pain rarely has any observable or behavioral signs although persons may appear anxious or depressed

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Chronic Pain Disorders

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Cancer Pain

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Pain that is associated with cancer or cancer treatment

May be attributed to • Tumor location• Chemotherapy • Radiation therapy• Surgical treatment

Pain Assessment

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Initial Pain Assessment should include:• Location(s) • Intensity • Sensory quality • Alleviating and aggravating factors

Any new onset of pain requires a new comprehensive pain assessment.

Modalities to objectively assess pain

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Patient self report of pain must be a source of assessment

Modalities to objectively assess pain

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Pain Reassessment

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• Every 8 hours minimally

• Following the administration of pain medications to determine the effectiveness of the medication and/or need for further intervention

• IV within 15 mins of administration PO/IM/SC within 1 hour of administration

Pain Management Approach

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Should be interdisciplinary and multimodal

Care is individualized and may depend on:

• Pain source and intensity• Patient’s age• Developmental, physical, emotional and cognitive status• Cultural beliefs • Treatment preferences• Concurrent medical conditions• Treat concurrent mood disorders, especially depression

Physical Therapy

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• A good baseline• Obesity/increased adiposity results

in endothelial dysfunction• Decreases inflammatory markers• Improves Insulin sensitivity • Improves mental health

Exercise is a physiological stressor:• Lower intensity• Shorter duration

Exercise induced hypoalgesia:• Increases sensitivity to opioids –

by Beta endorphin release• Assists with Noxious Inhibitory Control• Can assist with weaning or dose reduction

of opioids

Psychotherapy

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• Reduction in Brain Derived Neurotropic factor (BDNF)• Reduction in brain regional grey matter by 4.6 % for every 1 year of pain • Recovers with treatment• Central sensitization

- Upregulation of noxious signaling- Endogenous signaling

More efficient transmission of nociceptionFaciliatory Inhibitory

CCK SerotoninNitrous Oxide NoradrenalinExcitatory amino acids Dopamine

GABA

Dietetics

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Multimodal Analgesia

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This term describes the use of multiple modalities that are used to provide pain relief with various parts of the pain pathway targeted

Decreased dependence on a single modality agents decreases the risk of side effects:

May include• Pharmacological (opioids, NSAIDS, gabapentanoids)• Relaxation techniques (biofeedback, deep breathing)• Regional analgesia (nerve blocks, epidural catheters)

It allows for opioid sparing !!Reduces polypharmacy !!

Treatments May Include

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Non-pharmacologic Methods

• Heat/cold • Relaxation• Distraction• Graded motor

imagery• Acupressure/acupu

ncture• Repositioning

Pharmacologic Methods

• NSAIDS• Anti-seizure

medications• Anti-depressants• Opioid analgesics• Local anesthetics• Neurolytics• Cannabinoids

Acute vs. Chronic Pain Management

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Acute Pain Chronic Pain

Most often treated with:• NSAIDS• Opioids• Local anesthetics• Splinting• Positioning changes• Ice

Most often treated with:

• Combinations of paracetamol and opioids such as tramadol

• Opioids (oxycodone and tapentanol, combinations of opioid and naloxone)

• Anti-seizure medications (Carbamazepine

• Anti-depressant medications• NSAIDS• Implantable devices• Psychological therapy• Acupuncture

Undertreatment of Chronic Pain

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American Pain Society 2001, Gjachen

• > 40 -50 % of patients in the routine practice settings

• In a recent study of 805 Chronic Pain sufferers, > 50 % had to change physicians to establish pain control

??- Unwillingness to treat pain aggressively- Lack of empathy or belief in the patient’s perception of pain- Inadequate knowledge

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Responsible Opioid Prescribing

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Assess risk for opioid abuse

Risk factors for misuse or abuse of opioids include the following• Males between 18 and 45.• A personal history of substance abuse• A family history of substance abuse• A personal history of preadolescent sexual abuse• A personal history of psychological disease (depression, anxiety, obsessive-

compulsive disorder

Patient and Family Education

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Patients and family are given specific instructions prior to discharge regarding• Pain control• Pain medications• Management of potential side effects

Thank You

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Questions ?

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