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Pain Overview Pain assessment and pain management frameworks

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Slide 1 :

Pain OverviewPain assessment and pain management frameworks

Slide 2 :

Biopsychosocial factors that interact and modulate the experience of painHoldcroft A, et al. BMJ 2003; 326: 635-9

Slide 3 :

WHO's three step ladder to use of analgesic drugs www.who.int/cancer/palliative/painladder 3 1 2

Slide 4 :

Advice on analgesic options in the treatment of mild to moderate pain in adultsCSM Pain Management Working Group Guideline 2004MeReC Bulletin. May 2006; Vol. 16: 4 Adopt general principles of pain management; Diagnosis- adequate assessment and accurate diagnosis of cause of acute or chronic pain Acute on chronic pain- Pain management strategy as for an acute episode is advised Progressive conditions- pain management strategy will require continual adjustment Psychosocial factors- should be treated and/or referred

Slide 5 :

Advice on analgesic options in the treatment of mild to moderate pain in adultsCSM Pain Management Working Group Guideline 2004MeReC Bulletin. May 2006; Vol. 16: 4 Non-drug interventions - should be considered Pharmacological interventions - increase to full therapeutic or tolerated doses before switching Patient requirements - all strategies should be individualised Combination analgesics - treatment strategies should be worked out on the basis of single constituent analgesics. Fixed dose combinations have a limited role - if used give therapeutic doses e.g. Codeine 30mg +paracetamol 500mg per tablet

Slide 6 :

Advice on analgesic options in the treatment of mild to moderate pain in adultsCSM Pain Management Working Group Guideline 2004MeReC Bulletin. May 2006; Vol. 16: 4 Pain management strategy Class I. Acute pain either as a self-limiting episode or upon a background of chronic pain e.g. soft tissue injury, post op pain, OA, low back pain Step 1. Paracetamol Step 2. Substitute ibuprofen Step 3. Add paracetamol to ibuprofen Step 4. Continue paracetamol and replace ibuprofen with an alternative NSAID If NSAID is CI or not recommended, substitute low potency opioid e.g. codeine at steps 2 and 3 Where pain is not controlled at step 4 a low potency opioid may be added

Slide 7 :

3 steps to NSAID HeavenTM Don’t use them unless you have to The only way to avoid NSAID side-effects is not to use them Paracetamol works for many Employ non-drug interventions routinely Consider short-term course (1-2 weeks) of topical NSAID Consider glucosamine and chondroitin. If you have to use them, use them wisely The balance of benefits and risks needs to be carefully assessed; think about CV, GI and renal issues routinely Use a safer drug (ibuprofen, then naproxen) in the lowest effective dose for the shortest period NSAID users should be a high priority for medication review: Are NSAIDs effective/needed? Drug holidays? Don’t issue repeat prescriptions without review. Consider gastroprotection in those at high risk (NICE definition) Options are PPIs, double-dose H2RAs, misoprostol Coxibs should be considered only in those at high GI risk, but consider also the cardiovascular risks. All of this particularly applies to those aged over 65

Slide 8 :

Advice on analgesic options in the treatment of mild to moderate pain in adultsCSM Pain Management Working Group Guideline 2004MeReC Bulletin. May 2006; Vol. 16: 4 Class IIa. Chronic stable pain requiring long-term reg. analgesic use e.g. OA (severe progressive cancer pain not covered here) Step 1-4 may be effective Where chronic pain is not controlled after step 4 addition of low potency opioid at therapeutic doses should be considered Step 5. Full therapeutic dose of low potency opioid e.g. codeine in addition to full dose paracetamol or NSAID Most patients will respond to this, but for minority who do not Step 6. Therapeutic trial of antidepressant e.g. amitriptyline or anticonvulsant e.g. carbamazepine or gabapentin

Slide 9 :

Advice on analgesic options in the treatment of mild to moderate pain in adultsCSM Pain Management Working Group Guideline 2004MeReC Bulletin. May 2006; Vol. 16: 4 Class IIb. Chronic long-term pain of a progressive nature (includes cancer patients and some patients with neuropathic pain e.g. diabetic patients) Treatment should follow guidance for class 2a chronic pain in relatively stable conditions If a possibility of neuropathic pain early trial of TCA or anticonvulsant should be considered More potent opioids e.g. morphine considered as soon as pain fails to respond to lower potency opioids

Slide 10 :

Summary Pain is a subjective experience and is influenced by many factors not just physical processes The WHO pain ladder and the CSM pain management working group guidance is recommended Introduce drug therapy in stepwise manner, matching the initial analgesic to the level and type of pain Other interventions, drug and non drug should be considered

muhamad on May 10, 2009 Says :

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Continue paracetamol and replace ibuprofen with an alternative NSAID; If NSAID is CI or not recomme more Continue paracetamol and replace ibuprofen with an alternative NSAID; If NSAID is CI or not recommended, substitute low potency opioid e.g. codeine at steps … less