Pain Syndromes and Chronic Pain Management dictated slides 53-80

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Monitor Patients receiving Opioids:

Monitor Patients receiving Opioids Close observation of all patients receiving opioids Routine vital signs Sedation scales when indicated Particular close attention to patients: History of OSA Craniofacial anomalies Infants who are younger than 6 months or older infants with history of apnea or prematurity Opioid-naïve patients with continuous infusions

Naloxone:

Naloxone Opioid antagonist 1 ampule = 0.4 mg/mL Use when unresponsive to physical stimulation, shallow respirations (<8 breaths/min), pinpoint pupils Stop Opioid Mix Naloxone 1 ampule with NS 9 mL = 40 mcg/mL For <40 kgs: Naloxone ¼ ampule with NS 9 mL = 10 mcg/mL Administer slowly and observe response 1-2 mcg/kg/min Discontinue naloxone as soon as patient responds Duration 30-45 minutes Monitor the patient; repeat doses may be needed

Chronic Pain:

Chronic Pain Conditions can be: Abdominal Pain Headache Complex Regional Pain Syndrome Musculoskeletal Pain Sickle Cell Disease

Sickle Cell Pain:

Sickle Cell Pain Typically vaso-occlusive crisis Complete careful history and physical to rule out other causes of pain VOC may involve 2-3 sites and maybe migratory Assess pain (generally relies on self-report) Pay attention to degree of pain relief and any adverse reactions Change medications and doses depending on clinical response of patient Utilize non-pharmacologic management Involve patient in plan

Sickle Cell crises:

Sickle Cell crises Combinations of opioids and non-steroidal agents Infusional continuous and bolus infusions Avoidance of meperidine Need transition from infusional to oral or transdermal Delay in starting analgesics Need for observational units Confusion between tolerance, physical dependence and addiction

Vaso-occlusive Crisis:

Vaso-occlusive Crisis Acetaminophen and NSAIDS typically first line for mild to moderate pain Maybe combined with opioid for moderate pain Opioids to treat moderate to severe pain PCA if appropriate Rapid triage, physical assessment, and analgesia Start with appropriate dose of medication and re-evaluate If need more opioid, give 25-50% more of initial dose Once relief achieved, around-the-clock medication with breakthrough medications available Adjunct management with I.V. fluids Monitor patients closely for respiratory depression Hypoventilation may precipitate acute chest syndrome

Cancer Pain:

Cancer Pain Pain may be chronic and may require combinations of agent types and administrations Many sets of guidelines exist, but uniformity within and among centers is lacking Under-medication is a common issue, especially towards end of life Physiologic conditions dictate choice of agent, mode of administration and dosing Need transition from hospital to home setting

Cancer Pain:

Cancer Pain WHO analgesic ladder Pain at diagnosis Pain during treatment Mucositis Peripheral neuropathy Repeated procedures Pain from tumor growth Spread to spinal cord and nerve roots or metastasis to organs

Palliative Care:

Palliative Care Many have sub-optimal pain control in the last days of life Significant psychological impact on the patient and family Use WHO Analgesia Ladder Follow general principles of pain management Give medication to provide stable blood concentrations, through least invasive routes Some patients will need escalated opioid doses Use complementary/non-pharmacologic methods

Myofascial Pain Syndrome:

Myofascial Pain Syndrome Painful regional syndrome characterized by presence of an active trigger point in skeletal muscle Manipulation of trigger point by digital pressure or needle induces twitch response Felt as taut band Management: Repeated applications of cold spray over trigger point followed by gentle massage LA injection or dry needling Several injections at 1-3 week intervals Botox Physical therapy

Fibromyalgia:

Fibromyalgia History of widespread pain for at least 3 months Allodynia to digital pressure at 11 or more of 18 anatomically defined tender points Treatment Goal is to reduce pain, improve sleep, restore physical function, maintain social interaction, emotional balance Heat therapy Pharmacologic management: tramadol , antidepressant, pregabalin , sedative

Opposite spectrum from fibromylagia:

Opposite spectrum from fibromylagia Pain Asymbolia Also called pain dissociation, is categorized by the inability to recognize the unpleasant or disagreeable component of a painful or threatening stimulus Can feel pain but has no defense reaction Able to distinguish between sharp and dull pain and report the type of pain that they are experiencing ( ie : pinprick and report that it was sharp, but that it did not hurt) Congenital Insensitivity to Pain Extremely rare syndrome, characterized by a dramatic impairment of pain perception since birth, and caused by hereditary sensory and autonomic neuropathies involving small-caliber nerve fibers that normally transmit nociceptive inputs along sensory nerves People with this disorder simply do not feel pain. The body has pain receptors for a reason.� We need to be able to feel when there is something wrong, whether it is being burned or having an agonizing stomach ache that indicates to us that we need to go to the hospital because we might have appendicitis

Neuropathic Pain:

Neuropathic Pain Abnormal excitability in the PNS or CNS that may persist after injury heals or inflammation subsides Acute or chronic Burning, shooting, tingling, or stabbing quality Post-traumatic, post-surgical, phantom pain after amputation Responds poorly to opioids Best treated with TCAs and anticonvulsants (carbamazepine, gabapentin) Complex Regional Pain Syndrome

Herpes zoster:

Herpes zoster Neuropathic pain syndrome Prodrome of dermatomal pain before skin eruptions Management Analgesics Postherpetic neuralgia (PHN) 10-15% of patients develop pain that exists >3 months after rash resolved Occurs in 30-50% of elderly

Postherpetic Neuralgia:

Postherpetic Neuralgia Management Antiviral drugs Controversial studies with neuraxial and peripheral nerve blocks Treatment with anticonvulsants, opioids , antidepressants Nortriptyline Tramadol : max dose 400 mg/day Gabapentin : 1800-3600 mg/day Lidocaine patch to treat allodynia Max of 3 patches applied/day Intrathecal methylprednisone Spinal cord stimulation Intrathecal alcohol

Complex Regional Pain Syndrome (CRPS):

Complex Regional Pain Syndrome (CRPS) Old term was reflex sympathetic dystrophy (RSD) Two types (Type I and II): differ only in presence of documented nerve injury in Type II Present with allodynia and hyperalgesia Evidence of edema, changes in skin blood flow, and abnormal motor activity in region Thought to be hormonal/developmental in origin High percentage are white, female, very active high achiever from active family Patient usually >10 years of age

CRPS:

CRPS Presents with lower extremity pain Treatment Sympathetic blocks Physical therapy Gabapetin Memantine (NMDA blocker): 5 mg/day to max of 15 mg/bid Spinal cord stimulation

Phantom Pain:

Phantom Pain Occurs in up to 80% of amputees 50% of patients experience a decrease in pain over time Caused by both peripheral and central factors Prophylactic measures Perioperative epidural infusions of LA, opioids , clonidine Continous brachial plexus clock of Memantine Pharmacologic measures Opioids Gabapentin Antidepressants Other treatments TENS, spinal cord stimulators Biofeedback

Chronic Pain Medications:

Chronic Pain Medications Anticonvulsants Act as membrane stabilizers Work on neural receptors, ion channels, and nerve conductivity Gabapentin : binds to alpha-2 delta subunit of voltage dependent calcium channel and reduces glutamate in dorsal horn of spinal cord Young children: 10-15 mg/kg/dose tid >60 kg: 900-3600 mg/day

Other anticonvulsants:

Other anticonvulsants Tegratol: 200 mg/day Klonopin: 0.5 mg/day Valproate IV: 10-15 mg/kg/day Phenytoin IV: 15-18 mg/day in 1-3 divided doses Phenytoin po: 300 mg daily

Antidepressants:

Antidepressants Tricyclics (TCA) Amitriptyline : starting dose 5-10 mg po at night increasing to 20-25 mg in 1 week; can be escalated up to 1 mg/kg with a max of 300 mg/day Nortriptyline : 50-150 mg/day Effects seen in 1-3 weeks Selective serotonin reuptake inhibitors (SSRI) Venlafaxine : starting dose 37.5 mg/day > 60 kg and escalated to 300 mg/day Duloxetine : starting dose 20-60 mg/day to max of 120 mg/day

Muscle relaxants:

Muscle relaxants Cyclobenzaprine : starting dose 5 mg at night and increased to 10 mg tid Baclofen : Children 2-7 years: 10-15 mg/day bid or tid ; escalated to 40 mg/day Children > 8 and adults: max dose is 60 mg/day

Tramadol :

Tramadol Very weak mu-receptor agonist Doses vary from 25-100 mg four times/day (max of 400 mg/day)

Corticosteroids:

Corticosteroids Decadron po: 1-2 mg/day low dose 100 mg/day high dose

Interventional techniques:

Interventional techniques Discography Intradiscal Electrothermal Therapy (IDET) Percutaneous Disc Decompression ( nucleoplasty ) Vertebroplasty and Kyphoplasty Spinal Cord Stimulation Intrathecal Pumps Will be covered in DNP in Pain Management and at individual clinical sites

Key Points:

Key Points Treat pain Adhere to general principles of pain management Anticipate & prevent pain Adequately assess pain Use multi-modal approach Involve parents & patients Use non-noxious routes Understand the pharmacology of non-opioid and opioid analgesics Approach and treat different types of pain accordingly

Education and Research:

Education and Research Health care providers Children and adolescents Parents The greater community Pharmaceutical industry Federal Drug Administration National Institutes of Health Other granting agencies

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