INTRODUCTION TO PAIN MANAGEMENT: APPROACH

Calvin Lui, MD

PGY2

February 8, 2014

CLINICAL CASE

A 70-year-old male with recent diagnosis of multiple myeloma presents after a fall in which in breaks his wrist. He complains of pain from his shoulders, back, and wrist. His back pain is persistent for the past several months. It has two components: some “running shock-like down to his feet” and other “feeling as if his back is being eaten at.” There is radiologic evidence of bony metastases and DJD. He is taken to the OR for ORIF. What types of pain are involved in his case?

LEARNING OBJECTIVES Practical approach to pain management History taking Pain Syndromes

ETIOLOGIES OF PAIN

PainNeuropathi

c

Emotional/ anxiety

musculoskeletal

Compressive/visercal inflammatory

PAIN SYNDROMES Nocireceptive pain- Response to noxious stimuli

resolves usually with non-opioid or opioid analgesics Incorporates somatic and visceral pain

Somatic – focal, ache/throb/sharp swelling/edema/redness worse with movement, better at rest, maybe from trauma

Visceral – viscous organs colicky, vague, diffuse, possibly worse with meals Liver/spleen/pancreas – possibly constant/focal, worse with

eating uterine – colicky, pelvic, maybe with discharge

Neuropathic – burning, sharp, tingling Possibly dermatomal or stocking-glove worse with touch, May have associated numbness radiating

HISTORY TAKING FOR PAIN Pain location Radiation Intensity Characteristics/quality Temporal aspects:

duration, onset, changes since onset

Constancy or intermittency

Characteristics of any breakthrough pain

Exacerbating/triggering factors

Palliative/relieving factors

Nociceptive Restriction of range of

motion Swelling

Muscle aches, cramps, or spasms

Neuropathic Color or temperature

changes Changes in sweating Changes in skin, hair, or nail

growth Changes in muscle strength Changes in sensation, either

positive (dysesthesias/itching) or negative (numbness)

OTHER CLINICAL PEARLS

Uptitrate pain medications in short frequent dosages

No two patients are the same in terms of pain tolerance

Treat all types of pain at once to obtain better pain control

Reevaluate pain regimen for side effects and possible overdosages Methadone and consideration for naloxone

CHOOSING BASED UPON RISK FACTORS

Chronic kidney disease, advanced age - avoid NSAIDs and COX-2 inhibitors

Peptic ulcer disease, glucocorticoid use - avoid NSAIDs

Hepatic disease - avoid NSAIDs, COX-2 inhibitors, and acetaminophen (APAP); TCAs, antidepressants, opioids without APAP

Cardiovascular disease or risk - use lowest effective dose of NSAIDs; in patients who require treatment, suggest naproxen

CLINICAL CASE

A 70-year-old male with recent diagnosis of multiple myeloma presents after a fall in which in breaks his wrist. He complains of pain from his shoulders, back, and wrist. His back pain is persistent for the past several months. It has two components: some “running shocklike down to his feet” and other “feeling as if his back is being eaten at.” There is radiologic evidence of bony metastases and DJD. He is taken to the OR for ORIF. What types of pain are involved in his case?

PAIN ASSESSMENT OF CASE

Broken wrist with swelling Nocirecptive: visceral

DJD with likely nerve impingement Neuropathic Clues include radiation and shocklike sensations

Bone metastases Inflammatory/metastatic

SUMMARY The purpose of good history about pain is to discern

the pain syndrome and later define the agents that would useful for their treatment

The etiology of pain is multifactorial

When considering a pain regimen remember the side effect profiles of your medications to best select agent to be used.