Relieving Pain Pharmacologic and NonPharmacologic Approaches

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Relieving PainPharmacologic and
Non-Pharmacologic Approaches
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Pain Definition

• Pain refers to any type of physical pain or
  discomfort in any part of the body
• Pain may be localized or more generalized
• Pain may be acute, chronic, continuous,
  intermittent, occur at rest or with movement

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Factors Associated With Chronic Pain In The
Elderly

• Oral or dental pathology
• Chronic leg cramps
• Peripheral vascular disease
• Post-stroke syndrome
• Immobility, contractures
• Amputations

• DJD
• RA
• Low back disorder
• Osteoporosis
• Neuropathic pain
• headaches
• Pressure ulcers

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Total Pain The Complex and Interrelated
Dimensions of Pain

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The ABCs of Pain Management

• Always ask the patient
• Assess the pain and side effects systematically.
• Believe the patient and family
• Choose appropriate pain control
• Deliver medication in timely manor
• Empower and Educate patients and their families
• Enable patients to help control their treatment

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Pharmacologic Approach to Pain Management
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Pharmacologic Treatment

• World Health Organization (WHO) stepladder
• Step 3 drugs (severe pain)
• Step 2 drugs (moderate pain)
• Step 1 drugs (mild pain)

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WHO Approach

• Five Concepts
• By mouth
• By the clock
• By the ladder
• For the individual
• Pay attention to detail

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STEP 1Mild to Moderate Pain

• Acetaminophen (2.5-3.5 grams)
• NSAIDS (no prolonged use)
• Motrin, Relafin, Trilisate
• Adjuvant medications
• Cox-2 Inhibitors
• Vioxx, Celebrex

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COX-2 Inhibitors

• Advantages
• Better safety profile
• Selective inhibitor
• Fewer side effects
• Fewer drug interactions
• Disadvantages
• Allergies
• GI disturbances
• Asthma
• Elevated LFT
• Renal function
• Heart failure/fluid retention
• Requires monitoring of Renal Liver functions
  and CBC

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STEP 2Moderate to Severe Pain

• Addition of combination opiate to Step 1 drug
• Vicodin or Lortab, Vicoprofen
• Percocet
• Tylox Tylenol 3
• Be aware of the total daily Tylenol dosage
• Tramadol (Ultram)
• Morphine, Oxycodone

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STEP 3Severe Pain

• Substitution of Step 2 agent
• Morphine or Oxycontin preparation
• Oxycodone, Dilaudid
• Fentanyl patch (2nd line)
• Use of short and long acting preparation
• Combine with adjuvant

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Opioids

• Long acting opioids
• Methadone-Sustained release products
• Transdermal fentanyl
• Meperidine
• Metabolic accumulation
• Fentanyl patch
• Ease of administration
• Difficult to titrate- slow onset
• Absorption affected by muscle mass

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Adjuvant Analgesic in Pain Management

• Achieves a more favorable balance between side
  effects and pain relief of
• Neuropathic pain
• Visceral pain
• Bone pain

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Adjuvant Analgesics

• Steroids
• Antidepressants
• Anticonvulsants
• Antispasmodics

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Proactive Pain Management

• Anticipate painful events
• Avoid PRN dosing (
• Use long/short acting combination
• Timing of administration of one has no relation
  to timing of administration of the other
• Treat pain early and aggressively
• Anticipate swallowing problems

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Recognition and Prevention of Side Effects

• Constipation
• Nausea/vomiting
• Sedation/confusion
• Respiratory depression
• Drug accumulation
• Myoclonus

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General Recommendations

• Initiate pain management with immediate release
  form- adjust
• Once at optimal dose - switch to extended release
  preparations
• Breakthrough medication on board
• 2-4 days for dose titration (long-half life)
• Chronic pain -ATC
• Acute pain -PRN

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General Recommendations

• Reassess pain if opioid needs are changed
• Determine need for adjuvant therapy
• Employ oral route of administration
• Avoid IM route of administration
• Avoid Meperidine and Propoxyphene
• Use preventive bowel regimen

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Case Study

• Customer is 82 years old with prostate cancer,
  dementia, incontinence, and admitted after
  pneumonia. He is complaining of severe pain,
  mostly in legs and back. Demerol/Vistaril
  ordered in hospital.
• What type of pain syndrome is likely?
• What would be your approach?

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Non-Pharmacologic Approach To Pain Management
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The Pain Cycle
PAIN
DEPRESSION
LIMITED/LOST ABILITIES
STRESS
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ACTIVITY ACTIVITY
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Non-Pharmacologic Approaches

• Exercise and mobility training
• Heat, cold, massage, ultrasound, paraffin, and/or
  TENS
• Positioning and/or splinting
• Education
• Stress management techniques Biofeedback,
  relaxation, stress reduction
• Other techniques

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Who can provide these techniques?

• Rehabilitation department
• Activities department/Recreation Therapy
• Nursing
• Physicians

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Therapeutic Exercise

• Range of motion
• Strengthening
• Endurance training
• Aquatic therapy
• Functional mobility training

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Modalities

• Heat warm compress, hot packs and/or K-pads
• Cold ice pack, cold pack or ice massage
• Massage
• Ultrasound
• Paraffin
• TENS

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Positioning and/or Splints

• Bed positioning
• Wheelchair positioning
• Splinting
• Upper extremity
• Lower extremity
• Spinal
• EDUCATION

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Customer Education

• Posture
• Body mechanics
• Benefits of rest
• Joint protection
• Energy conservation

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Other Techniques

• Biofeedback
• Relaxation techniques
• Stress reduction
• Aromatherapy
• Pet Therapy

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Other Techniques

• Hypnosis
• Acupuncture
• Meditation
• Yoga

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Team Approach

• Communication amongst the team members is
  essential
• Develop coordination of pain medications with
  activity levels for customers functional
  activities (ADLs, transfers, bed mobility,
  exercises or ambulation)
• Keep it focused on maintaining a customers
  functional abilities while appropriately
  addressing pain concerns

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Questions?