Basics of Pain Management

1
Basics of Pain Management

• Dr. Allistair Dodds
• Dept. Pain Medicine
• Sunderland Royal Hospital
• July. 07

2
3 Types of Pain (temporal)

• Acute
• Chronic
• Cancer

3
Types of Pain (physiological)

• A? fibres
• C fibres
• Sensitisation

4
WHO should take the place of Descartes?
5
WHO ladder

• Cancer pain
• Step 3 opioid for moderate to severe pain /-
  non opioid /- adjuvant
• Step 2 opioid for mild to moderate pain /- non
  opioid /- adjuvant
• Step 1 non opioid /- adjuvant

6
The 5 phrases

• By mouth
• By the clock
• By the ladder
• For the individual
• Attention to detail

7
The 5 phrases

• By mouth
• For the individual
• Attention to detail

8
Science and Sociology

• Drugs targeted at the lesion
• Analgesia targeted to the patients requirements

9
Cyclo-oxygenase

• COX converts arachidonic acid to prostaglandin H2
  a precursor of the inflammatory prostaglandins.
• Type 1 - constitutive maintains the function of
  gut, kidneys, platelets etc.
• Type 2 inducible, expressed during the
  inflammatory response

10
Paracetamol

• Simple analgesic
• Anti-inflammatory - periphery
• Anti-pyretic - hypothalamus

11
Pharmacology

• Tablet, effervescent, syrup, suppository, iv
  infusion
• NNT 3.8 (3.4-4.4) 50 pain relief acute pain
• Henry McQuay Andrew Moore An evidence based
  resource for pain relief Oxford Medical
  Publications 1998

12
Non steroidal anti inflammatory drugs (NSAIDs)

• Simple analgesic
• Anti-inflammatory - periphery
• Anti-pyretic hypothalamus

13
Efficacy

• All common NSAIDs have an NNT of
• 2.3 (2.0-2.7) for 50 acute pain relief
• No difference between the cox 2 specific
  (rofecoxib), selective (naproxen) and
  indiscriminate (ibuprofen) drugs.
• Henry McQuay Andrew Moore An evidence based
  resource for pain relief Oxford Medical
  Publications 1998

14
Side effects

• Can be partially predicted by the interaction of
  NSAIDs and COX 1.
• Gastric ulceration
• Heart failure deteriorates
• Renal failure deteriorates
• Platelet dysfunction

15
Side effects newer drugs

• Newer Cox 2 specific drugs cause less gastric and
  platelet effects but just as dangerous in renal
  and heart failure.
• The reduction in dyspepsia sometimes improves
  compliance.

16
Opioids

• Bind to mu (µ) receptors in spinal cord and brain
  inhibiting the transmission of electrical
  activity that signals pain.
• Grouped according to potency
• (weak strong)

17
Weak opiods

• Codeine pro-drug not metabolised to active
  agent (morphine) in 17-34 of patients.
• Dihydrocodeine pro-drug, again a wide variation
  in patient response.
• Tramadol active drug.

18
Efficacy

• NNTs
• Tramadol 100mg 4.8 (3.8 - 6.1)
• Dihydrocodeine 30mg 8.1 (4.1 540)
• Codeine 60mg 16.7 (11- 48)
• But
• paracetamol 1g codeine 60mg 2.2 (1.7 2.9)
• Henry McQuay Andrew Moore An evidence based
  resource for pain relief Oxford Medical
  Publications 1998

19
Strong opiods

• No requirement for metabolism
• 50 oral bioavailability
• Fentanyl patch 25 - approx 90mg oral morphine per
  day

20
Morphine

• Presentation
• Tablets, capsules, solutions , patches,
  suppositories, iv injection.
• Usually titrated to effect.

21
Side Effects

• Common adverse reactions constipation, nausea
  and vomiting, drowsiness, dizziness, headache,
  itch, dry mouth,.
• Infrequent adverse reactions include
  dose-related respiratory depression , confusion,
  hallucinations.

22
Chronic Pain

• An alternative evidence based approach.

23
Pain Management Programme

• Given the multi-dimensional nature of
  long-standing pain problems, the most effective
  approach is to treat through multi-professional
  teams.
• PMP is a psychologically framed, group based
  rehabilitation treatment that utilises the
  biopsychosocial model as the philosophical
  underpinning to assist people in the further
  development of pain self-management.

24
Pain Management Programme

• Programme Structure
• PMP is a 12 session (x3.5 hrs) treatment
  delivered over a year
• 8 intensive sessions (weekly)
• 4 consolidation sessions over next 10 months (1,
  2, 4 and 6 months).
• Graduate programme

25
The Treatment Components

• 1. Educational eg. gate-control theory, active
  neuro-matrix.
• 2. Cognitive Restructuring Skills to modify
  unhelpful pain and negative affective state
  related cognitions.
• 3. Problem Solving Developing solutions to
  carry out desired goals.
• 4. Coping Skills Training Behavioural
  management (baselines, pacing).
• 5. Relaxation Assisting people gain increased
  control over heightened physiological arousal.
• 6. Exposure to Feared Activities Reduction of
  avoidance and testing out activities to reverse
  de-conditioning.

26
Acessing the Service

• Referal to the Pain clinic.
• Intitail MDT assessment.
• Those wishing to be considered for the PMP
  offered an education session about this
  treatment.
• Patients then offered a short PMP assessment to
  determine their therapeutic goals.
• Formal assessments are taken of key clinical
  parameters (defined from the biopsychosocial
  model) that are targeted for active change.
• Following the successful completion of these
  procedures, patients enter the treatment
  (structured in a group based format).