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Introduction to pain management, discussion of CAPC modules, comprehensive pain assessment, and pain cases. Learn about pain characteristics, functional history, and optimal dosing. Explore real-life scenarios and appropriate pain management strategies.
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Pain Management1st of 3 LecturesSeptember 18, 2017 John Hopper, MD L. Raquel Clary-Lantis, DO
Outline • Introduction • CAPC modules • Pain Assessment • Pain Cases
Introduction • 116 million affected by pain • Opiophobia: irrational fear by clinicians and patients related to appropriate use of opioids • Prescription Painkiller OD since 1999 • Up 265% in men • Up 400% in women • Increased misuseundertreatment of pain • Importance of a structured protocol
CAPC Modules • www.capc.org • create an account if you don’t have one • Go to CAPC Centraltraining curriculum • 41 modules altogether • we will focus on the 14 pain modules for these lectures
14 CAPC Pain Modules • Course 1: Comprehensive Pain Assessment • Course 2: Matching the Drug Class to the Pain • Course 3: Patient Factors that Influence Prescribing Decisions • Course 4: Assessing Risk for Opioid Substance Use Disorder • Course 5: Opioid Trials - Determining Design, Efficacy and Safety • Course 6: Prescribing an Opioid • Course 7: Prescribing Short-Acting Opioids - Four Case Studies • Course 8: Monitoring for Opioid Efficacy, Side Effects and Substance Use Disorder • Course 9: Converting from Short-Acting to Long-Acting Opioids • Course 10: Prescribing Practice and Opioid Conversions • Course 11: Advanced Conversions & Opioid Side Effects • Course 12: Special Populations & Patient-Controlled Analgesia • Course 13: Managing Pain in Patients at Risk for Substance Use Disorder • Course 14: Pain Management - Putting it All Together
Structured Protocol Course 1: Comprehensive Pain Assessment 1. Elicit pain characteristics: OP2QRST a. O=onset, acute versus persistent b. P2=palliative and provocative factors c. Q=quality of the pain i) Somatic: tissue damage, localized ii) Visceral: visceral organs, referred (nausea/sweats) iii) Neuropathic: injury & inflammation nerves, radicular d. R=radiation and region e. S=severity, pain intensity scale f. T=timing 2. Assess functional history -most useful measure of severity of pain is impact on fxn
Comprehensive Pain Assessment • Review prior drug and nondrug treatment • Not all pain needs an opiate or even a medication • WHO stepladder • Caution with polypharmacy 4. Examine patient and review data
Optimal Dose • Dose that will improve function or reduce intensity by at least 30% without major side effects or complications • Hand that writes the opiate is the hand that does the disimpaction
36 y woman with RUQ pain X 6 hours • Severe crampy pain, like childbirth • Comes in “waves”, doubled over • Started after eating chicken and waffles • Getting worse over last few hours • Now accompanied by nausea • Feels bloated, vomited once
36 y woman with biliary colic • What would you give for pain? • Drug • Dose • Route • When would you reassess for effect? • What is an effect anyway??? • What would the interval be for the next dose?
63 y man with hip pain • Stage 4 NSCLC pain in left hip from metastasis • Deep aching pain in hip and groin for weeks • Pain ranges from moderate to severe • Interferes with sleep and walking • Getting worse • Affecting mood • Irritable, short tempered
63 year old man with hip pain • What would you give for pain? • Drug • Dose • Route • When would you reassess for effect? • What would the interval be for the next dose? • Stage 4 NSCLC • Deep aching pain in hip and groin for weeks • Pain ranges from moderate to severe • Interferes with sleep and walking • Getting worse • Affecting mood • Irritable, short tempered
46 y man with acute arm pain • Fell from a ladder an hour ago • Severe, sharp, stabbingright arm pain • History of diabetic neuropathy on opioids • Outpatient Pain Regimen: • Oxycodone ER 60 mg BID • Duloxetine 60 mg daily
46 y man with fracture of humerus • What would you give for pain? • Drug • Dose • Route • When would you reassess for effect? • What would the interval be for the next dose? • Fell from a ladder an hour ago • Severe, sharp, stabbing right arm pain • History of diabetic neuropathy on opioids • Outpatient Pain Regimen: • Oxycodone ER 60 mg BID • Duloxetine 60 mg daily