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PRIMARY CARE APPROACH TO PAIN MANAGEMENT

PRIMARY CARE APPROACH TO PAIN MANAGEMENT. Dr. Nurver Turfaner , M.D., PhD, Assoc. Prof. Istanbul University Cerrahpasa Medical Faculty Department of Family Medicine. PAIN ASSESMENT. Pain: the 5 th vital sign (pulse, blood pressure, temperature, respiration)

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PRIMARY CARE APPROACH TO PAIN MANAGEMENT

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  1. PRIMARY CARE APPROACH TO PAIN MANAGEMENT • Dr. NurverTurfaner, M.D., PhD, Assoc. Prof. • Istanbul University • Cerrahpasa Medical Faculty • Department of Family Medicine

  2. PAIN ASSESMENT • Pain: the 5th vital sign (pulse, blood pressure, temperature, respiration) • an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

  3. Factors influencing pain perception • Age • Anxiety • Culture • Fear • Gender • Observational learning (family history of pain/previous experience of pain

  4. Factors influencing pain perception • Personality: • Introvert: greater sensitivity, fewer complaints • Extrovert: High pain tolerance • Psychological factors • Religion • Response of healthcare staff • Sleep deprivation • Society

  5. Barriers influencing pain assessment • Clinician influenced • Insufficient knowledge • Lack of pain training in medical school • Lack of pain-assessment skills • Rigidity or timidity in prescribing practices • Overestimation of risks involved in the therapy

  6. Barriers influencing pain assessment • Patient influenced • Reluctance to report pain • Reluctance to take opioid drugs • Poor adherence to management plan • Healthcare system influenced • Low priority given to symptom control • Unavailability or bureaucracy in opioid analgesic administration • Inaccesibility of specialised care

  7. Objectives of pain assessment • To make a working diagnosis define the extent of injury or disease • To determine the type of pain • To establish co-existing medical, emotional and psychological factors influencing pain (soldiers and sportsmen can sustain severe physical trauma without initially feeling pain)

  8. Objectives of pain assessment • To determine a pain management strategy on the basis of information obtained • To evaluate response to therapy • To compare and monitor progress of individual patients • To validate effectiveness of new treatments for clinical and research purposes

  9. Pain history • First- hand history from the patient • Pain description: a verbal picture of pain • Primary or secondary complaint • Location and radiation • Specific site of pain • Mode of onset • Intensity and severity • Character

  10. Pain history • Temporal features • Exacerbating and relieving factors • Associated symptoms • How pain has changed since onset • Treatments so far • Medical aspects • Functional status • Psychological assessment • Factors relevant to treatment

  11. Physical Examination • Inspection: Attention to symmetry and cutaneous landmarks • Skin colour, rashes, scars, abnormal hair growth, pseudomotor dysfunction, oedema, muscular atrophy, hypertrophy or fasciculations, spinal curvatures, limb lengths

  12. Physical Examination • Palpation: Perform in a systematic and comprehensive manner from the least painful to the most painful area helps differentiate normal tissues and painful region • Elicits gross sensory changes: allodynia, dysaesthesia,paraesthesia, hyper/hypoalgesia, hyperpathia, hypoaesthesia and analgesia dolorosa • Elicits painful muscle bands or nodules, (tender/trigger points), neuromas in scars, peripheral pulsations and temperature

  13. Percussion: can indicate nerve entrapment or presence of a neuroma (Tinel’s sign). Percussion of bony structures may indicate fracture, dislocation, inflammation, infection • Range of motion: for articulated areas, active and passive range of motion, all movements possible for that particular joint and their effect on pain in degrees • Motor examination: Muscle bulk, tone, isolated muscle power, involuntary movements should be assessed and correlated with myotomal innervations

  14. Physical Examination • Sensory examination: response to light touch, light pressure, pinprick or cold and vibration • Match any sensory changes to dermatomal and peripheral cutaneous nerve maps to assess the anatomical significance • Reflexes: tendon reflexes are increased in upper motor neurone lesions and decreased in lower motor neurone lesions and muscular diseases

  15. Provocative tests: concordant vs non-concordant pain • Phalen’s sign: carpal-tunnel’s syndrome • Patrick/Faber (Flexion ABduction External Rotation): for hip pathologies • Sciatic and femoral nerve stretching tests • Straight leg raising test • Lasegue’s test: differentiate hamstring tightness and spondylolisthesis • Crossed SLR • Bowstring test • Valsalva manoeuvre

  16. Investigations • radiological examinations; • Plain X-rays • MRI • fMRI • CT • SPECT scan • Others: thermography, diagnostic nerve blocks, measurement of autonomic variables • These investigations are helpful to rule out rather than diagnose the cause of pain

  17. Investigations • Repetition of investigations will have potentially negative effects on the patient’s expectations of management and be an unnecessary expense

  18. Pain Measurement • The multidimensional nature of pain offers many potential ‘targets’ for measurement. • Pain is a subjective, personal experience, the logical and true assessments of a patient’s pain must be the patient’s own report. The self-report is the gold standard of pain measurement. • Self report measurement tools: unidimensional (e.g. categorical scales, numerical rating scales (NRS), visual analogue scales (VAS), picture scales or pain drawings • Multidimensional: e.g. McGill pain questionnaire

  19. Pain Measurement • Categorical scales/verbal rating scales • Are you in Pain?-yes/no • none, mild, moderate,severe, excruciating • Pain relief: none, slightly, moderate, good, complete • 0,1,2,3,4 • Advantages: quick, simple,suitable for the elderly,olderchildren,visually impaired, sensitive to ethnic and gender differences • Disadvantages: subject to bias

  20. Pain Measurement • Visual analogue scales: 10 cm straight line, scoring by measuring the distance in mm from left to right no pain worst pain imaginable No pain relief complete pain relief

  21. Pain Measurement • Advantages: quick, simple, avoidance of imprecise, descriptive terms, suitable for children over 5 years, parametric statistical tests can be applied • Disadvantages:more demanding, requires greater cognitive skills (concentration,language), may not be easy to measure extremes, can be influenced by medication, sleep disturbance, it measures relief better

  22. Multidimensional Tools: • Classical Pain: three dimensions • sensory-discriminative • Motivational-affective • Cognitive-evaluative • Long-form McGill questionnaire • Short form of McGill pain questionnaire • Brief pain inventory • Health-related quality of life measures • Hospital anxiety and depression scale

  23. OTHER TYPES OF PAIN • Post-operative Pain • Assessment of pain in children: • Physiological: heart rate, blood pressure, respiratory rate, palmar sweating, transcutaneous oxygen, serum catecholamine, glucagon and cortisol • Behavioural: crying, grimacing, irritability • Self-report measures: faces scale,VAS,CHEOPS,FLACC(face-legs-activity-cry-consolability) • Pain in the elderly: be aware of dementia, confusion and cognitive deficit,deafness

  24. KEY POINTS • Pain assessment is multidimensional including biological, psychological and social elements • A thorough history is required along with what the pain means to the patient • Patient expectations must be assessed before a management plan is produced • Many scoring systems exist for scoring pain and are validated in a variety of clinical and research settings

  25. KEY POINTS • Patient self-reports of pain and direct involvement in assessment is the gold standard. Observational reporting and proxy reporting are less reliable • Pain should be considered as the 5th vital sign with documentation showing the intensity, action taken and response to intervention • Many pain scales are (e.g. VAS,VSR,NRS) easy to use in the clinical setting

  26. DIFFERENCES BETWEEN ACUTE AND CHRONIC PAIN Acute Pain Chronic pain <3 months duration >3 months duration Protective, preventing further damage Prevents normal functioning Useful Not useful e.g. broken limb, appendicitis e.g. post-herpetic neuralgia, chronic low back pain

  27. Risk factors for developing chronic low back pain and long-term disability • Belief that pain and activity are harmful • Sickness behaviors such as extended rest • Social withdrawal • Emotional problems such as low or negative mood, depression, anxiety or stress • Problems and/or dissatisfaction at work • Problems with claims or compensation or time off work • Overprotective family; lack of support • Inappropriate expectations of treatment

  28. Classification of the sensory component of chronic pain • Nociceptive Non-nociceptive • Visceral Somatic Neuropathic Idiopathic

  29. Nociceptive pain • is presumed to be maintained by continual tissue injury • Somatic pain: Arises in tissues such as joints, bones and muscles and is well localised. • e.g:arthritic pain • described as aching, stabbing or throbbing

  30. Nociceptive pain • Visceral pain: Arises from viscera in the thorax, abdomen or pelvis. • tends to be rather diffuse and poorly defined and may be described as deep, dull or colicky • referred to other locations • e.g: chronic refractory angina • associated with motor reflexes such as muscle spasms and with autonomic reflexes such as nausea and vomiting

  31. Non-nociceptive pain • Neuropathic pain: is due to injury to the nociceptive pathway, either peripherally or centrally • e.g: post-herpetic neuralgia is peripheral • e.g: post-stroke pain is central • described as burning or ‘electric shock-like’ • clinical features: allodynia, hyperalgesia and hyperpathia • Idiopathic pain: Noidentifiable organic cause • e.g: atypical facial pain

  32. Emotional Components of Chronic Pain Thoughts Physical sensation Feelings Behaviours

  33. Management of chronic pain • Analgesics • Adjunct analgesics • Neurostimulation techniques • Topical treatments • Injections • Neurolytic therapies • Improving and optimising the patient’s level of functioning: improving sleep, graded exercise programme, treatment of anxiety and depression

  34. KEY POINTS • The clinician has to understand the sensory and emotional components of chronic pain • The clinician has to be aware of treatments available for pain • Most importantly, the clinician has to understand the patient • Psychosocial factors are more important than medical factors in the development of disability

  35. Being off work with chronic pain for more than 6 months means the chance of returning to work is only 50%, after 1 year off work it is only 10% • The emotional aspects must not be underestimated as there is wide variation in the reported severity of pain experienced by individuals in association with comparable noxious stimuli • Improvements in how a patient manages their chronic pain can be very rewarding for the healthcare professionals involved

  36. THE WHO ANALGESIC LADDER Pain controlled Strong opioids (eg. morphine ±non-opioids ±adjuvants Weak opioids(eg.Codeine) ± Non-opioids ±Adjuvants Pain persisting or increasing Non-opioids (e.gparacetamol,NSAIDS) ±Adjuvants

  37. Routes of administration of analgesics • Route Comments • Oral: Ideal for chronic use, dependent on patient’s ability to swallow, gastric emptying,food and pH, opioids have low oral bioavailability • Intramuscular: Pain and tissue irritation on injection, unreliable plasma concentration especially in low perfusion, unsuitable for long term use

  38. Routes of administration of analgesics • Intravenous rapid action, can be titrated to effect High bioavailability, not dependent on patients characteristics unsuitable for long term use • Subcutaneous absorption is variable and dependent on tissue perfusion used for long term opioid administration especially in malignancy related pain • Transmucosal sublingual, buccal, and gingival modes of administration Offers rapid onset and patient comfort, oral transmucosalfentanyl citrate-for breakthrough cancer pain

  39. Routes of administration of analgesics • Rectal: Unreliable absorption and mucosal irritation • Transdermal: Improved patient compliance, long duration of action and steady plasma concentrations, slow onset makes it less useful for acute pain, Fentanyl and buprenorphine patches are popular in chronic pain management • Topical: Topical NSAIDS are effective in acute pain • Intraarticular: Not popular, intra-articular morphine provides good analgesia following arthroscopies; steroid injections are used in treating arthritis • Inhalational: Limited use, inhaled entonox (50% nitrous oxide+50% oxygen) is used for labour analgesia and change of dressing in burns

  40. Side Effects of Analgesics Class Complications NSAIDS Gastrointestinal ulceration/bleeding, impaired platelet function, fluid retention, reduction in renal blood flow, bronchospasm, Reye’s syndrome and anaphlaxis Opioids Respiratory depression, nausea and vomiting, constipation, euphoria/dysphoria

  41. EDUCATION IN MEDICATION USE • First session: • Introduction to drugs • Types of medicines • Benefits, uses, side-effects and problems. • Second session: • Tolerance • Addiction and dependence • Physical and psychological dependence • Withdrawal: problems and benefits • Monitoring medicines • When to use painkillers

  42. MEDICATION • Non-steroidal anti-inflammatory drugs (NSAIDS) • Opioids and opioid-containing medicines including co-compounds • Paracetamol • Tranquillisers (benzodiazepines) • Anti-depressants (tricyclic antidepressants, newer antidepressants, selective serotonin uptake inhibitors (SSRIs) • Anticonvulsants • Others

  43. PRINCIPLES OF DRUG WITHDRAWAL • Choose to reduce or withdraw from one drug at a time • Choose the easiest one first (probably the opioid) • Start by stabilising level of medication usage • Change from pain-contingent to time-contingent medication • Keep timing of medication the same (do not extend time between medication) • Reduce the amount taken by a small amount (half a tablet) at a time • Reward success

  44. PSYCHOLOGICAL COMPONENT • General guidelines for teaching relaxation exercises: • Adress posture and find a comfortable position • Begin with abdominal breathing • Wear loose, comfortable clothing • Importance of scheduling,space and time (aim to be undisturbed for 30’ min) • Anticipate ‘unsuccessful sessions and don’t lose confidence or become dishearted • Develop a relaxed approach rather than simply applying a technique

  45. Ways of implementing relaxation skills: • normal relaxation:15-30 min, once a day • Brief relaxation: 5-10 min, several times a day, in any position • Mini relaxation: few seconds to few minutes, anytime, often,identify ‘trouble spots’ for muscular tension

  46. Key facets of sleep hygiene: • Avoid stimulants such as caffeine,smoking, alcohol and proprietary painkilling or cold remedies, which contain stimulants particularly late in the day • Avoid excessive intake of liquid for some hours before sleep • Timetable analgesic medication appropriately • Stay in bed only when asleep and restrict the time in bed if not sleeping

  47. Key facets of sleep hygiene • Get up and go to another room and read or perform routine tasks until feeling sleepy then return to bed • Only use the bed for sleep (or physical intimacy)

  48. THANK YOU FOR YOUR ATTENTION

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