Introduction to Pain Management: Approach

1. Introduction to Pain Management: Approach Calvin Lui, MD PGY2 February 8, 2014

2. 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?

3. Learning Objectives Practical approach to pain management History taking Pain Syndromes

4. Etiologies of pain Emotional/ anxiety musculoskeletal Neuropathic Pain Compressive/visercal inflammatory

5. 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

6. 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)

7. 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

8. 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

9. 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?

10. 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

11. 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.