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18/02/2013
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Analgesia as part ofPain Management
Kathryn MarczewskiClinical Nurse Specialist
Pain Management&
Linda SimpsonSpecialist Pain Pharmacist
Agenda
Overview Pain and its impact Role of analgesia in pain management Some case studies
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Pain
"An unpleasant sensory and emotional experienceassociated with actual or potential tissue damage ordescribed in terms of such damage." IASP 1990
i.e. pain is as bad as thepatient says it iswith very few exceptions
What is Pain
“We all know what pain is.We’ve all had it. Sometimeswe hardly notice it.Sometimes its unbearable.Usually it goes away withtreatment. Rarely, it doesn’treally go away at all.”Pain SocietyUnderstanding andManaging Pain: Informationfor Patients
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Acute PainSurvive, escape, avoid, rest
Chronic Pain
Chronic pain is constant or intermittent painthat persists over a period of time
It lasts beyond the expected healing timeand often cannot be attributed to a specificcause or injury
Serves no useful purpose
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Nociceptive PainCaused by the presence of a stimulus
on nociceptorsNociceptors (sensory neurons) in
tissues send pain signals to CNS
Neuropathic PainInitiated or caused by a primary lesion
or dysfunction in the nervous systemDamage or dysfunction to the nerve
itself causes typical pain symptoms
Symptoms of neuropathic pain
Numbness and sensory loss Ongoing pain Shooting, burning or electric shock-like Numbness, pins and needles
Hyperalgesia Increased sensation of pain in response
to normally painful stimuli Allodynia Pain in response to normally non-painful
stimuliFEELS DIFFERENT
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Severe chronic pain is a considerable physicaland psychological burden
Chronic Pain and the 3 Is
Pain Interrupts
Pain Interferes
Pain takes Identity
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Chronic Pain Management Medication review & education, optimise &
rationalise Explore pts’ understanding of chronic pain & any
associated fears Look at effects on sleep and mood Set mutually agreed management goals Promote concept of self-management and increase,
maintain function Verbal & written info on pacing activity, relaxation,
work, exercise etc. Encourage pts to utilise local facilities
Self Report Gold Standard
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Pharmacological Management
Structured assessment Analgesic history Patients views on medication OTC analgesia Other sources and illicit drugs Review of other medication Focus of management may be reduction
of analgesia
Medication Use Review -Analgesics
How are analgesics taken v how prescribed?Why is there any disparityIf prescribed PRN- what does that mean to the patient?How effective is it and is this acceptable to patient?Any side effects or concerns?If prescribed opioids for how long and when was last reviewThe importance of analgesia to the patient and conditiontreatedWhat is the patient understanding of their medication?Any concerns with obtaining medication and storageWould they benefit from a compliance aide ?
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Patients Association Report on PublicAttitudes to Pain
1/3 of patients were unsure how to useprescribed medication
½ of patients were unsure about potential sideeffects of pain medication & were unaware ofaccess to information from other sources suchas pharmacists
Many patients did not feel able to approach theirGP with concerns over sides effects frommedication for fear of reproach orembarrassment
A third of patients were not adhering toprescriptions issued by their GPs
Analgesics used in pain management
Leeds Pain Service Guidelines NICE guidelines when appropriate. British Pain Society Guidelines
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Paracetamol
Sometimes worth going back to basics Can be underrated as a painkiller Take regularly Education re safety and possible dangers Caution of dispersible with hypertension Beware hepatic insufficiency / alcohol
dependence
How safe is Paracetamol? - recent research
‘Staggered overdose,’when two or more paracetamol doses are taken abovethe recommended level over a period of less than eighthours.Research has shown that this is slightly, moredangerous than single point overdose.Compared to single point overdose patients, staggeredoverdose patients were more likely:to be olderto have a history of alcohol abuseto have taken alcohol with their overdose
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Take home messages from research
Paracetamol is a safe and effective painkillerwhen taken correctly.The research provides important insight intothe outcomes that might occur whenParacetamol is not taken in the correct manner.Highlights the need for people to ensure theytake the correct amount, which is always statedon the drug packaging and in the informationleaflet inside.Always read the label and seek medicalattention if you believe you have taken anoverdose.
Non steroidal anti inflammatory drugsConsidered to be “simple” painkillers- can buy themOTCNot for prolonged useSafe in short term onlyUseful in flare-upsBeware renal impairment,Caution in hypertension, concominant steroids,asthmaConsider gastric protection.Consider topical NSAIDsLimited evidence of efficacy
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Why prescribe opioids?
Effective for nociceptive & neuropathic pain Not complete pain relief Facilitate rehabilitation Analgesia is main aim but also improvement in sleep, mood, and
physical, vocational, social and emotionalwell-being
Must demonstrate analgesia Not for anxiety or sedation
Weak Opioid Drugs
Effectiveness of Co-Codamol 8/500 DHC and Tramadol useful- slow release Ceiling dose Transdermal patches- Butrans Mild (er)side effects
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Strong Opioids
Patient education re equivalent dose of topweak opioid v strong opioid Transdermal patches Beware of rapid escalation New information form BPS for initiation&
top doses Limited benefit in NeP Manage side effects
Prolonged use of opioids might lead to astate of abnormal pain sensitivity.
Clinically, the patient on long term opioidtherapy presents with increased pain.
Pain associated with hyperalgesia is morediffuse than the pre-existing pain and lessdefined in quality.
The management of opioid inducedhyperalgesia is opioid dose reduction orchanging to an alternative opioidpreparation.
Opioid induced hyperalgesia
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Co-analgesicsAmitriptyline First line in NICE for NeP separate dose and effect as used in
depression –can be a concern for patients Side effects-such as dry mouth and
sedation Start low, go slow Taken a few hours before bed can reduce
“hangover effect”
Duloxetine
Licensed for PDN although on someguidelines as 2nd line for all neuropathicpain
Start 30mgs daily, max 60mgs bd Can cause nausea- advised to take with
food in evening
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Anticonvulsants
Gabapentin & Pregabalin most commonly used Pregabalin recommended by NICE as 1st line Easier to titrate Possibly less side effects Expensive! Mood stabilizer, anxiety Beneficial for slow wave sleep Initiate 25mgs BD
Routes of AdministrationOral instant release slow release- recommended as best practice Oramorph not recommended!Transdermal Patches, 3day, 7 day Lidocaine- VersatisTopical NSAID gels Capsaicin Freeze Gel
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Ian 1
Ian 56 yrs Insulin Dependent Type II Diabetic Foot & lower leg pain-PDN Pregabalin 100mgs & Co-dydramol
at night Reluctant to take Amitriptyline Pain effecting sleep
Ian 2 Medication not effective Low mood-no quality of life Angry about delayed diagnosis of
Diabetes. Working 7 days a week / “couch
potato” at home Social contact reduced Sleep poor but napping during day Wanted “to manage pain not pain
manage me”
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Ian 3
Lack of sensation in feet Nail been hammered into foot “could stand in hot water & not feel
temperature” Feet felt burning Cramping & numb SLANSS 16
Ian 4
Medication optimisation Treat mood Self management strategies
discussed and resources given
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Ian 5 Pain reduced by 80% Pregabalin 300mgs BD Paracetamol x 2 TDS / Co-dydramol
x 2 at night. Minimal disruption in sleep. Mood improved- taking anti
depressants. Continues to work long hours- not
doing any over time - a little moreactive at home.
John 1
26 yrs 4 year history lower back and leg
pain MRI scan,small disc bulge L4/5 Loss of function Unable to work Impact on finances Impact on mood Impact on relationships
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John 2
At assessment Very angry and tearful Shouldn’t have to live like this. Life is “shit” Only 24! Sleep a big problem Dog has saved his life
John 3 Analgesia at Assessment Tramadol 50mgs x2 four times daily Takes more at times Itchy skin Not sure of effectiveness Afraid of addiction to Amitriptyline Cautious about Paracetamol Has tried friend’s Butrans! Previously prescribed Co-Codamol
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John 4Plan following assessment Withdraw Tramadol Start Butrans 10 Anti emetic cover Regular paracetamol Physiotherapy Graded Activity Pacing advice Doesn’t want to consider treating
mood
John 5 Reviewed after 6 month Butrans 10 - 50% pain relief Constipation Helping sleep Having some good days Pain still huge impact on life Continues Tramadol 50mgs x10 on some days ! Wants to take analgesia only when he needs it Very angry and tearful, doesn't want to discuss
mood
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John 6
Plan following review Increase Butrans to 15 Laxative Withdraw Tramadol Continue Paractamol Pacing advice
John 7 Reviewed 4 months later Continues on Tramadol- wants
something stronger Stopped Butrans Started Amitriptyline by GP Not listening to him, remains very angry Wants PRN analgesia, doesn't get pain
all time Has had input from Mental Health Team Given TENS machine
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John 8
DNA ‘d a few times Reviewed after a few months TENS quite helpful! Continues Tramadol Continues Amitriptyline Mood a bit better Finances sorted out Taking dog out every day
John 9
Plan Discussion with GP Continue TENS May help reduce Tramadol Pacing / graded activity Review in a few weeks
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Donald , age 84Degenerative spine, neck and lower
back painWide spread joint painPrevious patient in secondary careHouse boundOnly comfortable in reclining chairwith head pushed forward.Low mood
Donald 1
01/05/13
Cartilage becomes pitted, rough and brittleUnderlying bone thickens and broadens to reduceload on cartilageBony outgrowths form at the outer edges of the joint,making it look knobblySynovial membrane and joint capsule thicken, andspace inside the joint narrowsThis leads to a stiff joint, which is painful to moveand sometimes inflamed
OA develops due to changes in cartilage(the soft tissue protecting bone surface)
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Wear and tearCrumbling spine“kisses of time”
Osteoarthritis
Donald 2Analgesic Regime
Butrans 5 Tramadol 200mgs MR at night, most effective
analgesic Co-Codamol 30/500mgs x 2 TDS Never tried non drug therapies
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Donald 3Management Plan
Replace Co-Codamol with Paracetamol Reduce and withdraw Butrans Increase Tramadol TENS Heat Consider treating low mood
Always consider...... Analgesics sometimes work better in combination(
combined drug or separately) For chronic pain take regularly Slow release when possible Manage side effects rather than stop drug Some drugs produce obvious side effects before any
benefit is seen Other analgesics have longer term side effects, can be
less obvious 10% population can’t convert codeine Education about analgesia use is part of management Consider stopping analgesia if not gaining benefit Analgesics only part of pain management
