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Pain Management

Pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage

IASP, 1979

Types of Pain

Types of Pain

Pain is often inadequately treated

Impediments to effective
pain control

Pain Management

Drugs for Pain

NSAIDs

Acetaminophen

Opioids

Opioids with Limitations

Neuropathic Pain

First-Line Drugs for Neuropathic Pain

Many Other Agents

Use of Pain Medicines

Use of Pain Medicines

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Pain Management

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Professor June L. Dahl

The University of Wisconsin School of

Medicine and Public Health

[email-masked]

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Pain Management

|
| Professor June L. Dahl
| The University of Wisconsin School of Medicine and Public Health
| [email-masked]

Pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage

IASP, 1979

Types of Pain

| |
| Acute
| Pin prick, strains, sprains, fractures, strep throat, postoperative pain, headache
| Chronic
| Recurrent acute – migraines, sickle cell pain
| Cancer
| Non-cancer pain – rheumatoid and osteoarthritis, peripheral neuropathies, low back pain, phantom limb pain

Types of Pain

| |
| Nociceptive
| Dull, aching, well localized OR referred to distant sites
| Neuropathic
| Sharp, shooting, stabbling, burning, numbness or tingling

Pain is often inadequately treated

|
| Acute pain
| Cancer pain
| Chronic non-cancer

Impediments to effective
pain control

|
| Deficits in  knowledge
| Inappropriate attitudes
| Problems in the health care and regulatory systems
| Lack of access, inadequate reimbursement
|

Pain Management

|
| Pharmacologic therapies
| Behavior methods
| Physical methods
| Expert treatment of psychological problems
| Interventional techniques

Drugs for Pain

| |
| Non-opioids (non-narcotics)
| Aspirin, ibuprofen, celecoxib
| Acetaminophen
| Opioids
| Morphine is the “prototype”
| Drugs for special pain problems
| Antidepressants, anticonvulsants, local anesthetics for neuropathic pain
| Steroids and others

NSAIDs

| | |
| Analgesic, antiinflammatory and antipyretic
| Two classes
| Older non-selective drugs
| Many adverse effects, especially on stomach
| COX-2 inhibitors –Celebrex
| Less effect on the stomach unless take in combination with low-dose aspirin
| Recent concerns about increased risk of heart attack and stroke

Acetaminophen

|
| Analgesic, antipyretic
| Doesn’t affect the stomach, kidneys, platelets as do NSAIDs
| Toxic to the liver at high dose
| Don’t take more than 4 g in 24 hours
| Often found in combination drugs with opioids

Opioids

| |
| Most are excellent pain relievers
| Don’t damage organs even with long term use
| Many possible side effects
| Constipation, sedation, dizziness, itching, respiratory depression in overdose
| Lots of myths about these drugs
| Tolerance and addiction
|

Opioids with Limitations

| |
| Codeine
| Hydrocodone because of acetaminophen
| Propoxyphene (Darvocet)
| Meperidine (Demerol)
| Mixed agonist-antagonist drugs
| Talwin, Nubain, Stadol
|
|

Neuropathic Pain

|
| First-line treatments have been identified
| Current practice:  trial and error
| There may be advantages to combining two first-line drugs
| May take “awhile” to get a response
| Relief may only be partial

First-Line Drugs for Neuropathic Pain

| |
| Not in order of preference
| Systemic analgesics
| Opioids and tramadol
| Topical analgesics – 5% lidocaine patch
| Antidepressants
| Tricyclics
| Venlafaxine (Effexor) and duloxetine (Cymbalta)
| Certain anticonvulsants
| Gabapentin (Neurontin) and pregabalin (Lyrica)
|
|

Many Other Agents

| |
| Steroids-many routes of administration
| Muscle Relaxants
| Limited usefulness
| Topical Agents
| Menthol based: Tiger Balm, Deep Heat
| Capsaicin - from chili peppers – don’t get in your eyes

Use of Pain Medicines

|
| A thorough understanding of your pain is essential to any decision about treatment
| The severity and type of pain will guide the choice of treatment
| The doses of a medication and the interval between doses is based on the properties of the medication
| You may need to have more than one type of pain medicine
| Some medicines take time to work so you may need to have considerable patience

Use of Pain Medicines

|
| If you are in pain more than half of the time, you need to be taking your medicine regularly
| Addition of non-drug therapies may result in better pain relief and fewer side effects
| Purpose of treatment is to relieve pain and improve function.

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Pain is an unpleasant sensory

and emotional experience

arising from actual or potential

tissue damage or described in

terms of such damage

IASP, 1979