PAIN

MANAGEMENT
A PAPER PRESENTED
BY
PHARM ODIHI, CHARITY ONYOWOICHO
ON 02/10/2014
AT
THE DEPARTMENTAL WEEKLY SEMINAR OF
PHARMACY DEPARTMENT
BENUE STATE UNIVERSITY TEACHING
HOSPITAL, MAKURDI

 Outline

Definition
Pain classification
Goals of pain

management
Pain management
team
Approaches for pain
management
Drug-drug
interactions

Drug-herb

interactions
Reasons for
deficiencies in
patient pain
management
Conclusion
References

Definition.
Pain management:

A branch of medicine employing an

interdisciplinary approach for easing the
suffering and improving the life of those in
pain (Wikipedia, 2014).

Pain:

Defined as an unpleasant sensory

and emotional experience associated
with actual or potential tissue
damage or described in terms of such
damage.

Pain Modulation :

Different individuals have variability in pain

felt even in injuries of similar magnitude.

Suggestions that a treatment will relieve

pain can have a significant analgesia effect
(placebo effect).

 Suggestion that pain will worsen

following administration of an inert
substance can increase its perceived
intensity (nocebo effect).

Pain Classification:
Referred pain

spatial displacement of pain

sensation from the site of injuries
that produces it.

 Neuropathic Pain:
Lesions of the peripheral or central
nociceptive pathway typically result
in loss or impairment of pain
sensation and can also produce pain.

 Neuropathic Pain contd.

Severe and resistant to standard
treatment for pain.

Usually burning, tingling, pulsating or

of electric shock-like quality.

May be triggered by very light

touch .

Neuropathic Pain contd.

Pains

which can be called neuropathic

include damages to peripheral nerves e.g.

diabetic neuropathy,

continued pain experienced from a limb

which has been amputated,

 Neuropathic Pain contd.

damages to primary afferents e.g.
herpes zoster,

damages to CNS e.g. Cerebrovascular

injuries to spinal cord, brain stem.

 Sympathetically maintained pain:

Spontaneous pain that occur in patients
with peripheral nerve injury.

Begins after a delay of hours to days or

even weeks.

Accompanied by swelling of the

extremities, periarticular bone loss and
arthritic changes.

 Sympathetically maintained pain contd:

CRPS 1 (reflex sympathetic dystrophy)

occurs without obvious nerve injury and
resolves with symptomatic treatment.
Signs and symptoms suggest over activity of
the sympathetic nervous system.

CRPS II (Post traumatic neuralgia or if

severe (causalgia).

Occurs with an identifiable nerve injury.

 Nociceptive Pain:
Nociceptive Pain:
Pains associated with sprained ankle.
Benign pathology, or by tumors or cancer
cells that are growing larger and crowding
other body parts near the cancer sites.
Pains in diseases such as arthritis
Divided into two types radicular or somatic.

Goals of pains management

To remove all the pain (if possible).
To remove the cause of the pain.
To minimize side effects of pain reliever.
To cause the patients would once more be able to carry out
activities that was hindered by the pain.

 Pain Management Team:

Pharmacists.

Medical practitioners.
Clinical psychologists.
Physiotherapists.
Occupational therapists.
Clinical nurse specialists.

Approaches for management of pain

Non pharmacological.
A. Diagnostic approach:
B. Physical approach:
.TENS (Transcutaneous electrical nerve
stimulation)
. Acupuncture
. Light therapy
. Ice, heat, ultrasound, massage, spinal
cord stimulation.
. Nerve blocks(somatic and sympathetic)

Non pharmacological contd:

C. Neurosurgery
D. Psychological Approach
.Cognitive behavioral therapy
(relationship between ones physiology
and pain. This involves life style
changes.
.Hypnosis

Pharmacologic management
Cox 2 inhibitor: Aspirin,

Acetaminophen, NSAIDS.

- Inhibit cyclooxygenase.
- Have anti-inflammatory action (except acetaminophen).
- Effective for mild to moderate headache.
- Usually available without prescription.

 Side effects:
Cox2 selective e.g. Celecoxib has less
gastric irritation but increases
cardiovascular risk contraindicated in
patients in the immediate period after
coronary bypass.

 Acetaminophen (paracetamol) in a
high dose is toxic to the liver.

Aspirin has high GIT irritability and

also causes GIT bleeding.

NSAIDS have nephrotoxicity and can

also increase blood pressure

Opoid analgesics:
- Most potent pain relieving drugs currently
available.
- Do not usually provide complete analgesia whether
pain is acute or chronic in origin.
- Drug tolerance, chemical dependency, diversion
and addiction may occur.
-Side effects include vomiting, pruritus, constipation
with respiratory depression (uncommon).

 Examples include oxycodone,

hydromorphone, methadone
bicarbonate, pentazocine and pethidine
(meperidine).

Normeperidine, a metabolite of
meperidine produces hyper excitability
and seizures that are not reversible
with anti opioids.

 Opioids can be given intrathecally

eg. (0.1-0.3)mg morphine (used in
cancer patients), intravenouslly (E.g.
5-10mg morphine ) intranasally
(butorphanol ), transdermally
(fentanyl)

 2nd and 3rd line in pain management.

Patients controlled Analgesia (PCA)
- New?

A microprocessor controlled infusion

device that can deliver a baseline
continuous dose of opioid drug as
well as preprogrammed additional
doses when the patient pushes a
button.

 To prevent overdosing, PCA are

programmed with a lock out period
of one hour.

Used for post-operative pain.

Should be used for short-term home
care of patients with intractable pain
such as metastatic cancer.

 Note it is important to assess the

patients for the risk of substance
abuse, misuse or addiction before
drugs are administered.

Chronic Pain:

This

is caused by

Disease e.g. Arthritis, Cancer, Chronic

daily headaches, fibromyalgia, diabetic
neuropathy etc.

 Secondary perpetuating factors initiated by

diseases and present after that disease has
resolved e.g. damaged sensory nerves,
sympathetic efferent activities, and painful
reflux muscle contraction.

Psychological Conditions
Drugs used in chronic pain management
include:

 1.Anti-depressant medications

TCAS e.g. nortryptytine and

desipramine

Although the mechanism is

unknown, analgesic effects of TCAs
has a more rapid onset and occurs at
a lower dose than in typically
required for the treatment of
depression.

 2.Selective serotonin reuptake

inhibitors (SSRIs) e.g. Fluoxetine
(Prozac). These groups have fewer
and less serious side effects than
TCAs.

Non tricyclic antidepressants.

Blocks both serotonin and
norepinephrine reuptake.

Appears to retain most of the pain relieving effects

of TCAs.

Side effects profile more like that of SSRIs.

Particularly useful in patients who cannot tolerate
the effects of TCAs

The first drug of choice in chronic pain management.

 3. Anticonvulsants:
-

For neuropathic pains mainly.

Phenytoin (Dilantin) and carbamazepine

(Tegretol) 1st used

- Newer drugs e.g. Gabapentin (neurotin) and
pregabalin (Lyrica) have a broad range for
neuropathic pain.
-

Newer drugs are first line (in the use of

anticonvulsants) because of favorable side effect

profile.

4. AntiArrythmics:
- Lidocaine & mexiletene are
examples.
- Less likely to be effective as even
the intravenous effects wane off
hours soon after administration.

 Drug-Drug Interactions.
Opioid and COX inhibitor
combination.
-

Additive effective.

- Side effects are non-additive

therefore combinations are used to
lower the of dose related side effects.

 Fixed ratio combination of opioid +

paracetamol can become a problem
since every increase in dose would
cause an increase of paracetamol
which could lead to toxicity .

Pentazocine and butorphanol have

mixed agonist antagonist properties.

Opioids and TCAs.

TCAs potentiate opioid analgesics

and are additive also in their side
effects.
Cimetidine, Gabapentin &
grapefruit juice potentiates
opiates by inhibitory cytochrome
450 enzymes in the liver.

Drug-Herb interactions:

NSAIDs e.g. Aspirin, interact with ginkgo, garlic,

ginger, bulberry, dongqual, feverfew, ginseng,
tumeric, meadow sweet.

paracetamol + gingko -increased bleeding.

Paracetamol + Echinacea and /or kava
hepatotoxicity.

- increased

 Paracetamol + herbs containing

salicylate gives an increase in
nephrotoxicity.

Opioid analgesic + valerein, kava and

chamomille cause an increase in
central nervous system depression.

Opioid analgesic +
ginseng___Inhibitory effect of
opioids.

Reasons for deficiencies in patient

pain management:

Physicians usually prescribe inadequate

dose of

opioids in managing severe pain for fear of being

accused of over prescribing .

 Misconception that pain is a normal

part of aging .

Inadequate training.
Personal bias.
Poor assessment.

Note that

Intrathecal drug

delivery system for

severe and persistent pain.

Epidural injection of glucocorticoids.

CONCLUSION

Pain is all around us (emotional, physical,

psychological etc) but if measures are taken
to assess properly the aspect of pain that is
most central in the life of any individual,
usually almost all other pains are taken care
of.

 Chronic pain management is

difficult.it is essential to be
objective and non judgemental when
discussing physical, psychological
and social factors without assuming
which is primary.

A sympathetic biopsychosocial
multidisciplinary approach is best in
managing chronic pain

* REFERENCES
* www. medtronicneuro.com. au/chronic paincommon type. html.
* www. power over your
pain.com/understand/chronic/pain types.
* www. medicinenent.com/painmanagement/page 2.html
* www.helpforpain.com/articles/understandneurpathic-pain/ understanding.html.
* www.webmd. com/painmanagement/guide/pain-managementsymptoms-types.

*REFERENCES contd

*www.annies remedy.com/chart/php.
*Kumar and Clark (2002) clinical medicine. 5th Edition. W.B

Saunder.
*Kumar and Clark(2012) clinical medicine.8th Edition. Elsevier
*Longo et al (2012).Harrisons principles of internal medicine 18 th
edition.
*http://en.wikipedia.org/wiki/ pain management.
*Colledge R.N; Walker R.B; Ralston H.S(2010). Davidson principle
and practice of medicine. 21st Edition. Churchill livingstone
Elsevier.

Thank
you.