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Questions and Answers
Which system is NOT involved in the pain experience?
What type of pain is characterized by being poorly localized and often radiating?
Which medication is most commonly used for severe pain that does not respond to non-opioids?
What is a common characteristic of acute somatic pain?
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When prescribing opiates, which factor should be considered regarding dosage?
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What is the maximum daily dosage of ibuprofen for adults?
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Which is a serious side effect of aspirin when given to children with flu-like symptoms?
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What should patients do after taking aspirin to ensure proper administration?
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What is the initial approach to opioid therapy for chronic pain management?
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Which of the following is NOT a criterion for continuing long-term opioid treatment?
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What is the maximum recommended dose of acetaminophen for adults in a 24-hour period?
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Which patient population is acetaminophen considered the drug of choice for?
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In administering NSAIDs, what monitoring is crucial to ensure patient safety?
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What is the appropriate dosage of acetaminophen for mild pain in an adult?
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For which condition is aspirin primarily used as a prophylactic treatment?
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What serious side effect should patients be educated to report when taking NSAIDs?
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Which statement regarding the use of aspirin in fever management is correct?
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What is the typical dosing for acetaminophen in children experiencing mild pain?
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What is the primary characteristic that differentiates pain threshold from pain tolerance?
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Which of the following factors does NOT decrease pain tolerance?
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What physiological indicator may be affected in children experiencing pain?
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What is a characteristic of chronic pain in older adults?
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Which statement is true regarding pain mechanisms in infants?
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Which of the following medications can be considered for abortive migraine therapy?
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What is the primary goal of preventive therapy for migraines?
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Which of the following is NOT a red flag for substance abuse?
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Which screening tool is adapted for substance abuse in patients?
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Which class of medications do triptans belong to and what is their primary use?
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What is one of the appropriate nonpharmacological measures for pain management?
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Which of the following statements about beta-blockers for migraine prevention is true?
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Which of these is an indication for using the CAGE-AID questionnaire?
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Study Notes
Pain Defined
- Pain is a subjective experience, meaning it is whatever the experiencing patient says it is.
- Pain is associated with actual or potential tissue damage, or described in terms of such damage.
Pain Threshold and Tolerance
- Pain threshold is the point at which a stimulus is experienced as pain.
- Pain tolerance is the duration of time or intensity of pain a person will endure before taking action to relieve it.
- Pain tolerance decreases with repeated exposure to pain.
- Fatigue, anger, fear, and sleep deprivation decrease pain tolerance.
Pediatric Pain
- Pain pathways and chemicals associated with pain are functional in preterm and newborn infants.
- Nociceptor system is functional by 24 weeks’ gestation.
- Endogenous opioids are released in the human fetus at birth and in response to fetal and neonatal distress.
Pain Assessment in Children
- Behavioral indicators of pain include crying, whimpering, whining, social withdrawal, changes in sleep pattern, facial expression, body posture, and poor feeding.
- Physiological indicators of pain include alterations in heart rate, oxygen saturation, respiratory rate, and pattern; however, these are not always sensitive or specific.
Pediatric Pain (continued)
- Chronic pain in children is rarely associated with sympathetic arousal.
- Early pain stimuli and experiences are remembered.
- Pain should be adequately controlled in infants and children, using weight-based dosing.
Aging and Pain
- Pain threshold increases with aging.
- This is due to peripheral neuropathies and skin thickness changes.
- Pain tolerance decreases with aging.
- This is due to alterations in drug and metabolite metabolism.
Older Adults and Pain
- Chronic pain is a significant problem in older adults.
- Joint pain and neuralgias are common.
- Many older adults may perceive pain as a normal part of aging.
- Pain Assessment in Advanced Dementia Scale (PAINAD) can help assess pain in individuals with dementia, considering breathing, vocalization, facial expression, body language, and consolability.
The Pain Experience
- Pain involves the interactions of three major systems: the sensory/discriminative system, the motivational/affective system, and the cognitive/evaluative system.
Acute Somatic Pain
- Arises from connective tissue, muscle, bone, and skin.
- Can be sharp and localized or dull and non-localized.
- Responds best to acetaminophen, corticosteroids, NSAIDs, opiates, local anesthetics, ice, and massage.
Acute Visceral Pain
- Pain in the internal organs and abdomen.
- Poorly localized due to C-fibers.
- Radiates.
- Most responsive to opiates.
- May also use corticosteroids and NSAIDs.
Drugs for Acute Pain
- Morphine and other opioid agonists are used for moderate to severe pain not responding to non-opioids.
- Centrally acting non-narcotic analgesics include acetaminophen.
- COX inhibitors include salicylates (ASA, indomethacin) which primarily target COX-1, and NSAIDs (Motrin [ibuprofen]) which target COX-1 and COX-2.
- COX-2 inhibitors include Celebrex [celecoxib], Voltaren [diclofenac], and others.
Morphine and Opiates
- Used for moderate to severe pain.
- Available in oral, intravenous, and transdermal forms.
- Choice of route depends on pain severity.
- Moderate pain may be treated with codeine or codeine/acetaminophen (Tylenol #3), or hydrocodone or hydrocodone/acetaminophen (Vicodin).
- Severe pain may be treated with morphine or oxycodone.
Prescribing Opiates
- Dosage should be appropriate, considering opioid-naive patients, patients with chronic pain, children, and older adults.
- Clear instructions should be provided, including "do not exceed".
- The right amount of medication should be dispensed.
- Refill considerations should be discussed.
- Patient education should include clear instructions regarding safety, ADRs, length of treatment, and non-opiate therapy.
- Monitoring should assess pain medication effectiveness, dosage tapering, and discontinuation.
- If pain is not controlled, the cause of pain should be reassessed.
- The Opioid Risk Tool (ORT) can be used to assess risk for opioid misuse.
Acetaminophen
- Central nervous system (CNS) action to inhibit prostaglandin.
- Used for mild to moderate pain.
- Safer than NSAIDs for most people.
- Safe in pregnancy, infants, and most older adults.
Prescribing Acetaminophen
Appropriate dosing:
- Mild pain: 325 to 650 mg every 4 to 6 hours (children: 10 mg/kg).
- Moderate pain: 500 to 1,000 mg every 4 to 6 hours (maximum: 4 g/24 hours, children: 15 mg/kg/dose).
- Clear instructions should be provided, including "do not exceed".
Acetaminophen: Clinical Use
- Drug of choice for mild to moderate pain in pregnancy, patients with history of GI bleed, aspirin allergy, blood coagulation disorders, and upper GI disease.
- Drug of choice for fever in adults, children, and infants younger than 6 months of age, especially during flu-like illness.
NSAIDs: Monitoring
- Monitor renal function with long-term therapy.
- Monitor for GI ulcer or bleed, and perform CBC prior to initiation of therapy and annually thereafter.
Acetaminophen: Monitoring
- Monitor for overdose with self-medication.
- Monitor liver function if on high-dose or long-term therapy.
NSAIDs: Patient Education
- Take as directed.
- Limit alcohol consumption.
- Maximum acetaminophen dose is 3 g/24 hours.
- Report GI upset or “coffee ground” emesis.
Aspirin: Clinical Use and Dosing
- Effective antipyretic (fever reducer).
- Do not use in pregnant patients or children.
- Gold standard for mild to moderate pain.
- Gold standard for Rheumatoid arthritis.
- Used for Osteoarthritis pain.
- Used for acute rheumatic fever.
- Used for myocardial infarction (MI) prophylaxis.
- 81 to 325 mg daily has been associated with a 20% reduction in risk of subsequent MI.
- One 325 mg tablet should be taken at the first sign of MI.
- Used for transient ischemic attacks, 50 to 325 mg/day for stroke prevention.
Aspirin: Patient Education
- Take with plenty of water, and remain upright for 15 to 30 minutes.
- Do not crush or chew enteric-coated tablets.
- Tablets with a vinegar-like odor should be discarded.
- Potential ADRs include GI upset, bleeding, ulcers, and Reye’s syndrome in children with flu-like illness.
Lifestyle
- Rest, heat, and exercise can help manage pain.
Prescribing NSAIDs for Pain
- Ibuprofen and naproxen are effective for acute pain.
- Short-acting and available over the counter (OTC).
Ibuprofen Dosing
- 200 to 800 mg/dose every 6 hours or every 8 hours.
- Maximum: 3,200 mg/day.
- Children: 5 to 10 mg/kg/dose (maximum: 40 mg/day).
Prescribing NSAIDs for Pain (continued)
- Naproxen: 500 mg, then 500 mg every 12 hours or 250 mg every 6 to 8 hours.
- Maximum: 1,250 mg/day.
Treatment of Chronic Pain
- Treatment involves assessment, trial, long-term management, and termination of treatment.
Phase 2: Trial of an Opioid
- Non-opioid therapy is preferred.
- Prior to initiating therapy, a Patient–Provider Agreement (PPA) and informed consent form should be obtained.
- Set realistic goals.
- Start with immediate-release opioid when starting therapy.
- Start low and go slow.
- Consider naloxone prescription.
Phase 3: Long-Term Treatment
- Transition to chronic management after a successful trial.
- Successful trial includes satisfactory pain relief, ability to manage ADLs, consistent pain scores on a reliable scale, no misuse or legal issues, and stable living situation.
Chronic Pain Plan
- Review patient’s history.
- Develop a treatment plan.
- Obtain informed consent.
- Evaluate patient periodically.
- Refer for additional evaluation, as needed.
- Document all information.
- Follow federal and state laws.
Rational Drug Selection
- Use an algorithm to select appropriate medication.
- Consider lifestyle modification.
- Medications may include NSAIDs, opiates, antidepressants, and antiepileptic drugs.
Substance Abuse
- Red flags for substance abuse include claims of lost prescriptions, using alcohol or street drugs, repeated requests for early refills, frequent emergency department visits for medication, multiple providers prescribing for the patient, and forging or buying/selling prescriptions.
Screening and Monitoring for Substance Abuse
- CAGE-AID questionnaire (Cut down, Annoyed, Guilty, Eye opener–Adapted to Include Drug use) can screen for substance abuse.
- DAST-20 (Drug Abuse Screening Test-20) is another screening tool.
- Monitor prescriptions and conduct urine drug screens.
Pain Contracts
- Recommended by the American Academy of Pain Management.
- Define behavior between patient and provider.
- Outline all aspects of treatment, not just drugs.
- Sample contract available at www.aapainmanage.org
Don’t Forget…
- Nonpharmacological measures like heat, ice, massage, touch, and distraction can be helpful.
Don’t Forget… (continued)
- Alternative therapies such as acupuncture, transcutaneous electrical nerve stimulation (TENS), yoga, and massage can be considered.
Migraine: Treatment
- Goals of therapy are to minimize impact on quality of life and avoid medication overuse.
- Treatment involves acute abortive therapy and prophylactic therapy.
Migraine: Abortive Therapy
- Over-the-counter (OTC) analgesics, such as NSAIDs (ibuprofen or naproxen) and migraine formulas (Excedrin Migraine or Advil Migraine), are most effective early in migraine.
Migraine: Triptans
- Serotonin receptor agonists, such as sumatriptan (Imitrex) and other "triptans".
- Taken at the onset of migraine.
- Contraindicated in patients with coronary artery disease, uncontrolled hypertension, and pregnancy.
- Drug interactions include ergotamines, monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors.
Migraine: Preventive Therapy
- Considered for patients with more than two migraines per month.
- Goal is 50% reduction in migraines.
- Takes time to work (minimum 4 weeks).
- HA diary used to track effectiveness.
- Beta blockers (propranolol, timolol), antidepressants (amitriptyline, venlafaxine), and antiepileptic drugs (divalproex sodium, sodium valproate, and topiramate) can be used.
Beta Blockers for Migraine
- Prevention:
- Propranolol: Start at 60 to 80 mg/day, and increase to 240 mg/day. Children: 0.5 mg/kg/day, increase to 2 to 4 mg/kg/day.
- Perform 3 month trial, reassess every 6 months.
- Taper off slowly.
- ADRs include fatigue, lethargy, and depression.
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Description
Test your knowledge on pain management concepts with this quiz. It covers aspects of pain types, pain experiences, and medications commonly used for severe pain. Ideal for healthcare professionals and students alike.
