Pain Management Hand-out

SLT 2024-2025
Juhaina Al-Maqbali, B.Sc., M.Sc., BCPS, and Ph.D. student
Senior Clinical Pharmacist Specialist-SQUH
 Learning points
-Principles of management of pain

-Types of pain assessment

-Pharmacotherapeutic options (NSAID, OPOIDS, and co-analgelics)

-Treatment ladder and strategies

-NSAIDs and gastrointestinal risk

-Cancer pain and breakthrough pain

-OPOIDs and its ADRs, syndromes, escalation, de-escalation , therapeutic

changes and conversions.
 What is pain?

“ unpleasant sensory and emotional experience associated with actual or potential tissue
damage”.

It is the most common symptom that make patient seek medical attention

• What is the function of pain?

Act as a vital defensive function as it warns about the
• factors in the immediate environment that could cause physical injury e.g. burns

• alerts about functions within the body that might require attention --- might be first
alert of ongoing pathologic process e.g. appendicitis, tooth ache …etc
 Understanding Pain

Anatomy of Pain Pain Perception

Understanding the physiological Pain perception is a complex

and neurological pathways of process involving the sensory
pain transmission is essential in nervous system and the brain,
developing effective pain influenced by various factors
management strategies. such as emotions and past
experiences.
Types of Pain
Chronic Pain Acute Pain Neuropathic Pain
Chronic pain persists for an Acute pain is often a protective Neuropathic pain arises from
extended period and can have a mechanism triggered by the damage or malfunction in the
significant impact on daily body in response to injury or nervous system, leading to
functioning and quality of life. illness, typically resolving as abnormal pain processing and
healing occurs. potential chronic symptoms.

Post-Operative Pain Oncological Pain

Is an anticipated and temporary Chronic visceral pain associated
pain that occurs following with cancer is usually related to
grafting procedures or burn disease progression (due to
excision and is most commonly visceral involvement,
the result of increased pain from compression, or neural
newly created wounds. infiltration )
Aims & Principles of Pain Management
• Aims:
• provide pain relief satisfactory to the patient
• identify and address the cause of pain
• maintain alertness and function
• allow rapid return of normal breathing, coughing and mobility

• Principles:
• pain assessment ----- to determine the severity of pain
• stepped combination approach to analgesia --- maximum pain relieve
• early analgesia ---- early restoration of alertness and function
• patient education --- reduction/proper use of medication
• identify the difficulties e.g. complex patients
Taking Pain History
• Site(s) of pain?
• Severity of pain?
• Date of onset?
• Duration?
• What aggravates or relieves pain?
• Impact on sleep, mood, activity?
• Effectiveness of previous medication?
Pain Assessment

Multidimensional
Assessment Pain Scales
Involves evaluating physical, Various tools, like the
psychological, and social numerical rating scale and
factors influencing pain visual scale, help assess pain
perception. intensity.
Non-Pharmacological Pain Management

Physical Therapy Mind-Body Techniques Acupuncture

Physical therapy focuses on Mind-body practices, such as Acupuncture involves the

improving mobility, function, meditation and deep breathing insertion of fine needles into
and pain relief through targeted exercises, help manage pain by specific points on the body to
exercises and therapeutic promoting relaxation and alleviate pain and restore
modalities. reducing stress. balance in the body's energy
flow.

Psychosocial Nerve Blocks

Interventions
Address psychological and Nerve blocks interrupt the
emotional aspects of pain transmission of pain signals in
through techniques like targeted nerves, offering
cognitive-behavioral therapy and localized pain relief for certain
relaxation. conditions.
 Pharmacological Pain
Management
Pain killers Opioids Adverse Effects

Various pharmaceutical agents, Opioids are potent pain relievers Understanding potential side
including paracetamol, that work by binding to opioid effects and monitoring for their
nonsteroidal anti-inflammatory receptors in the brain and spinal occurrence is crucial in
drugs (NSAIDs) and muscle cord, but their use requires pharmacological pain
relaxants, are commonly used to careful monitoring due to the management.
manage pain. risk of dependence and adverse
effects.
Treatment ladder
Important Strategies:
•Oral dosing of drugs whenever possible (as opposed to intravenous, rectal, etc.).

•Around-the-clock rather than on-demand administration (The prescription must follow the pharmacokinetic

characteristics of the drugs).

•Analgesics must be prescribed according to pain intensity as evaluated by a pain severity scale. For this

purpose, a clinical examination must combine with an adequate pain assessment.

•Individualized therapy (including dosing) addresses the concerns of the patient.

•Proper medication adherence, as any dosing alterations can lead to pain recurrence.
Pharmacotherapeutic Options
1. • Non-opioids 3. • Co-analgesics (adjuvant agents)
– Acetaminophen • Drugs with primary indication not for pain
• Often used for chronic pain or neuropathic type of pain
– NSAIDs • Improve opioid analgesia pain
Examples
• Tricyclic Antidepressant: amitriptyline
2. • Opioids
• Anticonvulsant: gabapentin/ pregabalin (approved for
– Morphine, oxycodone
neuropathic pain)
– Hydrocodone, hydromorphone
• Anti-arrhythmics
– Methadone, fentanyl
Ketamine
– Tramadol, tapentadol
• Skeletal muscle relaxants
– Codeine, meperidine
• Local anesthetic: lidocaine patch
– Buprenoprhine
• Corticosteroids
• Others: caffeine, clonidine
1. NSAIDs
1. Selected NSAIDs Indications

• Headache • Pain due to fever, cold, flu

• Toothache • Rheumatoid arthritis
• Sinus pain • Osteoarthritis
• Muscular pains • Ankylosing spondylitis
• Bursitis • Gout
• Tendonitis • Acute painful shoulder
• Backache • Sprains
• Primary dysmenorrhea
NSAID Adverse Effects

1. Dyspepsia, abdominal pain, GI discomfort

2. GI bleeding , cardiovascular events (worsening HTN, MI)
3. Hepatic (reversible) and renal impartment
4. Exacerbation of respiratory diseases

• Special considerations for children and pregnant or lactating women

• Risk of adverse effects is probably related to duration of therapy and

dose-related
 Primary Prevention of NSAID Induced Ulcers
1. Implement risk factor modification.
2. Test and treat for H. pylori if patient .
3. Determine level of GI-related risk (low, medium, high)
4. Determine level of cardiovascular (CV)risk.

High risk: Moderate risk: Low risk:

1. History of complicated ulcer 1. Age >65 years. No risk factors
2. Several (>2) risk factors 2. High-dose NSAID therapy.
3. Concomitant use of 3. History of uncomplicated ulcer.
corticosteroids, anticoagulants, or 4. Concurrent use of aspirin
antiplatelet drugs (including low dose), corticosteroids,
or anticoagulants.
NSAIDs according to risk of G.I.T toxicity
1. Some NSAIDs have less toxic to the GI such as: (1)ibuprofen >(2) diclofenac >(3) nabumetone .
2. NSAIDs which is considered moderate risk: Naproxen
3. Other agents are considered high-risk drugs such as: piroxicam, indomethacin, and ketolac.

Other conditions may increase NSAIDs risk on GIT

1. Duration of NSAID use (higher risk in first 3 months).
2. Presence of chronic debilitating disorders such rheumatoid arthritis or cardiovascular (CV) disease may
also contribute to the increased GI toxicity of NSAIDs.
3. H. pylori infection is thought to confer additive risk of GI toxicity in NSAID users.
 Preventive Strategies Based on Risk of NSAID-Related GI
Complications and CV Risk
1. If low CV risk
A. Low GI risk ( lowest dose NSAID)
B. Moderate GI risk ( NSAID + PPI )
C. High GI risk ( COX2 inhibitor + PPI)

2. If high CV risk
B. Low GI risk ( Naproxen + PPI)
C. Moderate GI risk ( Naproxen + PPI)
D. High GI risk ( avoid all )

Alternatives
1. Acetaminophen, aspirin, tramadol, or short-term narcotics.
2. Nonacetylated salicylates (sasalate or trilisate ).
3. Non–COX-2-selective NSAIDs.
4. COX-2 inhibitors should be reserved as last line.
5. In patients at increased risk of thromboembolic events, coadministration with aspirin and a PPI may be considered.
6. Routinely monitor BP, renal function, and signs of edema or GI bleeding.
2. OPIOIDS
2. Selected OPIOIDS Indications

1. Treatment of moderate to severe pain Role in therapy:

that does not respond to nonopioids alone 1. Acute (trauma, postoperative pain)

1. Cough 2. Breakthrough pain

2. Diarrhea 3. Cancer pain

3. Dyspnea 4. Chronic noncancer pain

4. Opioid dependence 5. Effective in visceral pain

6. Frequently given with non-opioid therapy
(dose-sparing)
Clinically significant Adverse events with OPIOIDS:
1. Nausea
2. Constipation
3. CNS AE (sedation, decreased cognition)
4. Respiratory depression
5. Pruritus

Others
1. Opioid-induced immunologic effects
2. Endocrinopathy (hypogonadism, hyperprolactinemia)
3. Infertility, reduce libido, reduced / absent menses
4. Fatigue
5. Osteoporosis / osteopenia
6. Opioid-induced hyperalgesia
7. Opioid-induced bladder dysfunction
8. Cardiac effects of opioids
9. Sleep-disordered breathing / sleep apnea
 Understanding Cancer
Pain

Neuropathic Pain Nociceptive Pain

Caused by nerve injury or Arises from tissue damage or
dysfunction, resulting in inflammation and is often
shooting or burning sensations. experienced as aching or
throbbing.

Cancer pain is general term for a large range of different pain conditions
Goals of cancer pain management

General Goal: safe and timely reduction of a physical symptoms to a level acceptable to the
patient, or to the surrogate, if the patient is unable to report distress.

5 A's
1. Analgesia: Optimize analgesia (pain relief)
2. Activities: optimize activities of daily living (psychosocial functioning)
3. Adverse effects: minimize adverse events
4. Aberrant drug taking: avoid aberrant drug taking (addiction-related outcomes)
5. Affect: relationship between pain and mood

• Asses and re-access the pain and patient.

Therapeutic regimen

• History, physical exam, diagnostic studies.

• DRUG-RELATED VARIABLES

• PATIENT-RELATED VARIABLES

• Risk assessment of substance abuse, misuse, addiction

1. Screener and Opioid Assessment for Patients with Pain (SOAPP)

2. Opioid Risk Tool (ORT)
Indices of toxic effect (OPIOID)

SUBJECTIVE OBJECTIVE

• Constipation • Bowel movement frequency

• Nausea • # episodes of emesis

• Sedation • Level of sedation

• Dizziness • Respiratory rate

• Confusion • Pupil size

• Itching • Mini-Mental State Examination

• Problems with urination • Excoriation

Adjusting the therapeutic regimen

1. Change dose or route of administration

2. Discontinuing therapy (particularly opioids)
3. Switch to a different drug in therapeutic class
4. Add a drug from a different therapeutic class
5. Providing rescue / breakthrough pain analgesia
6. Opioid rotation
 OPIOID initiation dosing
OPIOID dosage escalation strategies Oral morphine: 2.5-5 mg
every 4 hours

• For serious or advanced illness, the rule is:

– DECIDE if the pain is truly opioid-responsive
– for moderate to severe pain, increase opioid TDD by 50-100%, regardless of starting dose
– for mild-moderate pain, increase opioid TDD by 25-50%, regardless of starting dose

• Short-acting, immediate-release single-ingredient opioids (morphine, oxycodone, hydromorphone)

can be safely dose-escalated every 2 hours.

• Most long-acting, sustained-release opioids can be increased every 24 hours (this does not include
TDF or methadone)
OPIOID dosage Decreasing strategies
• Patients with serious / advanced illness:
1. – for patients with good pain control, but experiencing dose-related excessive side effects on an oral opioid
regimen, it would be appropriate to reduce the around-the-clock opioid by 30%, but keep the rescue dose
unchanged
2. – for patients with continued pain but experiencing an opioid-induced adverse effect, consider adding a
co-analgesic, and reducing the around-the-clock opioid by 30-50%
3. – if the patient undergoes a definitive pain-relieving procedure, reduce regularly-scheduled opioid by 50%
immediately, and continue to reduce dose every third day until opioid discontinued, keep rescue
4. dose in place
– tapers range from 10% per week reduction, to 50% reduction every few days

• Patient with chronic nonmalignant pain:

– slow taper vs. fast taper
Breakthrough pain

• Spontaneous
– Idiopathic, occurring with no known stimulus

• Incident
– Secondary to a stimulus which the patient may or may not be able to Control

• End-of-dose failure
– Pain at the end of the dosing interval of a long-acting opioid
Rescue dose of OPIOID for Breakthrough pain
1. ONE dose of rescue opioid (e.g., oxycodone, oxymorphone, morphine) should
be 10-15% of the TOTAL daily dose of oral long-acting opioid

Example: MS Contin® 30 mg q12h (extended release)

TDD = 60 mg
10%: 6 mg
15%: 9 mg
Morphine 5 or 10 mg q2h prn breakthrough pain

2. OR Rapid-acting oral transmucosal fentanyl products

3. And Rate pain before and after rescue opioid
Equianalgesic Opioid Dosing
Chemotherapy-induced peripheral neuropathy (CIPN)

• Antidepressants and anticonvulsants are considered first-line adjuvant analgesics

in this setting.

– Duloxetine is considered the preferred agent by ASCO Guidelines for CIPN.

• Topical baclofen, amitriptyline, and ketamine have shown promise in clinical trials, but there is
currently no FDA approved product.

• Lidocaine patch may also be considered.

Thank you