Providing Options for Pain Management

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Brenda Price
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Providing Options for Pain Management Nancy Bradley, BSN, RN-BC I am not experienced in giving lectures, nor do I profess to be an expert in Pain Management I have over 20 years experience in

1 Providing Options for Pain Management Nancy Bradley, BSN, RN-BC I am not experienced in giving lectures, nor do I profess to be an expert in Pain Management I have over 20 years experience in Oncology, hospital based I have worked the last 14 years in out patient Pain Management Clinic Objectives To be able to differentiate what type of pain is occurring To be aware of different conservative treatments available To have basic understanding of types of Pain Management injections available To have a basic understanding of some of the requirements needed when prescribing pharmacological agents for pain management 1

2 What kind of pain is it, Acute or Chronic? Acute Pain-Pain lasting no longer than 3 to 6 months. It may be related to a soft tissue injury. But, it has a short duration which resolves as the injury heals. Chronic Pain-Pain lasting more than twelve weeks. It may start with an initial injury or there may be no clear cause. What is the cause of the pain? Nociceptive Pain-Caused by injury to body tissue Somatic-Skin or musculoskeletal pain (surface) Visceral-Internal organ and smooth muscle pain (internal) Neuropathic Pain-Caused by injury to the nerve Why is it important to know the type and cause of pain? It is imperative to know what you are treating in order to treat it correctly-documentation is the first step to proper treatment When this has not been determined- 2

Conservative Treatments Ice and elevation-time Over the counter and/or prescription, Antiinflammatory medication (ibuprofen,

Nerve stabilizers (Neurontin, Elavil, Cymbalta)/Ice Conservative Treatments Imaging-is an x-ray or MRI needed?

injections TENs unit (Transcutaneous Electrical Nerve Stimulation) Message Therapy Acupuncture Intramuscular and/or trigger

3 Conservative Treatments Ice and elevation-time Over the counter and/or prescription, Antiinflammatory medication (ibuprofen, acetaminophen, icy hot, asper cream with lidocaine, Mobic, Celebrex, Prednisone) Muscle relaxants (Flexeril, Zanaflex)/Heat Nerve stabilizers (Neurontin, Elavil, Cymbalta)/Ice Conservative Treatments Imaging-is an x-ray or MRI needed? Physical Therapy-many insurance companies require 6 weeks of therapy prior to approving injections other than trigger point injections TENs unit (Transcutaneous Electrical Nerve Stimulation) Message Therapy Acupuncture Intramuscular and/or trigger point injections given in primary care physicians office Weight Loss/Dietary Support Counseling Joint Injections-Hips, Knees, Shoulders 3

Epidural-can have in the cervical, thoracic or the lumbar region A very small amount of steroid and numbing medication placed in the epidural space can decrease inflammation around

thoracic or lumbar region Facet mediate pain occurs and with turning and twisting and is primarily described as back pain Medication can be injected into the joint at 2-3 levels on

4 Epidural-can have in the cervical, thoracic or the lumbar region A very small amount of steroid and numbing medication placed in the epidural space can decrease inflammation around the nerveprovides pain relief directly to the source of the problem This primarily relieves pain that travels down an extremity Facet Joint Injections-can have in the cervical, thoracic or lumbar region Facet mediate pain occurs and with turning and twisting and is primarily described as back pain Medication can be injected into the joint at 2-3 levels on both sides Sacroiliac Joint Injections-can have on either side Pain occurs below the beltline and travels down back of the leg Often occurs in women who had large baby several years earlier 4

Sciatic/Piriformis Injection-can have on either side Pain in the butt and travels down back and or side of leg (Nerve gets trapped between gleut muscles) Sympathetic Nerve Blocks-lumbar for lower

5 Sciatic/Piriformis Injection-can have on either side Pain in the butt and travels down back and or side of leg (Nerve gets trapped between gleut muscles) Sympathetic Nerve Blocks-lumbar for lower extremity and stellate ganglion for upper extremity Fight or flight mechanism has remained on, usually after an injury Extremity has color change, temperature change, hypersensitive to touch, hair distribution changes, pain The sooner this patient is referred and injected the better chance for good outcome Need therapy in conjunction with injections to help desensitize the nerve Trigger Point Injections-used to treat muscle/myofacial pain Tight, knot or ropey band of muscle that forms when muscle fails to relax Can be felt under the skin and may twitch involuntarily when touched (called a jump sign) 5

6 Botox injections-given for severe muscle spasticity Can be caused from traumatic brain injury, multiple sclerosis, cerebral palsy and chronic headaches (more than 14 days a month, including migraine on 8 of those days) Block certain chemical signals from nerve that cause muscle to contract. This results in muscle paralysis, which can be therapeutic when muscles are chronically tight or spastic Pain Pump-typically used to treat cancer pain Will have a single shot or 4 day trial before surgically implant a pump Used to supply larger amount of medication more directly and continuously into the system Should decrease or eliminate oral pain medication Baclofen Pump-used to treat severe spasticity in patients with cerebral palsy and muscular dystrophy Requirements for Prescribing Narcotics Opioid Risk Assessment-Completed on all patients at their first visit and annually Depression and Fall Risk Assessment-Completed on all patients initially and at every re evaluation office visit Review Inspect/Kasper Report-Initially, at least annually and with any suspicious communication Medication Agreement-The physician has the right to refuse to prescribe narcotic medication to any patient Urine or Serum Drug Screen-Completed prior to prescribing Narcotics, Annually and Randomly Appointment Every 3-4 Months-FDA requirement, patient must keep scheduled appointments 6

Prescribing Narcotics Start with immediate release Start low and go slow!

expect your doctor to risk his license to prescribe higher doselook for other options

you feel comfortable with plan of care Be open to suggestions Use internet as personal

7 Prescribing Narcotics Start with immediate release Start low and go slow! Federal Government is mandating physicians keep Morphine equivalence under 100 Do not expect your doctor to risk his license to prescribe higher doselook for other options Discuss plan of care at every appointment Ask questions Continue to ask questions until you feel comfortable with plan of care Be open to suggestions Use internet as personal trainer/gym alternative Listen Keep Moving Enjoy Life to the Fullest! Daniel and Matthew Isaac Andrew 7

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