Cape Town Pain Clinic

Transcription

1 Cape Town Pain Clinic An Interdisciplinary approach to pain management Dr. Ché Venter Neurorehabilitation and Pain Practitioner Medico legal and RAF4 Independent medical Examiner MBChB (UCT) CIME MP Practice No Office: Suite 6, 2 Somerset Crescent, Durbanville

2 Disclosures None

3 What is Pain? An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. International Association for the Study of Pain (Merskey, 1979) Pain is always subjective. The patient s self-report of pain is the single most reliable indicator of pain It is NB that the clinician accepts this

4 Pain Management Policy at the Cape Town Pain Clinic Optimal acute pain management is essential to prevent chronic pain Appropriate screening and pain assessment Documentation Care and treatment Pain education

5 Pain Management Policy at the Cape Town Pain Clinic Putting the pieces of the puzzle together

6 The Pain Cycle

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8 Acute Pain VS Chronic Pain Presents most often with a clear cause, relatively brief in duration and subsides as healing takes place. Acute pain is often accompanied by observable objective signs of pain increased pulse rate increased blood pressure Non-verbal signs and symptoms such as facial expressions and tense muscles. Pain that is persistent and recurrent When pain persists, it serves no useful purpose and may dramatically decrease the quality of life and function Chronic pain rarely has any observable or behavioral signs although persons may appear anxious or depressed

9 Chronic Pain Disorders

10 Cancer Pain Pain that is associated with cancer or cancer treatment May be attributed to Tumor location Chemotherapy Radiation therapy Surgical treatment

11 Pain Assessment Initial Pain Assessment should include: Location(s) Intensity Sensory quality Alleviating and aggravating factors Any new onset of pain requires a new comprehensive pain assessment.

12 Modalities to objectively assess pain Patient self report of pain must be a source of assessment

13 Modalities to objectively assess pain

14 Pain Reassessment Every 8 hours minimally Following the administration of pain medications to determine the effectiveness of the medication and/or need for further intervention IV within 15 mins of administration PO/IM/SC within 1 hour of administration

15 Pain Management Approach Should be interdisciplinary and multimodal Care is individualized and may depend on: Pain source and intensity Patient s age Developmental, physical, emotional and cognitive status Cultural beliefs Treatment preferences Concurrent medical conditions Treat concurrent mood disorders, especially depression

16 Physical Therapy A good baseline Obesity/increased adiposity results in endothelial dysfunction Decreases inflammatory markers Improves Insulin sensitivity Improves mental health Exercise is a physiological stressor: Lower intensity Shorter duration Exercise induced hypoalgesia: Increases sensitivity to opioids by Beta endorphin release Assists with Noxious Inhibitory Control Can assist with weaning or dose reduction of opioids

17 Psychotherapy Reduction in Brain Derived Neurotropic factor (BDNF) Reduction in brain regional grey matter by 4.6 % for every 1 year of pain Recovers with treatment Central sensitization - Upregulation of noxious signaling - Endogenous signaling More efficient transmission of nociception Faciliatory Inhibitory CCK Serotonin Nitrous Oxide Noradrenalin Excitatory amino acids Dopamine GABA

18 Dietetics

19 Multimodal Analgesia This term describes the use of multiple modalities that are used to provide pain relief with various parts of the pain pathway targeted Decreased dependence on a single modality agents decreases the risk of side effects: May include Pharmacological (opioids, NSAIDS, gabapentanoids) Relaxation techniques (biofeedback, deep breathing) Regional analgesia (nerve blocks, epidural catheters) It allows for opioid sparing!! Reduces polypharmacy!!

20 Treatments May Include Non-pharmacologic Methods Heat/cold Relaxation Distraction Graded motor imagery Acupressure/acupu ncture Repositioning Pharmacologic Methods NSAIDS Anti-seizure medications Anti-depressants Opioid analgesics Local anesthetics Neurolytics Cannabinoids

21 Acute vs. Chronic Pain Management Acute Pain Chronic Pain Most often treated with: NSAIDS Opioids Local anesthetics Splinting Positioning changes Ice Most often treated with: Combinations of paracetamol and opioids such as tramadol Opioids (oxycodone and tapentanol, combinations of opioid and naloxone) Anti-seizure medications (Carbamazepine Anti-depressant medications NSAIDS Implantable devices Psychological therapy Acupuncture

22 Undertreatment of Chronic Pain > % of patients in the routine practice settings In a recent study of 805 Chronic Pain sufferers, > 50 % had to change physicians to establish pain control?? - Unwillingness to treat pain aggressively - Lack of empathy or belief in the patient s perception of pain - Inadequate knowledge American Pain Society 2001, Gjachen

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24 Responsible Opioid Prescribing Assess risk for opioid abuse Risk factors for misuse or abuse of opioids include the following Males between 18 and 45. A personal history of substance abuse A family history of substance abuse A personal history of preadolescent sexual abuse A personal history of psychological disease (depression, anxiety, obsessivecompulsive disorder

25 Patient and Family Education Patients and family are given specific instructions prior to discharge regarding Pain control Pain medications Management of potential side effects

26 Thank You

27 Questions?