Lecture 75 - Non-Malignant Pain Part 1

Question 1

What is pain?

Question 2

Why Does Pain Matter?

Answer 2

1 reason that patients seek

medical care
*75 - 100 million in US have chronic pain (~30% of Americans)
*40 million adults experience severe pain
Interferes with quality of life and productivity
*half of patients with low back pain report interference with basic and complex activities
Annual cost in the US exceeds 500 billion dollars Opioid epidemic
*Need for increased safety due to elevated opioid related deaths

Question 3

Role of Pharmacists

Answer 3

Assessment of pain
Recommend OTC medications
Refer patients to prescribers
Recommend initial prescription analgesics to providers
Educate patients on analgesic therapy
Evaluate safe and effective use (abuse, side effects, etc.)
Adjust medication therapy based on response

Question 4

Assessment of Pain

Answer 4

What questions would you want to ask to subjectively assess a patient’s pain?:
“PQRSTU” Mnemonic
Palliative or Precipitating factors
Quality of pain
Region of pain location
Severity (pain assessment instruments)
Time-related nature of pain
U Impact of pain on yoU
What have you tried to control the pain?

Question 5

Assessment of Pain

Answer 5

Objective information to assess pain
Behavioral changes
Physiological changes: Dilated pupils (mydriasis); Paleness (pallor); Sweating (diaphoresis); Tachycardia; Tachypnea
Pain intensity scales: Verbal; Numeric; Visual; Wong-Baker

Question 6

Classifying Pain

Answer 6

Pain:
acute - <3 months
chronic - >3 months –> nociceptive (tissue), neuropathic (nerve), mixed (tissue and nerve)
malignant

Question 7

Guidelines

Answer 7

Center for Disease Control (CDC) Guideline for Prescribing Opioids for Pain (US, 2022): Outpatients aged ≥18 years with acute (duration of <1 month), subacute (duration of 1–3 months), or chronic (duration of >3 months) pain; Excludes pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care.
Society of Critical Care Medicine (SCCM) Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (US, 2018): Referred to as PADIS Guideline
National Institute for Health and Care Excellence (NICE) Neuropathic pain in adults (UK, 2020)
Management of Acute Pain From Non–Low Back, Musculoskeletal Injuries in Adults: Academy of Family Physicians (AAFP) (US, 2020)

Question 8

Goals of Therapy

Answer 8

Correct: Correct underlying cause of pain if possible
Minimize: Minimize pain and symptoms from pain/injury (May not be possible to be free of pain)
Improve: Improve quality of life (QOL) and activities of daily living (ADLs)
Limit: Limit pharmacotherapy side effects

Question 9

Selecting an Analgesic - patient factors

Answer 9

Hepatic/renal function
Past medical history
Previous analgesic therapy
Routes for medication administration
Type of pain (neuropathic vs. nociceptive
Severity of pain

Question 10

Selecting an Analgesic - medications factors

Answer 10

Allergies
Cost
Drug-drug interactions
Duration of action/dosing frequency
Potency
Route of administration
Side effects

Question 11

Non-Pharmacologic Therapy

Answer 11

Can be used in combination with analgesics
Physical manipulation
Heat or ice
Massage
Acupuncture
Exercise
Correct the underlying cause (surgery, avoidance)

Question 12

Treatment approach

Answer 12

step 1: non-opioid +/- adjuvant analgesic
step 2: opioid for mild-moderate pain + non-opiod +/- adjuvant analgesic
step 3: opioid for moderate-severe pain + non-opioid +/- adjuvant analagesic
step up if pain is persisting or increasing
step down if pain is resolving or toxicity occurs

Question 13

Step 1: Non-opioid Analgesics

Answer 13

Non-opioids
* Acetaminophen
* Non-steroidal anti-inflammatory drugs (NSAIDS)
Adjuvant therapies
* Gabapentinoids
* Serotonin norepinephrine reuptake inhibitors (SNRIs)
* Tricyclic antidepressants (TCAs)
* Skeletal muscle relaxants
* Antiepileptics
* Topical agents

Question 14

Acetaminophen (Tylenol)

Answer 14

Analgesic and antipyretic
Available formulations: Tablet (regular strength = 325mg, extra strength = 500mg, arthritis = 650mg ER tablet); Capsule; Chewable tablet (80mg or 160mg); Liquid/gel; IV solution; Suppository
Recommended dosing: Adults: 325 -1000mg PO Q4-6H PRN (max dose ≤3-4
g/day); In liver disease, decrease max ≤2 g/day); Pediatrics: 10-15 mg/kg PO Q4H PRN (max dose 75mg/kg/day or ≤3-4 g/day)
Side effects: Hepatotoxicity (acute liver failure most likely with ≥10g dose)

Question 15

Acetaminophen clinical pearls

Answer 15

Gold standard for osteoarthritis due to fewer side effects in geriatric patients than NSAIDs
Educate patients about max daily doses, including combination products
Injection is expensive (often restricted use)

Question 16

NSAIDS

Answer 16

Analgesic, antipyretic and anti-inflammatory
Side effects: GI bleeding (black box warning); Nephrotoxicity; Fluid retention; Increase CV events (black box warning)
Clinical Pearls: Take with food; Caution use in geriatric patients due to increased side effects (Beer’s list); Avoid systemic NSAIDs in patients with cardiac history (can use topical NSAIDs); Avoid in severe liver disease or chronic kidney disease

Question 17

NSAIDS: Aspirin (Bayer)

Answer 17

Available formulations: Chewable tablet; Tablet; EC tablet; Capsule; ER capsule; Suppository
Recommended dosing: Adults: 325mg-1000mg PO q4-6h PRN (max 4g/day); Pediatrics: Avoid (Reye’s syndrome)
Clinical pearls: Avoid using for pain in patients taking blood thinners or antiplatelets; Some formulations available OTC

Question 18

Reye’s Syndrome

Answer 18

Rare but serious condition that causes swelling in the brain and liver
Associated with children/teens using aspirin when they have viral infections such as flu or chickenpox (with or without fever)

Question 19

NSAIDS: Ibuprofen (Advil, Motrin)

Answer 19

Available formulations: Capsule; Tablet (regular strength = 200mg); Chewable tablet; Suspension; IV solution
Recommended dosing: Adults: 200-800mg PO q6-8h PRN (max 3200mg/day); Pediatrics (>6 months): 5-10 mg/kg PO Q4-6H PRN (max 40mg/kg/day or 2400mg, whichever is less)
Clinical Pearls: Some formulations available OTC

Question 20

NSAIDS: Diclofenac (Voltaren)

Answer 20

Available formulations: Capsule; Tablet; IV solution; Suppository; Topical gel (Voltaren 1% gel); Topical solution; Ophthalmic solution; Patch
Recommended dosing: Adults: 50mg PO q8h or 2-4 g applied topically 4 times/day
Clinical pearls: Minimal systemic side effects with topical gel; Some formulations available OTC

Question 21

NSAIDS: Naproxen (Aleve, Naprosyn)

Answer 21

Available formulations: Capsule; Tablet; DR/ER tablet; Suspension
Recommended dosing: Adults: 220-500mg PO q6-12h (max 1000mg/day)
Clinical Pearls: Some formulations available OTC

Question 22

NSAIDS: Ketorolac (Toradol)

Answer 22

Available formulations: Tablet; IV/IM solution; Nasal spray; Ophthalmic solution
Recommended dosing: Adults: 15-30mg IV/IV q6h prn or 10mg PO q6h prn; Pediatrics: 0.5mg/kg/dose IM/IV q6h prn
Clinical pearls: Maximum duration is 5 days (parenteral + oral); Increased risk of GI bleed when used longer; Oral dosing is intended a as a continuation of IM or IV therapy

Question 23

NSAIDS: Celecoxib (Celebrex)

Answer 23

Available formulations: Capsule; Oral solution (less common)
Recommended dosing: Adults: 200mg PO BID Clinical pearls: COX 2 selective- less GI toxicity