Analgesic Policy
Total Page:16
File Type:pdf, Size:1020Kb
Load more
Recommended publications
-
Changes in Birth-Related Pain Perception Impact Of
Archives of Gynecology and Obstetrics https://doi.org/10.1007/s00404-017-4605-4 MATERNAL-FETAL MEDICINE Changes in birth‑related pain perception impact of neurobiological and psycho‑social factors Sebastian Berlit1 · Stefanie Lis2 · Katharina Häfner3 · Nikolaus Kleindienst3 · Ulf Baumgärtner4 · Rolf‑Detlef Treede4 · Marc Sütterlin1 · Christian Schmahl3,5 Received: 9 October 2017 / Accepted: 21 November 2017 © Springer-Verlag GmbH Germany, part of Springer Nature 2017 Abstract Purpose To analyse post-partum short- and long-term pain sensitivity and the infuence of endogenous pain inhibition as well as distinct psycho-social factors on birth-related pain. Methods Pain sensitivity was assessed in 91 primiparous women at three times: 2–6 weeks before, one to 3 days as well as ten to 14 weeks after childbirth. Application of a pressure algometer in combination with a cold pressor test was utilised for measurement of pain sensitivity and assessment of conditioned pain modulation (CPM). Selected psycho-social factors (anxiety, social support, history of abuse, chronic pain and fear of childbirth) were evaluated with standardised questionnaires and their efect on pain processing then analysed. Results Pressure pain threshold, cold pain threshold and cold pain tolerance increased signifcantly directly after birth (all p < 0.001). While cold pain parameters partly recovered on follow-up, pressure pain threshold remained increased above baseline (p < 0.001). These pain-modulating efects were not found for women with history of abuse. While CPM was not afected by birth, its extent correlated signifcantly (r = 0.367) with the drop in pain sensitivity following birth. Moreover, high trait anxiety predicted an attenuated reduction in pain sensitivity (r = 0.357), while there was no correlation with fear of childbirth, chronic pain and social support. -
CHRONIC NON PALLIATIVE PAIN (> 6 Months)
CHRONIC NON PALLIATIVE PAIN (> 6 months) IN ADULTS – Primary Care Treatment Pathway Please note that this pathway is currently under review following publication of NICE guideline [NG193] - Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain (April 2021): https://www.nice.org.uk/guidance/ng193. Initial Assessment • Exclude serious pathology / red flags (investigate / refer as necessary). • Investigate and manage any underlying condition. • Determine pain type - nociceptive, mixed, neuropathic. Typical features of neuropathic pain: burning, shooting, allodynia, hyperalgesia, unpredictable, abnormal sensations. • Determine baseline severity of pain & functional impact. Use visual analogue or numerical rating scales (pain scales available from the British Pain Society). • If musculoskeletal pain offer manual therapy in addition to or instead of analgesics if appropriate. • Explore use of non-drug options e.g. psychological therapy and physical intervention therapies. Consider early specialis t referral • Where pain is severe or not responding to management. • Patients considered at increased risk of poor outcomes. For back pain consider use of Keele STarT Back Tool. Before prescribing • Determine use of over-the-counter (OTC) treatments / complemen tary therapies. • Offer British Pain Society leaflet https://www.britishpainsociety.org/static/upload s/resources/files/patient_pub_otc.pdf • Agree and document achievable pain goal e.g. 50% reduction in pain, improved function. • Advise on risks/benefits of medication, regime and target dose . • Avoid effervescent preparations, particularly with hypertension (due to salt content). • Prescribe single-constituent analgesics where appropriate, to allow independent titration of each drug. • Avoid low dose compound analgesics (e.g. co-codamol 8/500 mg and co-dydramol 10/500 mg). -
Pain Management in People Who Have OUD; Acute Vs. Chronic Pain
Pain Management in People Who Have OUD; Acute vs. Chronic Pain Developer: Stephen A. Wyatt, DO Medical Director, Addiction Medicine Carolinas HealthCare System Reviewer/Editor: Miriam Komaromy, MD, The ECHO Institute™ This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under contract number HHSH250201600015C. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. Disclosures Stephen Wyatt has nothing to disclose Objectives • Understand the complexities of treating acute and chronic pain in patients with opioid use disorder (OUD). • Understand the various approaches to treating the OUD patient on an agonist medication for acute or chronic pain. • Understand how acute and chronic pain can be treated when the OUD patient is on an antagonist medication. Speaker Notes: The general Outline of the module is to first address the difficulties surrounding treating pain in the opioid dependent patient. Then to address the ways that patients with pain can be approached on either an agonist of antagonist opioid use disorder treatment. Pain and Substance Use Disorder • Potential for mutual mistrust: – Provider • drug seeking • dependency/intolerance • fear – Patient • lack of empathy • avoidance • fear Speaker Notes: It is the provider that needs to be well educated and skillful in working with this population. Through a better understanding of opioid use disorders as a disease, the prejudice surrounding the encounter with the patient may be reduced. -
Compound Analgesic)
Bex (compound analgesic) Bex was a strong compound analgesic which was popular in Australia for much of the twentieth century. It came in the form of APC (aspirinâ“phenacetinâ“caffeine) tablets or powder, containing 42% aspirin, 42% phenacetin, plus caffeine. Bex was a product of Beckers Pty Ltd., originally based at Pym Street, Dudley Park, South Australia, but which relocated to Sydney in the 1960s. It was advertised with the phrase, "Stressful Day? What you need is a cup of tea, a Bex and a good lie down". Bex was a strong compound analgesic which was popular in Australia for much of the twentieth century. It came in the form of APC tablets or powder, containing 42% aspirin, 42% phenacetin, plus caffeine.[1]. For faster navigation, this Iframe is preloading the Wikiwand page for Bex (compound analgesic). Home. News. Bex (compound analgesic) Bex was a strong compound analgesic which was popular in Australia for much of the twentieth century. It came in the form of APC (aspirinâ“phenacetinâ“caffeine) tablets or powder, containing 42% aspirin, 42% phenacetin, plus caffeine.[1] Bex was a product of Beckers Pty Ltd., originally based at Pym Street, Dudley Park, South Australia,[2] but which relocated to Sydney in the 1960s.[3] It was advertised with the phrase, "Stressful Day? What you need is a cup of tea, a Bex and a good lie. Compound analgesics are those with multiple active ingredients; they include many of the stronger prescription analgesics. Active ingredients that have been commonly used in compound analgesics include: aspirin or ibuprofen. -
Pain and Addiction Case Vignette: James J
Pain and Addiction James J. Manlandro, DO, FAOAAM, FACOFP, DABM American Osteopathic Academy of Addiction Medicine 1 James Manlandro, DO, FAOAAM FACOAFP, DABM Disclosures • James Manlandro, DO, FAOAAM, FACOAFP, DABM is a paid speaker for Reckitt Benckiser The contents of this activity may include discussion of off label or investigative drug uses. The faculty is aware that is their responsibility to disclose this information. 2 Planning Committee, Disclosures AAAP aims to provide educational information that is balanced, independent, objective and free of bias and based on evidence. In order to resolve any identified Conflicts of Interest, disclosure information from all planners, faculty and anyone in the position to control content is provided during the planning process to ensure resolution of any identified conflicts. This disclosure information is listed below: The following developers and planning committee members have reported that they have no commercial relationships relevant to the content of this module to disclose: PCSSMAT lead contributors Maria Sullivan, MD, PhD, Adam Bisaga, MD and Frances Levin, MD; AAAP CME/CPD Committee Members Dean Krahn, MD, Kevin Sevarino, MD, PhD, Tim Fong, MD, Robert Milin, MD, Tom Kosten, MD, Joji Suzuki, MD; AOAAM Staff Stephen Wyatt, DO, Nina Albano Vidmer and Lara Renucci; and AAAP Staff Kathryn Cates-Wessel, Miriam Giles and Blair-Victoria Dutra. All faculty have been advised that any recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported, or used in the presentation must conform to the generally accepted standards of experimental design, data collection, and analysis. -
Neuropathic Pain
www.bpac.org.nz keyword: neuropathic Pharmacological management of neuropathic pain Diagnosing neuropathic pain Pharmacological treatment Neuropathic pain is often described in the following A different analgesic ladder is used for neuropathic pain. terms: Adjuvants ▪ Burning Adjuvants can be continued through the pain ladder. ▪ Shooting Examples are capsaicin cream and local anaesthetic ▪ Stabbing gels. ▪ Lancinating Step one: Paracetamol It is classically associated with sensory changes to the Regular use of paracetamol is introduced first and is skin, either numbness or hypersensitivity (this may include recommended at every step of the pain ladder. allodynia – sensation of pain from light touch). There may also be visible autonomic changes (e.g. altered colouring or temperature of skin, sweating) or signs of motor damage Step two: Add a TCA (e.g. muscle wasting). Tricyclic antidepressants (TCAs) are usually prescribed at night as their sedative effects may assist sleep. Neuropathic pain may be caused by damage to central, Nortriptyline may be preferable due to its fewer adverse peripheral or autonomic nerves. effects, particularly in elderly people. Initial doses of TCAs are usually low, however doses can be increased to antidepressant level, if tolerated. BPJ | Issue 16 | 13 Neuropathic pain ladder STEP 1 STEP 2 STEP 3 Add or change to Add Anti-convulsant TCA Paracetamol Adjuvant treatment TCA dosing e.g. nortriptyline: titrate up from 10mg daily Step three: Add or change to an anticonvulsant until pain settles. Carbamazepine, sodium valproate and gabapentin are all Prescribe nortriptyline 10mg tablets. Increase the effective in treating neuropathic pain. dose as directed. Supply 70 tablets. Traditionally carbamazepine is the first choice but it Patient information: The dose may be increased as follows must be titrated very slowly to avoid side effects such as until the pain settles – Take one tablet (10mg) at night for nausea, vomiting and dizziness. -
An Overview of Current Drug Advancement for Acute and Chronic Pain
Open Access Austin Pain & Relief Mini Review An Overview of Current Drug Advancement for Acute and Chronic Pain Singh US* Department of Pharmaceutical and Biomedical Sciences, Abstract The University of Georgia, USA This short review focuses on medication for the management of pain along *Corresponding author: Uma S. Singh, Department with guidelines for the use of the prescribed medicines. WHO has suggested the of Pharmaceutical and Biomedical Sciences, College of pain ladder for the management of the acute and chronic pain. The use of the Pharmacy, The University of Georgia, Athens, GA 30602, non-opioid and opioids are reviewed. Also, the use of acetaminophen together USA with non-selective Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and COX-2 selective are described. Several other medicines which were originally invented Received: October 04, 2016; Accepted: November 03, for the cure of other diseases, but now they are well employed for pain treatment. 2016; Published: November 04, 2016 The anticonvulsant, gabapentin and pregabalin are in use for treatment of active pain. In the same way, for the treatment of osteoporosis, calcitonin was initially discovered but now it is in widely use for management of pain. The anesthetic ketamine is also used to treat pain. For the topical treatment, Lidocaine and capsaicin patches are being used to cure the localized pain. The applications of localized patches also help to avoid the maximum systemic adverse effect. Overall several drugs are being used for the treatment of the pain with the multi- component approaches for the acute and chronic pain relief. Keywords: Pain management; Opioids; Pain ladder; Analgesics Introduction start the oral administration of the drug with Non-Steroidal Anti- Inflammatory Drugs (NSAIDS) including COX-2 inhibitors for pain It is always a challenging task for a medical practitioner to relief [7]. -
Pain and Pregnancy and Labor
Core Curriculum for Professional Education in Pain, edited by J. Edmond Charlton, IASP Press, Seattle, © 2005. 36 Pain and Pregnancy and Labor I. Perception of pain in pregnancy Know the factors that can influence the perception of pain in pregnancy compared with the nonpregnant state: A. Fear of pain (Saisto and Halmesmaki 2003): may be primary (usually in nulliparous women, and may be associated with pre-existing psychological morbidity and/or ignorance), or secondary (e.g., as a result of a previous bad experience). B. Increased susceptibility to pain due to generalized anxiety (related to the pregnancy, its outcome, its implications for the woman, or other concerns). C. Positive attitudes to pregnancy and its social implications: may increase tolerance to pain, especially in labor (pain is seen as a “positive” force rather than a destructive one). D. Level of education: poor knowledge and/or misinformation may exacerbate the above. E. Age/parity: younger women may have increased tolerance to pain, but older multiparae may be more relaxed and therefore less fearful. F. Neuroendocrine system (Whipple et al. 1990; Shapira et al. 1995): sex steroids, e.g., 17 beta-estradiol and progesterone, can modulate the opioid system during pregnancy (e.g., via spinal dynorphin pathways), increasing pain tolerance. II. Causes of pain in pregnancy Be familiar with the spectrum of conditions that can present with pain during pregnancy: A. Not specific to, but common during, pregnancy. 1. Headache: most commonly tension headache or migraine; both have similar triggers and treatment. Recurrence may be due to reluctance to take analgesics in pregnancy, but the usual pattern is improvement over time, usually in the first trimester. -
Acute Pain Management Meeting the Challenges
Acute Pain Management Meeting the Challenges PBM Academic Detailing Service Acute Pain Management Meeting the Challenges A VA Clinician’s Guide VA PBM Academic Detailing Service Real Provider Resources Real Patient Results Your Partner in Enhancing Veteran Health Outcomes VA PBM Academic Detailing Service Email Group [email protected] VA PBM Academic Detailing Service SharePoint Site https://vaww.portal2.va.gov/sites/ad VA PBM Academic Detailing Public Website http://www.pbm.va.gov/PBM/academicdetailingservicehome.asp Meeting the Challenges of Acute Pain Management Major changes have occurred in the treatment of pain with the focus now on a biopsychosocial model of pain care using multimodal treatments. A focused efort is needed to reduce harm to Veterans from unnecessary opioid prescribing and improve pain control in patients with acute pain conditions, including postoperative pain, by including non-pharmacological and non-opioid pain management approaches. With the right approach, we can reduce the number of Veterans who develop opioid use disorder and reduce overdose deaths. Opioids are no longer considered frst line treatment for most types of acute and chronic pain.1 What started the changes?1,2 ü Recognition of overdose deaths related to prescription opioids ü Increasing rates of opioid use disorder, heroin use, and other opioid related harms ü Lack of evidence that opioids work for long-term pain management Despite knowledge of this, overdose deaths related to opioids continue to increase. Figure 1. Overdose Deaths Involving Opioids 2000–20151 11 Any Opioid 10 9 8 7 6 5 Natural & Semi-synthetic Opioids 4 Heroin 3 Other Synthetic Opioids 2 (e.g., fentanyl, tramadol) Deaths per 100,000 population 1 0 In 2015, overdoses involving opioids resulted in 33,091 deaths in the United States.1 1 Why is Treating Acute Pain with Opioids a Concern? We need to stop acute opioid use from turning into chronic use with possible worsening pain and functional ability, and the risk of progressing to opioid use disorder. -
Chronic Pain Ladder
PAIN LADDER - CHRONIC PAIN Pain treatment pathway for non-cancer chronic pain ≥ 3 months duration in adults in primary care1,2,3,4 Key Principles • Consider early referral to West Suffolk Pain Service Single Point of Access in patients with excessive, uncontrolled or rapid escalating opioid requirements, and/or significant pain preventing sleep, function or work, or causing distress • Progressing through the steps below does not guarantee increased benefit or better pain relief. Medication does not always work; stop medicines that are not working. • 3-monthly medication reviews are recommended for all patients taking regular analgesics; prioritise Polypharmacy Medication Reviews for patients taking opioids or gabapentinoids STEP 1 Assessment and non pharmacological strategies • Exclude red flags. Assess pain/impact and yellow flags • Consider possibility of neuropathic/mixed pain: neuropathic pain ladder • Establish expectations and agreed goals • Discuss non pharmacological strategies and provide signposting information • Consider referral to: Wellbeing Service, physiotherapy, gentle exercise/weight loss programmes or TENS STEP 2 Paracetamol oral/rectal 1g qds (1g tds if < 50 kg, malnourished, renal or hepatic impairment) Paracetamol alone is not recommended management for low back pain 3 + / OR Ibuprofen oral 400 mg tds /topical 5% gel tds OR Naproxen oral 250-500 mg bd NSAID at lowest effective dose for shortest period. Consider a PPI. Consider possibility of neuropathic/mixed pain; refer to neuropathic pain ladder Ineffective or not tolerated: STOP Partially effective: consider adding STEP 3 Codeine oral 15-60 mg qds Avoid if breast feeding or if patient has experienced excessive response to codeine previously* OR Tramadol oral 50-100 mg qds OR Meptazinol oral 200 mg 3-6 hourly Consider referral to West Suffolk Pain Service Single Point of Access. -
Central Nervous System 4.1 Hypnotics and Anxiolytics
BNF CHAPTER 4: CENTRAL NERVOUS SYSTEM Link to: CWP Mental Health Formulary 4.1 HYPNOTICS AND ANXIOLYTICS Benzodiazepine prescribing guidelines Benzodiazepines must not be prescribed routinely. Benzodiazepines must not be prescribed for more than 10 nights as a hypnotic or as an anxiolytic for more than 4 weeks. Apart from chronic users, patients should generally not be discharged from hospital taking a benzodiazepine. An example of where it may be appropriate includes patients receiving palliative care. Can be difficult to withdraw benzodiazepines if they have been taken regularly for more than a few weeks. 4.1.1 HYPNOTICS Temazepam 10mg tablets 10mg/5mL elixir Temazepam for ward stock must be ordered using the Controlled Drug order book. Zopiclone 3.75mg, 7.5mg tablets Hypnotics should only be prescribed for short term use. Patients requiring hypnotics in hospital should have them prescribed on the PRN side of the prescription chart. Such patients will not have hypnotics prescribed to them on discharge. It is recommended that, because of the lack of compelling evidence to distinguish between zopiclone or the shorter acting benzodiazepine hypnotics, the drug with the lowest purchase cost (taking into account daily required dose and product price per dose) should be prescribed. (NICE Technology Appraisal No 77). Temazepam is therefore the preferred option for all patients on the basis of cost. However, in the Trust, zopiclone may be considered for first line use as it is not subject to internal controlled drug restrictions. Joint -
Stanford Acute Pain Management Resident Rotation Syllabus Version 2019-2020 Updated February 19, 2019 Table of Contents
Stanford Acute Pain Management Resident Rotation Syllabus Version 2019-2020 Updated February 19, 2019 http://paincenter.stanford.edu Table of Contents PAIN MANAGEMENT FACULTY ........................................................................................................................ 2 GOALS AND OBJECTIVES ................................................................................................................................ 2 ADVERSE EFFECTS OF PERIOPERATIVE PAIN ........................................................................................... 5 OPIOIDS ............................................................................................................................................................. 7 NEURAXIAL ANALGESIA ................................................................................................................................. 15 REGIONAL ANESTHESIA AND PERIPHERAL NERVE CATHETERS .......................................................... 23 ADJUVANTS ..................................................................................................................................................... 30 OPIATE TOLERANT PATIENTS ....................................................................................................................... 40 CANCER PAIN .................................................................................................................................................. 37 ACUPUNCTURE AND PAIN MANAGEMENT ..................................................................................................