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Pain Consultations 101 Melissa Durham, Pharm.D. September 14th, 2011.

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Presentation on theme: "Pain Consultations 101 Melissa Durham, Pharm.D. September 14th, 2011."— Presentation transcript:

1 Pain Consultations 101 Melissa Durham, Pharm.D. September 14th, 2011

2 Acute vs. Chronic Pain CharacteristicAcute PainChronic Pain (No Self-Treatment) Relief of PainHighly Desirable Dependence & Tolerance to Medication UnusualCommon Psychological Component Usually Not PresentOften a Major Problem Organic CauseCommonOften Not Present Environmental Contributions & Family Involvement SmallSignificant InsomniaUnusualCommon Component Treatment GoalCureFunctionality

3 Assessment of Pain SCHOLAR Symptoms – Describe the symptoms you are experiencing Characteristics/Course – Is the pain throbbing, sharp, dull, tingling? Rate the pain on a scale of 1-10 History – How does it compare to other pain experienced? Has it gotten worse over time? Onset – When did the pain start? Location – Where is the pain located? Does it stay localized to one area or does it spread? Aggravating factors – What makes the pain worse? Relieving factors – What makes the pain better?

4  Temporary relief of minor aches and pain associated with the common cold  Reduction of fever  Sore throat  Headache (Episodic Tension, Migraine, Sinus)  Muscle aches  Minor aches and pains of arthritis  Acute back pain  Menstrual pain

5  Acetaminophen, AKA APAP (Tylenol) Mild-moderate pain, fever, headaches  NSAIDs  Ibuprofen (Motrin, Advil)  Naproxen sodium (Aleve) Mild-moderate pain, headaches, muscle pain, menstrual pain  Salicylates  Aspirin AKA ASA (Ecotrin, Bayer) Mild-moderate pain, muscle pain, menstrual pain, cardioprotection  Topicals (IcyHot, Bengay) Muscle soreness, muscle pain, osteoarthritis

6  Brand Name – Tylenol ®, FeverAll ®  Class – Analgesic/Antipyretic ◦ Not effective as an anti-inflammatory  Very few side effects ◦ Liver toxicity a major concern with chronic high doses  Very few drug interactions ◦ Warfarin, alcohol  DOC in pregnancy/breastfeeding

7  Used mostly for primary and secondary prevention of thrombotic events ◦ Ex. Aspirin 81mg/day  Has anti-inflammatory properties, but only at high doses  Major side effects are bleeding, GI ulcers, bronchospasm in patients with asthma  More DDIs than APAP  NOT for use in pregnancy/breastfeeding  Counseling point: TAKE WITH FOOD

8  Ibuprofen, naproxen sodium  More effective than APAP and ASA for most pain conditions  Analgesic and anti-inflammatory effects  Major side effects are bleeding, GI ulcers, bronchospasm in patients with asthma, increased blood pressure, fluid retention  Generally avoid in pregnancy but OK in breastfeeding  Counseling point: TAKE WITH FOOD

9  Used for minor aches and pains of muscles and joints, muscle soreness, osteoarthritis, lower back pain, neuropathy  Ben-gay, Icy-hot, Salonpas  Methyl salicylate, camphor, menthol, capsaicin  Combinations  Apply 3-4 times daily for a max of 7 days  Do not apply immediately after a hot shower or bath, do not use with a heating pad  Wash hands after applying

10 Types of Headache

11  Stress  Anxiety  Depression  Emotional conflicts  Fatigue  Repressed hostility

12  Excedrin ® Tension Headache ◦ 500mg Acetaminophen + 65mg caffeine  APAP  Ibuprofen  Naproxen  Other combo products

13  Physical therapy  Relaxation exercises  Massage  Topical Peppermint oil ◦ Applied to forehead and temples

14  Stress  Fatigue  Oversleeping  Fasting, missing a meal  Alcohol  Changes in barometric pressure or altitude  Menses  Hormone changes  Magnesium deficiency  Foods with nitrites, tyramine, phenylalanine, MSG, caffeine

15  Excedrin ® Migraine ◦ Acetaminophen 250mg/Aspirin 250mg/Caffeine 65mg ◦ 2 tabs at onset, no more than 2 tabs per 24 hours  Advil ® Migraine ◦ Ibuprofen 200mg (liquid filled) ◦ 2 caps at onset, no more than 2 tabs per 24 hours  Other analgesics will work, NSAIDs probably best  Initiate NSAIDS 2 days before menses for menstrual migraine  Self-treatment is only for patients who have been diagnosed with migraine by a physician

16  Regular sleeping & eating schedule  Avoidance of triggers (food, stress)  Cold packs + pressure  Lie in a dark, quiet room  Keep a headache journal

17 Symptoms of cluster headache Symptoms of migraine headache with no formal diagnosis Chronic tension headache (>15 days/month for > 6 months) Severe pain (pain score 8-10) Signs of infection (fever, purulent discharge, altered mental status) Headache that Lasts more than 10 days Occurs more than 3 times a week Not managed by NonRx dosing

18 Acute Low Back Pain Possible causes  Inactive lifestyle  Poor posture  Improper shoes  Excess body weight  Poor mattress  Poor sleeping posture  Improper lifting techniques

19 Most back pain disappears with home treatment and self-care Treatment options NSAIDs Topical analgesics Alternating heat/cold Massage Chiropractic manipulation Moderate physical activity when not acutely injured Chronic low back pain ( > 4 weeks) - Refer

20  Sprains – injury to ligaments ◦ Overextension of the joint ◦ Ankle inversion most common  Strains – injury to muscle or tendons ◦ Overuse or improper use Symptoms: Pain, bruising, loss of some function, stiffening  Treatment ◦ RICE Therapy ◦ NonRx NSAIDS

21 R est the injured area. I ce the area in 10 minute intervals, 3 – 4 times a day for 1 – 2 days. C ompress the area with elastic support. E levate the area above the heart for hours to decrease swelling and pain.

22  Delayed-onset muscle soreness most common and is self-treatable  Other types - Refer  NonRx treatment: ◦ NSAIDS ATC ◦ Topical Preparations (Salicylates, Camphor, Menthol)

23  Nonpharmacologic Therapies ◦ Low-impact exercise ◦ Weight-loss ◦ Shock-absorbing shoes ◦ Physical and occupational therapy ◦ Acupuncture  NonRx Therapies ◦ Tylenol is drug of choice ◦ NSAIDS ◦ Glucosamine & Chondroitin: Not for people with shellfish allergy, may raise blood sugar in diabetics, may increase the effect of warfarin ◦ Topical analgesics/counterirritants

24 OTC treatment options:  Midol ® Menstrual Complete: (Acetaminophen 500mg/Caffeine 60mg/Pyrilamine 15mg)  Midol ® Extended Relief (Naproxen sodium 220mg)  Midol ® Cramps and Body Aches (Ibuprofen 200mg)  Midol ® Teen Formula (APAP 500mg/Pamabrom 25mg) NonRx NSAIDs are the treatment of choice at MAX OTC doses

25  Heating pads  Regular exercise  Loose clothing  Massage  Smoking cessation

26  Do ◦ Give advice and make suggestions ◦ Determine if nonprescription medications will help ◦ Provide resources ◦ Suggest options and let people know their pain may be managed ◦ Use common sense  Don’t ◦ Say something you are not sure about ◦ Diagnose or suggest specific prescription therapy ◦ Recommend self-treatment when not appropriate ◦ Give false hope

27 Community Resources  Referral Sources: ◦ American Chronic Pain Association (www.theacpa.org)www.theacpa.org ◦ American Pain Foundation (www.painfoundation.org)www.painfoundation.org ◦ American Headache Society (www.americanheadachesociety.org)www.americanheadachesociety.org ◦ Arthritis Foundation (www.arthritis.org)www.arthritis.org  Referral for pain management: ◦ American Chronic Pain Association at ◦ Local hospice or cancer center  often know good pain specialists ◦ USC/Norris Comprehensive Cancer Center (323) , ask for referral to pain specialist ◦ USC pain center:  For those without a doctor or insurance: ◦ Local hospital’s social services department or local health department  LA Social Services Info Line at  LAC/USC Referral Line at ◦ Patient Advocate Foundation at  Poison Control:

28 Questions?


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