1. Pain Management 1st of 3 Lectures September 18, 2017
John Hopper, MD
L. Raquel Clary-Lantis, DO

2. Outline
Introduction
CAPC modules
Pain Assessment
Pain Cases

3. Introduction 116 million affected by pain
Opiophobia: irrational fear by clinicians and patients related to appropriate use of opioids
Prescription Painkiller OD since 1999
Up 265% in men
Up 400% in women
Increased misuseundertreatment of pain
Importance of a structured protocol

4. CAPC Modules www.capc.org create an account if you don’t have one
Go to CAPC Centraltraining curriculum
41 modules altogether
we will focus on the 14 pain modules for these lectures

5. 14 CAPC Pain Modules Course 1: Comprehensive Pain Assessment
Course 2: Matching the Drug Class to the Pain
Course 3: Patient Factors that Influence Prescribing Decisions
Course 4: Assessing Risk for Opioid Substance Use Disorder
Course 5: Opioid Trials - Determining Design, Efficacy and Safety
Course 6: Prescribing an Opioid
Course 7: Prescribing Short-Acting Opioids - Four Case Studies
Course 8: Monitoring for Opioid Efficacy, Side Effects and Substance Use Disorder
Course 9: Converting from Short-Acting to Long-Acting Opioids
Course 10: Prescribing Practice and Opioid Conversions
Course 11: Advanced Conversions & Opioid Side Effects
Course 12: Special Populations & Patient-Controlled Analgesia
Course 13: Managing Pain in Patients at Risk for Substance Use Disorder
Course 14: Pain Management - Putting it All Together

6. Structured Protocol Course 1: Comprehensive Pain Assessment
1. Elicit pain characteristics: OP2QRST
a. O=onset, acute versus persistent
b. P2=palliative and provocative factors
c. Q=quality of the pain
i) Somatic: tissue damage, localized
ii) Visceral: visceral organs, referred (nausea/sweats)
iii) Neuropathic: injury & inflammation nerves, radicular
d. R=radiation and region
e. S=severity, pain intensity scale
f. T=timing
2. Assess functional history
-most useful measure of severity of pain is impact on fxn

7. Comprehensive Pain Assessment
Review prior drug and nondrug treatment
Not all pain needs an opiate or even a medication
WHO stepladder
Caution with polypharmacy
4. Examine patient and review data

8. Optimal Dose
Dose that will improve function or reduce intensity by at least 30% without major side effects or complications
Hand that writes the opiate is the hand that does the disimpaction

9. Pain Cases

10. 36 y woman with RUQ pain X 6 hours
Severe crampy pain, like childbirth
Comes in “waves”, doubled over
Started after eating chicken and waffles
Getting worse over last few hours
Now accompanied by nausea
Feels bloated, vomited once

11. 36 y woman with biliary colic
What would you give for pain?
Drug
Dose
Route
When would you reassess for effect?
What is an effect anyway???
What would the interval be for the next dose?

12. 63 y man with hip pain Stage 4 NSCLC pain in left hip from metastasis
Deep aching pain in hip and groin for weeks
Pain ranges from moderate to severe
Interferes with sleep and walking
Getting worse
Affecting mood
Irritable, short tempered

13. 63 year old man with hip pain
What would you give for pain?
Drug
Dose
Route
When would you reassess for effect?
What would the interval be for the next dose?
Stage 4 NSCLC
Deep aching pain in hip and groin for weeks
Pain ranges from moderate to severe
Interferes with sleep and walking
Getting worse
Affecting mood
Irritable, short tempered

14. 46 y man with acute arm pain
Fell from a ladder an hour ago
Severe, sharp, stabbing right arm pain
History of diabetic neuropathy on opioids
Outpatient Pain Regimen:
Oxycodone ER 60 mg BID
Duloxetine 60 mg daily

15. 46 y man with fracture of humerus
What would you give for pain?
Drug
Dose
Route
When would you reassess for effect?
What would the interval be for the next dose?
Fell from a ladder an hour ago
Severe, sharp, stabbing right arm pain
History of diabetic neuropathy on opioids
Outpatient Pain Regimen:
Oxycodone ER 60 mg BID
Duloxetine 60 mg daily