1. I NTRODUCTION TO P AIN M ANAGEMENT : A PPROACH Calvin Lui, MD PGY2 February 8, 2014

2. C LINICAL C ASE A 70-year-old male with recent diagnosis of multiple myeloma presents after a fall in which in breaks his wrist. He complains of pain from his shoulders, back, and wrist. His back pain is persistent for the past several months. It has two components: some “running shock-like down to his feet” and other “feeling as if his back is being eaten at.” There is radiologic evidence of bony metastases and DJD. He is taken to the OR for ORIF. What types of pain are involved in his case?

3. Practical approach to pain management History taking Pain Syndromes

4. E TIOLOGIES OF PAIN Pain Neuropathic Emotional/ anxiety musculoskeletal Compressive/visercal inflammatory

5. P AIN S YNDROMES Nocireceptive pain- Response to noxious stimuli resolves usually with non-opioid or opioid analgesics Incorporates somatic and visceral pain Somatic – focal, ache/throb/sharp swelling/edema/redness worse with movement, better at rest, maybe from trauma Visceral – viscous organs colicky, vague, diffuse, possibly worse with meals Liver/spleen/pancreas – possibly constant/focal, worse with eating uterine – colicky, pelvic, maybe with discharge Neuropathic – burning, sharp, tingling Possibly dermatomal or stocking-glove worse with touch, May have associated numbness radiating

6. H ISTORY TAKING FOR PAIN Pain location Radiation Intensity Characteristics/quality Temporal aspects: duration, onset, changes since onset Constancy or intermittency Characteristics of any breakthrough pain Exacerbating/triggering factors Palliative/relieving factors Nociceptive Restriction of range of motion Swelling Muscle aches, cramps, or spasms Neuropathic Color or temperature changes Changes in sweating Changes in skin, hair, or nail growth Changes in muscle strength Changes in sensation, either positive (dysesthesias/itching) or negative (numbness)

7. O THER C LINICAL P EARLS Uptitrate pain medications in short frequent dosages No two patients are the same in terms of pain tolerance Treat all types of pain at once to obtain better pain control Reevaluate pain regimen for side effects and possible overdosages Methadone and consideration for naloxone

8. C HOOSING BASED UPON RISK FACTORS Chronic kidney disease, advanced age - avoid NSAIDs and COX-2 inhibitors Peptic ulcer disease, glucocorticoid use - avoid NSAIDs Hepatic disease - avoid NSAIDs, COX-2 inhibitors, and acetaminophen (APAP); TCAs, antidepressants, opioids without APAP Cardiovascular disease or risk - use lowest effective dose of NSAIDs; in patients who require treatment, suggest naproxen

9. C LINICAL C ASE A 70-year-old male with recent diagnosis of multiple myeloma presents after a fall in which in breaks his wrist. He complains of pain from his shoulders, back, and wrist. His back pain is persistent for the past several months. It has two components: some “running shocklike down to his feet” and other “feeling as if his back is being eaten at.” There is radiologic evidence of bony metastases and DJD. He is taken to the OR for ORIF. What types of pain are involved in his case?

10. P AIN A SSESSMENT OF C ASE Broken wrist with swelling Nocirecptive: visceral DJD with likely nerve impingement Neuropathic Clues include radiation and shocklike sensations Bone metastases Inflammatory/metastatic

11. S UMMARY The purpose of good history about pain is to discern the pain syndrome and later define the agents that would useful for their treatment The etiology of pain is multifactorial When considering a pain regimen remember the side effect profiles of your medications to best select agent to be used.