- Physical therapy
- Cognitive behavioral therapy
- Yoga
- Ice, heat, stretching
- pet and music therapy
- acupuncture
Non-Pharmacologic Pain Strategies
Pain management strategy that combines 2 or more analgesic agents/techniques that act by different mechanisms to provide analgesia
- Designed by American Society of Anesthesiologists (ASA)
- Guideline: all pts should receive around-the-clock regimen of a non-opioid agent
Multimodal analgesia
- NSAIDs (Non-steroidal anti-inflammatory drugs)
or COXIBs (Cyclooxyrgenase- 2 specific drugs) - Acetaminophen
Non-opioid agents
- ↓ opioids requirement to manage pain
- ↓ side effects of opioid-related AVE
- better pain relief
- better pt satisfaction
- improves pt functional outcomes
- ↓ length of stay
- avoids safety concerns and contribution to opioid epidemic :
addiction, dependence, and dependence diversion
Benefits of Multimodal Analgesia
pt who has taken opioids and their body can handle/tolerate opioids
Opioid tolerate pts
- watch vital signs: make sure respiratory rate is not too low and BP
- pain assessment: chart b/f and after, reassess 30 min to 1 hr after adm.
• know when med is expected to take effect - secure meds
- give IV opioids slowly over min
- opioids are sedating - don’t give w/ other sedating drug (ex. Benzodiazepine)
Safe opioid administration
- abruptly stop taking these drugs
- fetus develops during preg
Dependence (Abstinence Syndrome)
Overdose Tx (Antidote) for opioids
Naloxone (Narcan)
Non-opioid! CNS acting
- MOA:
• binds to Mu»_space; WEAK opioid activity
• inhibit norep. and serotonin - reuptake in SPINAL neurons - S/S:
• pain - neuropathic pain
• restless leg - Interactions:
• Monoamine Oxidase Inhibitors (MAOIs) and Selective Serotonin Reuptake Inhibitors (SSRIS) and carbamazepine»_space; can induce serotonin syndrome
• ALCOHOL»_space; sudden DEATH
Tramadol
- estimates risk of opioid-related aberrant (odd) behaviors
- pain meds should NOT be withheld for painful conditions b/c a pt is deemed “high risk”
• these pts should be considered for other modalities of pain control, if appropriate - high risk pts may be appropriate candidates for referral to pain management
- adm on initial visit
Opioid Risk Tool
- 0-3: low
- 4-7: moderate
- 8+ : high
Opioid Risk Tool scoring
- family & personal history of substance abuse • alcohol • illegal drugs • Rx drugs - age - history of preadolescent sexual abuse - psychological disease • ADD, OCD, bipolar, schizophrenia • depression
Opioid Risk Tool contributing factors
Antagonist at mu
agonist at kappa
- Less potential for abuse
- Psychomimetic
- anxiety
- nightmares
- hallucinations
- strange thoughts
buprenorphine
- pentazocine
- nalbuphine
- butorphanol
Opioid Agonist - binds to a receptor and causes a response
Source - seedpod of the poppy plant
IV admin slowly over 4 to 5 minutes
Not very lipid soluble, so does not cross blood-brain barrier easily
Morphine
5-7 times more potent than morphine
Tolerance and physical dependence is more intense than morphine because of high potency
May cause less nausea than morphine
Hydromorphone
High potency – 100 times that of morphine
Intravenous – surgical analgesia, ICU sedation
Transdermal–chronic pain only, opioid tolerant pts
Fold used patches and put in biohazard container
Onset of action may be up to 24 hours
Transmucosal
Lozenge, “lollipop”, buccal tablets/films, sublingual sprays/tablets – breakthrough cancer pain
Fentanyl
(+): Toxic metabolite accumulation - Can cause seizures
(-): Less likely to depress fetal RR contractions (shorter half life)
Meperidine
(+): Pain, Opioid addiction (prevents withdrawal symptoms)
(-): Prolongs QT interval – fatal dysrhythmias
Methadone
moderate pain
Antitussive; side effects are dose limiting, used infrequently
Codeine
moderate pain
combined with acetaminophen
Antitussive; analgesia similar to codeine
Hydrocodone
moderate pain
analgesia equal to codeine combined with aspirin, or acetaminophen
Oxycodone
moderate pain
extended release oxycodone given every 12 hours for ATC analgesia
Oxycodone ER
- Reversal of opioid OD
- Reversal of postoperative opioid effects
- Reversal of neonatal respiratory depression
Naloxone
Non-opioid! CNS acting
Alpha 2
- Severe Hypotension
- Rebound hypotension
- bradycardia
Clonidine
