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MP 0686328 | Practice No 0687359 Office: 021 975 7093 | Email: [email protected] | [email protected] | Suite 6, 2 Somerset Crescent, Durbanville
An Interdisciplinary approach to pain management
Dr. Ché VenterNeurorehabilitation and Pain PractitionerMedico legal and RAF4 Independent medicalExaminerMBChB (UCT) CIME
© Dr Ché Venter
Cape Town Pain Clinic
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Disclosures
© Dr Ché Venter
None
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What is Pain?
© Dr Ché Venter
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”
International Association for the Study of Pain (Merskey, 1979)
Pain is always subjective.• The patient’s self-report of pain is
the single most reliable indicator of pain
• It is NB that the clinician accepts this
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Pain Management Policy at the Cape Town Pain Clinic
© Dr Ché Venter
Optimal acute pain management is essential to prevent chronic pain
• Appropriate screening and pain assessment• Documentation• Care and treatment• Pain education
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Pain Management Policy at the Cape Town Pain Clinic
© Dr Ché Venter
Putting the pieces of the puzzle together
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The Pain Cycle
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Acute Pain VS
Presents most often with a clear cause, relatively brief in duration and subsides as healing takes place.
Acute pain is often accompanied by observable objective signs of pain
• increased pulse rate• increased blood pressure• Non-verbal signs and symptoms
such as facial expressions and tense muscles.
Chronic Pain
• Pain that is persistent and recurrent
• When pain persists, it serves no useful purpose and may dramatically decrease the quality of life and function
• Chronic pain rarely has any observable or behavioral signs although persons may appear anxious or depressed
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Chronic Pain Disorders
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Cancer Pain
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Pain that is associated with cancer or cancer treatment
May be attributed to • Tumor location• Chemotherapy • Radiation therapy• Surgical treatment
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Pain Assessment
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Initial Pain Assessment should include:• Location(s) • Intensity • Sensory quality • Alleviating and aggravating factors
Any new onset of pain requires a new comprehensive pain assessment.
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Modalities to objectively assess pain
© Dr Ché Venter
Patient self report of pain must be a source of assessment
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Modalities to objectively assess pain
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Pain Reassessment
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• Every 8 hours minimally
• Following the administration of pain medications to determine the effectiveness of the medication and/or need for further intervention
• IV within 15 mins of administration PO/IM/SC within 1 hour of administration
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Pain Management Approach
© Dr Ché Venter
Should be interdisciplinary and multimodal
Care is individualized and may depend on:
• Pain source and intensity• Patient’s age• Developmental, physical, emotional and cognitive status• Cultural beliefs • Treatment preferences• Concurrent medical conditions• Treat concurrent mood disorders, especially depression
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Physical Therapy
© Dr Ché Venter
• A good baseline• Obesity/increased adiposity results
in endothelial dysfunction• Decreases inflammatory markers• Improves Insulin sensitivity • Improves mental health
Exercise is a physiological stressor:• Lower intensity• Shorter duration
Exercise induced hypoalgesia:• Increases sensitivity to opioids –
by Beta endorphin release• Assists with Noxious Inhibitory Control• Can assist with weaning or dose reduction
of opioids
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Psychotherapy
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• Reduction in Brain Derived Neurotropic factor (BDNF)• Reduction in brain regional grey matter by 4.6 % for every 1 year of pain • Recovers with treatment• Central sensitization
- Upregulation of noxious signaling- Endogenous signaling
More efficient transmission of nociceptionFaciliatory Inhibitory
CCK SerotoninNitrous Oxide NoradrenalinExcitatory amino acids Dopamine
GABA
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Dietetics
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Multimodal Analgesia
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This term describes the use of multiple modalities that are used to provide pain relief with various parts of the pain pathway targeted
Decreased dependence on a single modality agents decreases the risk of side effects:
May include• Pharmacological (opioids, NSAIDS, gabapentanoids)• Relaxation techniques (biofeedback, deep breathing)• Regional analgesia (nerve blocks, epidural catheters)
It allows for opioid sparing !!Reduces polypharmacy !!
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Treatments May Include
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Non-pharmacologic Methods
• Heat/cold • Relaxation• Distraction• Graded motor
imagery• Acupressure/acupu
ncture• Repositioning
Pharmacologic Methods
• NSAIDS• Anti-seizure
medications• Anti-depressants• Opioid analgesics• Local anesthetics• Neurolytics• Cannabinoids
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Acute vs. Chronic Pain Management
© Dr Ché Venter
Acute Pain Chronic Pain
Most often treated with:• NSAIDS• Opioids• Local anesthetics• Splinting• Positioning changes• Ice
Most often treated with:
• Combinations of paracetamol and opioids such as tramadol
• Opioids (oxycodone and tapentanol, combinations of opioid and naloxone)
• Anti-seizure medications (Carbamazepine
• Anti-depressant medications• NSAIDS• Implantable devices• Psychological therapy• Acupuncture
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Undertreatment of Chronic Pain
© Dr Ché Venter
American Pain Society 2001, Gjachen
• > 40 -50 % of patients in the routine practice settings
• In a recent study of 805 Chronic Pain sufferers, > 50 % had to change physicians to establish pain control
??- Unwillingness to treat pain aggressively- Lack of empathy or belief in the patient’s perception of pain- Inadequate knowledge
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Responsible Opioid Prescribing
© Dr Ché Venter
Assess risk for opioid abuse
Risk factors for misuse or abuse of opioids include the following• Males between 18 and 45.• A personal history of substance abuse• A family history of substance abuse• A personal history of preadolescent sexual abuse• A personal history of psychological disease (depression, anxiety, obsessive-
compulsive disorder
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Patient and Family Education
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Patients and family are given specific instructions prior to discharge regarding• Pain control• Pain medications• Management of potential side effects
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Thank You
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Questions ?
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