Pain Management Guidelines 15-11-2012

7/25/2019 Pain Management Guidelines 15-11-2012

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1P a i n M a n a g e m e n t G u i d e l i n e s

Ministry of Health

P. O. Box 84 Kigali

www.moh.gov.rw

Republic of Rwanda

Pain Management Guidel ines

September 2012


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Pain Management Guidel ines

Ministry of Health

P. O. Box 84 Kigali

www.moh.gov.rw

Republic of Rwanda

September 2012


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P a i n M a n a g e m e n t G u i d e l i n e s iii

Table of Contents

Acronyms....................................................................................................v

Foreword..................................................................................................vii

1. Introduction............................................................................................1

2. Pain Assessment and Measurement.......................................................3

2.1. Goals o Pain Assessment.......................................................................32.2. Assessment by PQRS Checklist............................................................3

2.3. Measurement............................................................................................4

3. Treatment Approaches of Pain..............................................................9

3.1. Pharmacological Approach..................................................................10

3.2. Non-Pharmacological Approach........................................................11

4. Pain Classification and Management...................................................13

4.1. Acute Pain..............................................................................................13

4.2. Chronic Non Cancer Pain....................................................................19

5. Cancer Pain Management....................................................................25

6. Common Opioid SideEffects Management .......................................31

7. Appendix...............................................................................................35

7.1. Definition o erms................................................................................35

7.2. Non-Opioid Analgesic Doses................................................................37

7.3. Opioids Comparative able...................................................................37

7.4. Opioid Conversion ips........................................................................39

7.5. Initial Oral Opioid Dose Based on Pain Severity...............................40

7.6. itrating Opioids....................................................................................417.7. Adjuvant Medications with Analgesic Activity...................................42

7.8. Neuropathic Pain reatment Algorithm.............................................45

7.9. Breakthrough Doses...............................................................................46

8. References.............................................................................................47

9. List of participants...............................................................................49


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P a i n M a n a g e m e n t G u i d e l i n e s v

Acronyms

AEDs : Anti Epileptic DrugsASA : Acetyl Salicylic Acid

BB : Beta Blockers

BNZ : Benzodiazapins

BID : wice a Day

BPN : Branchial Plexus Neuropathy

CBI : Cannabinoids Receptor ype 1

CCB : Calcium Channel BlockersCIPN : Chemotherapy Induced Peripheral Neuropathy

CNCP : Chronic Non Cancer Pain

CNS : Central Nervous System

COPD : Chronic Obstructive Pulmonary Disease

CPG : Clinical Practice Guidelines

CR : Controlled Release

IR : Immediate Release

IV : Intravenous

N/A : Not Applicable

NMDA : N Methyl D Aspartate

NRS : Numerical Rating Scale

NSAIDs : Non Steroidal Anti-Inflammatory Drugs

OT : Occupational Terapy

PCA : Patient Controlled Analgesia

PE : Physical ExercisePED : Poly Ethylen Glycol

PHN : Post Herpetic Neuralgia

PO : Per Oral

PR : Per Rectal

PRN :Pro Re Nata (As needArises)

PT : Physical Terapy

q : Every

RoM : Range o Motion

SCS : Spinal Cord Stimulation

SR : Sustained Release

TCAs : ricyclic Antidepressants

TENS : ranscuteneus Electrical Nerve Stimulation

TID : Tree imes a Day

VAS : Visual Analogue Scale

WHO : World Health Organization


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P a i n M a n a g e m e n t G u i d e l i n e s vii

Foreword

he guidelines and protocols presented in this document are designedto provide a useul resource or healthcare proessionals involved inclinical case management in Rwanda. Tey were developed by taking

into consideration services provided at different levels within the healthsystem and the resources available, and are intended to standardize care atboth the secondary and tertiary levels o service delivery across differentsocio-economic levels o our society.

Te clinical conditions included in this manual were selected based onacility reports o high volume and high risk conditions treated in eachspecialty area. Te guidelines were developed through extensive consultativework sessions, which included health experts and clinicians rom differentspecialties. Te working group brought together current evidence-basedknowledge in an effort to provide the highest quality o healthcare to thepublic. It is my strong hope that the use o these guidelines will greatlycontribute to improved the diagnosis, management, and treatment opatients across Rwanda. And it is my sincere expectation that serviceproviders will adhere to these guidelines and protocols.

Te Ministry o Health is grateul or the efforts o all those who contributedin various ways to the development, review, and validation o the Clinicalreatment Guidelines. We would like to thank our colleagues rom District,Reerral, and University eaching Hospitals, and specialized departmentswithin the Ministry o Health, our development partners, and private healthpractitioners. We also thank the Rwanda Proessional Societies in their

relevant areas o specialty or their contributions and or their technicalreview, which enriched the content o this document, as well as the WorldHealth Organization (WHO) and the Belgium echnical Cooperation(BC) or their support.

We would like to especially thank the United States Agency or InternationalDevelopment (USAID) or both their financial and technical supportthrough the Management Sciences or Health (MSH) Integrated HealthSystem Strengthening Project (IHSSP) and Systems or Improved Access to

Pharmaceuticals and Services (SIAPS).

o end with, we wish to express our sincere gratitude to all those whocontinue to contribute to improving the quality o health care o the Rwandapopulation.

Dr Agnes BinagwahoMinister of Health


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1. Introduction

Pain management guidelines are systematically developedrecommendations that assist the health care practitioner and patient inmaking decisions about health care.

Te purpose o these guidelines are:- o optimize pain control, while recognizing that a completely

pain- ree state may not be attainable- Enhance unctional abilities, physical and psychological well

being- o enhance quality o lie o patients- Minimize adverse outcome

Tese guidelines will ocus on knowledge base, skills and range ointerventions that are the essential elements o effective management o

acute, chronic and pain- related problems.

Denitions

Pain: Is an unpleasant sensory and emotional experience associatedwith actual or potential tissue damage or described in terms o suchdamage.

Pain is an individual and Subjective experience modulated byphysiological, psychological and environmental actors such as previousevents, culture, prognosis, coping strategies, ear and anxiety.

- Nociceptive pain:Nociception is the activity in peripheral painpathways that transmits or processes the inormation aboutnoxious events associated with tissue damage.

Nociceptive pain can be: Somatic pain:Pain originating rom bone, muscle,

connective tissue etc. Tis type o pain can be described asaching, sharp, stabbing, throbbing and is well localized.

Visceral pain: Pain originating rom organs such aspancreas, liver, GI tract etc. Tis type o pain is describedas cramping, dull, colicky, squeezing, ofen poorlylocalized, and may be reerred to other areas.

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2 P a i n M a n a g e m e n t G u i d e l i n e s

- Neuropathic pain:It is caused by an injury or dysunction othe peripheral or central nervous system. It is ofen described

as: burning, shooting, stabbing, numbness or tingling. It has theollowing types: Central neuropathic pain :Example: Post stroke pain,

Spinal cord injury, multiple sclerosis and syringomyelia Peripheral

Focal: Examples: rigeminal neuralgia, Carpal tunnelsyndrome, ailed back surgery syndrome with nerveroot fibrosis, post -herpetic neuralgia

Multiocal: Examples: Vasculitis, diabetes mellitusand brachial or lumbar plexus

Symmetrical : Examples: Diabetes mellitus, ethanolabuse, toxins (e.g: vincristine) and amyloidosis

Othersensations o neuropathic pain Dysesthesia (bugs crawling on the skin, pins and

needles)

Allodynia (pain to a non painul stimulus) Hyperalgesia (increased pain sensation to a normally

painul stimulus)

- Mixed: Tis involves both Nociceptive and Neuropathic types opain.

Chapiter 1: Introduction


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2. Pain Assessment and Measurement

Pain assessment is critical to optimal pain management interventions.While pain is a highly subjective experience, its managementnecessitates objective standards o care.

2.1. Goals of pain assessment

- o capture the individuals pain experience in a standardized way

- o help determine type o pain and possible etiology- o determine the effect and impact the pain experience has on

the individual and his/her ability to unction- Basis on which to develop treatment plan to manage pain- o aid communication between interdisciplinary care team

members

Note:Pain assessment should be documented so that all members ofcare team will have a clear understanding of the pain.

Ongoing comprehensive assessment is the oundation o effective painmanagement, including interviews, physical assessment, medicationreview, medical and surgical review, psychosocial review, physicalenvironment and appropriate diagnostics. Assessment must determinethe cause, effectiveness o treatment and impact on quality o lie or thepatient and their amily.

2.2. Assessment by PQRST Checklist

Tis assessment checklist may be used or general assessment orspecifically or pain:

- P= Provocation and Palliation

What causes it? What makes it better? What makes it worse?

- Q= Quality and Quantity How does it feel, look or sound? How much of it is there?

- R= Region and Radiation Where is it? Does it spread?

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- S= Severity and Scale Does it interfere with activities?

How does it rate on a severity scale of 1 to 10?

- T= iming and ype o Onset When did it begin? How oen does it occur? Is it sudden or gradual?

2.3. MeasurementMost measures o pain are based on selreport. Tese measures lead tosensitive and consistent results i done properly. Selreport measuresmay be influenced by mood, sleep disturbance and medication.

In some instances it may not be possible to obtain reliable selreportso pain (e.g. patients with impaired consciousness or cognitiveimpairment, young children, elderly patients, or where there are ailureso communication due to language difficulties, inability to understandthe measures, unwillingness to cooperate or severe anxiety). In thesecircumstances other methods o pain assessment will be needed.

Tere are no objective measures o pain but associated actors such ashyperalgesia (e.g. mechanical withdrawal threshold), the stress response(e.g. plasma cortisol concentrations), behavioral responses (e.g. acial

expression), unctional impairment (e.g. coughing, ambulation)or physiological responses (e.g. changes in heart rate) may provideadditional inormation. Analgesic requirements (e.g. patient-controlledopioid doses delivered) are commonly used as post hoc measures opain experienced.

Recording pain intensity as the fifh vital sign aims to increaseawareness and utilization o pain assessment and may lead to improved

acute pain management. Regular and repeated measurements o painshould be made to assess ongoing adequacy o analgesic therapy. Anappropriate requency o reassessment will be determined by theduration and severity o the pain, patient needs and response, and thetype o drug or intervention.

Chapiter 2: Pain Assessment and Measurement


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Measures of Pain

Uni-dimensional measures of pain

Numerical rating scales Numerical rating scales (NRS) have both written and

verbal orms Te Verbal Numeric Rating Scale (VNRS)

o Patients rate their pain intensity on the scaleo 0 to 10 (Reer Figure: 1 below) where 0represents no pain and 10 represent worstpain imaginable. It is important that scalesare consistent, and it is recommended thatthe no pain point be represented as zero(0) rather than 1.

Verbal Rating Scale use phrases such as whatis your pain like? is it mild, moderate, orsevere?

Visual analogue scales(VAS) VAS (Reer Figure: 1 below) VAS are the most commonly used scales or ratingpain intensity, with the words no pain at the lef endand worst pain imaginable at the right. VAS ratingso greater than 70 mm are indicative o severe painand 0 to 5 mm no pain, 5 to 44 mm mild pain and45 to 74 moderate pain

Note:Tese scales are unsuitable for children under 5 years and mayalso be unsuitable in up to 26% of adult patients.


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Figure 1: Rating Scale


Categories Scoring

0 1 2Face No particular

expression or

smile; disinterested

Occasional grimace or

frown, withdrawn

Frequent to constant frown

clenched jaw, quivering chin

Legs No position

or relaxed

Uneasy, restless, tense Kicking, or legs drawn up

Activity Lying quietly

normal position,

moves easily

Squirming, shifting

back and forth, tense

Arched, rigid, or jerking

Cry No crying

(awake or asleep)

Moans or whimpers,

occasional complaint

Crying steadily, screams or

sobs, frequent complaints

Consolability Content, relaxed Reassured by occasional

touching, hugging or

talking to Distractable

Difcult to console

or comfort

Each of the ve categories (F) Face; (L) Legs; (A) Activity; (C) Consolability

is scored from 0-2, which results in a total score between 0 and 10

ASK PATIENTS ABOUT THEIR PAIN

INTENSITY - LOCATlON - ONSET - DURATION - VARIATION -QUALITY

NO HURT HURTS

LITTLE BITHURTS

LITTLE MORE

HURTS

EVEN MORE

HURTS

WHOLE LOT

HURTS

WORST

Unbearable

Pain

Distressing

Pain

No

Pain

Choose Number from 0 to 10 That Best Describes Your Pain

Figures: Tools Commonly Used to Rate Pain

Visual Analogue Scale

Faces Pain Rating Scale

Behavioral Observation Pain Rating Scale


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Multidimensional measures of pain

Rather than assessing only pain intensity, multidimensional tools

provide urther inormation about the characteristics o the painand its impact on the individual. Examples include e Brief Pain Inventory, which assesses pain intensity and

associated disability e McGill Pain Questionnaire (Refer gure 2 below),

which assesses the sensory, affective and evaluativedimensions o pain

Figure 2:McGill Pain Questionnaire


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ADULT PAIN TOOLMCGILL PAIN QUESTIONNAIRE HOW STRONG IS YOUR PAIN?

Part 1: Mark the areas on these drawings to showwhere you have pain. The marks can be as big orsmall as the pain feels.

Part 2: Present pain Intensity (PPI): Mark an X on the line belowto show how bad your pain is right now.

Part 3: Overall pain experience: Please circle the onedescriptor below that best describes your present pain.

Part 4: Each of the words in the left column describes a quality orcharacteristic that pain can have. For each pain quality in the left

column, place a check mark () In the column that tells how muchof tthai specic quality your pain has. Rate every pain quality.

Part 5: Which word would you use to describe the

pattern of your pain?1= Continuous

2= Intermittent

3= Brief

WHAT DOES YOUR PAIN FEEL LIKE? HOW DOES YOUR PAIN CHANGE

WITH TIME?

No pain Mild Discomforting

Distressing Horrible Excruclating

score

Part 1 Body outline (# 0f marks made)

Part 2 Present pain intensity (PPI)

Part 3 Evaluative descriptor of present pain

Part 4a Sensory-PRI (SUM 1-11; high score =33)

Part 4b Affective-PRI (SUM 12-15; high score =12)

Part 4a+b Total PRI

Part 5 Pattern of pain

Pain Quality None Mild Moderate Severe

1. Throbbing (0) (1) (2) (3)

2. Shooting (0) (1) (2) (3)

3. Stabbing (0) (1) (2) (3)

4. Sharp (0) (1) (2) (3)

5. Cramping (0) (1) (2) (3)

6. Grawing (0) (1) (2) (3)

7. Hot- burning (0) (1) (2) (3)

8. Aching (0) (1) (2) (3)

9. Heavy (0) (1) (2) (3)

10. Tender (0) (1) (2) (3)

11. Splitting (0) (1) (2) (3)

12. Tiring-exhausti ng (0) (1) (2) (3)

13. Sickening (0) (1) (2) (3)

14. Fearful (0) (1) (2) (3)

15. Punishing-Cruel (0) (1) (2) (3)

No

pain

Little

pain

Medium

pain

Large

pain

Worst possible

pain

4. Pain Rating IndexFor each pain quality a value is given that rates the intensity of that specic quality. Painqualities are categorized into two indexes:

a. Sensory words (S) found in Items 1-11b. Arrectfve words. ( A) found in Items 12-15

The sensory pain rating index score is obtained by adding Items 1-11 with the highest possiblescore being 33. The affective pain rating index score is obtained by adding items 12-15, withthe highest possible score being 12.

Any affective or evaluative rating suggests poor coping and the need for further assessmentwith the social worker and psychologist.

The total score is recorded ( PRI) by adding the sensory and affective scores.

5. Pattern of PainA numerical value is assigned to the word describing the pattern or the pain.

The McGILL Pain Questionnaire (MPQ)is used to specify the subjective pain experience usingsensory, affective, and evaluative word descriptors. There are FIVE major measures: the bodyoutline; the present pain Intensity (PPI); overall evaluation of the pain experience; the painrating Index (PRI-sensory and affective); and the pattern or pain over time.

SCORING THE McGILL PAIN QUESTIONNAIRE (MPQ)1. Body outlineUsing the template, note the number of body sites where pain is marked and record thenumber. A site is considered marked if 25% or more of the marking is in that particular area.

2. Present Pain IntensityThe ruler is used to obtain a numerical pain intensity score from 0 to 10.

3. EvaIuative intensityThe overall pain experience is measured using the 0-5 grading scale. A number is assigned tothe word or descriptor that is used to describe the overall evaluation of the persons presentpain. Evaluative ratings of 4 or 5 suggest the need for improved overall coping

Note: Adapted from Meizack. R. (1975) The McGill Pain Questionnaire: Major Properties and scoring methods. Pain, 1:277-299 and the Short Form McGill Pain Questionnaire, Copyright 1997(revised 2003).

0 1 2 3 4 5 6 7 8 9 10

0 1 2

3 4 5

A

B


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- Patients with special needs Communication aids and behavioral scales such as the

modified Faces, Legs, Activity, Cry and Consolability(FLACC) (Reer to Figure: 1) scale In neonates, inants and children, but must be both

age and developmentally appropriate. Tese includebehavioral assessments, pictorial scales (e.g. acesreer to Figure:1)

In Adult patients who have difficulty communicatingtheir pain, (e.g. patients with cognitive impairment

or who are critically unwell in the emergencydepartment or intensive care,) require specialattention as do patients, whose language or culturalbackground differs significantly rom that o theirhealth care team)



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3. Treatment Approaches of Pain

In acute pain problems, the goal is primarily pain relie. In chronicpain problems, achieving the best outcome or the patient ofeninvolves a variable blend o pharmacological and non-pharmacologicalapproaches that addresses the multidimensional components o painand suffering.

Treatment Continuum Approach

In order to make the most efficient use o locally available medicalresources and not expose the patient to unnecessarily risk, it makessense to approach the management o pain using treatments along acontinuum. Beginning with modalities that are more readily available,less expensive, more evidence-based, less invasive and with lesspotential side effects. I these modalities ail, one can then progress totreatment that is more specialized, more expensive and more invasive.

3

Figure 3:New adaptation of the analgesic ladder

Nerve blockEpiduralsPCA pump

Neurolytic block therapySpinal stimulatorsStrong opioids

MethadoneOral administrationTransdermal patch

Weak opioids

Nonopioidanalgesics

NSAIDS

Chronic pain

Non-malignant pain

Cancer pain

NSAIDs

(with or without adjuvants

at each step)

Neurosurgical

procedures

Acute painChronic pain without controlAcute crises of chronic pain

NSAID-nonsteroidal anti-inammatory drug, PCA-patient-controlled analgesia.

STEP 1

STEP 2

STEP 3

STEP 4


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3.1. Pharmacological approach

WHO Analgesic Ladder

- Step 1 Non opioid adjuvant : ASA, Paracetamol, NSAIDs/COX-

2sadjuvant

- Step 2 Opioid for mild to moderate pain nonopioid adjuvant:

Codeine, Tramadol, oxycodone, NSAIDs/COX 2s, adjuvants

- Step 3 Opioid for moderate to severe pain, non opioid,

Adjuvant: Oxycodone, Morphine, Hydromorphine,Fentanyl, methadone, NSAIDs/COX 2s, adjuvants

- Step 4: Nerve block, epidurals, PCA pump, neurolytic nerve

blocks,

Note: With some exceptions, most medication used in the treatment ofpain work best when titrated dose to effect. Tis means startingat a low dose and increasing the dose at scheduled intervals until

there is analgesic benefit or the patient experiences unacceptableand persistent adverse effects that do not improve with time andvigorous side-effect management.

Te exceptions to this principle are the non-steroidal anti-inflammatorydrugs (NSAIDs) and paracetamol, both o which have recommendeddose ceilings and some o the antidepressants and anticonvulsants

which have measurable therapeutic serum levels.

Chapiter 3: Treatment Approaches of Pain


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3.2.Non-pharmacological Approach PhysicalTreatment Options

- Exercises Stretching/ range of motion/ exibility Strengthening General aerobic conditioning Quota-based reactivation Coordination balance/proprioceptive training

Relaxation Postural stabiliation Yoga

- Passive physical modalities erapeutic cold

Cold packs Ice massage

Cold water immersion

erapeutic heat Hot packs/heating pads

- Occupational therapy techniques Ergonomic assessment / adaptations Activities of daily living/ work modications

Pacing strategies Body mechanics and dynamic posturing

- Manual therapy Mobiliation with stretching Manipulation (chiropractic treatment) Massage

- raction

Psychological Approach

Chronic pain and physical limitations can have great psychological andemotional effects on a person with pain related problems. Living withpain can lead to problems such as depression, anxiety and helplessness,all o which can exacerbate pain and disability.

- Psychological Interventions

Cognitive-behavior therapy (CBT): Consists of 3 phasesnamely

Chapiter 3: Treatment Approaches of Pain

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Education about biopsychosocial model o pain. Skills training: Relaxation techniques, activity

pacing, pleasant activity scheduling, imagerytechniques, distraction strategies, cognitiverestructuring (changing negative thought patterns),problems solving and goal setting.

Application phase : Practice and application o theskills in real-lie situations

Active coping characteried by

Solving problems Seeking inormation Seeking social support Seeking proessional help Changing environments Planning activities in response to some stress,

physical or emotional. Tis is to avoid copingstrategies, which lead people into activities (such as

alcohol use) or mental states (such as withdrawal)that keep them rom directly addressing stressulevents.


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4. Pain Classication and Management

4.1. Acute Pain

Denition:Recent pain that is usually transient in nature lasting orseveral minutes to several days. Is usually caused by tissue damageand is ofen associated with some degree o inflammation. Te generalapproach to the treatment o acute pain includes treatment goals,therapeutic strategies, and elements o pain management.

Common Types of Acute Pain

Type or source Definition Source or examples

Acute illness Pain associated with anacute illness

Appendicitis, renal

colic, myocardial

inarctionPerioperative(includespostperative)

Pain in a surgicalpatient because o pre-existing disease, thesurgical procedure (e.g.associated drains, chestor nasogastric tubes,complications) or both

Head and neck

surgery

Chest and chest wall

surgery

Abdominal surgery

Orthopedic and

vascular surgery (back

and extremities)

Post traumatic(major trauma)

Includes generalized orregionalized pain due tomajor acute injury

Motor vehicle accident

Burns Pain due to thermal orchemical burns

Fire, chemical

exposure

Procedural Pain associated with a

diagnostic or therapeuticmedical procedure

Bone marrow

biopsy, endoscopy,catheter placement,

circumcision, chest

tube placement,

suturing

Obstetrics Pain related to labor anddelivery

Childbirth by vaginal

delivery or cesarean

section

Pain

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Management

Management Goals Early intervention, with prompt adjustments in the

regimen or inadequately controlled pain Reduction o pain to acceptable levels Facilitation o recovery rom underlying disease or injury

Management Strategies Multimodal analgesia

Use o more than one method or modality ocontrolling pain

Drugs rom two or more classes Drug plus non drug treatment to obtain additive

beneficial effects; reduce side effects, or both.Tese modalities may operate through differentmechanisms or at different sites (i.e. peripheral

versus central actions). Example o multimodal analgesia is the useo various combinations o opioids and localanesthetics to manage postoperative pain.

Preemptive analgesia Administration o one or more analgesic(s) prior to a

noxious event (e.g. surgery) in an attempt to prevent

peripheral and central sensitization, minimizingpost-injury pain.

Chapiter 4: Pain Classication and Management


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Non-pharmacological

Non-Pharmacological Interventions or Acute Pain

Pain type orsource

Physical methods Psychologicalmethods

Other

Acute illness Vibrations or cold

or immobilization

Patient education,relaxation,imagery,distraction

Perioparativepain

Exercise or

immoblisation

Message

Application of heat

or cold

Electro analgesia

Patient education,relaxation,distraction,acupuncture,imagery, bioeedback, hypnosis

Acupuncture

rauma Rest, ice,

compression,

elevation Physical therapy

(e.g. stretching,

strengthening,

thermal therapy,

ENS, vibration

Relaxation,hypnosis,distraction,supportivepsychotherapy,copying skillstraining

Burns Limb elevation

Minimise number

o dress changes

Patient education,deep relaxation,

distraction,imagery, musicrelaxation

Procedural Application of

cold (pre and post

procedure)

Counter irritation

(simple massage,

scratching,pressure)

Rest or

immobilization

(post procedure)

Obstetrics Patient education,relaxationbreathing,

distraction


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Pharmacological Acute pain.

Most acute pain is nociceptive and responds to Nonopioids and opioids Adjuvant analgesics (e.g. local anesthetics)

Mild somatic pain responds well to Oral non-opioids

Paracetamol Nonsteroidal Anti-inflammatory drugs

[NSAIDs]) opical agents (e.g. local anesthetics) Physical treatments (e.g. rest, ice, compression,

elevation)

Moderate to moderately severe acute pain is more likely torespond to

Opioids

Non-opioids ofen combined with opioids to improvepain relie and diminish the risk o side effects.

Systemic Medication or Acute Pain Management



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PainTypeor

sourc

e

NonOpioid

Opioids

Adjuvant

analge

sics

Comments

Acute

illness

Paracetamol,NSAIDs

Systemicopioids

Perioperative

(inclu

des

postoperative)

Paracetamol,NSAIDs

SystemicopioidsincludingPCA

Locala

nesthetics

(Lidocaine,

bupiva

caine)

Usemultimodalwheneverpossiblerecorganise

needsforspecialpopulations,scheduledATC

dosingisusuarypreferredtoPRN

Majo

rtrauma

(generalized

pain)

Paracetamol,NSAIDs,

duringposttrau

ma

healingphase

Bolusorcontinou

sIVopioids

duringemergencyphase;IVorPO

opioidsduringhe

alingphase

IVketamine

(Veryrare)

Useofketamineisrestrictedtopainrefr

actory

toothertreatmentsduetosevereCNSs

ide

effects

Majortrauma

(regio

nalized

pain)

NSAIDS(paren

tal,

oralduringpost

traumahealingphase)

BolusorIVopioidsduring

emergencyphase

plusregional

anesthesia

IVketamine

(Veryrare)


actory


ide

effects,

Burns

Paracetamol,NSAIDs

duringrehabilitative

phase

HighdosesofIVopioids(e.g.

morphine,Fentan

ylPCAfor

NPOpatients:ora

lopioids(e.g.

morphine,Hydromorphone)when

takingPO

Parentalketamine

Veryrare

IVlido

caine

Veryrare


actory


ide

effects,

Infusionoflo

wdoselidocaineisrestrictedto

burnpaintha

tisrefractorytoopioids

Minortrauma

Paracetamol,NSAIDS

Opioidsformildtomoderatepain

Proce

dural

pain

NSAIDSfor

preemptiveanalgesia

andpostproced

ural

pain

IVopioids(morphine,

hydromorphonea

ndfentanyl)

Locala

nasthetics

(lidoca

ine,

Bupiva

caine,

IVketamine

Localanestheticsmaybeappliedtopically

or

injectedintothetissueorusedfornerveblocks.

UseofketaminelimitedbysevereCNSside

effects

Obste

trics

Pain

BolusIVopioids(morphine,

fentanylandhydromorphone


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Regional Anesthesia or Acute Pain Management

Perioparativepain

Epidural anesthesia with opioids or opioids plus localanesthesia mixture injected intermittently or inusedcontinuously

Intrathecal opioids or opioids plus local anesthetics Local neural blockade Other regional anesthesia techniques

Trauma Limited to local neural blockade during emergencyphase

Also included epidural analgesia with opioids and /or local anesthetics during post-trauma healing phase,especially or regionalized pain

Burns Pidural analgesia with opioids and/ or local anesthetics(only afer closure o burn wound)

Procedural Includes local inltration with local anesthetics

Obstetrics Epidural analgesia or spinal analgesia with local

anesthetics (e.g. bupivacaine, ropicaine and /or opioid Combined spinal-epidural techniques with opioids Epidural analgesia, spinal, or combined spinal-epidural

technique or cesarean section Tissue inltration with local anesthetics

Recommendations

- Analgesics, especially opioids should be under prescribed andunder dosed or both acute and chronic pain

- Moderate to severe acute pain should be treated with sufficientdoses o opioids to saely relieve the pain

- I drug side effects preclude achieving adequate pain relie, theside effects should be treated and/or another opioid should be

tried- Te concomitant use o other analgesics (e.g. non-opioids, localanesthetics) and non pharmacologic methods (e.g. applied heator cold, electroanalgesia, relaxation) maximizes pain relie andminimizes the risk o treatment-limiting side effects.



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4.2. Chronic Non Cancer Pain

Te general approaches to the treatment o chronic non-cancer pain(CNCP) include treatment goals, therapeutic approaches, and elementso treatment. It also provides general inormation about the treatmento some common types o CNCP (i.e. summary tables) and identifiesrelevant clinical practice guidelines (CPGs)

Management

General management goals Diminish suffering, including pain and associated

emotional distress Increase/restore physical, social, vocational, and

recreational unction Optimize health, including psychological well-being Improve coping ability (e.g. develop sel-help strategies,

reduce dependence on health care system) and

relationships with others (e.g. amily, riends, health careproessionals)

Management Strategies Multimodal therapy

Medication rom different classes (i.e. combinationdrug therapy)

Rehabilitative therapies (e.g. physical therapy,

occupational therapy) and medication Regional anesthesia (e.g. neural blockade) and

medication Interdisciplinary Management o CNCP: An

Examples o Interventions is below


Pain

Classif

cation

andManagement

4


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Patient education: Counseling about the pain, aggravating and

aIleviating factors, management strategies, lifestyle factors that

may inuence the pain (e.g ., use of nicotine, alcohol.

Physical rehabilitative approaches: Physical therapy modalities

for reconditioning, (e.g. walking, stretching, exercises to

improve strength and endurance, oscillatory movements)

Other physical approaches: Application of heat or cold, TENS,

massage, acupuncture

Occupational therapy: Attention to proper body mechanics,

resumption of normal levels of activities of daily living

Pharmaceuticals: Nonopioids, opioids, anti depressants,

antiepileptic drugs, stimulants, antihistamines

Regional anesthesia: Nerve blocks (e.g., diagnostic, somatic,

sympathetic, visceral, trigger point) and/or intraspinal analgesia

(e.g., opioids, clonidine, baclofen, local anesthetics)

Psychological approaches: Relaxation training, hypnosis,

biofeedback, copings skills, behavior modication,

psychotherapy

Surgery: Noeuroablation, neurolysis, microvascular

decompression



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Non

-pharmacological

Non-p

harmacologicalInterven

tionsforChronicNonca

ncerPain

Type

ofpain

Surgical

Otherp

hysicalmethods

Psychologicalmeth

ods

Other

Arthritispain

Includesarthroscopy,

synovectom

y,osteotomy

andspinalfusion

TENS,appliedheatorcold,lowimpact

aerobicandROMexercise,joint

protection(splintorbrace,massage

PE,(rest,exercise,n

utrition),and

socialsupport

Acupunc

ture

nutrition

al

supplements

Lowbackpain

Laminectomy,diskectomy,

lumberfusion,lumber

stabilisation

SCS,cry

oanalgesia,radiofrequency

,

coagulation,exercise,PT,OT,TENS

,

brace,vibration

PEbackschool

Biofeedback,psychotherapy

Acupunc

ture

manipulation

therapy

Fibro

myalgia

Applied

heatmassage,gentleaerob

ic,

gentleaerobicandstretching,attention

toprope

rposture,PT,TENS,vibration

PE,psychotherapy,relaxation,

hypnosis

Acupunc

ture

Sicklecelldisease

Carefulhydration,appliedheat,

massage

,ultrasound,PT,TENS,

possibly

SCS,appliedheatorcold,

massage

PE,psychotherapy,deepbreathing

andrelaxationtech

niques,

distraction,imagery

,meditation,

biofeedback

Acupunc

ture

Perip

heral

neuropathy

Decompressivesurgery

fornerveentrapment,

vascularsu

rgeryfor

vascularinsufficiency

Goodsk

inandfootcare,PT,TENS

PE,psychotherapy,relaxation,

biofeedback

Migraineand

other

typesof

headache

Appliedheatorcold,

exercise(prophylaxis),

vibration

PE,relaxation,biofeedback


Pain

Classif

cation

andManagement

4


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Pha

rmacological

Pharm

acologicalManagementforChronicNoncancer

Pain:(SelectedExamples)

Type

ofpain

Nonopioids

Opioids

A

djuvantAnalgesicsandd

isease-

specificdrugs

Comments

Arthritispain

Paracetamol

NSAIDs

SelectiveCOX-2

inhibitors

Shortterm

opioidforflare-

ups

C

orticosteroids

SelectNSAIDSbasedondosing,efficiency,

tolerance,costsandpatientpreference

Monitorclo

selyforNSAIDssideeffects

Opioidsare

appropriateforlongterm

treatmentinselectedpatients

Lowbackpain

Paracetamol

NSAIDs

SelectiveCOX-2

inhibitors

Shortterm

opioidformild

tomoderate

flare-ups

T

CAe.g.Amitriptyline

A

EDse.g.gabapentine,carb

amazapine

ShortactingMusclerelaxantse.g.

cyclobenzaprine

Opioidsare

appropriateforlongterm

treatmentinselectedpatients

Fibromyalgia

Paracetamol

NSAIDs

SelectiveCOX-2

inhibitors

Opioida

(occasionaluse

forares)

Tramadol

T

CAe.g.Amitriptyline

ShortactingMusclerelaxantseg

cyclobenzaprine

Tramadolm

ayhavelesspotentialfora

buse

Sicklecell

diseasepain

Paracetamol

NSAIDs

Shortorlong

termopioids

S

edatives

A

nxiolytics

Useshortactingopioidsforshortterm

treatmentandlongactingforlongtreatment

Peripheral

neuro

pathy

Paracetamol

NSAIDs

Shortterm

opioidsonly

T

CAe.g.Amitriptyline

A

EDse.g.gabapentine,carb

amazapine

Shortactingmusclerelaxantse.g.

cyclobenzaprine

AEDs,TCA

sandlocalanestheticsare

first

linetreatmentNSAIDsarereallyeffectivetry

opioidsaslastresort



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Pharmacological Management of Migraine and Other Types of Headache

Headache

types

Prophylaxis Arbotive Comments

Migraine AEDs e.g.Gabapentine

BBs e.g.propranolol

CCBs e.g.verapamil,niedipine

TCAs NSAIDs

NSAIDs Opioid

Combinationtreatment e.g.Paracetamol pluscodeine

DehydroegotamineRizapritanNaratriptan

Paracetamol plusASA plus codeinconsidered firstline treatment.First choiceNSAIDs are ASA,ibuproene andnaproxen, othersare also effectiveriptans areeffective andinitial choice orpatient with mildto severe HAand no contraindication

ension TCAs Paracetamol NSAIDs

Cluster CCBs Corticosteroids AEDs

Ergotamine Dihydroergotamine Inhalation ofoxygen

Regional Anesthesia for Chronic Noncancer Pain

Pain type Method

Arthritis pain Intra-articular injection of corticosteroids (e.g.methyl prednisolone

Intra- articular injection of sodium hyaluronate

Low back pain Facet joint injections with local anesthetics Sciatic nerve block with local anesthetic due to

sciatica Epidural steroid injections (e.g.

methylprednisolone) ofen with local anesthetic(e.g. lidocaine)

Headache andmigraine

Occipital nerve block with local anesthetic foroccipital headache


Pain

Classif

cation

andManagement

4


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5. Cancer Pain Management

Introduction

Cancer pain shares the same neuro-patho-physiological pathways asnon-cancer pain. It is a mixed mechanism pain that can be present asa pure neuropathic, visceral or somatic pain syndrome (however thisis rare). But it may involve inflammatory, neuropathic, ischaemic andcompressive mechanisms at multiple sites. Development over time

is complex and varied, depending on cancer type, treatment regimesand underlying concurrent morbidities. Opioids are the mainstay otreatment and are associated with tolerance.

Causes of Severity

- Direct tumour invasion o local tissues- Metastatic bone pain

- Osteoporotic bone and degenerative joint pain in older people- Visceral obstruction- Nerve compression and plexus invasion- Ischaemia- Inflammation

General Principles Be committed to the relie o suffering and promotion o

healing Do a thorough assessment o the pain and the patient Use a stepped approach to medication (WHO ladder) is the

best Work as a team to manage cancer pain, using multiple

proessions and multiple therapies reat moderate to severe pain while awaiting the result o

investigations Constant or requent pain requires regular medication A breakthrough dose o analgesic (10% o the total daily

opioid dose) should be available as needed reat opioid side effects rom the start Te oral route is preerable Consider adjuvant therapy or cancer pain itrate opioids to achieve the best analgesia with the ew

side effects

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Be open to non- pharmacological therapies and crediblecomplementary and alternative therapies that are helpul to

the patient On-going re-evaluation is the key to a better outcome Educate patient and their caregivers in a way that

incorporates them into the team and osters a sense o trustand confidence

Learn rom patients and be sel reflective

Assessment

Core elements o Initial Assessment include A detailed history to determine the presence o

persistent pain, breakthrough pain and their effect onunction

Definition: Breakthrough pain is defined asa transitory increase in pain that occurs on abackground o otherwise controlled persistentpain.

Assessment: Te presence o breakthroughpain, the requency and number o episodesper day, the duration with the time in minutes,the intensity and the time to peak in severity,the description o breakthrough pain, currentprevious analgesic history and any precipitatingactors

o Use the Brie Pain Inventory tool to assessthe location o pain, characteristics/description o the pain. Te severity/intensity o the pain, the duration o thepain, any aggravating actors and anyrelieving actors. Te effect o pain onunction and activities o daily living,the impact on quality o lie and the

impact on psychological well-being. Anysocial impact , any spiritual impact, painexpectations, Medication (current andprevious analgesics), Opioid toxicity andComplementary interventions

A psychosocial assessment Te patient understands their condition

What the pain means to the individual and theiramily

Chapiter 5: Cancer Pain Management


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How the pain may impact upon relationships withinthe patients amily

Whether the pain influences the patients mood Changes in mood Coping strategies adopted by the patient Te patients sleep pattern Any economic impact

A physical examination A diagnostic evaluation or signs and symptoms associated

with common cancer pain syndromes

Special higher risk Groups Older people Te cognitively impaired People with language barriers Known or suspected substance abusers Patients at the end o their lives

Note:Practitioners should use appropriate strategies to identify patientswho may be at a higher risk of under-treatment for cancer pain.Pain assessment tools to assess cancer pain in special groupsshould be made available.

Management

Pharmacological Opioids (mainstay o cancer pain management)

High doses i used as the sole analgesic Side Effects: Sedation, constipation, respiratory,

depression,Cognitive disturbances, toleranceand opioid-induced hyperalgesia

o manage side effects use Anti-emetics and

Laxativeo Side Effects o the Anti-emetics: olerance,

Dependency, Hyperalgesia, constipationand the suppression o the hypothalamic/pituitary axis


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Routes o administration ransdermal

o ransdermal brings advantages in termso increased bio-availability, reducedside effects and/or convenience or manypatients

Epidural and Intrathecalo Epidural and intrathecal routes or the

administration o opioids (morphine,

hydromorphone and entanyl) with orwithout local anaesthetics increaseseffectiveness, while reducing side effects,particularly drowsiness and constipation,and should be considered when pain cannotbe controlled by simpler means

Adjuvant analgesic

Lignocaine patches ricyclic antidepressants ramadol Post-synaptic NMDA receptors such as ketamine

and the dextro-isomers o many opioids, notablymethadone

NSAIDs and COX inhibitors Antiepileptic drugs Sodium channel blockers

Psychological approaches Coping skills training

Attention-diversion strategies Relaxation raining Diaphragmatic breathing

Guided imagery Engaging in meaningul and stimulatingactivities

Cognitives Cognitive therapy (cognitive restructuring)

Physical therapies Physiotherapy Occupational therapy



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Invasive procedures Coeliac plexus block

Intrathecal drug delivery Patient selection or an interventional procedure

requires knowledge o the disease process, theprognosis, the expectations o patient and amily,a careul assessment and discussion with thereerring physicians. Tere is good evidence orthe effectiveness o a coeliac plexus block andintra-thecal drug delivery. Saety, afercare and the

management o possible complications have to beconsidered in the decision-making process. Whereapplied appropriately and careully at the right time,these procedures can contribute enhanced painrelie, reduction o medication use and a markedlyimproved quality o lie.


5


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6. Pain Related to Cancer Treatments

Introduction

- Chemotherapy, surgery and radiotherapy are cancer treatmentsthat can cause persistent pain in cancer survivor patients andadversely affect quality o lie and unction

- Up to 50% o cancer survivors may experience chronic painsecondary to treatment, yet this is under-recognised and

under-reported (Burton, 2007). Pain in cancer survivors has anadditional burden in that it is ofen perceived to be indicative odisease recurrence.

- Painul chemotherapy-induced peripheral neuropathy (CIPN) Neurotoxicity is a dose-limiting side-effect o many

chemotherapies and biological therapies (also known asbiological response modifiers, which modulate the naturalresponse to tumour cells) used in the treatment o cancer.Peripheral neuropathy is the most prevalent orm oneurotoxicity

- Post-cancer surgical pain Pain syndromes afer cancer surgery have been ound

ollowing breast, thoracic, head and neck surgery

- Radiation-induced brachial plexus neuropathy (BPN) BPN usually occurs at least 6 months afer therapy,

although higher doses may have a reduced latency. Temajor differential diagnosis is tumour-related plexopathy.In addition to clinical actors, MRI may aid diagnosis.

Management of Sideeffects of Opoids General approach to treating Opioid Adverse effects

Distinguish Opioid side effects rom co-morbidconditions or other concurrent medication

Reduce the dose o the opioid i the pain is wellcontrolled. I pain not controlled:

Add a non-opioid co-analgesic (e.g. NSAIDs) Add a specific adjuvant pain medication (e.g.

gabapentin or Post Herpetic Neuralgia) arget the source o pain (e.g. hip replacement or

severe osteoarthritis)

PainRelatedto

CancerTreatm

ents

6


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Regional anaesthesia or ablative surgical techniques(e.g. radio acet neurotomy)

Switch opioids to see i another opioid has a betterbalance o analgesia vs. adverse effects. Symptomatic treatment o the adverse effect (s)

Constipation Add fibre to the patients diet Exercises Drink at least 4-6 glasses o water per day

When starting opioid therapy it is better to keepbowels loose

Add stimulant laxatives e.g. Bisacodyl startingat one tab twice daily and increasing to amaximum o 8 tabs daily

Lactulose/sorbital/ polyethylen glycol Suractant e.g. Docusate

Nausea & vomiting Antiemetics routinely when starting opioids ry Supine rest i nausea is intermittent ryDimenhydramine25-50mg PO or 50mg-100mg

per rectal(PR) q4-6hr PRN Next try Haloperidol 0.5-5mg daily to BID (usual

dose less than 2mg/day) Next tryProchlorperazine 5-10mg PO or PR q4-6hrs

PR Next try or addMetoclopramideor Domperidone 10-

40mg PO (especially i gastric motility decreased) ry transdermal Scoplominepatch, one applied every

2-3 days Small doses o oral Cannabinoids (Dronabinol or

Nabilone,) 5-10mg daily) may help Ondansetron0.15mg/kg I intolerable nausea, try switching to another opioid

Sedation Mild sedation usually occurs when first starting

opioids or with dosage titration It usually decreases with stable dosing within 7 -14

days i the dose is correct

Methadone- induced sedation may take longer toclear

Chapiter 6: Pain Related to Cancer Treatments


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No driving while titrating dose Stop all other sedation medication in case o

prolonged drowsiness Lower the opioid dose or switch opioids i drowsinessstill persist

Conusion/Pyschotomimetic Effects Dysphoria, hallucination, nightmares in a small

percentage o patients May occur in first ew days especially in elderly

patients or those into rapid dose titration Look or and correct other possible actors (especially

anti-cholinergic medication) May need initial small doses o haloperidol I persists, taper off opioid, restart lower dose and

titrate more slowly or switch opioids

Respiratory Depression

Very rare with titrated oral dosing (pain is theantagonist of respiratory depression)

Only a problem i too high a starting dose, toorapid titration or too large increments especiallyin patients with Chronic Obstructive PulmonaryDiseases (COPD), severe sleep apnea, renal ailure,gastroparesis

I acute, use Naloxone but in very small increments0.1mg IV q10-15 min

Urinary retention Rare except in older males, especially i also

constipated and / or on drug with anticholinergic sideeffects (e.g. CAs) ricyclic antidepressants

ry oralPilocarpine5mg ID

Dry mouth Common with potent opioids , tricyclics,

anticonvulsants, clonidine Dental problem reported in some patient on long-

term opioid treatment Meticulous oral hygiene required +requent oral

fluids+/- sugarless gum or candies

Pilocarpine 4% drops orally or oral Pyridostigmine


PainRelatedto

CancerTreatm

ents

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Increase sweat Very common (and persistent) with high doses o

opioids, especially with exertion ry Clonidine 0.1 mg BID and work up to 0.2mg IDi tolerated

Oral Glycorpyrrolate ransdermal Scopolaminepatches Low dose Phenothiazine

Depression

Opioids more commonly have euphoric rather than adepressant effect

Discontinue the opioid to see i mood improves andre-start the opioid to see i depression occurs, i so tryswitching to another opioid

I symptom o depression persist but good pain relie,try adding CA, (ricyclic antidepressants)

Bupropionor an anti-epileptic drugs

Pruritus Itchy skin in small patients ry older (Diphenhydramine)or new (Cetrizineand

Loratadine) antihistamine Cimetidine or Paroxetineora course o oral steroid.



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7. Appendix

7.1. Denition of Terms

TERM DEFINITION

Breakthroughpain (BP)

A transitory increase in pain that occurs on abackground o otherwise controlled persistent pain

itration Adjustment o the dose until the medication has

achieved the desired effectBreakthroughdoses (BD)

An as-needed dose o medication or sporadic worseningo pain; given to palliate breakthrough pain

Antagonist Drug that competes with agonist or opioid receptorbinding sites; can displace agonists, thereby inhibitingtheir action. Examples include naloxone, naltrexone.

Analgesia Absence o pain in response to painul stimulus

Allodynia Pain due to a stimulus that does not normally provokepain such as touch. ypically experienced in the skinaround areas affected by nerve injury, commonly seenby many neuropathic pain syndromes.

Dysethesia Dyesthesia is abnormal sensation that comes romdamage to nerves.

Hyperalgesia Increased sensitivity to stimulation, excluding thespecial senses

Nociceptor Is a sensory receptor that responds to potentiallydamaging stimuli by sending nerve signals to the spinalcord and brain

Neuralgia Pain in the distribution o a nerve (e.g. sciatica,trigeminal neuralgia) ofen elt as an electrical shocklike pain

Paresthesia Abnormal sensation, whether spontaneous or evoked,maniested by sensations o numbness, prickling,tingling and heightened sensitivity that is typically notunpleasant

Adjuvantanalgesia

A drug that has a primary indication other than pain(e.g. anticonvulsant, antidepressant ,sodium channelblocker, and muscle relaxant)

Metabolite Te product o biochemical reactions during drugmetabolism

Neuropathic Pain Pain sustained by injury or dysunction o theperipheral or central nervous system

7


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TERM DEFINITION

Nociceptive pain Pain that is sustained by ongoing activation o the

sensory system that subserves the perception o noxiousstimuli; implies the existence o damage to somatic or

visceral tissues sufficient to activate nociceptive system

Nonopioid erm used instead o non narcotics reers toparacetamol and nonsteroidal anti-inflammatorydrugs(NSAIDs)

Opioids Tis term is preerred to narcotics. Opioidsreers to codeine, morphine, and other natural,

semisynthetic,and synthetic drugs that relieve pain bybinding to multiple types o opioid receptors

Opioid nave An opioidnave person has not recently taken enoughopioid on a regular enough basis to become tolerant tothe effects o an opioid.

Preemptiveanalgesia

Pre-injury pain treatments (e.g. pre-operative epiduralanalgesia and pre-incision local anesthesia infiltration)to prevent the establishment o peripheral and central

sensitization o painSel report Te ability o an individual to give a report, in the case

o pain, especially intensity. Tis is considered the Goldstandard of pa assessment

Psychotomimetic characterized by or producing symptoms similar tothose o psychosis

Craving Intense desire or drugs

Central

neuropathic pain

Pain caused by a lesion or disease o the central

somatosensory nervous systemPeripheralneuropathic pain

Pain caused by a lesion or disease o the peripheralsomatosensory nervous system

Addiction Addiction is a primary, chronic, neurobiologic disease,with genetic, psychological, and environmental actorsinfluencing its development and maniestations. Itis characterized by behaviors that include one ormore o the ollowing: impaired control over drug

use, compulsive use, continued use despite harm andcraving.

PhysicalDependence

Physical dependence is a state o adaptation thatis maniested by a drug-class-specific withdrawalsyndrome that can be produced by abrupt cessation,rapid dose reduction, decreasing blood level o thedrug, and/or administration o antagonist.

olerance olerance is a state o adaptation in which exposure to a

drug induces changes that result in a diminution o oneor more o the drugs effects over time.

Chapiter 7: Appendix


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7.2. Non-Opioid Analgesic Doses

Medications Doserange/mg Max/day/mg Duration Considerations

Paracetamol/ylenol

500-1000 4000 4-6hrs Light headedness,dizziness, can causesevere liver toxicity

Aspirin 325-1000 6000 4-6hrs - do not use inchildren < 12yrs

- tinnitus

- gastro disturbances- allergic reactions- Rhinitis, asthma,

nasal polyps

Ibuproen 200-800 3200 4-6hrs

Naproxen 250-500 1500 6-8hrs

Indomethacin 25 200 8-12hrs Higher incidence oGI &CNS side effects

Dicloenac 50 150 8hrs

Nabumetone 500-750 2000 8-12hrs

Ketorolac 30-60 IM30 IV

120mg Ketorolac 30mg IV=4mg IV morphine

Celecoxib(Celebrex)

100-200 400 12hrs 400mg per oral dailyor menstrual cramps

7.3. Opioids Comparative Table

Warning: Equianalgesic doses are approximate and mostly based onsingle dose studies. When switching opioids, start with 50% to 75% othe proposed equianalgesic dose o the new opioid to compensate orincomplete cross-tolerance and individual variations, particularly i thepatient has controlled pain.


7


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DRU

G

Equianalg

esic

Dose

Onsetof

Action

PeakofAction

Durationof

Action

Starting

dose

inopioidnave*

patientswithrisk

factor(s)

(Adults)

Startingdosein

opioidnave*

patientswithno

riskfactor(s)

(Adults)

PO

IV/SC

SC/IV(PO)

SC/IV(PO)

SC/IV(PO)

Morphine

10mg

5mg

2.5min

(15min)

IV:15min

SC:30min

PO:30-60min

4hrs

(4-6hrs)

2.5mgSC

/IV

(5mgPO

)

5mgSC/IV

(10mgPO)

Hydromorphone

2mg

1mg

6min

(15min)

IV:15min

SC:15min

PO:30-60min

4hrs

(4-6hrs)

0.5mgSC

/IV

(1mgPO

)

1mgSC/IV

(2mgPO)

Fentanyl

N/A

50mcg

30-60min

IV:5-15min

SC:5-15

PO:N/A

30-60min

N/A

25mcgSC

/IV

50mcgSC/IV

Codeine

(IM/IVnot

recommended)

100mg

N/A

30-60min

PO:2-4hrs

4-6hrs

30mgPO

60mgPO

Oxyc

odone

7.5mg

N/A

IV/SC:N/A

PO15min

IV/SC:N/A

PO:30-60min

N/A3-6hrs

5mgPO

7.5mgPO

Tram

adol

50mg/

day

50-150m

gin4

dividedd

oses/day



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7.4. Opioid Conversion Tips

a) Calculate the rescue dose/break through dose- Calculate 10% o the provided total daily dose as an immediate

release ormulation.

b) Opioid adjustments- Calculate the total oral opioid taken in 24 hours by adding

the amount o the sustained-release and immediate-releaserescue doses

- Divide total daily dose into appropriate intermittent dosebased upon the specific opioid dosing intervals ound in thedosing and conversion table for opioid analgesics above

c) Changing to another oral opioid- Calculate the total daily dose o current opioid (add the long

acting and rescue doses)- Use the dosing and conversion table for opioid analgesics

above to calculate the equivalent total daily oral dose o thealternative opioid

- Divide the total daily dose o the alternative opioid intoappropriate intermittent doses based upon the specific opioiddosing intervals ound in the dosing conversion table oropioid analgesics

- Modiy by reducing dose by 25-50% or incomplete crosstolerance

d) Changing an oral opioid to its IV/SQ route- Calculate the total amount o oral opioid taken per 24 hours

(add long-acting and rescue doses)- Use the dosing and conversion table for opioid analgesics to

calculate the equivalent total daily parenteral dose.

e) Changing an oral or IV opioid to transdermal entanyl

- Calculate the total opioid dose- Use the dosing and conversion table for opioid analgesics to

calculate the equivalent total daily morphine dose.- Use the morphine to entanyl equivalents table equivalents

table to determine the equianalgesic dose of transdermalentanyl

) Changing an opioid agent and route (Oral to IV)

- Calculate the total daily dose o the original o the originalopioid (add long-acting and rescue doses).


7


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- Use the dosing and conversion table given above or opioidanalgesics to convert from oral to IV dose.

- Use the dosing and conversion table or opioid analgesics toconvert original opioid to an alternative, equivalent IV dose.- Adjust the dose or incomplete cross tolerance by reducing

dose by 25-50%.- Divide adjusted dose by 24 to obtain hourly opioid inusion

rate.

7.5. Initial Oral Opioid Dose Based on Pain

Severity

Opioid Pain Severity Dose Frequency

Codeine Mild tomoderate

30-60 mg every 4 hrs

CR Codeine (e.g. codeinecontin)

Mild tomoderate

50-100mg Every 12hrs

Oxycodone Moderate tosevere 5-10mg Every 6hrs

CR Oxycodone (e.g.oxyContin)

Moderate tosevere

10-20mg Every 12hrs

Morphine Severe 10mg Every 4 hrs

SR Morphine(e.g. MScontin)

Severe 15-30mg Every 12hrs

Hydromorphone Severe 2mg Every 4hrsCR Hydromorphone (e.g.hydromorph Contin)

Severe 3mg Every 12hrs

Note: In the elderly start doses should be 25-50% of those listedNote: Controlled or Sustained-release tablets (and capsule beads) shouldnever be chewed or crushed as this can lead to the rapid release andabsorption of the opioid medication, increasing the risk of overdose

Note for opioids:*Opioid- nave: Patient previously not on opioid or who have beenreceiving opioid or less than 7 days.

Renal failure: All the above opioids except entanyl producemetabolites, which can accumulate. Dosing interval should be increasedby approximately 50%.

Liver failure:Most opioid may have decreased clearance, however nospecific dose adjustment can be recommended.



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7.6. Titrating Opioids

In patient with uncontrolled pain who has been on an IR opioid, thepain control and the amount o medication used needs to be reviewedeach day. Add up the dose o breakthrough opioid used during theprevious 24 hours and combine that dose with the total daily dose othe regular administered opioid to give the total dose o opioid used inprevious 24 hours. Tat dose divided into the number o intervals, willbe the new regular dose.

For example i the regular is morphine 50mg every 4 hrs (300mg/day)the breakthrough dose will be 30mg IR morphine p.r.n.(calculated as300g10). I the pain dairy rom the previous 24 hours notes that 5breakthrough doses were taken 5 X 30mg = 150mg o breakthrough medication + 300mg/day o regular scheduled opioid 450mg used over the last 24 hours

Divided into 6 doses, the new regular opioid dose is 75mg every 4 hours(4506). Te new breakthrough dose will be 45 mg p.r.n. (45010).Tis method allows the systematic advance o the dose until the patientreports comort without troublesome side effects.

Te same method is used when titrating controlled-release medication.


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7.7.

AdjuvantMedicationswithAn

algesicActivity

Antidepressants

Startingdose

Titration

Maxdose/day

Considerations

Amit

riptyline

10mgHs

Increaseby10mgevery3-7days

accordingtotoleranceupto

30mgHschangetotabsof25,5

0

or75

mgupto150mg/day

150mg,butfor

nortriptylineand

despiraminearegiven

in

3divideddoses(Tid)

to

avoidinsomnia.

Sideeffects:drymo

uth,

urinaryretention,

constipation,sedation,

orthostatichypotension

Nortriptyline

Desipramine

Orthostatichypoten

sion

Clom

ipramine

Imipramine

Maprolitine

Dulo

xetine

30mgbid

Increaseto60mgeveryday,

from

1to2weeks

120mg

Venlafaxine

37.5mg

75m

gevery

1-4weeks

225mg

Paroxetine

10mg,

10m

gevery

1-4w

eeks

50mg

Citalopram

10mg,Single

dose

10m

gevery

1-4w

eeks

60mg

Bupropion

100mg,1-2

doses

100mgevery

1-4w

eeks

300mg



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Anticonvulsants

Startingd

ose

Titration

Maxdose/day

Duration

Considerations

Gabapentin

100-300m

gHsor100-300

mgTid

Increaseby100-300mgTidev

ery1

to4

weeks

3600mgdivided

3-4doses/day

6-8hrs

-Dizziness

-Drowsiness

-Constipation

-Peripheral

edema

-Weightgain

Prega

baline

25-50mgH

s,bidortid,Max

150mg/day

75m

g

600mg

12hrs

-Tremors

-Weightgain

Carbamazepine

50mg

100-

200mgperweek

1200mg

6-12hrs

Lamo

trigine

25mg

Slow

lytoavoidcutaneousreactions

50mg

Once/day

Topir

amate

15mg

15-2

5mgperweek

400mg

12hrs

-Tremors

-Arrhythmias

-Dyspepsia

-Weightloss

Levetiracetam

250mg

500m

gevery1to4weeks

3000mg

once

NMD

Areceptor

block

andopioid

StartDose

Titration

MaxDose

Meth

adone

2-3mgq6

-12hrsPRN

Adju

stonceeveryweekuntilp

ain

isrelieved

NMD

A-R/

block

erKetamine

10mgTidorQidwithjuice.

Iv,inemer

gency,startwith

theboluso

f10mgor20mg,or

3mg/hrin

infusion.

Dou

blethedoseevery2-7day

sand

max

dose450mg.

PerPO,450mg

in3-4divided

doses

Alpha-adrenergic

anda

nti-

arrythimic


7


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Anticonvulsants

Startingd

ose

Titration

Maxdose/day

Duration

Considerations

Clonidine

0.05mgon

ceday,Bid

0.1m

gevery2-4weeks

0.6mg

Tizan

idine

2mg

2-4m

gevery1-2weeks

Mexiletine

Cann

abinoids

Dron

abinol

Nabilone

0.5-1mgH

sorBid

6mg

THC/CBD

Baclo

fene

5mg,Tid

5mg

,tidevery3-7days

80mg

Corticosteroids

Dexamethasone

Prednisolone

Bisphosphonate

Pamidronate

Clodronate

Zoled

ronicacid

(Zom

eta)

Miscellaneous

Baclo

fene

5mg,Tid

5mg

,tidevery3-7days

80mg

Calcitonin

100-200IU

(Subcutaneousor

intranasal)/day



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7.8.

NeuropathicPainTreatmentA

lgorithm

1stlin

e

2ndline

3rdline

4thl

ine

Gaba

pentinoids

Selec

tiveserotoninnorepineph

rine

inhib

itors(SSNIs)

selectiveserotoninreuptake

inhibitors(SSRIs)

Methadone

Ketamin

e

Mexileti

ne

Baclofen

e

Clonidine

Clonazepam

Pregabalin

Gabapentin

Duloxetine

Venlafaxine

Citalopram

Paroxetine

Tricy

clicandTetracyclicAntid

epressants

Cann

abinoids

OtherAntidepres

sants

Amitriptyline

Clomipramine

Im

ipramine

Nortriptyline

Desipramine

M

aprolitine

Dronabinol

Nabilone

Te

trahydrocannabinol(THC

)

(byoral)

Bupropion

Loca

lAnesthesics

Otheranticonvulsants

Topic

alLidocaine10%

Topiramate

Carbamazpine

Lvtiractam

Lamotrigine

Note

:OpioidsorTrama

dol:UtilizeOpioidsortrama

do

linsecon

dlineasmonot

herapyorinas

sociation,

howeverwhe

nyou

anticipatetousethemf

or

long-termu

selonga

cting/sustainedre

leaseformu

lations.


7


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7.9. Breakthrough Doses

When prescribing an opioid on a regular scheduled basis (e.g. every 12hours), it is also important to provide an Immediate Release (IR) opioidfor p.r.n. dosing to manage episodes of breakthrough or incidentpain.

A breakthrough dose is calculated by taking approximately 10% o thetotal daily dose o the scheduled opioid and administering it as neededor uncontrolled pain. For example patient receiving controlled release

(CR) Oxycodone 40mg every 12 hours will have breakthrough dosecalculated as ollows:40mg X 2doses = 80mg/day80mg 10 mg =8mg approximately 10mg IR oxycodoneas needed

Te breakthrough dose is calculated in the same way no matter whatroute o administration is being used.



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8. References

1. Anderson R et al. Accuracy in equanalgesics dosing: conversiondilemmas J, Pain symptoms manage 2001: 21: 397-406

2. Aline Baulanger et al: managing pain. Te Canadian healthcareproessionals reerence: 2008 edition

3. Le medicin du Quebec, Vol 47 (1), Jan 2012 Le cahier de med

Actuel. Recommendation dun orum Quebiquois sur la douleurneuropathique

4. Diagnosis and reatment o Low Back Pain: A Joint ClinicalPractice Guideline rom the American College o Physicians andthe American Pain Society, Annals o Internal Medicine, 2 October2007, Volume 147 Issue 7 Pages 478-491

5. Chou R, Fanciullo GJ, Fine PG, Adler JA, et al, American PainSociety-American Academy o Pain Medicine Opioids GuidelinesPanel. Clinical guidelines or the use o chronic opioid therapy inchronic noncancer pain. J Pain published (2009) Feb; 10 (2): 113-30.

6. International association or the study o pain: www.iasp-pain.org

7. Society canadiene de la douleur: www.canadianpainsociety.ca

8. European ederation o neurological societies: guidelines

9. Australian and Newzealand college o anaesthetists and acultyo pain medicine: Acute pain management: Scientific evidence 3rdedition 2010

10. Cancer pain management: A perspective rom the British pain

society, supported by the association or palliative medicine andRoyal college o General Practioners. Jan 2010

11. Mc Gill University health centre: Opioid therapy guidelines: 2008

12. WHOs Pain ladder: http://www.who.int/cancer/palliative/pain


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9. List of participants

No Family Name First Name Title

1 Dr KIVIRI Anesthetist/ painmanagement specialist

2 Phn NYIRIGIRA John Clinical Pharmacist/pain managementspecialist

3 MBABAZI Perpetua Director o Nursing/

pain managementspecialist

4 Dr WAGIRUMUGABE Teogene Anesthetist specialist

5 Dr BUARE Richard QI/ technical Advisor

6 AWINE Joy QI / Senior echnicalAdvisor

7 Dr MUNYAMPUNDU Horatius QI/ health service

Advisor

8 HITAYEzU Felix Pharmacist

9 Dr MANZI Emmanuel QI/Advisor

10 DrNzEYIMANA Bonaventure Public Health FacilityExpert

11 NDAYAMBAJE Teogene Pharmacist

12 KAKANA Laetitia QI/Advisor


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1. Eczema Syndrome

Denition: Eczema is a syndrome comprising o a polymorphismsuperficial inflammation involving primarily the epidermis andcharacterized by itching.

Causes/types

CONTACT DERMATITIS OR ECZEMA

-

Definition:Polymorphic inflammation o the skin occurringat the site o contact with irritating or allergic substances

- Signs and symptoms

Acute phase: Itching erythema, papules, and vesicles

Chronic phase: Dryness, hyperkeratosis, and at timesfissures

- Investigations

Allergic: Contact Dermatitis: anamnesis, clinicalfindings, and epicutaneous test

Irritant:Contact Dermatitis: anamnesis, clinicalfindings

ATOPIC DERMATITIS AD

-

Definition:AD is a chronic, pruritic, inflammatory skin diseasewith a wide range o severity patients typically experienceperiods o remission that are marked by acute inflammatoryrelapses known as flares. AD may be associated with one or moreother atopic diseases that are: asthma, dermatitis, rhinitis andconjunctivitis.

- Causes

Predisposition to AD

Allergic substances

- Signs and symptoms

Itching: the primary and most distressing symptom

S ll h l l i l h li

Documents

Pain Management Guidelines 15-11-2012