Module 2: Direct Comprehensive Primary Care in the LTC Setting

52 2.5.10 Pain Management

Nociceptive Pain

  • Somatic
    • Caused by damage to soft tissue and bone
  • Visceral (two types)
    • Organ pain, caused by damage to organs, stretch of capsule
    • Colic, caused by obstruction of viscera
  • Neuropathic
    • Peripheral
    • Central, caused by injury to the CNS[1]

The World Health Organization or WHO Analgesic Ladder is the guide for pain management

First Step:

  • Mild Pain
  • Non-Opioid

Second Step:

  • Moderate Pain
  • Weak Opioid

Third Step:

Adjuvant Treatment

Consider the cause of the pain

Neuropathic Pain

  • Opioids are less effective for neuropathic pain.
  • Consider:
    • Pregabalin – less associated sedation, needs to be renally dosed.
    • Gabapentin – can be sedating, needs to be renally dose, has finer titration abilities given high ceiling dose.
    • Duloxetine has some evidence for diabetic peripheral neuropathy in the geriatric patient.

Nociceptive Pain

  • May be a role for NSAIDs, but approach with caution and short duration only
  • Botox for spasticity
  • Cannabinoids-increased risk for cognitive impacts, cautious dosing[7][8][9][10][11][12]

Geriatric Considerations

  • Don’t forget non-pharmacological interventions!
  • START LOW, GO SLOW
  • Consider: Does the medication need renal dosing?
  • Monitor for constipation
  • Avoid NSAIDs, if absolutely required, use short duration and ensure adequate hydration
  • Ensure you are targeting the treatment to the type of pain present
  • Consult and review with pharmacist

  1. Pallium Canada, 2018
  2. WHO Analgesic Ladder, Anker et al., 2023
  3. Registered Nurses’ Association of Ontario, 2007
  4. Zacharias et al., 2013
  5. RxFiles, n.d.
  6. Busse, 2017
  7. WHO Analgesic Ladder
  8. Anker et al., 2023
  9. Registered Nurses’ Association of Ontario, 2007
  10. Zacharias et al., 2013
  11. RxFiles, n.d.
  12. Busse, 2017

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Nurse Practitioners Delivering Primary Care in the Long Term Care Setting Copyright © 2024 by Erin Ziegler, Carrie Heer and Adhiba Nilormi is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License, except where otherwise noted.

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