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:

• Severe & Persistent Pain
• Strong Opioid^{[2][3][4][5][6]}

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