{"id":1129,"date":"2024-05-11T16:35:58","date_gmt":"2024-05-11T20:35:58","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/?post_type=chapter&#038;p=1129"},"modified":"2024-05-11T16:43:17","modified_gmt":"2024-05-11T20:43:17","slug":"2-5-10","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/chapter\/2-5-10\/","title":{"raw":"2.5.10 Pain Management","rendered":"2.5.10 Pain Management"},"content":{"raw":"Nociceptive Pain\r\n<ul>\r\n \t<li>Somatic\r\n<ul>\r\n \t<li>Caused by damage to soft tissue and bone<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t<li>Visceral (two types)\r\n<ul>\r\n \t<li>Organ pain, caused by damage to organs, stretch of capsule<\/li>\r\n \t<li>Colic, caused by obstruction of viscera<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t<li>Neuropathic\r\n<ul>\r\n \t<li>Peripheral<\/li>\r\n \t<li>Central, caused by injury to the CNS[footnote]Pallium Canada, 2018[\/footnote]<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\nThe World Health Organization or WHO Analgesic Ladder is the guide for pain management\r\n\r\nFirst Step:\r\n<ul>\r\n \t<li>Mild Pain<\/li>\r\n \t<li>Non-Opioid<\/li>\r\n<\/ul>\r\nSecond Step:\r\n<ul>\r\n \t<li>Moderate Pain<\/li>\r\n \t<li>Weak Opioid<\/li>\r\n<\/ul>\r\nThird Step:\r\n<ul>\r\n \t<li>Severe &amp; Persistent Pain<\/li>\r\n \t<li>Strong Opioid[footnote]WHO Analgesic Ladder, Anker et al., 2023[\/footnote]<span style=\"font-size: 14pt\">[footnote]Registered Nurses\u2019 Association of Ontario, 2007[\/footnote]<\/span><span style=\"font-size: 14pt\">[footnote]Zacharias et al., 2013[\/footnote]<\/span><span style=\"font-size: 14pt\">[footnote]RxFiles, n.d.[\/footnote]<\/span><span style=\"font-size: 14pt\">[footnote]Busse, 2017[\/footnote]<\/span><\/li>\r\n<\/ul>\r\n<div class=\"textbox textbox--exercises\"><header class=\"textbox__header\">\r\n<p class=\"textbox__title\">Recommended Reading<\/p>\r\n\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\n<a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK554435\/figure\/article-31358.image.f1\/?report=objectonly\">The revised WHO analgesic ladder. Contributed by Marco <\/a><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK554435\/figure\/article-31358.image.f1\/?report=objectonly\">Cascella<\/a><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK554435\/figure\/article-31358.image.f1\/?report=objectonly\">, MD - <\/a><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK554435\/figure\/article-31358.image.f1\/?report=objectonly\">StatPearls<\/a><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK554435\/figure\/article-31358.image.f1\/?report=objectonly\"> - NCBI Bookshelf<\/a>\r\n\r\n<\/div>\r\n<\/div>\r\n<h2>Adjuvant Treatment<\/h2>\r\nConsider the cause of the pain\r\n\r\nNeuropathic Pain\r\n<ul>\r\n \t<li>Opioids are less effective for neuropathic pain.<\/li>\r\n \t<li>Consider:\r\n<ul>\r\n \t<li>Pregabalin - less associated sedation, needs to be renally dosed.<\/li>\r\n \t<li>Gabapentin - can be sedating, needs to be renally dose, has finer titration abilities given high ceiling dose.<\/li>\r\n \t<li>Duloxetine has some evidence for diabetic peripheral neuropathy in the geriatric patient.<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\nNociceptive Pain\r\n<ul>\r\n \t<li>May be a role for NSAIDs, but approach with caution and short duration only<\/li>\r\n \t<li>Botox for spasticity<\/li>\r\n \t<li>Cannabinoids-increased risk for cognitive impacts, cautious dosing[footnote]WHO Analgesic Ladder[\/footnote][footnote]Anker et al., 2023[\/footnote][footnote]Registered Nurses\u2019 Association of Ontario, 2007[\/footnote][footnote]Zacharias et al., 2013[\/footnote][footnote]RxFiles, n.d.[\/footnote][footnote]Busse, 2017[\/footnote]<\/li>\r\n<\/ul>\r\nGeriatric Considerations\r\n<ul>\r\n \t<li>Don\u2019t forget non-pharmacological interventions!<\/li>\r\n \t<li>START LOW, GO SLOW<\/li>\r\n \t<li>Consider: Does the medication need renal dosing?<\/li>\r\n \t<li>Monitor for constipation<\/li>\r\n \t<li>Avoid NSAIDs, if absolutely required, use short duration and ensure adequate hydration<\/li>\r\n \t<li>Ensure you are targeting the treatment to the type of pain present<\/li>\r\n \t<li>Consult and review with pharmacist<\/li>\r\n<\/ul>","rendered":"<p>Nociceptive Pain<\/p>\n<ul>\n<li>Somatic\n<ul>\n<li>Caused by damage to soft tissue and bone<\/li>\n<\/ul>\n<\/li>\n<li>Visceral (two types)\n<ul>\n<li>Organ pain, caused by damage to organs, stretch of capsule<\/li>\n<li>Colic, caused by obstruction of viscera<\/li>\n<\/ul>\n<\/li>\n<li>Neuropathic\n<ul>\n<li>Peripheral<\/li>\n<li>Central, caused by injury to the CNS<a class=\"footnote\" title=\"Pallium Canada, 2018\" id=\"return-footnote-1129-1\" href=\"#footnote-1129-1\" aria-label=\"Footnote 1\"><sup class=\"footnote\">[1]<\/sup><\/a><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>The World Health Organization or WHO Analgesic Ladder is the guide for pain management<\/p>\n<p>First Step:<\/p>\n<ul>\n<li>Mild Pain<\/li>\n<li>Non-Opioid<\/li>\n<\/ul>\n<p>Second Step:<\/p>\n<ul>\n<li>Moderate Pain<\/li>\n<li>Weak Opioid<\/li>\n<\/ul>\n<p>Third Step:<\/p>\n<ul>\n<li>Severe &amp; Persistent Pain<\/li>\n<li>Strong Opioid<a class=\"footnote\" title=\"WHO Analgesic Ladder, Anker et al., 2023\" id=\"return-footnote-1129-2\" href=\"#footnote-1129-2\" aria-label=\"Footnote 2\"><sup class=\"footnote\">[2]<\/sup><\/a><span style=\"font-size: 14pt\"><a class=\"footnote\" title=\"Registered Nurses\u2019 Association of Ontario, 2007\" id=\"return-footnote-1129-3\" href=\"#footnote-1129-3\" aria-label=\"Footnote 3\"><sup class=\"footnote\">[3]<\/sup><\/a><\/span><span style=\"font-size: 14pt\"><a class=\"footnote\" title=\"Zacharias et al., 2013\" id=\"return-footnote-1129-4\" href=\"#footnote-1129-4\" aria-label=\"Footnote 4\"><sup class=\"footnote\">[4]<\/sup><\/a><\/span><span style=\"font-size: 14pt\"><a class=\"footnote\" title=\"RxFiles, n.d.\" id=\"return-footnote-1129-5\" href=\"#footnote-1129-5\" aria-label=\"Footnote 5\"><sup class=\"footnote\">[5]<\/sup><\/a><\/span><span style=\"font-size: 14pt\"><a class=\"footnote\" title=\"Busse, 2017\" id=\"return-footnote-1129-6\" href=\"#footnote-1129-6\" aria-label=\"Footnote 6\"><sup class=\"footnote\">[6]<\/sup><\/a><\/span><\/li>\n<\/ul>\n<div class=\"textbox textbox--exercises\">\n<header class=\"textbox__header\">\n<p class=\"textbox__title\">Recommended Reading<\/p>\n<\/header>\n<div class=\"textbox__content\">\n<p><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK554435\/figure\/article-31358.image.f1\/?report=objectonly\">The revised WHO analgesic ladder. Contributed by Marco <\/a><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK554435\/figure\/article-31358.image.f1\/?report=objectonly\">Cascella<\/a><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK554435\/figure\/article-31358.image.f1\/?report=objectonly\">, MD &#8211; <\/a><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK554435\/figure\/article-31358.image.f1\/?report=objectonly\">StatPearls<\/a><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK554435\/figure\/article-31358.image.f1\/?report=objectonly\"> &#8211; NCBI Bookshelf<\/a><\/p>\n<\/div>\n<\/div>\n<h2>Adjuvant Treatment<\/h2>\n<p>Consider the cause of the pain<\/p>\n<p>Neuropathic Pain<\/p>\n<ul>\n<li>Opioids are less effective for neuropathic pain.<\/li>\n<li>Consider:\n<ul>\n<li>Pregabalin &#8211; less associated sedation, needs to be renally dosed.<\/li>\n<li>Gabapentin &#8211; can be sedating, needs to be renally dose, has finer titration abilities given high ceiling dose.<\/li>\n<li>Duloxetine has some evidence for diabetic peripheral neuropathy in the geriatric patient.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Nociceptive Pain<\/p>\n<ul>\n<li>May be a role for NSAIDs, but approach with caution and short duration only<\/li>\n<li>Botox for spasticity<\/li>\n<li>Cannabinoids-increased risk for cognitive impacts, cautious dosing<a class=\"footnote\" title=\"WHO Analgesic Ladder\" id=\"return-footnote-1129-7\" href=\"#footnote-1129-7\" aria-label=\"Footnote 7\"><sup class=\"footnote\">[7]<\/sup><\/a><a class=\"footnote\" title=\"Anker et al., 2023\" id=\"return-footnote-1129-8\" href=\"#footnote-1129-8\" aria-label=\"Footnote 8\"><sup class=\"footnote\">[8]<\/sup><\/a><a class=\"footnote\" title=\"Registered Nurses\u2019 Association of Ontario, 2007\" id=\"return-footnote-1129-9\" href=\"#footnote-1129-9\" aria-label=\"Footnote 9\"><sup class=\"footnote\">[9]<\/sup><\/a><a class=\"footnote\" title=\"Zacharias et al., 2013\" id=\"return-footnote-1129-10\" href=\"#footnote-1129-10\" aria-label=\"Footnote 10\"><sup class=\"footnote\">[10]<\/sup><\/a><a class=\"footnote\" title=\"RxFiles, n.d.\" id=\"return-footnote-1129-11\" href=\"#footnote-1129-11\" aria-label=\"Footnote 11\"><sup class=\"footnote\">[11]<\/sup><\/a><a class=\"footnote\" title=\"Busse, 2017\" id=\"return-footnote-1129-12\" href=\"#footnote-1129-12\" aria-label=\"Footnote 12\"><sup class=\"footnote\">[12]<\/sup><\/a><\/li>\n<\/ul>\n<p>Geriatric Considerations<\/p>\n<ul>\n<li>Don\u2019t forget non-pharmacological interventions!<\/li>\n<li>START LOW, GO SLOW<\/li>\n<li>Consider: Does the medication need renal dosing?<\/li>\n<li>Monitor for constipation<\/li>\n<li>Avoid NSAIDs, if absolutely required, use short duration and ensure adequate hydration<\/li>\n<li>Ensure you are targeting the treatment to the type of pain present<\/li>\n<li>Consult and review with pharmacist<\/li>\n<\/ul>\n<hr class=\"before-footnotes clear\" \/><div class=\"footnotes\"><ol><li id=\"footnote-1129-1\">Pallium Canada, 2018 <a href=\"#return-footnote-1129-1\" class=\"return-footnote\" aria-label=\"Return to footnote 1\">&crarr;<\/a><\/li><li id=\"footnote-1129-2\">WHO Analgesic Ladder, Anker et al., 2023 <a href=\"#return-footnote-1129-2\" class=\"return-footnote\" aria-label=\"Return to footnote 2\">&crarr;<\/a><\/li><li id=\"footnote-1129-3\">Registered Nurses\u2019 Association of Ontario, 2007 <a href=\"#return-footnote-1129-3\" class=\"return-footnote\" aria-label=\"Return to footnote 3\">&crarr;<\/a><\/li><li id=\"footnote-1129-4\">Zacharias et al., 2013 <a href=\"#return-footnote-1129-4\" class=\"return-footnote\" aria-label=\"Return to footnote 4\">&crarr;<\/a><\/li><li id=\"footnote-1129-5\">RxFiles, n.d. <a href=\"#return-footnote-1129-5\" class=\"return-footnote\" aria-label=\"Return to footnote 5\">&crarr;<\/a><\/li><li id=\"footnote-1129-6\">Busse, 2017 <a href=\"#return-footnote-1129-6\" class=\"return-footnote\" aria-label=\"Return to footnote 6\">&crarr;<\/a><\/li><li id=\"footnote-1129-7\">WHO Analgesic Ladder <a href=\"#return-footnote-1129-7\" class=\"return-footnote\" aria-label=\"Return to footnote 7\">&crarr;<\/a><\/li><li id=\"footnote-1129-8\">Anker et al., 2023 <a href=\"#return-footnote-1129-8\" class=\"return-footnote\" aria-label=\"Return to footnote 8\">&crarr;<\/a><\/li><li id=\"footnote-1129-9\">Registered Nurses\u2019 Association of Ontario, 2007 <a href=\"#return-footnote-1129-9\" class=\"return-footnote\" aria-label=\"Return to footnote 9\">&crarr;<\/a><\/li><li id=\"footnote-1129-10\">Zacharias et al., 2013 <a href=\"#return-footnote-1129-10\" class=\"return-footnote\" aria-label=\"Return to footnote 10\">&crarr;<\/a><\/li><li id=\"footnote-1129-11\">RxFiles, n.d. <a href=\"#return-footnote-1129-11\" class=\"return-footnote\" aria-label=\"Return to footnote 11\">&crarr;<\/a><\/li><li id=\"footnote-1129-12\">Busse, 2017 <a href=\"#return-footnote-1129-12\" class=\"return-footnote\" aria-label=\"Return to footnote 12\">&crarr;<\/a><\/li><\/ol><\/div>","protected":false},"author":517,"menu_order":49,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-1129","chapter","type-chapter","status-publish","hentry"],"part":3,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters\/1129","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/users\/517"}],"version-history":[{"count":3,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters\/1129\/revisions"}],"predecessor-version":[{"id":1132,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters\/1129\/revisions\/1132"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/parts\/3"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters\/1129\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/media?parent=1129"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapter-type?post=1129"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/contributor?post=1129"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/license?post=1129"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}