APSASIA PAIN MANAGEMENT Project Pain Consultations 101 Melissa

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APSA/SIA PAIN MANAGEMENT Project Pain Consultations 101 Melissa Durham, Pharm. D. September 14 th,

APSA/SIA PAIN MANAGEMENT Project Pain Consultations 101 Melissa Durham, Pharm. D. September 14 th, 2011

Acute vs. Chronic Pain Characteristic Acute Pain Chronic Pain (No Self-Treatment) Relief of Pain

Acute vs. Chronic Pain Characteristic Acute Pain Chronic Pain (No Self-Treatment) Relief of Pain Highly Desirable Dependence & Tolerance Unusual to Medication Common Psychological Component Usually Not Present Often a Major Problem Organic Cause Common Often Not Present Environmental Contributions & Family Involvement Small Significant Insomnia Unusual Common Component Treatment Goal Cure Functionality

Assessment of Pain SCHOLAR • Symptoms – Describe the symptoms you are experiencing •

Assessment of Pain SCHOLAR • Symptoms – Describe the symptoms you are experiencing • Characteristics/Course – Is the pain throbbing, sharp, dull, tingling? Rate the pain on a scale of 1 -10 • History – How does it compare to other pain experienced? Has it gotten worse over time? • Onset – When did the pain start? • Location – Where is the pain located? Does it stay localized to one area or does it spread? • Aggravating factors – What makes the pain worse? • Relieving factors – What makes the pain better?

Common Indications for Non. Rx Analgesics Ø Temporary relief of minor aches and pain

Common Indications for Non. Rx Analgesics Ø Temporary relief of minor aches and pain associated with the common cold Ø Reduction of fever Ø Sore throat Ø Headache (Episodic Tension, Migraine, Sinus) Ø Muscle aches Ø Minor aches and pains of arthritis Ø Acute back pain Ø Menstrual pain

Non. Rx Pain Medications v Acetaminophen, AKA APAP (Tylenol) üMild-moderate pain, fever, headaches v

Non. Rx Pain Medications v Acetaminophen, AKA APAP (Tylenol) üMild-moderate pain, fever, headaches v NSAIDs v. Ibuprofen (Motrin, Advil) v. Naproxen sodium (Aleve) üMild-moderate pain, headaches, muscle pain, menstrual pain v Salicylates v. Aspirin AKA ASA (Ecotrin, Bayer) üMild-moderate pain, muscle pain, menstrual pain, cardioprotection v Topicals (Icy. Hot, Bengay) üMuscle soreness, muscle pain, osteoarthritis

Acetaminophen (APAP) Brand Name – Tylenol®, Fever. All® Class – Analgesic/Antipyretic ◦ Not effective

Acetaminophen (APAP) Brand Name – Tylenol®, Fever. All® Class – Analgesic/Antipyretic ◦ Not effective as an anti-inflammatory Very few side effects ◦ Liver toxicity a major concern with chronic high doses Very few drug interactions ◦ Warfarin, alcohol DOC in pregnancy/breastfeeding

Aspirin (ASA) Used mostly for primary and secondary prevention of thrombotic events ◦ Ex.

Aspirin (ASA) Used mostly for primary and secondary prevention of thrombotic events ◦ Ex. Aspirin 81 mg/day Has anti-inflammatory properties, but only at high doses Major side effects are bleeding, GI ulcers, bronchospasm in patients with asthma More DDIs than APAP NOT for use in pregnancy/breastfeeding Counseling point: TAKE WITH FOOD

NSAIDS Ibuprofen, naproxen sodium More effective than APAP and ASA for most pain conditions

NSAIDS Ibuprofen, naproxen sodium More effective than APAP and ASA for most pain conditions Analgesic and anti-inflammatory effects Major side effects are bleeding, GI ulcers, bronchospasm in patients with asthma, increased blood pressure, fluid retention Generally avoid in pregnancy but OK in breastfeeding Counseling point: TAKE WITH FOOD

Topical Analgesics/Counterirritants Used for minor aches and pains of muscles and joints, muscle soreness,

Topical Analgesics/Counterirritants Used for minor aches and pains of muscles and joints, muscle soreness, osteoarthritis, lower back pain, neuropathy Ben-gay, Icy-hot, Salonpas Methyl salicylate, camphor, menthol, capsaicin Combinations Apply 3 -4 times daily for a max of 7 days Do not apply immediately after a hot shower or bath, do not use with a heating pad Wash hands after applying

Types of Headache

Types of Headache

Triggers of Tension Headache Stress Anxiety Depression Emotional conflicts Fatigue Repressed hostility

Triggers of Tension Headache Stress Anxiety Depression Emotional conflicts Fatigue Repressed hostility

Non. Rx Options for Episodic Tension Headache Excedrin® Tension Headache ◦ 500 mg Acetaminophen

Non. Rx Options for Episodic Tension Headache Excedrin® Tension Headache ◦ 500 mg Acetaminophen + 65 mg caffeine APAP Ibuprofen Naproxen Other combo products

Nonpharmacologic Treatment of Tension Headache Physical therapy Relaxation exercises Massage Topical Peppermint oil ◦

Nonpharmacologic Treatment of Tension Headache Physical therapy Relaxation exercises Massage Topical Peppermint oil ◦ Applied to forehead and temples

Migraine Triggers Stress Fatigue Oversleeping Fasting, missing a meal Alcohol Changes in barometric pressure

Migraine Triggers Stress Fatigue Oversleeping Fasting, missing a meal Alcohol Changes in barometric pressure or altitude Menses Hormone changes Magnesium deficiency Foods with nitrites, tyramine, phenylalanine, MSG, caffeine

Non-Rx Pharmacologic Therapy for Migraine Headache Excedrin® Migraine Advil® Migraine Other analgesics will work,

Non-Rx Pharmacologic Therapy for Migraine Headache Excedrin® Migraine Advil® Migraine Other analgesics will work, NSAIDs probably best ◦ Acetaminophen 250 mg/Aspirin 250 mg/Caffeine 65 mg ◦ 2 tabs at onset, no more than 2 tabs per 24 hours ◦ Ibuprofen 200 mg (liquid filled) ◦ 2 caps at onset, no more than 2 tabs per 24 hours Initiate NSAIDS 2 days before menses for menstrual migraine Self-treatment is only for patients who have been diagnosed with migraine by a physician

Nonpharmacologic Therapy for Migraine Headache Regular sleeping & eating schedule Avoidance of triggers (food,

Nonpharmacologic Therapy for Migraine Headache Regular sleeping & eating schedule Avoidance of triggers (food, stress) Cold packs + pressure Lie in a dark, quiet room Keep a headache journal

Go see MD! ü Symptoms of cluster headache ü Symptoms of migraine headache with

Go see MD! ü Symptoms of cluster headache ü Symptoms of migraine headache with no formal diagnosis ü Chronic tension headache (>15 days/month for > 6 months) ü Severe pain (pain score 8 -10) ü Signs of infection (fever, purulent discharge, altered mental status) ü Headache that ü Lasts more than 10 days ü Occurs more than 3 times a week ü Not managed by Non. Rx dosing

Acute Low Back Pain Possible causes ØInactive lifestyle ØPoor posture ØImproper shoes ØExcess body

Acute Low Back Pain Possible causes ØInactive lifestyle ØPoor posture ØImproper shoes ØExcess body weight ØPoor mattress ØPoor sleeping posture ØImproper lifting techniques

Acute Low Back Pain • • Most back pain disappears with home treatment and

Acute Low Back Pain • • Most back pain disappears with home treatment and self-care Treatment options • NSAIDs • Topical analgesics • Alternating heat/cold • Massage • Chiropractic manipulation • Moderate physical activity when not acutely injured • Chronic low back pain ( > 4 weeks) Refer

Sprains & Strains Sprains – injury to ligaments Strains – injury to muscle or

Sprains & Strains Sprains – injury to ligaments Strains – injury to muscle or tendons ◦ Overextension of the joint ◦ Ankle inversion most common ◦ Overuse or improper use Symptoms: Pain, bruising, loss of some function, stiffening Treatment ◦ RICE Therapy ◦ Non. Rx NSAIDS

Rice Therapy Rest the injured area. Ice the area in 10 minute intervals, 3

Rice Therapy Rest the injured area. Ice the area in 10 minute intervals, 3 – 4 times a day for 1 – 2 days. Compress the area with elastic support. Elevate the area above the heart for 48 -72 hours to decrease swelling and pain.

Muscle Pain (Myalgia) Delayed-onset muscle soreness most common and is self-treatable Other types -

Muscle Pain (Myalgia) Delayed-onset muscle soreness most common and is self-treatable Other types - Refer Non. Rx treatment: ◦ NSAIDS ATC ◦ Topical Preparations (Salicylates, Camphor, Menthol)

Osteoarthritis Nonpharmacologic Therapies Non. Rx Therapies ◦ ◦ ◦ Low-impact exercise Weight-loss Shock-absorbing shoes

Osteoarthritis Nonpharmacologic Therapies Non. Rx Therapies ◦ ◦ ◦ Low-impact exercise Weight-loss Shock-absorbing shoes Physical and occupational therapy Acupuncture ◦ Tylenol is drug of choice ◦ NSAIDS ◦ Glucosamine & Chondroitin: Not for people with shellfish allergy, may raise blood sugar in diabetics, may increase the effect of warfarin ◦ Topical analgesics/counterirritants

Menstrual Pain OTC treatment options: Midol® Menstrual Complete: (Acetaminophen 500 mg/Caffeine 60 mg/Pyrilamine 15

Menstrual Pain OTC treatment options: Midol® Menstrual Complete: (Acetaminophen 500 mg/Caffeine 60 mg/Pyrilamine 15 mg) Midol® Extended Relief (Naproxen sodium 220 mg) Midol® Cramps and Body Aches (Ibuprofen 200 mg) Midol® Teen Formula (APAP 500 mg/Pamabrom 25 mg) Non. Rx NSAIDs are the treatment of choice at MAX OTC doses

Nonpharmacologic Treatment for Menstrual Pain Heating pads Regular exercise Loose clothing Massage Smoking cessation

Nonpharmacologic Treatment for Menstrual Pain Heating pads Regular exercise Loose clothing Massage Smoking cessation

Do’s and Don’ts Do Give advice and make suggestions Determine if nonprescription medications will

Do’s and Don’ts Do Give advice and make suggestions Determine if nonprescription medications will help Provide resources Suggest options and let people know their pain may be managed ◦ Use common sense ◦ ◦ Don’t ◦ ◦ Say something you are not sure about Diagnose or suggest specific prescription therapy Recommend self-treatment when not appropriate Give false hope

Community Resources Referral Sources: ◦ American Chronic Pain Association (www. theacpa. org) ◦ American

Community Resources Referral Sources: ◦ American Chronic Pain Association (www. theacpa. org) ◦ American Pain Foundation (www. painfoundation. org) ◦ American Headache Society (www. americanheadachesociety. org) ◦ Arthritis Foundation (www. arthritis. org) Referral for pain management: ◦ American Chronic Pain Association at 800 -533 -3231 ◦ Local hospice or cancer center often know good pain specialists ◦ USC/Norris Comprehensive Cancer Center (323) 865 -3000, ask for referral to pain specialist ◦ USC pain center: 323 -442 -6202 For those without a doctor or insurance: ◦ Local hospital’s social services department or local health department LA Social Services Info Line at 800 -339 -6993 LAC/USC Referral Line at 323 -226 -4970 ◦ Patient Advocate Foundation at 800 -532 -5274 Poison Control: 1 -800 -222 -1222

Questions?

Questions?