INTRODUCTION TO PAIN
MANAGEMENT: APPROACH
Calvin Lui, MD
PGY2
February 8, 2014
CLINICAL CASE
A 70-year-old male with recent diagnosis of
multiple myeloma presents after a fall in
which in breaks his wrist. He complains of
pain from his shoulders, back, and wrist.
His back pain is persistent for the past
several months. It has two components:
some “running shock-like down to his feet”
and other “feeling as if his back is being
eaten at.” There is radiologic evidence of
bony metastases and DJD. He is taken to
the OR for ORIF. What types of pain are
involved in his case?
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Practical approach to pain management
History taking
Pain Syndromes
ETIOLOGIES OF PAIN
Emotional/
anxiety
Neuropathic
Compressive/visercal
Pain
musculoskeletal
inflammatory
PAIN SYNDROMES
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Nocireceptive pain- Response to noxious stimuli
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Somatic – focal, ache/throb/sharp swelling/edema/redness
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worse with movement, better at rest, maybe from trauma
Visceral – viscous organs
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resolves usually with non-opioid or opioid analgesics
Incorporates somatic and visceral pain
colicky, vague, diffuse, possibly worse with meals
Liver/spleen/pancreas – possibly constant/focal, worse with
eating
uterine – colicky, pelvic, maybe with discharge
Neuropathic – burning, sharp, tingling
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Possibly dermatomal or stocking-glove
worse with touch,
May have associated numbness
radiating
HISTORY TAKING FOR PAIN
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Pain location
Radiation
Intensity
Characteristics/quality
Temporal aspects:
duration, onset, changes
since onset
Constancy or
intermittency
Characteristics of any
breakthrough pain
Exacerbating/triggering
factors
Palliative/relieving factors
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Nociceptive
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Restriction of range of
motion
Swelling
Muscle aches, cramps, or
spasms
Neuropathic
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Color or temperature
changes
Changes in sweating
Changes in skin, hair, or
nail growth
Changes in muscle
strength
Changes in sensation,
either positive
(dysesthesias/itching) or
negative (numbness)
OTHER CLINICAL PEARLS
Uptitrate pain medications in short frequent
dosages
 No two patients are the same in terms of pain
tolerance
 Treat all types of pain at once to obtain better
pain control
 Reevaluate pain regimen for side effects and
possible overdosages
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Methadone and consideration for naloxone
CHOOSING BASED UPON RISK FACTORS
Chronic kidney disease, advanced age - avoid
NSAIDs and COX-2 inhibitors
 Peptic ulcer disease, glucocorticoid use - avoid
NSAIDs
 Hepatic disease - avoid NSAIDs, COX-2
inhibitors, and acetaminophen (APAP); TCAs,
antidepressants, opioids without APAP
 Cardiovascular disease or risk - use lowest
effective dose of NSAIDs; in patients who require
treatment, suggest naproxen
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CLINICAL CASE
A 70-year-old male with recent diagnosis of
multiple myeloma presents after a fall in
which in breaks his wrist. He complains of
pain from his shoulders, back, and wrist.
His back pain is persistent for the past
several months. It has two components:
some “running shocklike down to his feet”
and other “feeling as if his back is being
eaten at.” There is radiologic evidence of
bony metastases and DJD. He is taken to
the OR for ORIF. What types of pain are
involved in his case?
PAIN ASSESSMENT OF CASE
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Broken wrist with swelling
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Nocirecptive: visceral
DJD with likely nerve impingement
Neuropathic
 Clues include radiation and shocklike sensations
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Bone metastases
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Inflammatory/metastatic
SUMMARY
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The purpose of good history about pain is to discern the
pain syndrome and later define the agents that would
useful for their treatment
The etiology of pain is multifactorial
When considering a pain regimen remember the side
effect profiles of your medications to best select agent to
be used.