Pain Consultations 101
Melissa Durham, Pharm.D.
September 14th, 2011
Acute vs. Chronic Pain
Characteristic
Acute Pain
Chronic Pain
(No Self-Treatment)
Relief of Pain
Highly Desirable
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
• 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?
Temporary relief of minor aches and pain
associated with the common cold
 Reduction of fever
 Sore throat
 Headache (Episodic Tension, Migraine, Sinus)
 Muscle aches
 Minor aches and pains of arthritis
 Acute back pain
 Menstrual pain

 Acetaminophen, AKA APAP (Tylenol)
Mild-moderate pain, fever, headaches
 NSAIDs
Ibuprofen (Motrin, Advil)
Naproxen sodium (Aleve)
Mild-moderate pain, headaches, muscle pain, menstrual
pain
 Salicylates
Aspirin AKA ASA (Ecotrin, Bayer)
Mild-moderate pain, muscle pain, menstrual pain,
cardioprotection
 Topicals
(IcyHot, Bengay)
Muscle soreness, muscle pain, osteoarthritis


Brand Name – Tylenol®, FeverAll®
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

Used mostly for primary and secondary
prevention of thrombotic events
◦ Ex. Aspirin 81mg/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






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







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






Stress
Anxiety
Depression
Emotional conflicts
Fatigue
Repressed hostility

Excedrin® Tension Headache
◦ 500mg Acetaminophen + 65mg caffeine

APAP

Ibuprofen

Naproxen

Other combo products
 Physical
therapy
 Relaxation exercises
 Massage
 Topical Peppermint oil
◦ Applied to forehead and temples






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

Excedrin® Migraine

Advil® Migraine

Other analgesics will work, NSAIDs probably best

Initiate NSAIDS 2 days before menses for menstrual
migraine

Self-treatment is only for patients who have been
diagnosed with migraine by a physician
◦ Acetaminophen 250mg/Aspirin 250mg/Caffeine 65mg
◦ 2 tabs at onset, no more than 2 tabs per 24 hours
◦ Ibuprofen 200mg (liquid filled)
◦ 2 caps at onset, no more than 2 tabs per 24 hours





Regular sleeping & eating schedule
Avoidance of triggers (food, stress)
Cold packs + pressure
Lie in a dark, quiet room
Keep a headache journal

Symptoms of cluster headache

Symptoms of migraine headache with no formal
diagnosis

Chronic tension headache (>15 days/month for > 6
months)

Severe pain (pain score 8-10)

Signs of infection (fever, purulent discharge, altered
mental status)

Headache that
 Lasts more than 10 days
 Occurs more than 3 times a week
 Not managed by NonRx dosing
Acute Low Back Pain
Possible causes
Inactive lifestyle
Poor posture
Improper shoes
Excess body weight
Poor mattress
Poor sleeping posture
Improper lifting techniques
•
•
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 – 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
◦ NonRx NSAIDS
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.



Delayed-onset muscle soreness most
common and is self-treatable
Other types - Refer
NonRx treatment:
◦ NSAIDS ATC
◦ Topical Preparations (Salicylates,
Camphor, Menthol)

Nonpharmacologic Therapies

NonRx 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
OTC treatment options:




Midol® Menstrual Complete:
(Acetaminophen 500mg/Caffeine 60mg/Pyrilamine 15mg)
Midol® Extended Relief
(Naproxen sodium 220mg)
Midol® Cramps and Body Aches
(Ibuprofen 200mg)
Midol® Teen Formula
(APAP 500mg/Pamabrom 25mg)
NonRx NSAIDs are the treatment of choice at MAX OTC doses
 Heating
pads
 Regular exercise
 Loose clothing
 Massage
 Smoking cessation

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 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?