Elizabeth Kvale, MD
Assistant Professor of Medicine
University of Alabama at Birmingham
Unpleasant sensory and emotional
experience associated with actual or
potential tissue damage.
 Physical pathology does not need to be
present
 Pain is one of the most common reasons
Americans 18+ seek medical attentions.
 25-50% community-dwelling older adult
have pain
 45-80% nursing home residents have pain

Sensory-Discriminative
Pain Perception
Affective-Motivational
Noxious Stimulus
Autonomic & Motor Responses
Commons Myths Regarding Pain

In the presence of tissue damage there must
be pain, and vice versa.
 It is useful to classify pain as either organic
(biological) or functional (psychogenic)
 A placebo response verifies that pain is
psychological in origin
BIOPSYCHOSOCIAL MODEL OF
PAIN (and symptoms)
BIOMEDICAL
- Pathology
- Injury
- Nociception
SOCIOCULTURAL
- Age, Sex, Race
- Income, Education
- Social Milieau
PSYCHOLOGICAL
- Anxiety, Depression
- Cognitive Factors
- Behavioral Factors
Pain Behavior
Suffering
Pain
Nociception

Acute pain
◦ identified event,
resolves days–weeks
◦ usually nociceptive

Chronic pain
◦ cause often not easily
identified, multifactorial
◦ indeterminate duration
◦ nociceptive and / or
neuropathic





Nociceptive – Arthritis,
fracture, laceration
Visceral – Pancreatitis,
M.I., Constipation
Neuropathic – Herpes
zoster, diabetic
neuropathy,
Complex Regional
Pain Syndromes – RSD
Central Pain


Pain is a subjective experience – the patient is
the best source of information about their pain
Pain History – site(s), intensity, temporality,
character, exacerbating and alleviating factors
Comprehensive and ongoing
assessment.
 Medical history
 Physical exam
 Psychosocial
 Family and culture
 Pain history (including previous
treatment)
 Comprehensive medication history

The nature and intensity of the pain.
Current and past treatments for the pain.
Underlying or coexisting diseases or
conditions.
 The effect of the pain on the physical and
psychological function.
 Documentation of a history of substance
abuse.
 Documentation of one or more recognized
medical indications for the use of a
controlled substance.



American Academy of Pain Medicine, Long-term
Controlled Substances Therapy for Chronic Pain, July 2004

The use of an instrument to assess pain
allows you to know and document
whether you have helped the patient
Grimace, Groan, Rub, Guard, Brace
 Can be observed and quantified

Don’t delay for investigations or disease
treatment
 Unmanaged pain  nervous system
changes

› permanent damage
 amplify pain

Treat underlying cause (eg, radiation for
a neoplasm)
74 yo with multiple medical issues, many
of which contribute to pain
 Multiple medications
 Declining functional ability
 Recent Falls
 Lives alone, but with supportive family
near

Routine assessment and documentation
 Patient and family education
 Non-pharmacologic strategies
 Serial Trial Intervention
 Documentation

Heat
 Cold
 Positioning
 Distraction
 Relaxation
 Massage
 Controlled breathing and guided
imagery
 Music

Regular use of acetaminophen
 Consider nonsteroidal anti-inflammatory

› For intermittent pain
› Many medical contraindications

Consider low dose pain medications
› Oxycodone, morphine, hydromorphone
› ? Use of combination medications

Re-evaluate


Match the medication to the amount of discomfort
the patient is having
severe
WHO 3-step
Ladder
3
2 moderate
A/Codeine
1 mild
A/Hydrocodone
A/Oxycodone
ASA
Acetaminophen
NSAIDs
± Adjuvants
A/Dihydrocodeine
Tramadol
± Adjuvants
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
± Adjuvants

A structured approach to “let’s try it and
see what happens”
Patients and caregivers are essential
team members in evaluating and
managing pain
 Caregiver resistance to pain
management strategies ensures failure
 Explore areas of concern or resistance to
tailor education efforts most effectively

Use a
standard
scale to
track the
course of
pain




Identify objectives that will be used to
determine treatment success including but not
limited to pain relief, improved physical
function, and improved psychological function.
Documentation of the need for further
diagnostic evaluations or other treatments
which may be planned.
Adjustment of drug therapy based on the
individual medical needs of each patient.
Consideration of other treatment modalities or
rehabilitation programs depending on the
extent and etiology of the pain.
Encourage activity and self-care
Employ physical modalities: heat, cold,
massage, acupuncture, transcutaneous
electrical nerve stimulation
Recommend cognitive-behavioral
interventions: relaxation and imagery,
psychotherapy, structured support
Educate the patient
 The
risk of under treating pain is a
greater concern than the risk of
worsening delirium with medications
 None systemic therapies, intraarticular steroid injections, lidocaine
patches, topical preparations

Opioids are first-line therapy for severe
acute pain and chronic moderate to
severe persistent pain due to cancer, AIDS,
and other advanced illnesses.

Consider the individual’s risk of drug abuse
and addiction and provide appropriate
and structured therapy.

Opioids are metabolized by the liver and
excreted by the kidney
 Peak plasma concentration is reached:
 60-90 minutes after oral dosing
 30 minutes after SC or IM dosing
 6 minutes after IV injection
 Effective half-lives of 3–4 hours with normal
renal clearance
 Steady state achieved in 24 hours
 Extended-release forms release over 8, 12, or
24 hours; fentanyl patch provides continuous
relief for 48–72 hours
Use short-acting opioids to determine opioid
requirements over 24 hours
If pain remains uncontrolled, increase doses
by 25% to 50% for mild to moderate pain and
by 50% to 100% for severe pain
Provide “rescue” analgesia for breakthrough
pain or acute pain flares
 5% to 15% of the 24-hr dose
 Offer every 1 hr orally; 30 min SC/IM; 10 min IV
Urine drug screening (UDS) is
recommended on initiation of therapy
and randomly at subsequent visits
 Implement as a global policy rather than
a targeted policy
 Evaluate for aberrant drug use and
adherence to therapy you are providing
 Interpretation of UDS results can be
challenging

Provides a report of all schedule 2
prescriptions filled by patient in state of
Alabama
 Results of report can be shared with
patient, but you cannot give a copy of
the report to the patient
 Reports should not be placed in the
medical record
 http://pdmp.alabama.gov/index.html

Reduce pain severity
 Improved and or restore function
 Improve mood and sleep patterns
 Reduce misuse or overuse of medication
 Return to productive activity
 Increase ability to manage pain
 Effective treatment should be as costeffective as possible
