Multidisciplinary Management of Chronic Pain: A Practical Guide for Clinicians

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University of Michigan, Ann Arbor, Michigan. Help Contact Us About us. Advanced Search. Journal of Psychiatric Practice. Effective pain management relies on care planning to manage baseline pain and future pain episodes. Regularly reassess pain,and review management if pain scores are repeatedly high and breakthrough strategies are used more than twice in 24 hours.

Nonmedication and complementary therapies eg. Diversional therapies may help, as well as offering nutrition and fluids, ensuring the resident is warm and comfortable, and reducing lighting and surrounding noise. Physiotherapists trained to evaluate nociceptive and neuropathic pain can assist choosing nonmedication therapies to enhance medication. Physical therapies include TENS , walking programs, strengthening exercises and massage. Heat or cold packs need to be used with care to avoid burns or hyperalgesia.

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Cognitive behavioural therapies CBT are beneficial for older patients, including residents who have mild dementia. Patients will often benefit from a clear explanation about the cause of their pain, as well as behaviours and positive thoughts to enhance their own capacity to manage pain. Choice of medication is based on pain severity. Begin with a mild analgesic such as paracetamol, and build up stepwise to opioids for severe unrelieved pain.

Regular medication for baseline pain, that maintains a therapeutic blood level, is more beneficial than administering analgesia when residents ask for it or as staff consider it necessary. Treat breakthrough and incident pain with additional analgesia. Analgesia can be given 30 minutes before activities such as pressure area care, dressings, physiotherapy,and hygiene procedures. Paracetamol is the preferred analgesic for older people and is effective for musculoskeletal pain and mild forms of neuropathic pain.

Lower doses should be used in patients with hepatic or renal impairment. Aspirin is not recommended for use as an analgesic in older people because of the risk of gastrointestinal bleeding. Codeine has a short half life and is suitable for incident pain or predictable mild to moderate short lasting pain. Tramadol is a centrally acting analgesic that also weakly acts on opioid receptors and as an inhibitor to noradrenaline and serotonin reuptake. It is a useful medication in a significant minority of older people with chronic noncancer pain, but should be used with caution because of the high incidence of side effects up to one-third experience nausea, vomiting, sweating, dizziness or hallucinations and medication interactions eg.

SSRI s. Low doses are recommended initially mg per day for the first 3 days with careful titration and monitoring. Patients over 75 years of age should not have more than mg per day. Opioids should not be withheld if pain is moderate to severe and unresponsive to other interventions. In general, commence with low doses of short acting opioids and titrate the dosage slowly. More rapid dosage escalation is appropriate in very severe pain, cancer pain and palliative care. When changing the route of administration of opioids, adjust the new dose accordingly.

Tolerance to opioids may develop necessitating an increase in dose or decreased interval of administration to achieve the same pain relief. Long acting opioid agents can be used in conjunction with short acting opioids to treat incident pain. In moderate to severe noncancer pain, dosage increments are usually less frequent and the target degree of pain relief may need to be modified, maintaining function and other patient defined goals.

Apart from codeine, the main opioids are morphine, oxycodone and fentanyl. Morphine is suitable for the treatment of severe pain in older people, and is available in forms for most routes of administration. Starting doses for severe acute pain are mg hourly orally, 2. In chronic severe pain, unresponsive to other interventions, after 24 hour dosage needs are established, long acting morphine MS Contin can be introduced.

Oxycodone is available in immediate release endone, oxynorm and sustained release form oxycontin for oral administration.

Multidisciplinary team approach in chronic pain management - Pergolizzi

Endone or oxynorm immediate release may be used for the initial establishment of tolerance and dosage needs, and later for breakthrough pain. Oxycontin sustained release is recommended for chronic pain with the recommended dose of mg twice per day. Transdermal fentanyl is used for ongoing severe pain.

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It is potent and long acting and the risk for delirium and respiratory depression is high. It should be used only when the resident has had opioids previously and high dosage needs are established.

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Fentanyl is metabolised in the liver and is suitable for patients with renal failure. Its adverse effects are similar to those of morphine but with a lower incidence of constipation and confusion. To change the type of opioid medication or route of administration, convert dose to equivalent dose of oral morphine, as shown in Table 11 and Table Conversion doses are only approximate, if drowsiness occurs reduce the dose, if pain increases, increase the dose. Where a fentanyl patch is substituted for another opioid, the total daily dose of the opioid should be first converted to mg per day of morphine.

Table 12 gives data on ranges for conversion, as fentanyl patches may have variable rates of delivery eg. Patches produce a reservoir in the underlying skin and consequent continued absorption and are usually changed every 3 days. In some patients, breakthrough needs may increase on the third day and the patch may need to be changed more frequently eg.

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Multidisciplinary Care in Pain Management - Physiopedia

After the patch is removed the half life of fentanyl in the blood is hours. Adjuvant medications used in pain management are medications not primarily used for pain treatment but that have analgesic properties. They may be given alone or in conjunction with analgesics. Types of adjuvant medications:. Medical care of older persons in residential aged care facilities The Silver Book Pain management. Table Opioid Conversion factor from oral morphine Approx. References Flicker L. Clinical issues in aged care, managing the interface between acute, sub-acute, community and residential care. Aust Health Rev ; Lewis G, Pegram R.

Residential aged care and general practice. Workforce demographic trends Med J Aust ; Geriatric medicine: a pocket book for doctors, nurses, other health professionals and students. Melbourne: Ausmed Publications, Aged care Australia: the future challenges. Accreditation guide for residential aged care services. Residential aged care services in Australia A statistical overview. Canberra: AIHW, Carers Australia. Submission to the House of Representatives Standing Committee on Ageing : inquiry into long term strategies to address the ageing of the Australian population, Outside looking in: a resource kit on carer friendly practices in aged care facilities.

Carers Victoria, Flicker L, op. NACA issues paper. The aged care - health care interface, Quality indicators for the management of medical conditions in nursing home residents. J Am Med Dir Assoc ; ANMC national competency standards for the enrolled nurse. Healy J, Richardson S. Who cares for the elders? What we can and can't know from existing data. Guidelines for medication management in residential aged care facilities.


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