Pain Management – Fy2007

[Guest allan]

PAIN MANAGEMENT – FY2007

If you have questions regarding Pain Management, you may call Dr.

Thiru Anaswamy, MD, MA, Physical Medicine and Rehabilitation Service at 214-

857- 0273 or you may send him an e-mail message through Veterans

Health Information Systems and Technology Architecture (VISTA) or Microsoft

(MS) Exchange (Outlook).

1. Short-acting analgesic medications may be helpful for patients with chronic

pain. If a patient's pain control is sub-optimal with frequent doses of short-acting

pain medications every day, it is appropriate for the physician to consider the

addition of a "long-acting" medication for improved pain control.

2. Significant progress has been made over the last 30 years in diagnosing and

managing patients with chronic pain. The vast majority of patients will benefit

from these advances. Treatment methods cover the whole spectrum from

physical and occupational therapy to medication and psychological counseling to

interventional pain management procedures and surgical operations.

3. The risk of addiction to opioid (narcotic) pain medication is a common fear

among patients with chronic pain. Addiction is defined as psychological

dependence and continued use of medication despite harm (e.g. overdose).

Addicted persons lose control over the medication and make great efforts to

obtain as much medication as possible. Addiction is a multifactorial phenomenon

with a genetic component. Patients without a mental history of addictive illness

who have chronic pain and use the medication as prescribed very rarely get

addicted.

4. Patients with previous and/or ongoing episodes of illicit drug use are at much

higher risk to become addicted when they are given opioids. To minimize this risk

it is recommended to obtain an Opioid Agreement, do frequent drug screens to

recognize a relapse and to prescribe medication with slightly less abuse and

addiction potential. Short-acting opioids like hydrocodone have a high abuse

potential while slow-onset long-acting opioids (like methadone) are less often

abused. Patients with ongoing illicit drug abuse should be referred to Mental

Health for Substance Abuse counseling before any opioids are considered.

5. Patients who take opioids for over 2 weeks will usually experience

withdrawal (increased pain, sweating, chills, anxiety), when the medication

is discontinued abruptly. This physiological dependence must not be

confused with psychological addiction. It is comparable to the rebound

phenomena that happens after abrupt discontinuation of beta-blockers or

clonidine. It is important to make the distinction between physiological

dependence and psychological addiction clear to the patient and the family.

6. The VA North Texas Healthcare System (VANTHCS) offers, through

its multiple specialty clinics, expertise and facilities to treat patients with

chronic pain. A lot of information about these clinics and what service they offer

can be found in the Pain Management Policy (CP-10), which is posted on the

VA Intranet under the section: VANTHCS Policies.

7. Interventional pain management, which is the utilization of injections

and "blocks" for the treatment of pain, can often result in better pain control

and improved functioning. These procedures are performed at the VA

North Texas Health Care System (VANTHCS) by physicians with special

training and expertise in pain management following the same standards

as respective physicians outside the VANTHCS.

8. The goal of multidisciplinary pain management is to leverage the

expertise and experience from different departments to improve the patient's pain

and function using an integrated and collaborative approach. This

includes addressing the physical, mental health and spiritual needs of the

patients. Multidisciplinary approach to pain management often results in

better outcomes.

9. Pain is very common in cancer (especially late in the disease process) and

has to be addressed aggressively. The majority of cancer patients can achieve

adequate pain control and live with the use of opioids and adjuvant

(supplemental) pain medications. A small minority of patients will need additional,

more invasive procedures to decrease their pain and improve their functioning.

10. Many of the elderly attribute pain as part of the natural aging process and

therefore tend not to report their pain. Unrelieved pain in the elderly leads to

disturbed sleep patterns, fatigue, depression and functional impairment, which

greatly affect their quality of life. Elderly patients in pain may avoid certain

movements and may require assistance with Activities of Daily Living (ADLs).

11. Pain assessment is a subjective self-report requiring verbalization of

pain; however, patients with dementia may be unable to self-report their

pain. Therefore, it is important to be aware of possible objective indicators of

pain including frowning, grimacing, tense body posturing, agitation,

aggression, sadness, wandering, pacing, and noisy breathing.

12. Pain assessment in the elderly can be difficult or inaccurate because

they may have sensory impairment, depression, or decreased

cognitive functioning. Some elderly patients may describe their pain as

discomfort, burning, soreness, heaviness, or aching, which can be misinterpreted

by staff since they may not use the word "pain" as a descriptor. Therefore, it is

important to use a variety of measures including verbal communication (pain

descriptive scale), visual communication (visual analog scale), assessment of

behavior (faces scale) and the Non Verbal pain Scale (NVPS) to assess pain

accurately in the elderly.

13. Chronic pain is frequently associated with fear of movement,

reduced physical activity and deconditioning. On advice from a treating physician

or care provider, patients with chronic pain may begin and maintain a

regular, prescribed exercise program to counteract the ill effects of inactivity

and deconditioning. This exercise program may need to be reviewed and

revised periodically.

14. Heat, cold, and electric stimulation are commonly used to effectively

reduce and manage pain. This type of stimulation is often prescribed and used

by physical and occupational therapists. The VA North Texas Healthcare System

(VANTHCS) physical and occupational therapy services are available through

Physical Medicine & Rehabilitation Service (PM&RS). A consultation/referral to a

therapist in PM&RS may be appropriate for a patient in pain.

15. Patients who receive long-acting medication for pain control should have

a short acting medication available for "breakthrough" pain, when a longacting

drug fails to control their pain effectively.

16. There is no "ceiling" (maximum) dose for opioid medications, large doses

may be given safely in a patient to maintain an acceptable level of pain control

with attention to potential side effects.

SOURCE:

http://www.north-texas.med.va.gov/orientation/MET/Pain_Management.pdf

[john999]

Allan

Vets on lots of pain meds need to be aware of the fact that many pain meds have acetaminophen in them. The acetaminophen is much more dangerous than any pure opiate. I have the VA send me drugs with no acetaminophen(tylenol) in them. I use the long acting morphine and it does have a depressing affect on me. I notice it and I mention it to the doctors.

[Guest allan]

Allan

Vets on lots of pain meds need to be aware of the fact that many pain meds have acetaminophen in them. The acetaminophen is much more dangerous than any pure opiate. I have the VA send me drugs with no acetaminophen(tylenol) in them. I use the long acting morphine and it does have a depressing affect on me. I notice it and I mention it to the doctors.

>I use the long acting morphine and it does have a depressing affect on me.

Hello John,

I had the same reaction to morphine. Made me feel like a zombie.

I didn't know about tylenol being dangerous. Thanks for the heads up.

Allan