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Types of pain
- 1. nociceptive: graded
- a. somatic (bone, joints): aching, throbbing, well localized
- b. visceral (organs): aching and well localized in organ capsules OR cramping and poorly localized if obstructive
- 2. neuropathic: PNS/CNS dysfunction, continuous+burning OR spontaneous+shooting
- 3. acute: associated with injury
- 4. chronic: >3months beyond normal healing time
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Pain measurement
- 1. verbal rating scale (VRS): 4 point
- 2. numeric rating scale (NRS):
- a. 0-5=none to mild
- b. 5-7= moderate
- c. >7= severe
- 3. picture scale
- 4. McGill pain questionnaire5. visual analogue scale (VAS):
- a. 0-5mm= none
- b. 5-44mm= mild
- c. 45-74mm= moderate
- d. >70mm= severe
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Special pain situations
- 1. dental pain: NSAIDs>>APAP+codeine
- 2. renal colic: NSAIDs>>opioids
- 3. biliary colic: NSAIDs=opioids
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Causes of cancer pain
- 1. cancer: infiltration, compression
- 2. related to cancer: muscle spasms, bedsores, DVT/PE
- 3. related to cancer Tx: post-operative, post-radiation, post-chemotherapy
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WHO Analgesic ladder
- 1. Mild (1-3)= APAP, NSAIDs
- 2. Mild-Mod (4-6)= codeine, dihydrocodeine, hydrocodone, oxycodone
- 3. Mod-Severe (7-10)= morphine, fentanyl, oxycodone, hydromorphone
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S/E of opioids
- 1. can be tolerated: N/V, sedation, pruiritis, respiratory depression
- 2. cannot be tolerated: constipation (esp. >2-3d), dry mouth, myoclonus/hallucinations
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Causes of non-cancer pain
- 1. peripheral neuropathy: DM, nerve compression, PHN, trigeminal neuralgia, complex regional pain syndrome
- 2. central neuropathic pain: post-stroke, PD, MS, myelopathies
- 3. non-neuropathic pain: arthritis, low back pain, neck pain, fibromyalgia, post-trauma
- 4. other: myofascial pain, HA, chronic pelvic pain, surgery
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Canadian Pain Society guidelines for neuropathic pain
- 1. first: TCA, GBP, PGB
- 2. second: venlafaxine, topical lidocaine
- 3. third: tramadol, CR opioid
- 4. fourth: cannabanoids, methadone, LTG, TPM, VPA
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Neuropathic pain dose regimens
- 1. Antidepressants
- a. ami/imi 25mg QHS-->150mg/d
- b. nor/desi 25mg QAM/QHS-->150mg/d
- c. bupropion 100mg QD-->200mg BID
- d. venlafaxine 37.5mg QD-->300mg/d
- 2. AEDs
- a. CBZ 200mg QD-->400mg QID
- b. GBP 100-300mg QHS-->1300-3600mg div TID
- c. PGB 150mg QHS for DM neuropathy
- d. PGB 300mg BID for PHN
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