PAIN BOOKLET Table of Contents

1. Introduction 2. Pain Assessment

• Tools • Initial Assessment

3. Common Pain Syndromes • Cancer • Chronic • Headache

4. Pharmacological Management • Definitions Related to the Use of Opioids in Pain Treatment • Pharmacological Management Recommendations • Narcan Administration for Adults • NSAIDS, Salicylates and Acetaminophen • Opioids/Opioid-Like Analgesics • Initial IV PCA Prescription Range • Increasing an Opioid Dose • Central Nervous System Agonists/Combination Products • Benzodiazepine Anti-Anxiety Adjuvants • Anticonvulsants Adjuvants • Tricyclic Anti-Depressants Adjuvants • Opioid Side Effects • Drugs and Routes of Administration Not Recommended for Treatment of Pain

5. Non-Pharmacological Management • Non–Drug Interventions for Pain Management • Complementary Healing Interventions • Psychosocial Interventions

6. Myths 7. Services Available to Help Treat Pain

• Reiki • Spiritual Care • Occupational Therapy • Physical Therapy • Recreational Therapy • GHL-TV • Pain Management Center

- Headache Clinic - Advanced Pain Therapies: Discography/Intrathecal Drug Delivery System/Intradiscal Electrothermal Therapy/ Nucleoplasty/Radiofrequency Denervation/Spinal Cord Stimulation/Vertebroplasty/ Laser-Assisted Spinal Endoscopy Therapy/Kyphoplasty

8. Resources/References

Reviewed: 11/03

SECTION 1 INTRODUCTION

Acute, chronic and cancer pain continues to be a major concern for the consumer and the healthcare professionals who assist them. Under treated pain may increase the time a patient stays in the hospital or may make it difficult for the patient to care for himself/herself and return to optimal functioning. Recognizing the impact and consequences of pain, the JCAHO (Joint Commission for the Accreditation of Hospitals Organization) that accredits 80% of the nation’s hospitals, recently included improved pain management as an imperative in the survey process for hospitals. Genesis Medical Center takes the responsibility of improving pain management very seriously and offers the following information to staff and consumers.

SECTION 2 PAIN ASSESSMENT

TOOLS

NUMERICAL SCALE 0 – 10 (0=No pain, 10=Worst pain) DESCRIPTIVE SCALE 0-10 (0=No pain, 2=Mild, 4=Uncomfortable, 6=Distressing, 8=Horrible, 10=Excruciating) SEDATION SCALE S = Sleep 1 = Awake and alert 2 = Occasionally drowsy, easy to arouse 3 = Frequently drowsy, arousable, drifts off to sleep during conversation 4 = Minimal or no response to stimuli, loss of lid reflex Note: At level 3 consider dose adjustment

INITIAL ASSESSMENT

1. LOCATION: ____________________________________________________________________

2. INTENSITY: Patient rates the pain. Scale used ________________________________________

Present: ______________________________________________________________________

Worst pain gets: _______________________________________________________________

Best pain gets: _________________________________________________________________

Acceptable level of pain: _________________________________________________________

3. QUALITY: (Use the patient’s own words, e.g., prick, ache, burn, throb, pull, sharp) ___________

4. ONSET, DURATION, VARIATIONS, RADIATING: _______________________________________

5. MANNER OF EXPRESSING PAIN: ___________________________________________________

6. WHAT RELIEVES THE PAIN? _______________________________________________________

7. WHAT CAUSES OR INCREASES THE PAIN? ___________________________________________

8. EFFECTS OF PAIN: (Note decreased function, decreased quality of life.)

Accompanying symptoms (e.g., nausea) _____________________________________________

Sleep ________________________________________________________________________

Appetite ______________________________________________________________________

Physical activity ________________________________________________________________

Relationship with others (e.g., irritability) ____________________________________________

Emotions (e.g., anger, suicidal, crying) ______________________________________________

Concentration __________________________________________________________________

Other ________________________________________________________________________

9. OTHER COMMENTS: _____________________________________________________________

10. PLAN: ________________________________________________________________________

From McCaffery M, Pasero C: Pain: Clinical manual, p. 60. Copyright 1999, Mosby, Inc.

SECTION 3 COMMON PAIN SYNDROMES

COMMON CANCER PAIN SYNDROMES DUE TO PERIPHERAL NERVE INJURY

PAIN SYNDROME

ASSOCIATED SIGNS AND SYMPTOMS

AFFECTED NERVES

Tumor infiltration of a peripheral nerve

Constant burning pain with dysesthesia in an area of sensory loss; pain is radicular and often unilateral

Peripheral

Postradical neck dissection Tight, burning sensation in the area of sensory loss; dysesthesias and shocklike pain may be present; second type of pain may occur, mimicking a dropped shoulder syndrome

Cervical plexus

Postmastectomy pain Tight, constricting, burning pain in the posterior arm, axilla and anterior chest wall; pain exacerbated by arm movement

Intercostobrachial

Postthoracotomy pain Aching sensation in the distribution of the incision with sensory loss with or without autonomic changes; often exquisite point tenderness at the most medial apical points of the scar with a specific trigger point; secondary reflex sympathetic dystrophy may develop

Intercostal

Postnephrectomy pain Numbness, fullness or heaviness in the flank, anterior abdomen and groin; dysesthesias are common

Superficial flank

Postlimb amputation Phantom limb pain usually occurs after pain in the same site before amputation; stump pain occurs at the site of the surgical scar several months to years after surgery; it is characterized by a burning dysesthetic sensation that is exacerbated by movement

Peripheral endings and their central projections

Chemotherapy-induced peripheral neuropathy

Painful paresthesias and dysesthesias; hyporeflexia; less frequently: motor and sensory loss; rarely: autonomic dysfunction; commonly associated with the vinca alkaloids, cisplatin and Taxol

Distal areas of peripheral (e.g., polyneuropathy)

Radiation-induced peripheral nerve tumors

May promote malignant fibrosarcoma; painful, enlarging mass in a previously irradiated area; patients with neurofibromatosis more susceptible

Superficial and deep

Cranial neuropathies Severe head pain with cranial nerve dysfunction; leptomeningeal disease; base of skull metastasis

Cranial V, VII, IX X, XI, XII are most common

Acute and postherpetic neuropathy

Painful paresthesia and dysesthesia; constant burning and aching pain; shocklike paroxysmal pain; immunosuppression from disease or treatment is a risk factor; postherpetic neuropathy incidence increases with age

Thoracic and cranial (VI) are most common

CHRONIC PAIN SYNDROMES

Pain Syndromes

Cause/ Signs/ Symptoms

Treatment Options

Back Pain: -Low Back Pain -Spinal Stenosis -Spondylolesthesis -Compression Fracture -Degenerative Disc -Herniated Disc -Ruptured Disc -Osteoporosis -Rheumatoid Arthritis -Osteoarthritis -Pinched Nerve -Sciatica -Cervical Pain -Whiplash

Pathology of the • Discs • Joints • Muscles • Ligaments • Nerves

Signs and symptoms are very diverse and reflect the cause of the pain. Location: ranging from localized to diffuse. Intensity: may be mild, moderate, or severe. Description (quality) of the pain varies from related to the cause. Examples include; dull, sharp, aching, throbbing, pressing, pulling, burning, shooting

• Rest • Heat or Cold Application • Medications such as:

- Non-opioids - Opioids - Antidepressants - Anticonvulsants - Muscle relaxants - Local Anesthetics

• Exercise • Weight Control • Stress Control • Occupational Therapy • Physical therapy • Massage Therapy • TENs Unit • Injections or Nerve Blocks:

Epidural Steroid Injection Nerve Root Injection Sympathetic Block Intercostal Block Facet Block Sacro-Iliac Joint Injection Trigger Injection

Ligament Injection • Advanced Pain Therapies:

Radiofrequency Denervation Intrathecal Drug Delivery Spinal Cord Stimulation Discography Laser-Assisted Spinal Endoscopy Therapy (LASE Therapy) Intradiscal ElectroThermal Therapy Nucleoplasty Vertebroplasty Kyphoplasty

• Surgery

Osteoarthritis Risk factors include age, obesity, stress to the joints, and female gender Symptoms:

• Swelling or tenderness in one or more joints

• Loss of flexibility of a joint

• Stiffness • Bony lumps on the

joints of the fingers • Feeling of bone rubbing

on bone (crunching)

• Exercise • Anti-inflammatories • Analgesics • Heat/Cold Application • Weight Control • Steroid Injections • Surgery

Pain Syndromes

Cause/ Signs/ Symptoms

Treatment Options

Rheumatoid Arthritis Cause: Immune system

attacks healthy joints causing inflammation and subsequent joint damage Symptoms: Stiffness, swelling, pain in joints of hands, fingers, wrists, ankles, feet, elbows and knees, fatigue, low fever, appetite loss, small bumps under the skin near the affected joints

• Anti-inflammatories • Analgesics • Disease-Modifying Medication • Rest • Exercise • Joint Protection Devices • Physical Therapy • Occupational Therapy • Surgery

Chronic Regional Pain Syndrome (Formerly Known as Reflex Sympathetic Dystrophy)

Unknown cause: Can occur as result of injury to nerves, bones, joints, muscles, tendons or ligaments primarily affecting hands or feet Symptoms: Burning pain, swelling, changes in temperature and color of skin, rapid nail growth, stiffness, muscle spasms, degenerative changes to the bone

• Anti-inflammatories • Analgesics

Nerve Blocks / Procedures:

• Sympathetic Nerve Block • Stellate Ganglion Block • Radiofrequency Denervation • Occupational Therapy • Physical Therapy • TENs Unit

Peripheral Neuropathy

Cause: Damage to the peripheral nerves caused by diseases such as diabetes, uremia, AIDS, nutritional deficiencies, vascular or collagen disorders or by mechanical, thermal, or chemical trauma Symptoms: Numbness, tingling, weakness, burning, or abnormal sensations in the arms, hands, legs, and/or feet

• Control of disease process • Surgical excision of tumor or

decompression of nerves • Physical Therapy • Occupational Therapy • Medication Management

Antidepressants Anticonvulsants

Post Herpetic Neuralgia

Cause: Follows an episode of shingles (which is a reactivation of the dormant varicella-zoster virus on a spinal nerve) Symptoms: Persistent severe burning or stabbing pain in the same location as the healed shingles lesions

• Medication Management Anti-viral

Analgesics Anti-inflammatories Antidepressants Anticonvulsants Topical Local Anesthetics

Pain Syndromes

Cause/ Signs/ Symptoms

Treatment Options

Fibromyalgia Unknown Cause: Can be

linked to factors such as physical or emotional trauma, an infectious process, hormonal changes, muscle abnormalities, abnormal triggering of neurotransmitters Symptoms: Multiple tender points, fatigue, depression, anxiety, concentration difficulties

• Rest • Relaxation Techniques • Analgesics • Sleep Aids • Exercise

Stretching and Aerobics

HEADACHE PAIN

Types of Headache Causes Treatment Options

Headache: -Analgesic Rebound -Migraine with Aura -Migraine without Aura -Hormonal -Tension-Type -Cluster

Neurovascular Inflammation due to one or more of the following:

• Sleep Disorders Insomnia Sleep Apnea • Stress

Depression

• Hypertension • Foods/Chemicals

Caffeine Chocolate Alcohol MSG • Environmental

Barometric Light Pungent Odors • Hormones

Menstruation • Neck Abnormalities

Arthritis

• Rest • Heat or Cold Application • Abortive Medication

Analgesics Anti-Inflammatories Triptans • Preventative Medication

Antidepressants Anticonvulsants Antihypertensives • Manipulation/Mobilization • Massage Therapy • TENs Unit • Psychotherapy • Relaxation Therapy • Acupuncture • Reiki Therapy • Therapeutic Touch • Stress Management • Biofeedback • Nutritional Counseling • Guided Imagery

SECTION 4 PHARMACOLOGICAL MANAGEMENT

DEFINITIONS RELATED TO THE USE OF OPIOIDS IN PAIN TREATMENT

The committee on Pain of the American Society of Addiction Medicine recognizes the following definitions as appropriate and clinically useful definitions and recommends their use when assessing the use opioids in the context of pain treatment. PHYSICAL DEPENDENCE: Physical dependence on an opioid is a physiologic state in which abrupt cessation of the opioid or administration of an opioid antagonist results in a withdrawal syndrome. Physical dependency on opioids is an expected occurrence in all individuals in the presence of continuous use of opioids for therapeutic on for nontherapeutic purposes. It does not, in and of itself, imply addiction. TOLERANCE: Tolerance is a form of neuroadaptation to the effects of chronically administered opioids (for other medications), which is indicated by the need for increasing or more frequent doses of the medication to achieve the initial effects of the drug. Tolerance may occur both to the analgesic effects of opioids and to the unwanted side effects such as respiratory depression, sedation or nausea. The occurrence of tolerance is variable, but it does not, in and of itself, imply addiction. ADDICTION: Addiction in the context of pain treatment with opioids is characterized by a persistent pattern of dysfunctional opioid use that may involve any or all of the following: • Adverse consequences associated with the use of opioids • Loss of control over the use of opioids • Preoccupation with obtaining opioids despite the presence of adequate analgesia

PHARMACOLOGIC MANAGEMENT RECOMMENDATIONS

1. Medications for persistent cancer-related pain or acute pain should be administered on an around-

the-clock basis with additional “as needed” doses, because regularly scheduled dosing maintains a constant level of drug in the body and helps to prevent a recurrence of pain.

2. Pacing activities rather than using breakthrough analgesia is encouraged in the treatment of chronic pain when the patient is taking long-acting opioids.

3. Patients receiving opioid agonists should not be given a mixed agonist-antagonist because doing so may precipitate a withdrawal syndrome and increase pain.

4. Meperidine is not recommended for cancer pain control or chronic pain control. 5. Opioid tolerance and physical dependence are expected with long-term opioid treatment

and should not be confused with addiction. 6. Intramuscular administration of drugs should be avoided because this route can be painful and

inconvenient and absorption is not reliable. 7. Failure of maximal systemic doses of opioids and coanalgesics should precede the consideration of

intraspinal analgesic systems. 8. Constipation is a common problem associated with long-term opioid administration and should be

anticipated, treated prophylactically and monitored constantly. 9. Naloxone, when indicated for reversal of opioid-induced respiratory depression, should be titrated

in doses that improve respiratory function but do not reverse analgesia. 10. Placebos should not be used in the management of cancer pain or chronic pain. 11. The four essential concepts to drug therapy of cancer pain or chronic pain are: by the mouth, by

the clock, for the individual, and with attention to detail. 12. Use of opioids in the management of headaches may cause “rebound” headaches (medications

themselves may create a headache).

NALOXONE (NARCAN) ADMINISTRATION FOR ADULTS 1. Stop the administration of the opioid and any other sedative drugs. If given IV, maintain IV

access. 2. Mix 0.4 mg (1 ampule) of naloxone and 10 ml of normal saline in a syringe for IV administration. 3. Administer the dilute naloxone solution IV very slowly (0.5 ml over 2 min).1 4. The patient should open his/her eyes and talk to you within 1-2 minutes. If not, continue IV

naloxone at the same rate up to a total of 0.8 mg or 20 ml of dilute naloxone. If no response, begin looking for other causes of sedation and respiratory depression.

5. Discontinue the naloxone administration as soon as the patient it responsive to physical stimulation and able to take deep breaths when told to do so.

6. Resume opioid administration at one half the original dose when the patient is easily aroused and respiratory rate is >10 breaths/min.

These guidelines provide the recommended titrate-to-effect procedure for administering naloxone (Narcan) to reverse clinically significant respiratory depression. Giving too much naloxone or giving it too fast can precipitate severe pain, which is extremely difficult to control, and increase sympathetic activity leading to hypertension, tachycardia, ventricular dysrhythmias, pulmonary edema and cardiac arrest. In physically dependent patients withdrawal syndrome can be precipitated; patients who have been receiving opioids for more than 1 week may be exquisitely sensitive to antagonists. 1If IV route is inaccessible administer undiluted naloxone, 0.4 mg, subcutaneously or intramuscularly. The patient should respond within 5 minutes. If not, repeat dose up to a total of 2 mg.

From McCaffery M, Pasero C: Pain: Clinical manual, p. 270. Copyright 1999, Mosby, Inc.

NONSTEROIDAL, ANTI-INFLAMMATORIES, SALICYLATES AND ACETAMINOPHEN Useful first line and adjunct for all forms of cancer including bone pain; use caution in patients with active peptic ulcer disease, gastrointestinal bleeds, severe thrombocytopenia, or coagulopathies; nonsteroidals have a ceiling effect in respect to the dose; consideration should be made to using a cytoprotective agent when appropriate; administer with/after food. Acetaminophen provides a satisfactory pain relief with a much lower risk of side effects than with nonsteroidals in the elderly population.

DRUG

LIQUID AVAILABLE

DOSE RANGE 50kg or MORE

DOSE RANGE LESS THAN 50kg

COMMENTS

Acetaminophen (Tylenol)

80mg/0.8ml 160mg/5ml

325-1000mg

q4-6h Maximum dose:

4g/day

10-15mg/kg q4h

(po) 15-20mg/kg q4h

(pr)

No anti-inflammatory effects; lacks GI and anti-platelet effects

Choline Mag. Trisalicylate (Trilisate)

500mg/5ml

1000-1500mg q8h

Maximum dose: 6 doses/day

25mg/kg q8h

No platelet effects

Diclofenac (Voltaren)

25-50mg q6-8h

Maximum dose: 200mg/day

Diclofenac/ Misoprostol

(Arthrotec)

50/200-75/200 q6-8h

Maximum dose: 225/800/day

Contraindicated in pregnancy

due to misoprostol

Ibuprofen (Motrin)

100mg/5ml

400-800mg q6-8h

Maximum dose: 3.2g/day

10mg/kg q6-8h

Nabumetone (Relafen)

1000-2000mg qd-bid

Maximum dose: 2000mg/day

Naproxen (Naprosyn)

125mg/5ml

250-500mg q6-8h

Maximum dose: 1.25g/day

5mg/kg q8h

Naproxen Sodium (Anaprox)

275-550mg q6-8h

Maximum dose: 1.375g/day

Celecoxib (Celebrex)

100-200mg q12h

100mg q12h Adults only; no pediatric data

Cross reaction in pts. allergic to sulfonamides No platelet

effects Rofecoxib (Vioxx)

12.5mg/5ml 25mg/5ml

50mg q12h No pediatric data No platelet effects

Valdecoxib (Bextra)

20mg q12h

No pediatric data Cross reaction in pts. allergic to sulfonamides No platelet

effects

OPIOID/OPIOID-LIKE ANALGESICS (Initiate a laxative program with the initiation of narcotic therapy; there is no maximum dose in respect to

the narcotics; the dose listed is a guide—the appropriate dose is the dose that controls the pain.)

Drug (Opioid Agonist)

Route Dose Ranges Adult

Dose Ranges Pediatrics

Mg/kg/dose

Comments

Morphine po/sl/pr/iv 20-60mg q4h 0.3 po 0.08-0.1 q4h iv

Morphine, controlled-release

(MS Contin)

po/pr 15-120mg q8-12h

N/A Do not break or crush; may be

prepared for pr

Hydromorphone (Dilaudid)

po/pr/iv 4-8mg q3-4h po

2-4mg q3-4h iv

3mg q4h pr

0.06 q3-4h po 0.015 q3-4h iv

Methadone (Dolophine)

po 5-10mg q8-12h

0.2 q8-12h Very long acting;

provide for breakthrough

Codeine po/im 30-60mg q3-4h po/im

0.5-1.0 q4h po/im

Oxycodone (Roxicodone)

po 15-30mg q3-4h

N/A

Oxycodone, controlled-release

(Oxycontin)

po 10-80mg q8-12h

N/A Do not break or crush

Fentanyl (Duragesic)

Trans-dermal

25-100mcg/hr q72h

N/A Not first-line TX; provide

for breakthrough

*Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with addiction.

INITIAL IV PCA PRESCRIPTION RANGES FOR OPIOID-NAÏVE ADULTS

Drug Typical

Concentration Loading

Dose PCA Dose Delay Basal Rate

Morphine 1 mg/ml 2.5 mg repeat PRN

0.6-2.0 mg 5-10 min 0-1.3 mg/h

Hydromorphone 0.2 mg/ml 0.4 mg repeat PRN

0.1-0.3 mg 5-10 min 0-0.2 mg/h

Fentanyl 10 mcg/nl 25 mcg 5-20 mcg 4-8 min 0-10 mcg

FOR PATIENTS WHO ARE NOT OPIOID NAÏVE Maximum dose is determined only by patient comfort and side effects produced. If patients are not responding to increasing doses of opioids and are exhibiting agitation or twitching, consider switching to another opioid with an appropriate reduction in rate.

INCREASING AN OPIOID DOSE

When an increase in the opioid dose is necessary, it can be done by percentages. When a slight improvement in analgesia is needed, a 25% increase in opioid dose may be sufficient; for moderate effect, a 50% increase, and for a strong effect, such as for the treatment of severe pain, a 100% increase may be indicated (Levy, 1996).

CALCULATION OF RESCUE DOSES

The formula for calculating rescue doses usually is one eighth (1/8) to one sixth (1/6) (12% to 15%) of the total daily dose. Whenever possible, rescue doses should be the same opioid and route as the ATC drug (e.g., use oral immediate-release morphine as rescue for controlled-release morphine.) Immediate-release oral morphine usually is recommended for controlled-release opioid formulations that do not have an immediate-release formulation of the same opioid available. To use oral immediate-release morphine, it is necessary to convert the other opioid to morphine equivalents. From McCaffery M, Pasero C: Pain: Clinical manual, p. 245. Copyright 1999, Mosby, Inc.

CENTRAL NERVOUS SYSTEM AGONISTS/COMBINATION PRODUCTS (Initiate a laxative program with the initiation of this group)

DRUG LIQUID

AVAILABLE DOSE RANGE

50kg OR MORE

DOSE RANGE LESS THAN

50kg Mg/kg/dose

COMMENTS

Codeine 15,30,60mg/

APAP 300mg or ASA 325 mg

(Tylenol #2,#3,#4,

ASA/Codeine)

Tylenol w/Codeine

12mg/120mg/ 5ml

1-2q4h 0.5-1.0 q4h codeine

Maximum APAP 4gms q24h

Hydrocodone/ APAP 500mg

(Lortab 2.5,5,7.5,10)

Lortab Elixir 2.5mg/

167mg/5ml

1-2 q4-6h 0.2 q3-4h Maximum APAP 4gms q24h

Oxycodone 5mg/APAP

325 mg or ASA 325 mg

(Percocet, Percodan)

1-2 q4-6h N/A Maximum APAP 4gms q24h

Propoxyphene 65mg

(Darvon)

65-130mg q3-4h

N/A Propoxyphene in all forms is a weaker

analgesic Propoxyphene 100mg/APAP

650mg (Darvocet N-

100)

1-2 q3-4h N/A Propoxyphene N 100mg=Propoxyphene

HCI 65mg Maximum APAP 4gms

q24h Tramadol (Ultram)

50-100mg q4-6h

Max=400mg/day

N/A May have properties similar to opioids

Tramadol/APAP 37.5/325

(Ultracet)

1-2 q4-6h Maximum=8/d

ay

Short-term use only 5 days or less

May have properties

similar to opioids

BENZODIAZEPINE ANTI-ANXIETY ADJUVANTS (Useful for adjuvant pain management, spasms and anxiety)

DRUG

LIQUID AVAIL-ABLE

DOSE RANGE 50kg OR MORE

DOSE RANGE LESS THAN 50kg

COMMENTS

Alprazolam (Xanax) 0.25-0.5mg q6-8h

N/A Intermediate acting

Clonazepam (Klonopin) 0.5-1mg q8-12h

10 years or less or 30kg

0.01- 0.05mg/kg/day divided tid

Longer acting

Lorazepam (Ativan)

2mg/ml 0.5-2mg q4-8h

po/sl/iv

0.05mg/kg/dose q4-8h po/iv

Short acting; may be compounded by

Rx for pr administration

ANTICONVULSANT ADJUVANTS (Useful for the management of neuropathic pain, especially when the pain is lancinating or burning)

DRUG LIQUID

AVAILABLE INITIAL

DOSE 50kg OR

MORE

INITIAL DOSE LESS THAN

50kg

COMMENTS

Gabapentin (Neurontin)

100-300mg q8h may titrate up to max of 3600mg/day

15mg/kg/day 12 years or

greater

Well-tolerated; primary side

effects include somnolence,

dizziness, fatigue and ataxia

Tiagabine (Gabitril)

4mg qd Maximum=56

mg/day Divided bid-qid

Increase dose by 4-8mg/week

Reduce dose with impaired liver

function Zonisamide (Zonegran)

100mg/day Max=300-400mg/day

May divide bid

Contraindicated in patients with sulfonamide

allergy Increase doses @ 2-4 week intervals

due to long half-life

Use with caution in renal/hepatic impairment

TRICYCLIC ANTI-DEPRESSANT ADJUVANTS (TCA’S) (Useful for pain related to neuropathies and postherpetic neuralgias. These drugs should not be used in

patients with cardiac conduction abnormalities, which may be exacerbated by TCAs. This may be a particular risk in patients on anthracycline anti-tumor agents. A baseline ECG may be necessary to

exclude patients at risk.)

DRUG LIQUID

AVAILABLE INITIAL DOSE 50kg OR MORE

INITIAL DOSE LESS THAN 50kg

COMMENTS

Amitriptyline (Elavil)

10-100mg/day qhs 0.1mg/kg/dose up to 0.5-

2mg/kg/dose qhs

Best documented analgesia, but

higher incidence of anticholinergic,

sedative and orthostatic

hypotension side effects

Desipramine (Norpramin)

10-100mg/ day divided q6-8h

1-3mg/kg/day divided q8-12h

Fewest side effects

Max=5mg/kg/day Nortiptyline (Pamelor)

10mg/5ml 10-75mg/day divided q8-12h

1-3mg/kg/day divided q8-12h

Fewer side effects

Trazodone (Desyrel)

100-400mg/day divided q12-24h

1.5-2mg/kg/day Maximum= 6mg/kg/d

1-4 weeks to see results

Give large portion of dose at

bedtime due to sedative effects

Not a TCA-triazolopyridine

derivative

OPIOID SIDE EFFECTS Clinicians who follow patients during long-term opioid treatment should watch for potential side effects and use adjuvant agents to counteract them. • Constipation. Treat constipation (an inevitable side effect). Constipation requires treatment with a

stimulating cathartic (e.g., bisacodyl, standardized senna concentrate, senekots, or hyperosmotic agents, orally or via suppository). Dietary fiber may be of additional benefit.

• Nausea and vomiting. Treat with antiemetics such as phenothiazines or metoclopramide. Depending on the antiemetic chosen, monitor the patient for increased sedation.

• Sedation and mental clouding. When possible, treat persistent drug-induced sedation by reducing the dose and increasing the frequency of opioid administration. CNS stimulants such as methylphenidate may be useful to help decrease opioid sedative effects.

• Respiratory depression. Patients receiving long-term opioid therapy generally develop tolerance to the respiratory depressant effects of these agents. When indicated for reversal of life-threatening, opioid-induced respiratory depression, administer naloxone, titrated in small increments to improve respiratory function without reversing analgesia. Monitor the patient carefully until the episode of respiratory depression resolves.

• Subacute overdose. Far more common than acute respiratory depression, subacute overdose manifests as slowly progressive (hours to days) somnolence and respiratory depression. Withhold one or two doses until the symptoms have resolved, then reduce the standing dose by 25 percent.

• Other opioid side effects. Dry mouth, urinary retention, pruritis, myoclonus, altered cognitive function, dysphoria, euphoria, sleep disturbances, sexual dysfunction, physiologic dependence, tolerance and inappropriate secretion of antidiuretic hormone.

*See drug notes for specific medications.

DRUGS AND ROUTES OF ADMINISTRATION NOT RECOMMENDED FOR TREATMENT OF PAIN

CLASS DRUG RATIONALE FOR NOT

RECOMMENDING Opioids Meperidine Short (2-3 hour) duration. Repeated

administration may lead to CNS toxicity (tremor, confusion or seizures). High oral doses required to relieve severe pain and these increase the risk of CNS toxicity.

Miscellaneous Cannabinoids Cocaine

Side effects of dysphoria, drowsiness, hypotension and bradycardia preclude its routine use as an analgesic. Has demonstrated no efficacy as an analgesic or coanalgesic in combination with opioids.

Opioid agonist-antagonist

Pentazocine Butorphanol Nalbuphine

Risk of precipitating withdrawal in opioid-dependent patients. Analgesic ceiling. Possible production of unpleasant psychomimetic effects (e.g., dysphoria, hallucinations).

Partial agonist Buprenorphine Analgesic ceiling. Can precipitate withdrawal. Antagonist Naloxone

Naltrexone May precipitate withdrawal. Limit use to treatment of life-threatening respiratory depression.

Combination Preparations

Brompton’s cocktail DPT (Meperidine, Promethazine, and Chlorpromazine)

No evidence of analgesic benefit to using Brompton’s cocktail over single opioid analgesics. Efficacy is poor compared with that of other analgesics. High incidence of adverse effects.

Anxiolytics ALONE

Benzodiazepine (e.g., alprazolam)

Analgesic properties not demonstrated except for some instances of neuropathic pain. Added sedation from anxiolytics may limit opioid dosing.

Sedative/ Hypnotic drugs ALONE

Barbiturates Benzodiazepine

Analgesic properties not demonstrated. Added sedation from sedative/hypnotic drugs limits opioid dosing.

ROUTES OF ADMINISTRATION RATIONALE FOR NOT RECOMMENDING

Intramuscular (IM) Painful. Absorption unreliable. Should not be used for children or patients prone to develop dependent edema or in patients with thrombocytopenia

Transnasal The only drug approved by the FDA for transnasal administration at this time is butorphanol, an agonist-antagonist drug, which generally is not recommended. (See opioid agonist-antagonist above.)

SECTION 5 NON-PHARMACOLOGICAL MANAGEMENT

NONDRUG MANAGEMENT:

PHYSICAL AND PSYCHOSOCIAL MODALITIES—

1. Cutaneous stimulation techniques, including applications of superficial heat and cold, massage, pressure or vibration, should be offered to alleviate pain associated with muscle tension or muscle spasm.

2. Patients should be encouraged to remain active and to participate in self-care when possible. 3. Clinicians should reposition patients on a scheduled basis during long-term bed rest and provide

active and passive range-of-motion exercises. For a patient in acute pain, exercise should be limited to self-administered range of motion.

4. Prolonged immobilization should be avoided whenever possible to prevent joint contracture, muscle atrophy, cardiovascular deconditioning and other untoward effects.

5. Patients who choose to have acupuncture for pain management should be encouraged to report new pain problems to their health care team before seeking palliation through acupuncture.

6. Psychosocial interventions should be introduced early in the course of illness as part of a multimodal approach to pain management. They generally should not be used as substitutes for analgesics.

7. Because of the many misconceptions regarding pain and its treatment, education about the ability to control pain effectively and correction of myths about the use of opioids should be included as part of the treatment plan for all patients.

8. Clinicians should offer patients and families means to contact peer support groups. 9. Pastoral care members should participate in health care team meetings that discuss the needs and

treatment of patients. They should develop information about community resources that provide the spiritual care and support of patients and their families.

NON-DRUG INTERVENTIONS FOR PAIN MANAGEMENT PHYSICAL INTERVENTIONS

Intervention Indications Contraindications

Heat

May be useful to: relax muscles ↓ muscle spasms ↑ flexibility/ROM

Hypersensitivity to temp ↓ sensation PVD/diabetes with circulatory impairment Moderate to severe kidney/heart disease Malignancy that is vascularly fed that will worsen with treatment Impaired communication

Cold

May be useful to: ↓ muscle spasms ↓ spasticity ↓ edema/inflammation

↓ sensation PVD Not for use on damaged tissue (i.e. from radiation) Not for use on any area that has had frostbite Hypersensitivity to cold ↓ circulation Raynaud’s disease (for cold used alone) ↓ thermoregulation (very young, very old, very ill)

Intervention Indications Contraindications

Ultrasound

May be useful for: muscular problems arthritis pain neuromas sympathetic nervous system disorders (RSD) contracture/adhesion resolution

Not for use when cardiac demand type pacemakers may be exposed to Ultrasound field Not to be use over: malignant or benign tumors, infected areas, eyes, Not for use over fetus, or abdomen/ pelvis/sacrum of patient with suspected pregnancy Not for use over cervical, stellate ganglia or heart area Thrombophlebitis Not for use over epiphyses of growing bone Not for use over spinal cord areas that do not have normal bony protection (i.e. laminectomy) Not for use with patients with bleeding Or hemorrhaging tendencies Cannot be used in conjunction with deep x-ray, radium, or radioactive isotopes (must wait 6 months after last treatment before doing ultrasound)

Electrotherapy (TENs, FES,Iontophoresis)

May be useful to: ↓ edema ↓ muscle spasm problems ↑ circulation

Not for use with patients with seizures, phlebitis, hypotension, active hemorrhage Cannot be used over fresh fractures (less than 3 days) Cannot be used over carotid sinus, directly over heart, or over or near demand type pacemakers or baclofen pumps. Cannot be used over uterus if pregnant.

Anodyne Therapy May be useful to: address neuropathic pain ↑ circulation ↓ inflammation ↓ edema

Not for use with patients who are pregnant or have active malignancy

Massage

↑ muscle relaxation ↑ circulation promotes general relaxation

Not for use with patients with: Confusion or delusions Aneurysm Acute dermatitis Acute infections of any type Thrombosis/thrombophlebitis Acute inflammation (locally contraindicated) Acute burn Lymphangitis Advanced arteriosclerosis Nephritis Severe debilitation

Intervention Indications Contraindications

Manual Edema Mobilization

May be useful with lymphedema management

Exercise/ROM

Mobilizes stiff joint, promotes increase in strength and flexibility, enhances coordination and balance

Limit exercise to self-administered ROM during acute pain. Avoid weight-bearing exercise if bone fracture is probable (i.e. osteoporosis or bone mets).

Positioning/Immobilization

Useful to maintain proper alignment and to reduce the risk of skin breakdown

Need to adhere to post-procedural and post-surgical restrictions for positioning.

COMPLEMENTARY HEALING INTERVENTIONS

Intervention Indications Contraindications

ComplementaryMedicine (Homeopathy, Naturopathy, Traditional Oriental Medicine, Ayurveda)

Alternative to traditional Western medicine

Energy Therapies (Qi Gong, Reiki, Therapeutic Touch, Healing Touch)

Working with energy pathways may assist in relaxation, managing stress and reducing pain

Biology-Based Therapies (Trace Elements, Herbal Remedies, Nutritional Supplements)

May have anti- inflammatory benefits (i.e. gold, glucosamine, etc.)

May be contraindicated with some medical interventions Possible drug interactions

Aromatherapy Soothing aromas may ↑ relaxation response

Some aromas may trigger allergies and respiratory symptoms

PSYCHOSOCIAL INTERVENTIONS

Intervention Indications Contraindications Progressive Muscle Relaxation

May be useful with headache patients

Not for use with patients who have musculoskeletal disorders or where muscle fatigue is an issue

Imagery

↑ relaxation response distraction from pain

Not for use with patients with cognitive impairment or significant psychiatric instability (delusions, etc.)

Breathing exercises ↑ relaxation response distraction from pain

Not intervention of choice for individuals with condition where respiration is compromised

Meditation and Prayer

↑ relaxation response distraction from pain enhance sense of empowerment and control

Time Management/Pacing Useful in facilitation of balance between activity and rest, activity requiring different energy expenditure

Energy Conservation/Work Simplification/Body Mechanics/Adaptive Techniques and Equipment

Can assist with completion of routine daily tasks utilizing alternative methods to conserve energy and minimize pain

Biofeedback

EMG type good for muscle tension headaches and tone management Thermal type for Raynaud’s pain or migraines May be good for patients with decreased insight

Not for use with patients with cognitive impairment or significant psychiatric instability (delusions, etc.)

Hypnosis Not for use with patients with cognitive impairment or significant psychiatric instability (delusions, etc.)

Cognitive Behavioral Therapy/Psychotherapy

May be useful for individuals with chronic pain

Not for use with patients with cognitive impairment or significant psychiatric instability (delusions, etc.)

Distraction (leisure interests, music, humor, pet therapy, play therapy)

Can be used with all patients-adjunct to drug and physical interventions

SECTION 6 MYTHS

MYTHS ABOUT PAIN

Pain is often under treated because patients and healthcare providers believe myths about pain. Patients may be reluctant to report pain because they believe the following myths:

• Opioids are addictive and a treatment of last resort • Severe or chronic pain cannot be effectively controlled • Pain is always evidence of disease progression • It is more admirable or socially acceptable to ignore pain • Pain is an unavoidable result of aging or the disease process

Healthcare providers dispel these myths through improved communication and patient and family education. However, many healthcare providers also believe myths about pain. A healthcare provider may under treat pain because of misconceptions about assessment, neurophysiology, and treatment that include myths that:

• Pain perception can accurately be correlated with vital sign changes and evidence of injury • Patients in pain readily express their pain to healthcare providers • There is no physiological basis for the moderating effects of emotions on pain perception • Patients from certain cultural, ethnic or socioeconomic background consistently under report or

over report pain • Opioids are addictive and treatment of last resort because of unmanageable side effects • Patients experiencing chronic pain over report pain because they are addicted to opioids • Children, older adults and cognitively impaired patients do not perceive pain as intensely as other

patients Myths believed by healthcare providers can be dispelled by increased emphasis on pain management in academia and continuing education. Source: Pain Management, Graphic Education Corporation

SECTION 7 SERVICES AVAILABLE TO HELP TREAT PAIN

REIKI

Reiki is a gentle, natural healing method that supports the body’s natural ability to heal itself. Reiki promotes relaxation and relief of stress and anxiety, which can often lessen pain and discomfort.

SPIRITUAL CARE A complex experience, pain can often have spiritual components and competent spiritual care can be an important factor in pain control. Professional chaplains from the Genesis Spiritual Care Department work together with other members of the care team to provide sensitive, effective pain management.

OCCUPATIONAL THERAPY

Identification of activities that trigger pain and learning new techniques to minimize pain during

these tasks while enhancing independence Stress management/relaxation training Instruction/practice in energy conservation/work simplification to maximize ability within physical

limitations Exercise/activities to increase activity tolerance Positioning, manual edema mobilization and massage Patient/family education regarding enhancing functional performance

PHYSICAL THERAPY

Modalities (heat/cold/ultrasound, TENs, FES, Iontophoresis) to decrease pain symptoms Exercise and mobility training to address musculoskeletal limitations Positioning, manual edema mobilization and massage Patient/family education regarding prevention

RECREATIONAL THERAPY

Promotion of leisure skill development for use as distraction and coping Relaxation training Pet therapy

GHL-TV

The Relaxation Channel

Why watch the Relaxation Channel??? Learn to manage pain more effectively Sleep restfully and peacefully Learn to overcome anxiety and stress

HOW TO ACCESS GHL-TV 1. Tune video to first open channel between 82-89. 2. Use phone to dial 1500 3. Enter patient’s room number 4. Follow the prompts and menus 5. The Relaxation Channel is under the heading *RELAXATION WITH NARRATION and RELAXATION WITHOUT NARRATION

The following relaxation videos are included on this channel:

A Day Away from Stress:

• 30-minute video • Available with and without narration • Provides beautiful nature scenes, soothing music and environmental sounds while teaching

techniques • Narrative version teaches exercises including diaphragmatic breathing, canning, and progressive

relaxation Just Relax:

• 30-minute video • Available with and without narration • Beautiful scenery and soothing music • Exercises include differential relaxation, controlling your inner dialogue, and conscious-breathing

techniques • NOT recommended for patients with acute cardiac conditions

Laughing Matters:

• 31-minute video • Helps viewers to understand important points about managing stress and putting unpleasant

events in their proper perspective Relaxing Through the Seasons:

• 33-minute video • Available with and without narration • Journey through the seasons while learning ways to relax • Narrative version teaches exercises including breathing, stretching, and meditation

Saving for Stress:

• 14-minute video • Imagine what would happen if stress cost money, and every stressful event was like a withdrawal

from a savings account. • Now imagine what would happen if you could make deposits to that account by exercising,

meditating, etc. • Using this analogy, this video helps viewers understand why they need to practice stress

management.

Short Circuiting Stress:

• 18-minute video • Provides a layman’s introduction to cognitive restructuring (mental techniques for reducing

stress) • Uses real-life scenarios and scenes from “It’s a Wonderful Life” to teach people to think their way

through stress Sick of Stress:

• 20-minute video • Helps people understand why they need to manage stress by showing the health consequences of

ignoring it • Explains fight or flight, burnout, cognitive restructuring techniques, and relaxation techniques • Great overview for patient and staff education

Some General Guidelines:

• Relaxation exercises should not be done with patients with altered mental state (confusion, delusional, etc.)

• Techniques should not cause discomfort • Use caution when doing tensing/relaxing exercises with patients who have cardiac history

THE GENESIS PAIN MANAGEMENT CENTER

The Genesis Pain Management Center offers services to manage acute, chronic, and cancer pain. The goal for our patients is to reduce pain, improve functioning and quality of life, decrease dependency on the health care system, and return patients to a healthier lifestyle. Our anesthesiologists, nurses, and social worker are all highly skilled and specially trained in pain management. A wide variety of simple and complex pain problems are treated at the Genesis Pain Management Center. Common pain conditions treated include: -Low Back Pain -Spinal Stenosis -Spondylolesthesis -Facet Joint Arthropathy -Compression Fracture -Degenerative Disc -Herniated Disc -Ruptured Disc -Osteoporosis -Rheumatoid Arthritis -Osteoarthritis -Pinched Nerve -Sciatica -Cervical Pain -Whiplash -Headache -Peripheral Neuropathy -Chronic Regional Pain Syndrome -Post Herpetic Neuralgia -Fibromyalgia and Myofascial Pain

Advanced pain therapies provided include: -Steroid Injections -Radiofrequency Denervation -Spinal Cord Stimulation -Implantation of Intrathecal Drug Delivery Systems -Discography -Nucleoplasty -Intradiscal Electrothermal Therapy -Vertebroplasty -Kyphoplasty -Laser-Assisted Spinal Endoscopy (LASE) A physician referral is necessary for the initial appointment.

GENESIS HEADACHE CLINIC: The Genesis Headache Clinic is dedicated to the management of head pain. The focus is on the management of headache without the use of narcotic analgesics. Practitioners utilize an interdisciplinary approach to the treatment of head pain. The clinic is unique in the fact that patients are required to attend two free classes and meet with the social worker prior to an initial diagnostic appointment with the physician. The purpose of the classes is threefold: to give an introduction to the cause and medical treatment of headache; to describe adjunctive treatments to headache (in addition to medications); and to discuss the role of stress management in headache treatment. Following the classes, patients are asked to keep a detailed headache diary and bring this information with them to their first appointment. Clinicians in the Headache Clinic include a neurologist, an advance practice nurse, a social worker and a registered nurse. Each has an important role in assisting the patient to understand and manage head pain. The Clinic is open on Tuesday afternoons and is located at the Genesis Pain Management Center in Bettendorf. A referral from a primary care physician is required to be seen in the Headache Clinic. For more information, please call the Genesis Pain Management Center at 563-421-3555. ADVANCED PAIN THERAPIES: DISCOGRAPHY: This is a diagnostic procedure to test an intervertebral disc to determine if it leaks and/or reproduces pain. The procedure is performed on an outpatient basis. Local anesthetic and mild sedation are used to reduce discomfort during the procedure. The patient is awake enough to provide important feedback to the physician during the procedure. Through x-ray guidance, the physician advances a needle into the disc and injects a contrast substance. The disc is studied and the patient is also asked to report any pain sensation during the injection. The procedure usually takes 30-60 minutes. A CT scan is performed following the procedure. The physician provides activity and rehabilitation guidelines for each patient prior to discharge the day of the procedure. A follow-up appointment is made at the Pain Center for discussion of results and plan of care.

LASER-ASSISTED SPINAL ENDOSCOPY (LASE) THERAPY: For many patients, a contained herniated disc is the cause of pain. This means the center portion of the disc (the nucleus) is pushing up against the outer portion of the disc (the annulus). This causes the disc to bulge and press against the nerve. Physicians conduct a clinical examination, MRI and/or CT, and perform discography to confirm this diagnosis. For these patients, LASE Therapy may be recommended. The procedure is usually performed on an outpatient basis. Local anesthetic and mild sedation are used to reduce discomfort during the procedure. The patient is awake enough to provide important feedback to the physician during the procedure.

Through x-ray guidance, the physician advances a miniature endoscope with a laser fiber into the disc. The LASE endoscope allows the doctor to see the bulging disc tissue and remove it with the laser fiber. By removing some of the nucleus from the disc, the pressure on the nerve is reduced or eliminated. At the end of the procedure, the miniature endoscope is removed. A band-aid is placed over the endoscope insertion site. The disc healing process and rehabilitation process takes 12-16 weeks. The physician provides activity and rehabilitation guidelines for each patient during this time. Expected outcomes include relief of lower back pain, reduction of or elimination of medication use, and an increase in functional abilities.

INTRATHECAL DRUG DELIVERY SYSTEM: This is a method of providing continuous pain medication directly pain receptors in the spinal cord. Delivering medication by this route enables a much smaller amount of medication to achieve pain relief and minimizes side effects. A programmable pump (about 3” x1” in size) is surgically placed under the skin of the abdomen. The pump delivers medication through a tunneled catheter into the space surrounding the spinal cord. The best candidates for the Intrathecal Drug Delivery System have severe chronic pain which has not responded to more conservative therapies. Other criteria that doctors may consider are that no further surgery would be of benefit, no untreated drug addiction exists, a successful trial stimulation period has been completed, the patient has made a strong commitment to be an active participant is his/her recovery, and there are no psychological issues that would interfere with treatment. Placement of the Intrathecal Drug Delivery System is usually performed as an outpatient surgery. A general anesthetic is used during the surgical procedure. The physician provides activity and rehabilitation guidelines for each patient upon discharge from the hospital. Expected outcomes include improved pain relief, reduction or elimination of medication use, reduction of medication side effects, and an increase in functional abilities. INTRADISCAL ELECTROTHERMAL THERAPY (IDET): For many patients, cracks or fissures in the wall of the intervertebral discs may be the cause of prolonged severe lower back pain. Physicians conduct a clinical examination, MRI and/or CT, and perform discography to confirm this diagnosis. For these patients, Intradiscal Electrothermal Therapy or IDET may be recommended. The procedure is usually performed on an outpatient basis. Local anesthetic and mild sedation are used to reduce discomfort during the procedure. The patient is awake enough to provide important feedback to the physician during the procedure. Through x-ray guidance, the physician advances a needle into the disc. A catheter is passed through the needle into the disc. Once the catheter is properly placed, a section of the catheter is heated. This process results in closure of the crack or fissures and destroys pain sensors within the disc. At the end of the procedure, the needle is removed. A band-aid is placed over the needle insertion site. The disc healing process and rehabilitation process takes 12-16 weeks. The physician provides activity and rehabilitation guidelines for each patient during this time. Expected outcomes include relief of lower back pain, reduction or elimination of medication use, and an increase in functional abilities.

NUCLEOPLASTY: For many patients, contained herniated intervertebral discs may be the cause of prolonged severe lower back pain. Physicians conduct a clinical examination, evaluate by CT or MRI, and perform discography to confirm this diagnosis. For these patients, nucleoplasty may be recommended. The procedure is usually performed on an outpatient basis. Local anesthetic and mild sedation are used to reduce discomfort during the procedure. The patient is awake enough to provide important feedback to the physician during the procedure.

Through x-ray guidance, the physician advances a needle into the disc. A special wand is then passed through the needle into the disc. Tissue is removed as the wand is advanced into the disc. This creates a small channel. The temperature of the wand is gradually increased while it is being removed so that it seals the new channel. At the end of the procedure, the wand and needle are removed. A band-aid is placed over the needle insertion site. The healing and rehabilitation process requires 6-12 weeks. The physician provides activity and rehabilitation guidelines for each patient during this time. Expected outcomes include relief of lower back pain, reduction of or elimination of medication use, and an increase in functional abilities. RADIOFREQUENCY DENERVATION: This is a procedure that stops select sensory nerve fibers in the body that are transmitting pain messages to the brain. The procedure is usually performed on an outpatient basis. Local anesthetic is used to reduce discomfort during the procedure. The patient is awake to provide important feedback to the physician during the procedure. Through x-ray guidance, the physician advances a needle or probe near the nerve. Gradually, the temperature of the probe is raised which destroys the outer sheath of the nerve fiber. This process results in the inability of the nerve fiber to transmit messages of pain to the brain. These nerve fibers are not responsible for motor control. Once the procedure is completed, the needle is removed. The healing process takes place over 4-6 weeks. The physician provides activity and rehabilitation guidelines for each patient during this time. Expected outcomes include relief of lower back pain, reduction or elimination of medication use, and an increase in functional abilities. SPINAL CORD STIMULATION: A Spinal Cord Stimulator is a device that delivers tiny electrical pulses through an implanted lead system placed near the spinal cord. The lead is attached to a battery- powered pulse generator, similar to a pacemaker, which is implanted under the skin. The pulses block pain messages being sent to the brain. Typical candidates for the Spinal Cord Stimulator have well localized, severe, chronic leg pain which has not responded to more conservative therapies. Other criteria that doctors may consider are that no further surgery would be of benefit, a psychological screening has been performed, no untreated drug addiction exists, no pacemaker is present, a successful trial stimulation period has been completed, and that the patient has made a strong commitment to be an active participant in his/her recovery. Placement of the Spinal Cord Stimulator is usually performed as an outpatient procedure. Local anesthetic and mild sedation are used to reduce discomfort during the procedure. The patient is awake enough to provide important feedback to the physician during the procedure. Expected outcomes include relief of back and/or extremity pain, reduction of or elimination of medication use, and an increase in functional abilities. VERTEBROPLASTY: A vertebral compression fracture can be caused by osteoporosis, bone tumors, or metastasis of cancer to the spine. For many of these patients, prolonged severe back pain persists despite ongoing medical therapy. Vertebroplasty may be recommended for this very difficult pain problem following a physician’s clinical examination, evaluation by MRI to confirm the presence of a new fracture and blood work. This will not decrease the pain from an old vertebral fracture. The procedure is usually performed on an outpatient basis. A prophylactic antibiotic may be given before or during the procedure. Local anesthetic and sedation are used to reduce discomfort during the procedure. The patient is awake enough to provide important feedback to the physician during the procedure.

Through x-ray guidance, the physician advances a special needle through the tissue of the back and into the bone. Bone cement is then injected through the needle into the fracture. The thick paste-like substance quickly hardens and stabilizes the fracture. At the end of the procedure, the needle is removed. A band-aid is placed over the needle insertion site. The physician provides activity and rehabilitation guidelines for each patient during this time. Expected outcomes include almost immediate relief of pain, stabilization and strengthening of the vertebral bone structure, reduction of or elimination of medication use, and an increase in functional abilities. KYPHOPLASTY: A vertebral compression fracture can be caused by osteoporosis, bone tumors, or metastasis of cancer to the spine. For many of these patients, prolonged severe back pain persists despite ongoing medical therapy. Kyphoplasty may be recommended for this very difficult pain problem following a physician’s clinical examination, an evaluation by MRI to confirm the presence of a new fracture and blood work. The procedure is usually performed on an outpatient basis. A prophylactic antibiotic may be given before or during the procedure. Local anesthetic and sedation are used to reduce discomfort during the procedure. The patient is awake enough to provide important feedback to the physician during the procedure. Through x-ray guidance, the physician advances a special needle through the tissue of the back and into the fractured vertebrae. A balloon is then inflated which creates a cavity for bone cement to be injected. The thick, paste-like substance quickly hardens and stabilizes the fracture and restores height. The balloon is then withdrawn. At the end of the procedure, the needle is removed. A band-aid is placed over the needle insertion site. The physician provides activity and rehabilitation guidelines for each patient. Expected outcomes include almost immediate relief of pain, stabilization and strengthening of the vertebral bone structure, restoration of height, reduction of or elimination of medication use, and an increase in functional abilities.

SECTION 8

RESOURCES/REFERENCES

RESOURCES WEB SITES: http://www.genesishealth.com/services/physical.aspx http://www.spineuniverse.org/ http://www.ampainsoc.org/ http://www.arthritis.org/ http://www.iasp-pain.org/ http://www.partnersagainstpain.com/ http://www.asipp.org/ http://www.painfoundation.org/ http://www.headaches.org/ http://www.aspmn.org/ BOOKS AND NON-PHARMACOLOGICAL DOCUMENT RESOURCES:

McCaffery, Margo RN, MS, FAAN and Pasero, Chris RN, MSNc: Pain Clinical Manual Second Edition, St. Louis, 1999

Quick Reference Guide for Clinicians; Management of Cancer Pain: Adults, Publication 94-0593, March 94. U.S. Department of Health and Human Services “OT’s Role in Managing Chronic Pain,” OT Practice. October 9, 2000 Schneider, Mark, PhD., Cortext Educational Seminars, Spring 2002 Recognizing Pain as the 5th Vital Sign: A Guide to Developing and Implementing an Effective Pain Management Program, Implementation Manual, pp. 53-56 “Superficial Physical Agent Modalities and Ultrasound for Occupational Therapists,” Carey, James, MA, PT, 1997

REFERENCES:

Agency for Health Care Policy and Research. Management of Cancer Pain. Clinical Practice Guideline, Number 9. March 1994: US Department of Health and Human Services. American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 3rd Edition. 1993. American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 4th Edition. 1999. Barone MA. The Harriet Lane Handbook. 14th edition. St. Louis: Mosby; 1996. Benitz WE, Tatro DS. The Pediatric Drug Handbook. 3rd edition. St. Louis: Mosby; 1995. Drug Facts and Comparisons. St. Louis: Facts and Comparisons; 1999. McCaffery, Margo, RN, MS, FAAN, Pasero, Chris, RN, MSNc, Pain Clinical Manual, Mosby, Inc., St. Louis, Missouri, Second Edition, 1999.