Non OPIOD management of pain by Dr.Vismaya

NON OPIOD MANAGEMENT OF PAIN

1. NON OPIOD MANAGEMENT OF PAIN DR VISMAYA R S DNB PG

2. DEFINITION Pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” when there is no physical derangement.

3. FUNCTION OF PAIN: 1. Make us aware 2. promote healing by decreasing movement 3. No fn: neuropathic, migraine, fibromyalgia

4. PAIN ASSESSMENT TOOLS

5. Memory, Concentration , Judgement LONG TERM OPIOD Minimal effect on pain Tolerance Drowsiness Dependence Immunosupression CONSTIPATION

6. CLASSIFICATION PRIMARY POST SURGIAL POST TRAUMATIC CANCER RELATED NEUROPATHIC VISCRAL MUSCULOSKELETAL HEADACHE INCLUDING MIGRAINE

7. ACUTE PAIN CHRONIC PAIN

8. PAIN CATASTROPHIZING Overly negati ve thoughts about pain with a tendency to feel helpless and magnify the threat of pain. P ain will thereby interfere with daily activities. Rx 1. Self-efficacy 2. Coping strategies 3. Resilience

9. PSYCHOLOGICAL THERAPY Interdisciplinary pain treatment programme . Involve pt in Rx plan Pharma + non pharma Rx For example, CHRONIC LBA Ist LINE: SELF MANAGEMENT 2 nd LINE: SUPERVISED EXERCISE +CBT+PSYCHOLOGIC MANIPULATION REFRACTORY:PHARMAC/SURGICAL INTERVENTION

10. ???WHY NOT GAINING POPULARITY??? RESISTANCE ON PATIENT SIDE LOW RESOURCE LOW INSURANCE COVERGE UNCORDINATED HEALTHCARE SYSTEM

11. PHARMACOLOGICAL Rx

12. NSAID GROUP

13. ACETAMINOPHEN MOA: COX inhibitor DOSE: 650 mg orally every 4 to 6 hr; max 4000 mg/day INDICATION: Mild-to-moderate pain SIDE EFFECT: Overdose-liver damage OTHER INFO: No evidence of an effect on neuropathic pain

14. ASPIRIN MOA: COX inhibitor DOSE: 350–650 PO 4hrly ; Max:3600 mg/day INDICATION: Mild pain ( temporary use ), IRD SIDE EFFECT: GI, Bleeding,Hypersensitivity OTHER INFO: C/I in hypersensitivity ; Not for < 16(Reyes risk ); no e/on neuropathic pain

15. NSAIDS MOA: COX Inhibitor DOSE : Dose depends on the specific drug; recommended dose is the lowest effective dose for the shortest period INDICATION: Mild-to-moderate pain, pain associated with inflammation SIDE EFFECT: GI, risks of MI, CVA OTHER INFO: no e/on neuropathic pain

16. AMITRIPTYALINE MOA: TCA DOSE: 25–150 PO, OD/BD, max single dose: 75 mg , >75 mg/day with caution in > 65 yr of age INDICATION: Neuropathic ( Ist line ), Fibromyalgia, Prevention of tension type headache or migraine SIDE EFFECT: GI, CNS, Wt gain, orthostatic hypotension OTHER INFO: Low dose in CYP2D6 poor metabolism , no abrupt discontinuation; CI in recent MI/ rhythm disorder, caution with serotonergic agents

17. DULOXETINE MOA: SNRI DOSE: 60–120 mg PO, OD/BD INDICATION : Neuropathic( Ist line), chronic musculoskeletal pain, fibromyalgia SIDE EFFECT: GI, CNS, incr BP OTHER INFO: Abrupt discontinuation avoided ; caution with other serotonergic agents

18. GABAPENTIN MOA: DOSE: 900–3600 mg/d PO, TID INDICATION: First-line therapy for neuropathic pain SIDE EFFECT: Dizziness, somnolence, lack of coordination, blurred vision,peripheral edema,nausea OTHER INFO: Dose adjustment in compromised renal function; misuse, abuse , and dependence have been reported

19. PREGABALIN MOA: DOSE: 300–600 mg PO BD INDICATION: Neuropathic ( Ist line), fibromyalgia SIDE EFFECT: CNS, Edema, GI, Wt gain , disorientation OTHER INFO: Same as GABAPENTIN

20. LIDOCAINE PATCH (1.8 % or 5% patch) MOA: LA DOSE: 1–3 Patches to intact skinup to 12 hr/day INDICATION: Peripheral neuropathic pain SIDE EFFECT: Application-site pain, pruritus , erythema , and skin irritation OTHER INFO: Approved by FDA and EMA for postherpetic neuralgia only

21. Capsaicin , 8% patch MOA: LA DOSE: 1–4 Patches applied to intact skin for 30 or 60 min every 3 mo INDICATION: Peripheral neuropathic pain SIDE EFFECT: Application-site pain and erythema , transient increase in blood pressure; risk of reduced sensation OTHER INFO: Applied by a health care professional wearing nitrile gloves

22. INTERVENTIONAL SURGERY if underlying can be cured( tumor/ herniated disc) SPINAL CORD STIMULATION : painful DM neuropathy, Post sx Chronic back leg pain TRANSCRANIAL MAGNETIC STIMULATION : neuro , FM TRIGEM NEURALGIA : Microvascular decompression/ percutaneous radiofrequency rhizotomy . CLUSTER HEADACHE : Occipital nerve stimulation. CANCER: Epidural/ Intrathecal ( clonidine , bupivacaine , ziconotide )

23. COMPLEMENTARY THERAPIES MEDITATION&YOGA: improve wellbeing ACCUPUNCTURE &MASSAGE : ACP recommended for chronic LBA MUSIC THERAPY HEAT THERAPY GUIDED IMAGERY BIOFEEDBACK

24. CONCLUSION For the management of acute pain, the use of multiple approaches that do not include opioids and the establishment of acute pain services for postoperative pain management can reduce opioid -related adverse effects and dependence Patient education, psychological treatments, and avoidance of opioids may be useful for the management of chronic pain.