Chronic Noncancer Pain

Info

🌱 來自: Huppert’s Notes

Chronic Noncancer Pain🚧 施工中

Chronic Noncancer Pain

•   Clinical:

-   Assess pain: OPQRST- Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Timing

-   Review past medical history, social history, psychological history (depression, anxiety, stress, ongoing substance abuse can exacerbate chronic pain)

-   Assess functional impairment

•   Physical exam: Full physical exam, additional maneuvers as appropriate if localized pain (e.g., back or knee)

•   Treatment: Recommend multi-modal approach:

-   Non-pharmacological: Patient education/reassurance, physical therapy (stretches, exercise), relaxation techniques (meditation, mindfulness practices), sleep hygiene, psychotherapy (cognitive behavioral therapy), acupuncture, massage, heat/cold packs

-   Pharmacological:

•   Topical agents:

-   Good for localized pain, low side effect profile, may be cost-prohibitive for some patients

-   Examples: OTC analgesic balm, lidocaine patches/gel (best evidence in postherpetic neuralgia), diclofenac gel (not systemically absorbed; may be used in ESRD), capsaicin (avoid mucosal surfaces)

•   Acetaminophen:

-   Most patients can take up to 4 grams/day; in liver disease, typically recommend only up to 2 grams/day

•   Non-steroidal anti-inflammatories (NSAIDs):

-   Caution if history of gastritis, AKI/ESRD

-   Examples: Ibuprofen, indomethacin, naproxen

•   Gabapentin/pregabalin:

-   Useful in neuropathic pain

-   Side effects: Sedation, dizziness. Renally cleared (adjust dose if renal impairment).

•   Tricyclic antidepressants (TCAs):

-   Useful in neuropathic pain; okay to use with or without coexisting depression

-   Examples: Nortriptyline, amitriptyline

-   Side effects: Sedation (highest with amitriptyline), anticholinergic side effects

•   Serotonin norepinephrine reuptake inhibitor (SNRIs):

-   Useful in neuropathic pain; okay to use with or without coexisting depression

-   Examples: Venlafaxine, duloxetine

-   Side effects: Nausea, insomnia; avoid duloxetine if hepatic or renal impairment

•   Muscle relaxants:

-   May be useful if muscular contractions/spasms (although limited evidence). Typically only prescribe a short course

-   Examples: Baclofen, carisoprodol

-   Side effects: Sedation, low muscle tone/weakness, risk of physical dependency and seizures with carisoprodol

•   Tramadol:

-   Opioid agonist, lower risk of dependence than opioids

-   Prescribe only short course (maximum 2 weeks)

-   Caution if using other serotonergic agents given the risk of serotonin syndrome

•   Opioids:

-   Generally not recommended for chronic non-cancer pain; may be appropriate for acute pain episodes

-   Examples: Oxycodone, hydrocodone, codeine

-   Side effects: Sedation, nausea/vomiting, constipation, tolerance, physical dependence

•   Monitoring:

-   Recommend frequent visits to monitor progress with pain relief. Use PEG scale (Pain, Enjoyment of life, and General Activity) during visits.

-   Set realistic expectations and goals

-   Consider early referral to pain specialist for procedural interventions if indicated (e.g., intra-articular injections, nerve blocks)