Module 7: Pain Management – Topic C Provide information on pharmacological and non-pharmacological management of pain to persons experiencing pain, including the risks, benefits, and place in therapy of each alternative.

Learning Objectives

By the end of this topic, the student should be able to:

• Identify pharmacological and non-pharmacological interventions for the management of pain.
• Describe the risks and benefits of therapeutic interventions for pain medication.
• Develop a plan of care that includes educating persons experiencing pain about alternative interventions.
• Demonstrate an appreciation of pain as a private, individualized experience affected by multiple factors.

Key Concepts

• Pain is an individual experience for each person and is affected by multiple factors, including age, gender, culture, previous experience of pain, anxiety, fear, and so on.
• Pain tolerance is also an individual experience that can vary depending on the situation within which the person is experiencing pain.
• The goal of pain management is improved function and a reduction in the intensity and frequency of symptoms, not necessarily the complete elimination of pain. Realistic expectations and frequent reassessment are recommended as a means of recognizing incremental gains and refocusing goals.
• Numerous non-pharmacological interventions, such as relaxation, meditation, and massage, have been shown to be effective in ameliorating pain.
• Different types of pain may respond differently to pharmacological and non-pharmacological interventions.
• Management of pain requires a detailed and comprehensive assessment of pain, as well as regular and frequent reassessments.
• Trials of non-opioid interventions need to be adequate in terms of duration, dosage, and frequency and include pain reassessment.
• Non-pharmacological options may be used alone or in combination with pharmacological interventions to develop a comprehensive, individualized plan of care.
• Optimal management of chronic pain requires a multidisciplinary team approach.
• Opioids used in the management of chronic non-cancer pain should be administered on a regular schedule, not as needed (PRN).
• Trusting relationships between health and social service providers and persons experiencing pain are required for optimal care. The plan of care should always incorporate the person’s goals.

Treatment of Pain

Numerous and varied pharmacological and non-pharmacological interventions are available to people experiencing pain, whether acute or chronic. The use of a pain management intervention may be limited by:

• side effects
• risks
• cost
• availability
• efficacy, or
• the availability of needed support.

A combination of optimum pharmacological and non-pharmacological interventions is the best approach for most people.

NOTE: The likelihood that pain management will be successful is increased by a trusting relationship between the person and the health and social service provider, and the availability of an interdisciplinary team to assist in pain management.

Non-Pharmacological Interventions for Pain Management

A variety of non-pharmacological interventions are available for the management of acute and chronic pain that vary in efficacy. Those that have shown small to moderate effects in managing pain include the following:

Acute Pain

• Reassurance – client education focusing on the likelihood of a positive outcome has shown benefit in treating acute back pain. In general, a confident and reassuring attitude on the part of the health and social service provider is recommended when treating people experiencing pain.
• Diversion or distraction – using visual or auditory distractions such as virtual reality and relaxation music, respectively, has been shown to reduce the experience of acute pain (De Silva et al., 2016).
• Application of cold packs and heat – using a combination of cold and heat therapy has been shown to improve acute low back pain (Dehghan & Farahbod, 2014).

Chronic Non-Cancer Pain

• acupuncture and acupressure
• massage
• physiotherapy (specific targeted exercises, such as stretches)
• low-level laser therapy
• yoga
• tai chi
• application of heat or cold
• psychotherapy, such as cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT), operant therapy, progressive relaxation, electromyography feedback, mindfulness meditation
• music therapy
• pet therapy
• therapeutic touch
• transcutaneous electrical nerve stimulation (TENS)

Benefits

Non-pharmacological interventions generally carry a low risk for side effects and adverse events.

Drawbacks

• Non-pharmacological interventions can be prohibitively expensive for persons who have no additional health care coverage or who are geographically disadvantaged in terms of access.
• Access to clinician-led interventions (e.g., psychologist, occupational therapist) can be difficult and expensive.
• There are digital options for CBT and other behavioural methods, as well as mindfulness meditation, but these can also be expensive, and the efficacy of these approaches is not well known.

Pharmacological Interventions for Acute Pain

A variety of non-opioid and opioid analgesics reduce acute pain.

Acetaminophen

Acetaminophen is used for mild to moderate pain.

Risks

• hepatotoxicity (liver damage) with overuse or in persons with active liver disease

Benefits

• fewer side effects and adverse events than full-dose non-steroidal anti-inflammatories

Non-Steroidal Anti-Inflammatories (NSAIDS)

NSAIDs including ibuprofen, naproxen, and ketorolac. They are used to manage mild to moderate acute pain.

Risks

• gastrointestinal upset, peptic ulcer disease
• must be used with caution in persons with asthma, heart failure, renal failure, and hypertension

Benefits

• effective analgesic, antipyretic, and anti-inflammatory

Opioids

Opioids, including morphine, hydromorphone, and oxycodone, have potent analgesic effects.

Risks

• depression of physiological systems
• central nervous system (decreased respirations, sedation), and gastrointestinal system (constipation)
• long-term use can cause hormonal changes that can result in changes in mood, sexual function, amenorrhea (absence of menstruation), gynecomastia (breast enlargement), hyperalgesia (when opioids worsen pain instead of improving it), tolerance, dependence and withdrawal, and opioid use disorder (from Module 7, Topic B)
• risk for overuse, abuse, diversion

Benefits

• no major organ toxicity

Pharmacological Interventions for Chronic Pain

In addition to the treatments available to relieve acute pain, chronic pain can also be treated with other pharmacological interventions.

Tricyclic Antidepressants

Tricyclic antidepressants such as nortriptyline, desipramine, and amitriptyline.

Risks

• anticholinergic effects (dry mouth, constipation, urinary hesitancy, urinary retention in persons with benign prostatic hypertrophy, tachycardia)
• orthostatic hypotension
• delirium
• lowered seizure threshold
• sexual dysfunction
• cardiac arrhythmia, Q-T prolongation

Benefits

• effective in treating neuropathic pain
• improves sleep

Serotonin Norepinephrine Reuptake Inhibitor (SNRI) Antidepressants

SNRI antidepressants such as venlafaxine and duloxetine.

Risks

• CNS effects: drowsiness
• fatigue
• GI upset, nausea
• sleep disturbance
• dose-related hypertension (>225 mg per day of venlafaxine)

Benefits

• effective for neuropathic pain

Anticonvulsants

Anticonvulsants such as gabapentin, divalproex, topiramate, pregabalin, and carbamazepine

Risks

• relatively common for most anticonvulsants: dizziness, somnolence, headache, confusion or abnormal thinking, weight gain or weight loss
• gabapentin and pregabalin can be associated with misuse

Benefits

• demonstrated efficacy in the treatment of neuropathic pain and migraine prophylaxis (gabapentin, divalproex, topiramate)
• may be useful against sharp, stabbing, or zinging pain
• pregabalin has been shown effective in the treatment of postherpetic neuralgia, diabetic neuropathy, and fibromyalgia and has a positive effect on sleep

Cannabinoids

Cannabinoids, which include CBD (cannabidiol)/THC (tetrahydrocannabinol) in cannabis plant material and pharmaceutical cannabinoids.

Risks

(listed in order of decreasing frequency)

• CNS effects: sedation, dizziness, ataxia, numbness
• disturbance in attention or disconnected thoughts, impaired memory, disorientation or confusion
• blurred vision or visual hallucinations

Benefits

NOTE: very low-quality evidence from studies (Mücke et al., 2018)

• chronic pain (neuropathic and cancer): ~30% efficacy of cannabinoids
• neuropathic pain: ~30% efficacy of cannabinoids
• could consider for refractory neuropathic pain or for pain in palliative care

Topical Anesthetics

Topical anesthetics, including lidocaine topical 5% and lidocaine/xylocaine 5% for localized pain.

Risks

• few; possible local reaction
• unintended non-adherence or errors in administration—patch should be used 12 hours on and 12 hours off for localized pain

Benefits

• effective in postherpetic neuralgia.
• can be used for localized neuropathic pain if oral medication contraindicated

Topical Capsaicin

Topical capsaicin which includes capsaicin 0.025% or 0.075%.

Risks

• local burning, stinging, or erythema
• needs an adequate trial of 6–8 weeks

Benefits

• efficacy in treating neuropathic pain and musculoskeletal pain

Topical NSAIDs

Topical NSAIDs, such as diclofenac and ketoprofen (compounded).

Risks

• little evidence of efficacy in chronic non-cancer pain
• local irritation

Benefits

• fewer systemic side effects than oral preparations

Questions

True or false: A trusting relationship with a health and social service provider is required for optimal care.

a. True

b. False

Correct! Significant positive outcomes have been reported when the person experiencing pain and the health and social service providers providing interventions collaborate in developing the plan of care.

Incorrect. The correct answer is a. Significant positive outcomes have been reported when the person experiencing pain and the health and social service providers providing interventions collaborate in developing the plan of care.

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Which of the following is a risk when using non-steroidal anti-inflammatory medication for the management of pain?

a. Delirium

b. Gastric upset

c. Sexual dysfunction

d. Hepatotoxicity

Correct! Gastric symptoms are the most common side effects of NSAIDs.

Incorrect. The correct answer is b. Gastric symptoms are the most common side effects of NSAIDs.

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When educating a person about the use of cannabinoids for the treatment of pain, how would you describe the evidence-based benefits?

a. No benefits

b. Known to reduce pain

c. Studies of low quality

d. No studies have been done

Correct! There have been some studies of the use of cannabinoids in pain management, but the results are limited by the low quality of the studies.

Incorrect. The correct answer is c. There have been some studies of the use of cannabinoids in pain management, but the results are limited by the low quality of the studies.

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Which of the following are non-pharmacological interventions that have proven beneficial in the treatment of chronic non-cancer pain? Select all that apply. (Select all that apply.)

a. Cognitive Behavioural Therapy (CBT)

b. TENS

c. Acupuncture

d. Massage

Check

Please select an answer.

Correct! Non-pharmacological interventions have been shown to be effective as adjunctive therapy for persons experiencing chronic non-cancer pain.

Incorrect. The correct answers were a, b, c, and d. Non-pharmacological interventions have been shown to be effective as adjunctive therapy for persons experiencing chronic non-cancer pain.

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References