Pain Management In The

Hospitalized Patient

Presented By R2
92/09/16
 Pain Introduction (1)
Neurotransmitters : substance P ,
glutamate , prostaglandins and
leukotrienes
spinothalamic and spinoreticular tracts
 Pain Introduction (2)
Hypothalamus, pons and
somatosensory cortex : stimulation of
these areas causes analgesia
Three endogenous systems involved in
the inhibitory pathways for pain: (1) the
opioid system, (2) the noradrenergic
system, and (3) the serotonergic system
 Pain Introduction (3)
Types of pain : somatic pain , visceral
pain , neuropathic pain
Evaluation and measurement of pain
Pain should be treated as a vital sign
 Acetaminophen
With the addition of acetaminophen, opioid
requirements can be reduced up to 30%
Hepatoxicity can occur with acute
intoxication with more than 15 g/day
500 ~ 1000 mg q3h ~ q6h
In liver disease : < 2 gm/d
In healthy : < 4 gm/d
Nonsteroidal anti-inflammatory
drugs (1)
Traditional NSAIDs are effective in the
treatment of mild to moderate pain, but their
use is limited by potentially serious adverse
effects
ketorolac : indicated only in the
management of moderately severe acute
pain that requires opioid level analgesics ;
no more than 5 days
Nonsteroidal anti-inflammatory
drugs (2)
COX-2 selective inhibitors [celecoxib
(Celebrex), rofecoxib (Vioxx) and
valdecoxib (Bextra)]
200-fold to 300-fold selectivity for
inhibition of COX-2 over COX-1
 Tramadol
centrally acting synthetic analgesic whose
mode of action is not completely
understood
minimal sedation or respiratory
depression
For moderate to moderately severe pain
 Antiepileptic drugs
Antiepileptic drugs have been used for
many years in the treatment of neuropathic
pain
phenytoin, carbamazepine, and valproic
acid
The newer agents, gabapentin appears to be
the most effective and well tolerated
 Phenytoin
postherpetic neuralgia
side effects include gingival hyperplasia and
even peripheral neuropathy
Dosage : 100 mg TID
Require blood test if long term used
 Carbamazepine ( Tegretol )
for trigeminal neuralgia, diabetic
neuropathy, and pain syndromes associated
with multiple sclerosis
hematological side effects and chronic use
also requires regular blood tests
Dosage : 100 mg/d up to 1200 mg/d
 Gabapentin (Neurontin)
postherpetic neuralgia and diabetic
neuropathy
Initial dosage : 300 mg TID , may up to
3.6 gm/d
 Antidepressants
Antidepressants are effective agents in the
treatment of neuropathic pain
serious side effects , include anticholinergic
effects including dry mouth, confusion, and
urinary retention
Imipramine ( Tofranil ) : 50~150 mg/d
The World Health Organization
three-step analgesic ladder
Each step of the WHO Analgesic Ladder
encourages the use of adjuvant analgesic
agents
Adherence to this guideline with
appropriate dosing of drugs can provide
adequate pain relief in 70% to 90% of
patients
Concerns surrounding the use of
opioids
fewer than 1 in 1000 patients using opioids
for pain would be expected to develop an
addiction
Addiction , Physical dependence ,
Tolerance
Addiction is not a predictable drug effect.
Physical dependence and tolerance are
predictable
 Conclusion
Pain is unnecessary.
Effective tools are available to help doctors evaluate pain in
their patients. Unrelieved pain should be treated just like any
other vital sign: with aggressive measures.
Effective therapies are available to treat pain. Use guidelines
to develop a rational plan to relieve pain.
Side effects are manageable. Anticipate side effects and treat
aggressively.
Addiction rarely occurs. Trust your patient when they report
pain. Tolerance and physical dependence can occur.
Plan and you will succeed. Take the initiative and focus on
relieving pain at your hospital. Your patients depend on it.
Thanks for Your
Attention !!!