General Approach to Treatment

Effect nn,o„es a„ e,a,m«o„ of .he ca,,e, duraUon ant „ne„s«y of the pain and selection of an appropriate treatment modality for the pain situation. Depending on the type of pain, treatment might involve pharmacologic and nonphar-macologic therapy or both. General principles for the pharmacologic management of pain are listed in the section: Patient Care and Monitoring. Two common approaches to the selection of treatment are based on severity of pain and the mechanism responsible for the pain (Fig. 33-2). Clinical practice guidelines for pain management are available from the APS, the Agency for Health care Research and Quality (AHRQ), the American Geriatrics Society (AGS), and the American Society of Anesthesiologists (ASA).

Selection of Agent Based on Severity of Pain

^^ Whenever possible, the least potent, oral analgesic should be selected. Guidelines for the selection of therapeutic agents based on pain intensity are derived from the World Health Organization (WHO) analgesic ladder for the management of cancer

pain (Table 33-1). Mild-to-moderate pain is generally treated with nonopioid analgesics. Combinations of medium-potency opioids and acetaminophen (APAP) or nonsteroidal anti-inflammatory drugs (NSAIDs) are often used for moderate pain. Potent opioids are recommended for severe pain. Throughout this progression, adjuvant medications are added, as needed, to manage side effects and to augment analgesia. While these guidelines can be useful for initial therapy, the clinical situation (type of pain), cost and pharmacokinetic profile of available drugs, and patient-specific factors (age, concomitant illnesses, previous response, and other medications) must also be con sidered. Pain medications might also be used in the absence of pain in anticipation of a painful event such as surgery to minimize peripheral and central sensitization.

Table 33-1 Selection of Analgesics Based on Intensity of Pain

Corresponding Pain Intaniily_Humeriml HüHrtQ

WHOThtMpeurk Ret am m en dations

ÍKJimpIfli of Inilifll



WonopunJ ¿njlgrai:; legulaf it Muled (khirii

Adrián opioid ^ the rrarwtiiüid tor modufalp ÎWifiçr^uli" «htiftjl«! 4bjhg

íwrtch toa high-potency Opmlt rcíjuljc ich«JlJ|«i ctosnq

Acplammophsn 1,000 mg liytfyt hours; tjupryicn tilO mg every 6 Irauri

Aíwarininophín 3ÎS fly] + oockHraf 60 <ng wcry 11vxirn

US mq + oxycodone 5 mg evfy 4 hours rAorphine l(Jmg every 4 hours; hyiomçfphgrie irigevfty \ hours tansidci ¿tiding an iitíjuncl (X ilrtrrvnc regimen if (Hin knot rcducrd jh t-2 dayi (oftjlder itep-up ih^rspy if pain h not "(¡liewd by two (a im^if (Éfienerw (Jri.135

WI-KtVlfcfM Health úí¿>ariiíAiií.ri. Hrom R<-í. y?.

WI-KtVlfcfM Health úí¿>ariiíAiií.ri. Hrom R<-í. y?.

FIGURE 33-2. Pain algorithm.

Mechanistic Approach to Therapy

Current analgesic therapy is aimed at controlling or blunting pain symptoms. However, diverse mechanisms contributing to the various types of pain continue to be further elucidated. An understanding of these new mechanisms of pain transmission might lead to improvement in pain management, as pharmacologic management of pain becomes more mechanism-specific. Use of NSAIDs for inflammatory types of pain is an example of a mechanistic approach. Since several mechanisms of pain often coexist, a polypharmacy approach seems rational to target each mechanism.

Two current foci in pain management are to identify the mechanisms that are responsible for pain hypersensitivity and to prevent this initial hypersensitivity. Therefore, the goal of pain therapy is to reduce peripheral sensitization and subsequent central stimulation and amplification associated with wind-up, spread, and central 17


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