Hospitalized Chronic Pain Patient : A Multidisciplinary Treatment Guide

This practical guide provides the perspectives needed to treat acute and chronic pain in the hospital. Authored by experts of diverse specialty backgrounds, chapters bring the available evidence together with modern strategies for caring for patients with complex pain. Basic considerations and multimodal and multidisciplinary approaches with the greatest impact on minimizing suffering and burden of care are covered in detail. The material in this text will assist the learner, the teacher, and the life-long learning practitioner by providing basic considerations for treating acute and chronic pain in the hospital. This book may also serve as a quick reference, review manual or teaching tool by teachers on rounds. Preface Contents Contributors Abbreviations 1: Introduction to the Chronic Pain Patient Introduction References 2: Definitions Introduction Reference Part I: Pathophysiology 3: Acute Pain Relationship of Acute Pain to Chronic Pain Mechanism of Acute Pain Treatment of Acute Pain References 4: Chronic Pain Prevalence and Risk Factors Pathophysiology of Chronic Pain Phase I: Acute Surgical Response and Acute Pain Phase II: Centralized Chronic Pain Prevention and Treatment Principles of Chronic Pain Conclusion References 5: Opioid-Induced Hyperalgesia Clinical Examples of OIH Remifentanil Methadone Mechanism Underlying OIH References Part II: Admission and Consultation 6: History History of Presenting Illness Pain Assessment Tools Functional Status Past Medical History/Past Surgical History Medication List Review of Systems Psychological History Special Considerations Implantable Pain Devices: Spinal Cord Stimulator and Intrathecal Drug Delivery Device Post-Surgical Patients Patients with an Epidural Patients with a Peripheral Nerve Block Summary 7: Physical Examination Goals of the Exam Vital Signs Head and Neck Evaluation Neurological Examination Skin Examination Cardiovascular Examination Respiratory Examination Abdominal Examination Genitourinary Examination Extremity Examination Musculoskeletal Examination Examination of Surgical Site Examinations of Epidural Analgesia Examination of Peripheral Nerve Blocks Summary References 8: The SCRIPT History Template Introduction Pain Red Flags References 9: Patient Reported Outcomes Patient Reported Outcomes PROs in the Hospitalized Chronic Pain Patient General Strategy Frequency of Administration Specific Choice of Instrument Domain Selection Daily Instruments (Table 9.2) Longitudinal Instruments NIH’s Patient Reported Outcomes Measurement Information System (PROMIS—www.healthmeasures.net) Conclusion References 10: Clinical and Experimental Tools for Measuring Pain Introduction QST Methodology Stimulus Modalities and Target Tissues QST Response Measures Static Dynamic Clinical Relevance Predicting Clinical Pain Predicting Treatment Responses Conclusion References Part III: Cases 11: Case 1: High Dose Opioids and Multiple Pain Medications Considerations for Treatment of Acute on Chronic Pain High Dose Opioids Multimodal Analgesia Co-Morbid Conditions and Risk of Overdose References 12: Case 2: Buprenorphine Background Pharmacology Buprenorphine Formulations Buprenorphine Management for Surgery Regional and Neuraxial Anesthesia Option 1: Elective Surgery: Continue Buprenorphine Therapy, Consider Dose Reduction Option 2: Urgent/Unexpected Surgery: Use Clinical Judgment Case Discussion References 13: Case 3: Methadone Pharmacology Methadone Indications Methadone and QTc References 14: Case 4: Abdominal Pain Abdominal Wall Pain Chronic Pancreatitis Inflammatory Bowel Disease Gastroparesis References 15: Case 5: Unknown Pain Source Fibromyalgia Conservative and Alternative Management Pharmacologic Management Temporomandibular Joint Disorder Conservative Management Pharmacologic Management Interventional and Surgical Management Functional Abdominal Pain and Irritable Bowel Syndrome Conservative Management Pharmacologic Management Interstitial Cystitis Conservative Management Pharmacologic Management Interventional and Surgical Management Chronic Pelvic Pain Pharmacologic Management Interventional Management References 16: Case 6: Sickle Cell Disease Background Symptom Clinical Manifestations Acute Care Presentation Triage Management of Acute Pain Crisis Non-Opioid Analgesia Recommendations Role for Opioid Use for Acute Management of Pain Conversion Towards Chronic Pain Chronic Opioid Therapy Comorbid Psychological Disturbances Treatment Challenges References 17: Case 7: A Cancer Pain Crisis Treatments and Care Plan Outcome Multidisciplinary Approach and Considerations [5, 6] References 18: Case 8: Spasticity and Pain Treatments and Care Plan Multidisciplinary Approach and Considerations References 19: Case 9: Renal and Hepatic Disease Pharmacologic Impact of Renal Impairment Hepatic Disease References 20: Case 10: Chronic Pain Patient After Spine Surgery Review of Recent Literature Treatments and Care Plan Multimodal Therapy References 21: Case 11: Angry Patient Evidence Based Approaches for Difficult Encounters Treatments and Care Plan Approaching the Difficult Patient References 22: Case 12: Intrathecal Pain Pump Background MRI Compatibility Alarming Pump Intrathecal Infusion Considerations Case Scenario References 23: Case 13: Spinal Cord Stimulation Background Risks Scenario Treatment Recommendations References 24: Case 14: Opioid Use Disorder Introduction What Opioids Do to the Brain What Happens to People with an Addiction to Opioids Vulnerability to OUD and Co-Occurring Psychiatric Disorders The Best Way to Treat Opioid Addiction Recovery from Opioid Addiction Stigma: An Attribute, Behavior, or Condition That Is Socially Discrediting Opioid Withdrawal Symptoms Important Points to Remember (Tables 24.5, 24.6 and 24.7) Acute Pain Management in Patients Taking Buprenorphine for MAT Treating the Pregnant Patient References 25: Case 15: Comorbid Psychological Condition Literature Review Case Scenario Care Plan References 26: Case 16: Poor Prognosis in a Palliative Care Patient Treatments and Care Plan References 27: Case 17: Management of a Pain/Dyspnea in an Actively Dying Patient Outcome References Part IV: Medication Treatments 28: Opioids Common Opioids Opioid Cross-Tolerance Opioid Conversion Opioid Metabolites Opioid Rotation Opioid Addiction References 29: Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Background Types of NSAIDs Benefits Adverse Effects References 30: Acetaminophen Mechanism of Action Administration Dosage Contraindications References 31: Local Anesthetics What Are Local Anesthetics? Mechanism of Action Pharmacokinetics Metabolism Why Use Local Anesthetic Regional Techniques for the Chronic Non-cancer Patient With Acute Pain? Why Use Intravenous Lidocaine for the Chronic Non-cancer Patient with Acute Pain? What Are the Risks of Local Anesthetic Administration? Local Anesthetic Systemic Toxicity References 32: NMDA Antagonists Introduction Routes Side Effects/Toxicity Conclusion References 33: Alpha-2 Agonists What Are Alpha-2 Agonists? Clonidine Metabolism Tizanidine Metabolism Dexmedetomidine Metabolism Guanfacine Metabolism References 34: Gabapentin and Pregabalin Basics Mechanism of Action Dosing Adverse Effects References 35: Tricyclic Antidepressants and Serotonin-Norepinephrine Reuptake Inhibitors Tricyclic Antidepressants Initiation and Side Effects Serotonin-Norepinephrine Reuptake Inhibitors Duloxetine Milnacipran Venlafaxine/Desvenlafaxine Continuation as Inpatient References 36: Steroids Endogenous Steroids Role of Steroids in Pain Inflammatory Pain Neuropathic Pain Steroids in Cancer and Associated Conditions Administration Side Effects References 37: Cannabinoids Background Public and Mental Health Concerns References Part V: Interventional Treatments 38: Peripheral Regional Anesthesia Blocks Introduction Complications/Precautions References 39: Neuraxial Blocks Anatomy Technique Pharmacology Physiological Response Side Effects and Complications Conclusion References 40: Vertebroplasty and Kyphoplasty Background Literature Review Treatments and Care Plan [1] Multidisciplinary Approach and Considerations Case Result Summary References 41: Surgical Interventions for Pain Low Back Pain Osteoarthritis/Rheumatoid Arthritis Cancer-Related Musculoskeletal Pain References Part VI: Palliative Care 42: Opioid and Non-opioid Therapies in Palliative Care Non-opioid Therapies NSAIDs Corticosteroids Neuropathic Agents Cannabinoids Opioid Therapies Titration and Rotation Opioid Side Effects Constipation Nausea and Vomiting Sedation/Delirium References 43: Crisis Management and Refractory Pain Assessment of a Patient in a Pain Crisis Management of a Pain Crisis Opioids Route Starting Doses Titrate Based on Response Non-opioid Adjuvant Medications Refractory Pain Assessing for Psychological Distress References Part VII: Discharge 44: Transition to Outpatient Care and Readmissions Transition to Outpatient Care of the Surgical Patient Transition to Outpatient Care of the Medical Patient Special Considerations: Use of Controlled Substances Special Considerations: Caregiver and Family Support References 45: Opioid Tapering for Acute on Chronic Non-cancer Pain Why Taper Opioids for Patients with Acute on Chronic Non-cancer Pain? When to Taper Opioids for Acute on Chronic Non-cancer Pain How to Taper Opioids for Acute on Chronic Non-cancer Pain Consequences of Opioid Tapering Withdrawal Worsening Pain Conclusions References Index