SECTION I

NEUROPHYSIOLOGY OF PAIN AND ANALGESIA AND THE PATHOPHYSIOLOGY OF NEUROPATHIC PAIN

1

SECTION II

ASSESSMENT

13

1

Underlying Complexities of Pain Assessment

15

Failure to Assess Pain and Underestimation of Pain

15

Failure to Accept Patient’s Reports of Pain

17

Failure to Act on Patient’s Reports of Pain

19

Conclusion

19

2

Misconceptions that Hamper Assessment and Treatment of Patients Who Report Pain

20

Subjectivity of Pain

20

Pain Threshold: Uniform versus Variable

24

Pain Tolerance: High versus Low

24

Behavioral and Physiologic Responses to Pain

25

Causes of Pain

29

Addiction

32

Pain Relief from Placebos

42

Other Hidden Biases and Misconceptions

45

Conclusion

47

3

Assessment Tools

49

Tools for Initial Pain Assessment

49

Pain Intensity Rating Scales

54

Assessment of Neuropathic Pain

95

Assessment of Breakthrough Pain

101

Reassessment

102

Communication Strategies

119

Pain Assessment in Patients Who Cannot Self-Report

123

Conclusion

142

4

Other Challenges in Pain Assessment

143

Patients Who are Critically III

143

Patients Who are Unconscious

147

Patients Who are Intellectually Disabled

148

Patients Who are Mentally III

153

Cultural Considerations

159

SECTION III

NONOPIOID ANALGESICS

177

5

Indications for Administration of Acetaminophen or NSAIDs

181

Acute Pain

183

Persistent (Chronic) Pain

183

Nonopioid Plus Opioid

184

Conclusion

184

6

Adverse Effects of Acetaminophen and NSAIDs

185

Adverse Effects of Acetaminophen

185

Adverse Effects of NSAIDs

190

Hypersensitivity to Nonopioids: Respiratory and Cutaneous Reactions

207

Conclusion

208

7

Individualizing the Selection of Nonopioid Analgesics

209

General Considerations

209

Choice of Starting Dose and Dose Titration

217

Special Circumstances and Conditions

220

Conclusion

226

8

Perioperative Nonopioid Use

227

Effectiveness

227

Perioperative Multimodal Analgesia

228

Preemptive Analgesia

228

Accelerated Multimodal Postoperative Rehabilitation

229

Selected Nonopioids and Routes of Administration

230

Adverse Effects

233

Conclusion

238

9

Nonprescription Nonopioids

239

Buffered Aspirin

239

Caffeine

239

Antihistamines

240

Conclusion

245

10

Acute Overdose

247

Acetaminophen

247

Aspirin and Other Salicylates

247

Other NSAIDs

248

Conclusion

248

SECTION IV

OPIOID ANALGESICS

277

11

Physiology and Pharmacology of Opioid Analgesics

283

Groups of Opioids

283

Underlying Mechanisms of Opioid Analgesia and Adverse Effects

283

Pharmacologic Concepts

286

Conclusion

300

12

Key Concepts in Analgesic Therapy

301

Multimodal Analgesia

301

WHO Analgesic Ladder for Cancer Pain Relief

301

Preemptive Analgesia for Postoperative Pain Management

305

Accelerated Multimodal Postoperative Rehabilitation

306

Persistent Postsurgical Pain

307

Around-the-Clock (ATC) Dosing

308

PRN Dosing

312

Patient-Controlled Analgesia (PCA)

313

Conclusion

322

13

Guidelines for Opioid Drug Selection

323

Characteristics of Selected Mu Agonist Opioids

324

Other Mu Opioid Analgesics

353

Characteristics of Selected Agonist-Antagonist Opioids

356

Dual Mechanism Analgesics

360

Effects of Patient Characteristics on Opioid Drug Selection

362

Conclusion

367

14

Guidelines for Selection of Routes of Opioid Administration

368

Oral

368

Oral Transmucosal

378

Intranasal

384

Nebulized

386

Rectal

387

Stomal

389

Vaginal

389

Transdermal

390

Parenteral

396

Conclusion

401

15

Intraspinal Analgesia (Epidural and lntrathecal)

404

Spinal Anatomy

404

Delivery of Intraspinal Analgesics

408

Selected Analgesics Administered by the Intraspinal Routes

417

Complications Associated with the Intraspinal Routes of Administration

430

Operator Errors

438

Tapering and Cessation of Epidural Analgesia

440

Conclusion

440

16

Initiating Opioid Therapy

442

Selecting an Analgesic and Route of Administration

442

Selecting an Opioid Dose

443

Dose Titration

450

Opioid Range Orders

458

Conclusion

461

17

Intravenous Patient-Controlled Analgesia

462

Initial Intravenous Patient-Controlled Analgesia (PCA) Prescription

462

Titration of IV PCA

468

PCA by Proxy

468

Authorized Agent-Controlled Analgesia

470

Operator Errors: Misprogramming Analgesic Infusion Pumps

471

Infusion Solution and Tubing Changes

471

Tapering and Cessation of Parenteral Analgesia

471

Conclusion

472

18

Switching to Another Opioid or Route of Administration

473

Switching from Epidural to IV Opioid Analgesia

478

Switching from IV to Oral Opioid Analgesia

478

Switching from Oral to IV Opioid Analgesia

479

Switching from Multiple Opioids and Routes to One Opioid and Route

480

Switching from an Oral Opioid to Epidural Analgesia in Opioid-Tolerant Patients

481

Conclusion

482

19

Management of Opioid-Induced Adverse Effects

483

Constipation

484

Postoperative Ileus

491

Nausea and Vomiting in Patients Receiving Long-Term Opioid Therapy

492

Postoperative Nausea and Vomiting (PONV)

493

Biliary Spasm

498

Pruritus

499

Hypotension

501

Urinary Retention

502

Myoclonus

502

Mental Status Changes

503

Sedation or Cognitive Impairment During Long-Term Opioid Therapy

565

Sedation during Short-Terrn Opioid Therapy in Opioid-NaïVe Patients

509

Respiratory Depression

513

Conclusion

522

20

Unwarranted Withholding of Opioids

523

Long-Term Opioid Use in Patients with Persistent Noncancer Pain

523

Withholding Opioids from Patients with Addictive Disease

527

Opioid Use during Pregnancy

530

Opioid Use during Breast-Feeding

533

Opioid Use in the Critically III

533

Managing Pain in the Terminally III

535

Conclusion

537

SECTION V

ADJUVANT ANALGESICS

623

21

General Considerations in the Use of Adjuvant Analgesics

631

Drug Selection

631

Dosing

632

Variability in Response

632

Patient Co-Morbidities

632

Adjuvant Analgesics during Pregnancy and Breast-Feeding

632

Multimodal Therapy

633

Polypharmacy

633

Positioning of Treatment

634

Conclusion

635

22

Multipurpose Adjuvant Analgesics

636

Antidepressant Drugs

636

Corticosteroids

645

Alpha₂-Adrenergic Agonists

648

Cannabinoids

650

Conclusion

652

23

Adjuvant Analgesics for Persistent (Chronic) Neuropathic Pain

653

Anticonvulsant Drugs

653

Sodium Channel Blockers

666

Gamma Aminobutyric Acid (GABA) Agonists

672

N-Methyl-D-Aspartate (NMDA) Receptor Antagonists

674

Ziconotide

680

Conclusion

683

24

Topical Analgesics for Persistent (Chronic) Pain

684

Lidocaine Patch 5%

684

EMLA

688

Other Local Anesthetics

689

Capsaicin

689

Antidepressants

691

Anticonvulsants

691

Clonidine

691

Ketamine

692

Summary of Indications for Topical Analgesics for Persistent Pain

692

Summary of Adverse Effects of Topical Analgesics for Persistent Pain

692

Conclusion

692

25

Adjuvant Analgesics for Musculoskeletal Pain

693

Skeletal Muscle Relaxants

693

Benzodiazepines

695

Conclusion

695

26

Adjuvant Analgesics for Postoperative and Other Acute Pain

696

Continuous Peripheral Nerve Block

696

Continuous Local Anesthetic Wound Infusion

704

IV Lidocaine

705

Anticonvulsants

707

Clonidine

710

Corticosteroids

712

N-Methyl-D-Aspartate (NMDA) Receptor Antagonists

713

Conclusion

717

27

Adjuvant Agents for Goal-Directed Sedation in the Critically III and for Procedural Sedation

718

Propofol

718

Fospropofol

722

Dexmedetomidine

722

Benzodiazepines

724

Ketamine

725

Conclusion

725

28

Local Anesthetics for Procedural Pain

726

Infiltrated Lidocaine

726

EMLA

727

L.M.X.4

729

Synera

729

Jet Injection

729

LET, TLC, and TAC

730

Other Local Anesthetic Approaches for Procedural Pain

730

Conclusion

732

29

Adjuvant Analgesics for Persistent (Chronic) Bone Pain

733

Calcitonin

733

Bisphosphonates

734

Radiopharmaceuticals

735

Conclusion

736

30

Adjuvant Analgesics for Malignant Bowel Obstruction

737

Anticholinergic Drugs

738

Octreotide

739

Corticosteroids

740

Conclusion

740

31

Adjuvants Less Often Used

741

Psychostimulants and Anticholinesterases

741

Calcitonin

742

Neuroleptics

743

Benzodiazepines

743

Adenosine

744

Antihistamines

744

Botulinum Toxin Type A

744

Vitamin D

745

Nicotine

745

Alcohol (Ethanol)

746

Conclusion

746

Appendix A

Pain Resources on the Internet

819

Appendix B

Clinical Aspects of the Use of Opioid Agreements for Chronic Noncancer Pain

827

Appendix C

Use of Electronic Medical Records in Pain Management

837

Appendix D

Terminology

858

Index

863