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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Part I: Special Concerns in Pain Management

    Special Concerns

    Ongoing Assessment in Pain Management

    Special Concerns in Pain Management


    • The perception that the administration of opioid analgesics for pain management causes addiction is a prevalent myth that inhibits adequate pain control
    • Confusion about the differences between addiction, tolerance, and physical dependence is in part responsible
    • Addiction, as the term is now used, is a complex phenomenon involving:
      • Psychological dependence on drugs
      • Behavioral syndrome characterized by:
        • Compulsive drug use
        • Continued use, despite harm
    • Care must be taken to differentiate a true addiction (substance use disorder) from:
      • Pseudo addiction due to under treatment of pain
      • Behavioural/family/psychological dysfunction
      • Drug diversion with criminal intent
    • To manage pain effectively, physicians will need to educate patients, families, and other professionals about the inappropriate fear of addiction
      • Opioids by themselves do not cause psychological dependence
      • Addiction is a rare outcome of pain management when there is no history of substance abuse


    Pharmacologic Tolerance

    • Pharmacologic tolerance is the reduced effectiveness of a given dose of medication over time
    • Tolerance to side effects is observed commonly and is favorable
    • Tolerance to analgesia is rarely significant clinically when opioids are used routinely
    • Doses may remain stable for long periods if the pain stimulus remains unchanged
    • When increasing doses are required, suspect worsening disease rather than pharmacologic tolerance


    Physical Dependence

    • Physical dependence is the result of neurophysiological changes that occur in the presence of exogenous opioids
    • Similar outcomes occur in the presence of exogenous hormones and other medications (beta-blockers, alpha-2 agonists, etc)
    • Abrupt opioid withdrawal may result in an abstinence syndrome characterized by:
      • Tachycardia
      • Hypertension
      • Diaphoresis
      • Piloerection
      • Nausea and vomiting
      • Diarrhea
      • Body aches
      • Abdominal pain
      • Psychosis and/or hallucinations
    • Physical dependence is NOT:
      • The same as addiction
      • Evidence for addiction
    • Its presence does not mean that opioids cannot be discontinued
      • If the pain stimulus decreases or disappears, opioid doses usually can be reduced in decrements of 50% or more every 2 to 3 days, and finally stopped

      • If the dose is lowered too quickly and abstinence symptoms occur distressing symptoms may be settled with:

        • A transient increase in the opioid dose,
        • Treatment with clonidine, or
        • A small dose of a benzodiazepine (e.g., lorazepam)


    Pain Management among Patients with Substance Abuse Histories

    • Patients with histories of substance abuse can also develop significant pain, and they deserve compassionate treatment of their pain when it occurs
    • Most will need to adhere to strict dosing protocols
    • Contracting may become necessary
    • Physicians who are unfamiliar with these situations may need the help of specialists in pain management and/or addiction medicine


    Pain That Responds Poorly to Routine Opioid Therapy

    If dose escalation results in adverse effects, consider one of the following options:

    • More sophisticated adverse effect therapy, such as a psychostimulant, may help sedation
    • An alternate route of administration (e.g., intraspinal opioid)
    • Switch to an alternative opioid ("opioid rotation")
    • An adjuvant analgesic (e.g., NSAID) may help reduce the amount of opioid required
    • Nonpharmacologic approaches


    Ongoing Assessment in Pain Management

    • If pain control is inadequate, the dose of analgesics should be increased until either:
      • Pain relief is achieved, or
      • Unacceptable adverse effects occur
    • In contrast with acetaminophen and the NSAIDs, there is no maximum dose of a pure agonist opioid
    • If adverse effects become intolerable, effective pain control without the same adverse
      effects may be achieved through:
      • An alternative analgesic
      • An alternative route of administration
    • Some patients will also experience less pain spontaneously or with changes in their
      underlying cause
    • If the pain decreases or disappears, analgesic doses may need to be reduced or discontinued
    • Driving is safe for patients who:
      • Have good pain control on stable doses of an opioid
      • Are not experiencing any adverse effects (especially drowsiness)
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