PDF Pharmacologic Treatment of Pain in Special Populations
7/2/2019
Pharmacologic Treatment of Pain in Special Populations
Kimberley Haynes-Henson, MD Associate Professor of Anesthesiology/Pain Management
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Objectives
? Identify classes of medications utilized for pain ? Discuss benefits an side effects of meds for geriatric,
pediatric, and obstetric patients ? Integrate the role of medication assisted treatment into
special populations
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Pediatric Pain
Common Pain Conditions in Children
Complex Regional Pain Syndrome Headaches
Abdominal Pain Cancer Pain
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Complex Regional Pain Syndrome
Typically extremity pain--non-dermatomal Allodynia, hyperalgesia, sudomotor dysfunction, neurovascular degeneration, loss of motor function, hair/nail growth changes, osteoporosis
Type I--No definable nerve injury Type II--Evidence of nerve dysfunction
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Budapest Criteria
Symptoms Continuing regional pain
Comments Disproportionate to inciting event
Sensory Vasomotor Sudomotor/edema Motor/trophic
Hyperalgesia Allodynia
Temperature asymmetry Skin color changes Skin color asymmetry
Swelling due to edema Sweating changes Sweating asymmetry
Decreased range of motion Motor dysfunction Changes in hair, skin, nail, bone
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Non-pharmacologic Options
Physical therapy--TENS units, active/passive modalities, desensitization, warm/cold baths, massage Behavioral therapy--biofeedback, visual guided imagery, structured counseling
with/without family members Multidisciplinary Pain Programs
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Pharmacologic Options
Antidepressants Anticonvulsants Systemic vasodilators--significant orthostatic hypotension Regional anesthesia and sympathetic blocks Opioids are typically not helpful
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Antidepressants
Tricyclics Amitriptyline anticholinergic effects Nortriptyline has fewer Both for neuropathic pain, cause QT prolongation
Serotonin/norepinephrine reuptake inhibitors--treat neuropathic pain and psychological comorbidities
Serotonin reuptake inhibitors--can treat pain-induced psychological issues
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Anticonvulsants
Gabapentin and pregabalin somnolence and weight gain--especially pregabalin
RCT of amitriptyline vs. gabapentin for pediatric CRPS I decreased pain, increased sleep, equally safe
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Brown S, et al. A randomized controlled trial of amitriptyline versus gabapentin for complex regional pain syndrome type I and neuropathic pain in children
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Low Dose Naltrexone
Competitive inhibitor of mu and kappa receptors at high doses Low dose--1-5 mg qd Inhibits microglial activation Decreases downstream activity leading to inflammation Transient opioid receptor blockade leading to upregulation of endogenous
opioids Used for autoimmune diseases--MS, infl bowel dz
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Trofimovitch D, et al. Pharmacology Update: Low-Dose Naltrexone as possible nonopioid modaligy for some chronic, nonmalignant pain syndromes
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High-Dose Ketamine Infusion
Young female adult, ................
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