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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