1. APSA/SIA PAIN MANAGEMENT Project
Pain Consultations 101
Melissa Durham, Pharm.D.
September 14th, 2011

2. Acute vs. Chronic Pain Characteristic Acute Pain Chronic Pain
(No Self-Treatment)
Relief of Pain
Highly Desirable
Dependence & Tolerance to Medication
Unusual
Common
Psychological Component
Usually Not Present
Often a Major Problem
Organic Cause
Often Not Present
Environmental Contributions & Family Involvement
Small
Significant
Insomnia
Common Component
Treatment Goal
Cure
Functionality

3. Assessment of Pain SCHOLAR
Symptoms
Describe the symptoms you are experiencing
Characteristics/Course
Is the pain throbbing, sharp, dull, tingling? Rate the pain on a scale of 1-10
History
How does it compare to other pain experienced? Has it gotten worse over time?
Onset
When did the pain start?
Location
Where is the pain located? Does it stay localized to one area or does it spread?
Aggravating factors
What makes the pain worse?
Relieving factors
What makes the pain better?

4. Common Indications for NonRx Analgesics
Temporary relief of minor aches and pain associated with the common cold
Reduction of fever
Sore throat
Headache (Episodic Tension, Migraine, Sinus)
Muscle aches
Minor aches and pains of arthritis
Acute back pain
Menstrual pain

5. NonRx Pain Medications
Acetaminophen, AKA APAP (Tylenol)
Mild-moderate pain, fever, headaches
NSAIDs
Ibuprofen (Motrin, Advil)
Naproxen sodium (Aleve)
Mild-moderate pain, headaches, muscle pain, menstrual pain
Salicylates
Aspirin AKA ASA (Ecotrin, Bayer)
Mild-moderate pain, muscle pain, menstrual pain, cardioprotection
Topicals (IcyHot, Bengay)
Muscle soreness, muscle pain, osteoarthritis

6. Acetaminophen (APAP) Brand Name – Tylenol®, FeverAll®
Class – Analgesic/Antipyretic
Not effective as an anti-inflammatory
Very few side effects
Liver toxicity a major concern with chronic high doses
Very few drug interactions
Warfarin, alcohol
DOC in pregnancy/breastfeeding

7. Aspirin (ASA)
Used mostly for primary and secondary prevention of thrombotic events
Ex. Aspirin 81mg/day
Has anti-inflammatory properties, but only at high doses
Major side effects are bleeding, GI ulcers, bronchospasm in patients with asthma
More DDIs than APAP
NOT for use in pregnancy/breastfeeding
Counseling point: TAKE WITH FOOD

8. NSAIDS Ibuprofen, naproxen sodium
More effective than APAP and ASA for most pain conditions
Analgesic and anti-inflammatory effects
Major side effects are bleeding, GI ulcers, bronchospasm in patients with asthma, increased blood pressure, fluid retention
Generally avoid in pregnancy but OK in breastfeeding
Counseling point: TAKE WITH FOOD

9. Topical Analgesics/Counterirritants
Used for minor aches and pains of muscles and joints, muscle soreness, osteoarthritis, lower back pain, neuropathy
Ben-gay, Icy-hot, Salonpas
Methyl salicylate, camphor, menthol, capsaicin
Combinations
Apply 3-4 times daily for a max of 7 days
Do not apply immediately after a hot shower or bath, do not use with a heating pad
Wash hands after applying

10. Types of Headache

11. Triggers of Tension Headache
Stress
Anxiety
Depression
Emotional conflicts
Fatigue
Repressed hostility

12. NonRx Options for Episodic Tension Headache
Excedrin® Tension Headache
500mg Acetaminophen + 65mg caffeine
APAP
Ibuprofen
Naproxen
Other combo products

13. Nonpharmacologic Treatment of Tension Headache
Physical therapy
Relaxation exercises
Massage
Topical Peppermint oil
Applied to forehead and temples

14. Migraine Triggers Stress Fatigue Oversleeping Fasting, missing a meal
Alcohol
Changes in barometric pressure or altitude
Menses
Hormone changes
Magnesium deficiency
Foods with nitrites, tyramine, phenylalanine, MSG, caffeine

15. Non-Rx Pharmacologic Therapy for Migraine Headache
Excedrin® Migraine
Acetaminophen 250mg/Aspirin 250mg/Caffeine 65mg
2 tabs at onset, no more than 2 tabs per 24 hours
Advil® Migraine
Ibuprofen 200mg (liquid filled)
2 caps at onset, no more than 2 tabs per 24 hours
Other analgesics will work, NSAIDs probably best
Initiate NSAIDS 2 days before menses for menstrual migraine
Self-treatment is only for patients who have been diagnosed with migraine by a physician

16. Nonpharmacologic Therapy for Migraine Headache
Regular sleeping & eating schedule
Avoidance of triggers (food, stress)
Cold packs + pressure
Lie in a dark, quiet room
Keep a headache journal

17. Go see MD! Symptoms of cluster headache
Symptoms of migraine headache with no formal diagnosis
Chronic tension headache (>15 days/month for > 6 months)
Severe pain (pain score 8-10)
Signs of infection (fever, purulent discharge, altered mental status)
Headache that
Lasts more than 10 days
Occurs more than 3 times a week
Not managed by NonRx dosing

18. Acute Low Back Pain Possible causes Inactive lifestyle Poor posture
Improper shoes
Excess body weight
Poor mattress
Poor sleeping posture
Improper lifting techniques

19. Acute Low Back Pain Chronic low back pain ( > 4 weeks) - Refer
Most back pain disappears with home treatment and self-care
Treatment options
NSAIDs
Topical analgesics
Alternating heat/cold
Massage
Chiropractic manipulation
Moderate physical activity when not acutely injured
Chronic low back pain ( > 4 weeks) - Refer

20. Sprains & Strains Strains – injury to muscle or tendons
Sprains – injury to ligaments
Overextension of the joint
Ankle inversion most common
Strains – injury to muscle or tendons
Overuse or improper use
Symptoms: Pain, bruising, loss of some function, stiffening
Treatment
RICE Therapy
NonRx NSAIDS

21. Compress the area with elastic support.
Rice Therapy
Rest the injured area.
Ice the area in 10 minute intervals, 3 – 4 times a day for 1 – 2 days.
Compress the area with elastic support.
Elevate the area above the heart for hours to decrease swelling and pain.

22. Muscle Pain (Myalgia) NSAIDS ATC
Delayed-onset muscle soreness most common and is self-treatable
Other types - Refer
NonRx treatment:
NSAIDS ATC
Topical Preparations (Salicylates, Camphor, Menthol)

23. Osteoarthritis Nonpharmacologic Therapies NonRx Therapies
Low-impact exercise
Weight-loss
Shock-absorbing shoes
Physical and occupational therapy
Acupuncture
NonRx Therapies
Tylenol is drug of choice
NSAIDS
Glucosamine & Chondroitin: Not for people
with shellfish allergy, may raise blood sugar in diabetics, may increase the effect of warfarin
Topical analgesics/counterirritants

24. Menstrual Pain OTC treatment options: Midol® Menstrual Complete:
(Acetaminophen 500mg/Caffeine 60mg/Pyrilamine 15mg)
Midol® Extended Relief
(Naproxen sodium 220mg)
Midol® Cramps and Body Aches
(Ibuprofen 200mg)
Midol® Teen Formula
(APAP 500mg/Pamabrom 25mg)
NonRx NSAIDs are the treatment of choice at MAX OTC doses

25. Nonpharmacologic Treatment for Menstrual Pain
Heating pads
Regular exercise
Loose clothing
Massage
Smoking cessation

26. Do’s and Don’ts Do Don’t Give advice and make suggestions
Determine if nonprescription medications will help
Provide resources
Suggest options and let people know their pain may be managed
Use common sense
Don’t
Say something you are not sure about
Diagnose or suggest specific prescription therapy
Recommend self-treatment when not appropriate
Give false hope

27. Community Resources USC pain center: 323-442-6202 Referral Sources:
American Chronic Pain Association (
American Pain Foundation (
American Headache Society (
Arthritis Foundation (
Referral for pain management:
American Chronic Pain Association at
Local hospice or cancer center  often know good pain specialists
USC/Norris Comprehensive Cancer Center (323) , ask for referral to pain specialist
USC pain center:
For those without a doctor or insurance:
Local hospital’s social services department or local health department
LA Social Services Info Line at
LAC/USC Referral Line at
Patient Advocate Foundation at
Poison Control:

28. Questions?