Updates in pain management by Gavin Pattullo

Opioids are often a mainstay of therapy in trauma pain, though they are in turn the cause of much trauma. For every 4000 Australians prescribed an opioid there will be one death in the community as a result. In-patients similarly have greater risk of harm when their analgesia is opioid based.

This presentation will focus on some of the valuable lessons learnt in pain management resulting from the opioid crisis. These include:

1. Our need to differentiate clinically between pain and nociception. Pain - the affective unpleasant experience - is assessed by clinicians enquiring with the use of the words: coping, bothersomeness and troubling. While nociception is focussed on asking about physical feelings and sensations.

Profound levels of nociception and the potential to lead to reports of significant pain, a major feature of trauma patients, requires firstly a focus on the two most effective anti-nociceptive strategies of neural blockade and NSAIDs/COX-2 inhibitors before introducing less effective strategies.

1. Pain, the affective distressing unpleasant experience, when present with or without the use of anti-nociceptive strategies has historically been managed solely with biological strategies of opioids and adjuvant agents.  An increasing focus in clinical practice on non-pharmacological strategies to manage pain, including placebo enhancing communication strategies and message framing.
2. Avoidance of over-reliance on pain scores. Clinicians are too often misled and poor decisions are made when the robustness of pain scores is over-relied upon. Pain scores can be useful provided there is clear understanding in both the enquirer and the patient of whether the question is relating to the level of nociception or pain being experienced.
3. Ensuring optimal effectiveness of the opioid avoiding strategy of neural blockade. Four clinical assessment endpoints indicate effectiveness of neural blockade: presence of Dynamic pain relief, Analgesia, Sensory anaesthesia and Opioid sparing/elimination (DASO).

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