Practical Treatment of Wound Pain and Trauma: A Patient-Centered Approach. An Overview

Madhuri Reddy, MD, FRCPC(Geriatric Med); Rosemary Kohr, RN, MScN, ACNP; Douglas Queen, BSc, PhD, MBA; David Keast, MD, FCFP; and R. Gary Sibbald, MD, FRCPC(Med)(Derm)

However, consensus statements from major professional pain organizations (eg, the Canadian Pain Society, the American Academy of Pain Management, and the American Pain Society) endorse their use in appropriate situations, and the practice is becoming more acceptable.4 Although healthcare providers have been reluctant to prescribe these drugs because of political and social pressures, the incidence of addictive behavior among patients taking opioid drugs for medical reasons is low.32-35
Consultation with a specialist in pain medicine may be needed, but unfortunately these consultants are not always available on a timely basis to primary care physicians. Therefore, a consultation with a specialist in pain management should not be a prerequisite to the use of opioid therapy.36
Opioid peak concentrations occur 60 to 90 minutes after oral ingestion. When given as breakthrough doses for dressing changes, these drugs should be given in the appropriate time frame to be effective (see Table 3).
Long-term opioid therapy should be started at low doses and carefully titrated until an adequate level of analgesia is obtained or until unmanageable side effects occur. Use of combination products (eg, oxycocet [Oxycet, Technilab, Quebec, Canada, or Percocet, Dupont Pharma, Ontario, Canada]) may be limited because of ceiling doses of acetaminophen or acetylsalicylic acid (ASA) which are combined with the opioid. In addition, these combination medications often contain caffeine as a co-analgesic and may be undesirable in some patients. Use of an opioid with a long duration of action has many advantages for treating chronic pain: It can facilitate patient adherence and provide a more consistent blood level (hence, fewer side effects).37 Breakthrough opioid doses should be provided and may be used, for example, before dressing changes. The goal of optimal opioid titration is to decrease the frequency of breakthrough doses to a minimum.36
Methadone is a potent µ-opioid-receptor agonist. It can be an effective medication for treatment of chronic pain and may slow the development of opioid tolerance. However, it is difficult to titrate because of its long and variable half-life.38 Clinicians prescribing methadone must be experienced with its use in closely monitored settings.39 In some jurisdictions, methadone prescription is limited to specifically authorized physicians who prescribe it primarily for the treatment of drug habituation (see Table 4).
Monitoring side effects of opioid therapy should focus on neurologic, gastrointestinal, and cognitive-behavioral effects. Common side effects should be anticipated and prevented before they become severe problems. A prophylactic bowel regimen should be initiated with the commencement of persistent opioid therapy.
Adjuvant drugs. A number of drugs developed for purposes other than analgesic may alter or modulate pain perception. Selective serotonin-reuptake inhibitors (SSRI) have improved the treatment of depression, but have not been effective against pain. Amitriptyline, nortriptyline, desipramine (all antidepressants) and gabapentin (an anti-epileptic) may be considered alternatives but should be used with caution in the elderly as they may cause unacceptable side effects.
Drugs to avoid. Meperidine should be avoided in treating chronic pain, particularly in the elderly patient, because of the increased risk for seizures. It is best used in the short term for acute pain. Other drugs that are also not recommended include pentazocine.16

Patient-Centered Concerns in Wound Care
Pain in the context of wound care often has been described as the patient's subjective experience. However, more often than not, it is the caregiver who interprets patient pain according to his/her own cultural/environmental perspective.


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