Pain

Use one of the following standardized pain assessment tools to evaluate pain and monitor the effectiveness of pain management.

• PEG 3-Item Scale (Pain, Enjoyment and General Activity scale) Adapted from the brief pain inventory, assesses pain intensity and interference
• ESAS-r pain rating
• More detailed tool: AHS Initial Pain Assessment Tool

Consider psychosocial contributors and screen for co-existing mental health conditions as these will affect the pain experience:

• Depression
• Anxiety
• Others (Post-traumatic stress disorder, psychosis)

Ask about alcohol and other substance use as this may affect your management decisions.

• Links to structured screens:
• Alcohol use disorder: AUDIT-C (3 questions)
• Drug misuse screening: DAST-10 (10 questions)

Screen for opioid risk:

• Opioid Risk Tool-revised

These may have varying uptake and utility for each person and should be suggested on a case-by-case basis. Common examples:

• • Exercise
  • Mind-body practices (e.g. meditation/yoga)
  • Counselling

Nociceptive pain arises from damage or injury to nociceptors and encompasses both somatic (soft tissue, bone, joints) and visceral pain (from vital organs). This is often the most common type of pain.

Localized pain may respond to local treatment. For non-localized chronic pain, acetaminophen is recommended as first-line.

Neuropathic pain arises from structural or functional derangement of the tissues of the nervous system itself. Adjectives like burning or electrical may indicate neuropathic pain.

True neuropathic pain is uncommon. Gabapentin and pregabalin have the potential for misuse. Avoid prescribing these for pain unless you can make a clear diagnosis of neuropathic pain (see Chronic pain tips ).

• The risks and benefits of opioid medications need to be very carefully weighed in all patients, but particularly in those patients with cirrhosis.
• Consider opioids only in patients who have failed non-opioid therapies and have refractory pain that is significantly impacting quality of life and function
• Unless the practitioner is very experienced, assistance should be sought before using opioids in the following situations:

• • Contributing psychosocial determinants or untreated mental health disorders (see Total Pain Syndrome under Chronic Pain Tips)
  • High addiction risk (Opioid risk tool revised Link)
  • Uncontrolled hepatic encephalopathy (see CCAB HE page)

-Patients meeting these criteria often benefit from consultation with an inter-disciplinary Pain Clinic (earlier stages of cirrhosis), palliative care (end-of-life), hepatology (uncontrolled hepatic encephalopathy).

-If clinic wait lists are too long or rapid assistance is required, in Alberta, these specialists can be reached through RAAPID North (780-735-0811) or RAAPID South (403-944-4486).

–Click here for instructions on getting a telephone consultation at the University of Alberta Pain Medicine clinic.

• The use of opioids in people with more advanced liver disease has implications around pharmacokinetics and stigmatization around people who may be living with opioid use disorder. This requires careful attention to addressing opioid myths and monitoring for opioid toxicity (Guideline for treatment of opioid neurotoxicity).
• Review the results of the opioid risk tool revised. If the patient is at risk, suboxone (buprenorphine/naloxone) is recommended as the drug of choice, unless the prescriber has specific training in Addiction Medicine
• Educate the patient about expected side effects
• Review the patient’s Personal Pain Goal (numerical pain intensity they can function in the capacity they are best able, see general approach to symptom assessment box at top of page), in addition to goals for increased function and quality of life. Reinforce that in a best-case scenario, pain typically decreases by 30-50%
• Start low doses and titrate up slowly to the lowest effective dose
• Do not initiate long-acting formulations in patients with cirrhosis
• In physically or cognitively frail patients, some experts start with a single dose of an opioid at qhs to assess tolerance, and to add doses from there
• All opioids are associated with a risk of constipation and worsening hepatic encephalopathy.
• Order a bowel routine (see Constipation page) and for the first 3-5 days of therapy (or dose changes), order prn anti-nauseants (see Nausea page).
• Consider Home Care involvement if the patient is unable to take their own medications

If using opioids, ensure that you monitor for the signs of opioid toxicity and ensure timely management of this. Guidance on opioid induced neurotoxicity can be found here

AVOID

Non-steroidal anti-inflammatory drugs

• • Increases the risk of renal dysfunction and bleeding

Demerol

• • Build-up of toxic metabolites.

USE WITH CAUTION

Codeine

• • Pro-drug that requires conversion to morphine in the liver. Results in variable analgesia as liver dysfunction progresses.
  • Clearance can also be slowed, resulting in depressed ventilation. If used, start with lower doses and longer dosing intervals (15-30 mg PO tid), followed by careful titration. AVOID in Child Pugh C disease.

Oxycodone

• • Relies on CYP metabolism to its active metabolite. Unpredictable levels. No subcutaneous alternative for end-of-life.

Fentanyl transdermal patch

• • Do not use in opioid naïve patients
  • Avoid in “severe hepatic impairment”
  • Consult pain management specialist or if the patient is end-of-life, a palliative specialist

Tramadol/Tramacet

• • Requires activation by hepatic oxidation so effects may be less predictable with hepatic dysfunction. Avoid in Child Pugh C disease.
  • Lowers the seizure threshold.
  • Metabolism decreases with progression of liver disease, reducing the analgesic effect.
  • Be aware that Tramacet contains acetaminophen (daily total limit of acetaminophen is 2-3g over 24h)
  • The British Association for the Study of the Liver guidance recommends against use in cirrhosis

Non-steroidal anti-inflammatory drugs

• • Increases the risk of renal dysfunction and bleeding

Demerol

• • Build-up of toxic metabolites.

USE WITH CAUTION

• Ongoing pain reassessment (q 2-4 weeks) is critical (PEG, ESAS-r, Follow-up pain assessment tool)
• Uncontrolled pain is defined as >3 breakthrough doses per day for 3 consecutive days

1. Pain management remains suboptimal despite above approach.
2. An opinion about safety and limits of therapy is needed.
3. Assistance with management of Total Pain Syndrome is needed.
4. Tertiary palliative care unit or Hospice placement is required (Palliative Care specialist, may be regional variation).
5. Practitioner uncertain regarding any of the above steps.
6. Multi-symptom complexity, including pain.
7. Patient or family psychosocial distress compounding the pain experience.
8. Complex advance care planning in combination with pain.