Transcript Document

END-OF-LIFE CARE:
Module 2
Pain Management
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Case of Mrs. Dolores Long
Mrs. Dolores Long is a 70-year old widowed African American female
who was recently diagnosed with lung carcinoma and metastasis to
bone. She is being admitted to the hospital for a round of
chemotherapy.
A medical resident performs the admission H&P. Mrs. Long denies any
symptoms. Physical examination is unremarkable. Mental status exam
is significant for flat affect and poor eye contact. The resident finishes
the exam and leaves the room. Mrs. Long’s daughter steps outside
with the resident and explains that her mother has complained of
severe pain and has become sedentary and withdrawn. She has
refused the acetaminophen with codeine that was prescribed because
she doesn’t want to “get hooked,” and the pills don’t help anyway.
The resident is surprised, as Mrs. Long did not appear to be in pain.
He explains that “nothing more can be done” for the pain, as strong
narcotics like morphine might cause her to stop breathing and NSAIDs
like ibuprofen could cause GI bleeding. However, psychiatry will be
consulted to evaluate her depression.
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Learning Objectives
Recognize and address barriers to effective
EOL pain care
Develop a better understanding of attitudes and
beliefs about pain management
Improve your knowledge and skills in assessing
and treating pain
Incorporate this content into your clinical
teaching
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Outline of Module
Background
Barriers to treating pain
Pain Assessment
Non-pharmacologic treatment approaches
Break
Pharmacologic strategies
Pain medications
Application exercise
Summary and goals
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Pain in the Hospitalized
Seriously Ill
50% of conscious patients were in moderate to
severe pain at least half the time in the three
days prior to death
SUPPORT Study (1995), N = 9105 patients
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Pain in Nursing Home Patients
• 30% reported daily pain
• 26% of these patients received no analgesia
• Only 26% of them received strong opioids
What predicted inadequate pain management?
• Advanced age: >85 years old
• Poor cognitive function
• Minority status
Bernabei (1998), N = 13,625 cancer patients
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Pain in Outpatients
• 67% outpatients with metastatic CA were in pain
• 42% of those not given adequate analgesic therapy
What predicted inadequate pain management?
• Discrepancy between patient and MD assessment of
pain
• Advanced age: >70 years old
• Female
• Better performance status
• Minorities
Cleeland (1994), N = 1308
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Pain in 103 Children who Died
of Cancer or its Complications
• 89% died while suffering pain or other
symptoms
• Of those whose pain was treated,
treatment was successful in only 27%
Wolfe, 2000
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Brainstorm
What makes pain so difficult to treat?
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Six Major Barriers to Adequate
Pain Care
• Myth: That addiction is a common result of
treating pain with opioids
• Regulatory and legal concerns
• System barriers
• Deficits in knowledge and education
• Fear of side effects
• Assessment challenges
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Definitions
• Addiction: Psychological dependence on a drug. Drugseeking behavior despite adverse consequences
• Physical Dependence: Development of physical
withdrawal reaction upon discontinuation or antagonism
of a drug
• Tolerance: Need to increase amount of drug to obtain the
same effect
• Pseudoaddiction: Behavior suggestive of addiction
occurring as a result of undertreated pain
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Barrier #1: The Myth of
Addiction
• Addiction differs from chemical dependence,
tolerance, and pseudoaddiction
• Increased use of opioid analgesics for pain does
not appear to contribute to increases in opioid
abuse (Joranson, 2000)
• Fears are exaggerated due to referral bias
• Pseudoaddiction complicates the picture
• Increased opioid requirement is usually related
to progression of disease, not tolerance
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Barrier #2: Regulatory and
Legal Concerns
• Physicians are wary of prescribing controlled
substances for fear of criminal and/or licensing
sanctions
– Risk is very low if indication and response are
properly documented
• Regulatory policies that control opioids get in the
way
– Triplicates
– Renewal policies
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#3 System Barriers
• Lack of systemic use of practice guidelines
• Pain management historically has not been
incorporated into quality management structure
• Many institutions still lack pain and/or palliative
care services
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Barrier #4: Deficits in
Knowledge and Education
• In patients, families, physicians, and other health
care professionals
• Pain management is still rarely addressed in
medical school curricula
• It is rarely included in textbooks
– < 2% medical textbook content (Rabow, 2000)
– < 5% nursing textbook pages (Ferrell, 1999)
• Physicians lack awareness of their own
knowledge deficits in pain management
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Barrier #5: Bad Side Effects of
Opioids - Key Points
• Pain is a partial antagonist to respiratory
depression and CNS sedation
• Respiratory depression, sedation, and N&V
relate more to changing blood serum levels of
opioids than the steady state dose
• Pain management and constipation relate to
steady state dosing, not the rising blood opioid
level
– Treat prophylactically and continually
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Barrier #6: Assessment
Challenges
• Health care professionals are more comfortable
measuring objective data
• We lack a scanner that is more accurate than
patient report
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Assessment of Pain:
Key Dimensions
Mechanism
• Neuropathic pain
Abnormal state of central or peripheral nervous system
gives rise to pain
• Nociceptive pain
Nerves responding appropriately to a painful stimulus
Timeline
• Acute
• Chronic
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We are All ‘Color-blind’ to
Chronic Pain
Patients’
assessments
correlated
with those of:
Nurse
0-2
Little or no
pain
3-6
7-10
Moderate pain Severe pain
82%
51%
7%
House Officer 66%
26%
21%
Onc Fellow
70%
29%
27%
Caregiver
79%
37%
13%
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A Tool to Help Assess Pain
N - Number of pains?
O - Origin/causes?
P - Palliates, potentiates?
Q - Quality?
R - Radiation?
S - Severity, suffering?
T - Timing, trend?
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Neuropathic Pain
• Origin:
– Nerve damage
• Palliates/potentiates:
– Set off by unusual stimuli, light touch, wind on skin,
shaving (trigeminal neuralgia)
• Quality:
– Electric, burning, tingling, pins & needles, shooting
(system isn’t working right)
• Radiation:
– Nerve-related pattern
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Nociceptive Pain
• Origin:
– Tissue damage
• Palliates/potentiates:
– Worse with stress, pressure
– Responds better to opioids, NSAIDs
• Quality:
– Sharp, dull, stabbing, pressure, ache, throbbing
• Radiation:
– Occasionally radiates (less well-defined), but not
along an obvious nerve distribution
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Visual Analog Scale
1-3 Tolerable
4-6 Change therapy soon
7-10 Emergency SOS - change therapy now
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Suffering
“A state of severe distress associated with events
that threaten the intactness of the person”
Cassell,1982
• Subjective: No way to measure it
• Significantly diminishes quality of life
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Back to the Mnemonic
• Timing:
– When the pain occurs or with certain activities
• Trend:
– Whether a pain is getting better or worse over time
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Total Pain
P - Physical pain
A - Affective distress
I - Interpersonal distress
N - Non-acceptance, or spiritual distress
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Discussion
Strategies for alleviating pain:
Non-pharmacologic options
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Non-pharmacologic
Approaches to Pain
Behavioral therapy
Spiritual counseling
Physical therapy
Psychotherapy
Splinting
Surgical correction
Cold packs
Meditation
Support groups
Radiation therapy
Acupuncture
Hypnosis
Cultural healing rituals
Heat packs
Prayer
Community resources
And others…
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General Principles for
Alleviating Pain
•
•
•
•
Assess with NOPQRST
Identify types(s) and location(s) of pain
Correct underlying cause, if possible
Consider special circumstances
–
–
–
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Avoid specific toxicities
Look for ‘two-fers’
Medication routes
Self-administered or by others
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Severity
Pattern Matching
Time
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Severity
How Would You Treat the
Acute Pain Pattern?
Time
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Severity
What Would a Chronic Pain
Pattern Look Like?
Time
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Treating Chronic Pain
Basal pain medicine plus a different therapy for
spikes:
– Predictable spikes - Short-acting agent prior to event
– Unpredictable spikes - Short-acting agent readily
available
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Case Discussion
Chronic pain escalating at night - Why?
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Brainstorm
How might we treat Mrs. Long’s pain?
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Neuropathic Pain Medications
• Opioids, NSAIDs somewhat less effective
• Classes of agents:
– Tricyclic for dysesthetic pain
– Anticonvulsants for shooting pain
– Steroids to decrease peri-tumor edema
• ‘Two-fers’ important in choice of agent(s)
• Generally harder to treat than nociceptive pain
– More likely to need specialist expertise
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NSAIDs
• May be more effective than opioids with certain
forms of pain
• Not necessarily less toxic than opioids
• Toxicity can be minimized
• For basal pain relief, consider longer-acting
agent for ease of dosing
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Combination Drugs
• Advantages:
– Aspirin or acetaminophen may act as co-analgesic
– Lower level regulatory control
• Disadvantages:
– Available in short-acting formulations only
– ‘Combo wall’
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Acetaminophen With Codeine
• Advantages:
– Low regulatory control
– Inexpensive
– Widely available
• Disadvantages:
– 10% cannot convert codeine to morphine
– Many drugs interfere with conversion
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Acetaminophen with
Oxycodone, Hydrocodone
• Oxycodone combination contains 325 mg
acetaminophen
• Hydrocodone combination contains 500 mg
acetaminophen
• No clear advantage between the two
• Dose equivalence is poorly established for
hydrocodone
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Case Discussion
• Why didn’t Mrs. Long respond to acetaminophen
with codeine?
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Opioids
•
•
•
•
Morphine
Oxycodone
Hydromorphone
Transdermal fentanyl
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Principles of Opioid Use
•
•
•
•
No ceiling effect
Dose to pain relief without side effects
Give orally when possible
Sub-cutaneous administration is basically
equivalent to intravenous (and preferable)
• Treat constipation prophylactically
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Morphine
• Advantages:
– Inexpensive
– Routes: PO, PR, IV, SC, lingual
• Disadvantages:
– Histamine release
– Side effects, toxicity in high dose/renal failure
– ‘Psychological allergy’
• Formulation:Long-acting ‘wax matrix,’ shortacting liquid, tab
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Standard Starting Dose
• For opioid-naïve, 5-10 mg PO q4 PRN
• After getting an idea of the 24-hour dose, go
to long-acting
• Or start with 15 mg q12 long-acting
• There is no ceiling effect
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Oxycodone
• Advantages:
–
–
–
–
Good alternative to morphine
Available PO: long-acting (q8-12) or short-acting
? Less CNS alteration than with morphine
? Less histamine release
• Disadvantages:
– More expensive than morphine
– No parenteral form available in the U.S.A.
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Hydromorphone
• Advantages:
–
–
–
–
Available PO, IV, SC
Good alternative to morphine for parenteral use
No known toxic metabolites
Long-acting oral form now available
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Transdermal Fentanyl
• Advantages
– Non-enteral administration
– Change q72h
– Steady blood levels
• Disadvantages
–
–
–
–
–
Local skin problems
Delayed onset and offset
Cumbersome to titrate (only q72h)
20% of people need it changed q48h
Expensive
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Question
What were the general principles of opioid use we
mentioned earlier?
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Case Discussion
What do you suggest to help alleviate Mrs. Long’s
pain?
What more do we need to know?
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Case Discussion, Continued
Mrs. Long has bony pain in the hip that seems to
be nociceptive
• What might this pain pattern look like?
• What should we treat her with, and why?
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Opioid Conversion
• This is a crucial skill in ELC
• Traditionally, it was viewed as a task
• It would be more correct to think of it as a
process
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Using Opioid Conversion
Tables
•
•
•
•
•
•
Calculate 24h equivalent of old drug
Convert to 24h equivalent of new drug or route
Calculate new dosing interval
Divide 24h dose by new dosing interval
Round off this value
Account for residual drug
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Application
• Mrs. Long is admitted to the hospital and can no
longer take pills
• She has been taking sustained action oral
morphine 60mg q12
• Her family just managed to get her to take her
last dose 2 hours ago
• Her pain is well controlled
• You want to start her on a SC infusion of
morphine
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Warnings
• Most narcotic conversion charts are based on
peak drug levels
• Increase on percentage basis not dosage: 2550% per each 24 hours
• Dose to comfort or side effects (monitor)
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Opioids May Differ
Opioids may differ from each other significantly in:
• Mechanism of action
• Degree of cross-tolerance
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Two Principles
In the conversion process:
• For the new drug, use basal doses initially
• Be relatively liberal in your use of
breakthrough/short-acting doses
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Conclusion
Practice!
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Module #2
Learning Objectives
Recognize and address barriers to effective .
pain care
Develop a better understanding of attitudes and
beliefs about pain management
Improve your knowledge and skills in assessing
and treating pain
Incorporate this content into your clinical
teaching
http://www.growthhouse.org/stanford
Module #2