Transcript Pain Management - Powerpoint - Joan C. Edwards School of

Pain Management
Robert B. Walker, M.D., M.S.
DABFP, CAQ (Geriatrics)
Robert C. Byrd Center
for Rural Health
Marshall University
Introduction
End of Life Pain

50% of elders report “significant problems with
pain” in the last 12 months of life.

One-third of nursing home patients complain
daily pain.

Predictable, explainable pain is under treated.

Elders list pain control as one of their
top 5 quality of life concerns

Patients “have a legal right” to proper
pain assessment and treatment.
Common
Misconceptions
• “I should expect to have pain”
• “I’ll hold off so the medicine will
work when I really need it”
• “Pain is for wimps”
• “I don’t want to get hooked”
Barriers

We assess pain poorly and erratically

We haven’t been well trained in pain
management

We’re afraid of addiction issues

We’re afraid of mistreating the patient
Basic Approach to Pain
Management
• Ask the patient about pain and
believe them.
• Use a pain scale.
• Document what you know about
the pain
• Reassess the pain
Diagnosing and
Documenting Pain
Examples of Pain
Scales
Documenting Pain

Onset
• What relieves?

Location
• What worsens?

Intensity
• Effects on Daily Activities

Quality
• Treatment History
Neurological
Classification

Nociceptive Pain

Neuropathic Pain
Nociceptive Pain

Damage is to other tissue and nerve fibers
are stimulated.

Travels along usual pain and temperature
nerves

Responds well to common analgesics and
opioids

Sharp, throbbing, aching
Neuropathic Pain

The nervous system itself damaged

Direct damage to nerves, plexes, spinal
cord (shingles, diabetic neuropathy)

Burning, tingling, shooting

May not respond as well to usual analgesics
including opioids
Physical Examination

motor, sensory, reflexes

headaches: intracranial mass
zoster, pressure sores
 non-verbal communication

Treating Pain
Treatment of Pain

Treat Causes if possible

Remember Non-Drug Treatments

Analgesics: Narcotic, Non-narcotic

Adjuvants: Anti-convulsants, Antidepressants
Standard Approach

Treat Quickly (Pain leads to more pain)

Mild Pain: acetaminophen, ASA, NSAIDS

Moderate: mixtures, weak opioid, maybe
adjuvants

Severe: strong opioid and non-opioid,
maybe adjuvant
Non-Narcotic
Analgesics

Acetaminophen (< 4 g / 24 hrs.)

NSAIDS (bone pain or
inflammation)
– Lots of side effects
– Newer are expensive
Basics of Analgesic Use

1. By Mouth When Possible

2. Timed Doses

3. Whatever dose it takes

4. Watch for Expected Side Effects

5. Consider Adjuvants
Narcotic Analgesics:
Morphine

IV: if >50 Kg. Give 10 mg. IV Q3-4 h

If child or <50 kg. Give 0.1mg/kg. IV

If Opioid Naïve, consider lower dose

Oral: Start 5-10 mg. Titrate Up
Morphine

Max Effect: IV -15 minutes

SC- 30 minutes

PO: -I hr.
Using Concentrates

Dying Patient; Can’t swallow

MSIR 20 mg/ml : .25 to .50 ml. Q
1 hr. sl. PRN

Oxycodone conc. 20 mg/ml : .25
to .50 ml. Q 1 hr. sl. PRN
DOSING

Titrate Up Slowly Until pain controlled
or side effects occur

Anticipate Next Dose: tend to give a
little early

Use Breakthrough Doses When
Needed
Extended Release

Better Compliance

More Expensive

Dose q 8,12, or 24
Extended Release

Don’t Crush or Chew

May flush through feeding tubes

Don’t Start with Extended Dose
Breakthrough Pain

Is it new incident (new cause? or
end-of-dose?)

Use 10% of total daily dose
(rounded up) up to q 1-2 h
Continuing Use

Can continue to increase (no real
upper limit)

Gradually increase – Limited by Side
effects

Note that the effective rescue dose
increases as total dose does
Other Options: Fentanyl
Patch

25, 50, 75, 100 mcg/hr.

Apply every 3 Days

Divide Morphine Daily Dose in Half

Rescue with Opioids
Other Options: Fentanyl
Patch

Initial Dose May Take 12- 24 hrs.

May continue previous meds for
8 - 12 h

If switching, remove and use
rescue for 24 hrs.
Fentanyl is well absorbed across
mucous membranes
 “Lolly-pop”
 approved only for breakthrough
in already receiving opioids
 not to be chewed 200ug units
 not proven to be more effective
than morphine concentrates

Other Options:
Methadone

Starts working in about 1 hr.

Inexpensive

Neuropathic Pain
A patient with advanced lung cancer has severe
pain from a localized bony metastasis. He
begins to consistent feel pain about four hours
after his last dose of opioid medication.

1. According to the program which
of the following would be most
helpful?
A.
Increase medication dose
Change medication
Begin to give the medication at intervals of
less than four hours
Add adjuvant medication.
B.
C.
D.
Answer C.
A.
Begin to give the
medication at intervals of
less than four hours
2. The most likely classification
of this pain is:
A.
B.
C.
D.
Referred Pain
Nociceptive Pain
Neuropathic Pain
Visceral Pain
Answer B.
Nociceptive Pain
3. The oral morphine preparation
given to this patient will begin to
take full effect in about:
A.
B.
C.
D.
15 minutes
30 minutes
1 hour
2 hours
Answer C.
1 hour
Problems with Pain
Management
Problems with Opiates:
Addiction

Define: compulsive use, lack of control,
harmful use

Iatrogenic: may be as low as 1% if no
previous history

Avoid making this tricky diagnosis

“Have you used this drug five times in your
life?”
Warning signals
Dominating Concerns over Availability
Non-Provider Sanctioned Increases
Ignoring Major Side Effects
Warning signals

Altering, losing Prescriptions

Multiple Sources

Unaccounted Medication
Problems with Opiates:
Dependence

Defined by the occurrence of a
withdrawal syndrome after reduction
or cessation.

May occur after only 2- 3 days of
strong opioids

Usually well controlled by tapering
Problems with Opiates:
Tolerance

Need for higher doses for same effect

Can occur with effects other than analgesia

Often develops faster for sedation,
respiration, nausea than analgesia

Slow tolerance to obstipation
Problems with Opiates:
Obstipation

Fluids, Bran

Pericolace or Senicot-S

No BM in 48 hrs: MOM or Lactulose

No BM in 72 hrs: Rectal Exam; Mag
Citrate, Fleets, Oil
Problems with Opiates:
Nausea/Vomiting

Usually occurs initially

Improves with Time

May be Able to Prevent with
other meds, no movement
Problems with Opiates:
Respiratory Depression

Remember, fairly rapid tolerance develops

Almost always associated with sedation

Follow Respiratory Rate

Withhold Next 2 Doses
Naloxone

Dilute 1 Vial (0.4mg) in 10 cc.
Normal Saline

Give 1 cc. per minute until
respiratory rate OK
Problems with Opiates:
Sedation

Look at Other Meds

Look for Other Reasons

Try Decrease Dose 25%

Try another Analgesic,
Psychotropic
A patient with widespread cancer is being
treated with a mixed narcotic analgesic.
Addition of non-narcotic pain medication
for breakthrough is being considered.
Which of the following is the most
significant pharmacologic concern?
A. Acetaminophen hepatic toxicity
B. Addiction
C. Tolerance
D. Respiratory depression
Answer A.
Acetaminophen hepatic toxicity
If a decision is made to change to a
strong opioid alone, which starting dose
of oral morphine would be reasonable?
A.
B.
C.
D.
1 mg.
5 mg.
10 mg.
50 mg.
Answer C.
10 mg.
To which of the following morphine
effects will tolerance probably develop
most slowly?
A.
B.
C.
D.
Sedation
Nausea
Pain relief
Obstipation/constipation
Answer D.
Obstipation/constipation
Adjuvant Use

Anticonvulsants (Shooting Pain)
– Gabapentin (expensive, 100 mg TID)
– Carbamazine 100 mg. PO TID
– Valproic Acid 250 mg. QHS
– Clonazepam 0.5 mg PO BID (sedating)
Adjuvant Use

Tricyclic Antidepressants (Burning, Tingling)
– Low Doses (10 - 25 mg.)
– Amitriptyline
– Anticholenergic (sedating, drying, cardiac effects)

Gabapentin
Special Situations
Terminal Events

Can’t Swallow: Go to
Concentrate

If No Urine Output: Titrate to Pain
(no routine dosing)
Converting from IV to Oral

Morphine, Oxycodone, Meperidine: 3
X dose

Hydromorphone (Dilaudid): up to 5 X
dose

Then Reduce by 25% (cross
tolerance)
West Virginia Schedule II.
Regulations

In Emergency May Telephone or Mail (60
doses)

One Drug Per Prescription with MD/DO
Name Printed on Blank

May Fax to Long Term Care or Hospice

Should Write Out Concentrations
Non-Drug Treatments







Blocks & Infusions
Surgery: rhizotomy
and nerve
decompression
Radiation: localized
Tumor Treatment
Heat & Cold
TENS
Relaxation


Complementary
Medicine:
acupuncture,
chiropractic,
massage
Spiritual Therapy
Diversions: Pets,
Music, Art, Humor
SUMMARY
Optimizing well-being of the
patient and loved ones
 Improving control over one’s life
 Can reduce uncontrolled pain to
less than 1 in 20.
 We primary care physicians can,
and must, get better at this.

A patient with advanced, widespread
cancer is at end-stage of her disease. She
begins to experience breakthrough pain
every 1 or 2 hours between doses of
OxyContin.
What dose should be given for rescue or
breakthrough pain?
A. Regular interval dose
B. 10% of total daily dose
C. 20% of total daily dose
D. 30% of total daily dose
Answer B.
10% of total daily dose
This patient lives many miles from the
office and the Hospice nurse wished to
increase the regular interval dose of
medication. Which of the following is a
legal option?
A.
B.
C.
D.
Give doses of another patient’s medicine
Fax a prescription for the regular
medication to the local pharmacist.
Give a medication on-hand not previously
prescribed
Wait until a written script can be obtained.
Answer B.
Fax a prescription for the regular
medication to the local
pharmacist.
The patient begins to take no fluids
and has instructed no IV be started.
Urine output ceases. How should
dosing be determined?
A.
B.
C.
D.
Titrate to pain, using rescue dose only
Half the usual interval dose
Give 10% of the usual interval dose
Double the usual interval dose.
Answer A.
Titrate to pain, using rescue
doses only