Transcript No Slide Title

Diana J. Wilkie, PhD, RN, FAAN
© 2001 D.J. Wilkie
Comfort: Pain Management
Neurophysiology of Pain:
Physiological & Sensory Responses
• Most patients facing the
end-of-life transition have pain
• Selection of effective
pharmacological and
nonpharmacological therapies
requires consideration of the
holistic nature of pain, which is a
multidimensional experience
Pharmacological
x
Nonpharmacological
TNEEL-NE
Slide 2
Comfort: Pain Management
Nociceptive Pain Definition
• Pain resulting from
activation of primary
afferent nociceptors by
mechanical, thermal or
chemical stimuli
Chemical
Stimuli
Mechanical
Thermal
TNEEL-NE
Slide 3
Comfort: Pain Management
Neuropathic Pain Definition
Pain resulting from damage to
peripheral nervous or central nervous
system tissue or from altered
processing of pain in the central
nervous system
TNEEL-NE
Slide 4
Comfort: Pain Management
Multiple Dimensions of Pain
The ABCs of Pain
Affective Dimension
Behavioral Dimension
Cognitive Dimension
Physiological-Sensory Dimension
TNEEL-NE
Slide 5
Comfort: Pain Management
Analgesic Ladder
Pain relief
Step 3
Opioid for moderate to severe pain
+/- Non-opioid
+/- Adjuvant
Pain persisting
Step 2
Opioid for mild to moderate pain
+/- Non-opioid
+/- Adjuvant
Pain persisting
Step 1
Non-opioid
+/- Adjuvant
PAIN
TNEEL-NE
Source: World Health Organization, 1992
Slide 6
Comfort: Pain Management
Pharmacology Concepts
Pharmacokinetics
Pharmacodynamics
Desired effects
Side effects
TNEEL-NE
Slide 7
Comfort: Pain Management
Analgesic Ladder:
Step One Drugs
Step 1
NSAIDs
Acetaminophen
PAIN
TNEEL-NE
Source: World Health Organization, 1992
Slide 8
Comfort: Pain Management
NSAIDs:
Mechanisms of Actions
What do these drugs do?
How do these drugs work?
Anti-inflammatory
Analgesic
Antipyretic
TNEEL-NE
Slide 9
Comfort: Pain Management
NSAIDs:
Mechanisms of Actions
Anti-inflammation
peripheral effect
Analgesic
peripheral effect
(probable central effect)
Antipyretic
central effect
TNEEL-NE
Slide 10
Comfort: Pain Management
NSAIDs:
Mechanisms of Actions
5HT
Afferent
Fiber
BK
H
PGE
Trauma
Tissue
TNEEL-NE
Slide 11
Comfort: Pain Management
NSAIDs:
Mechanisms of Actions
Copyright 1989 D.J. Wilkie
Arachidonic
cascade
5-Lipoxygenase
Cyclo-oxygenase
Phospholipids
released
Leukotrienes
Prostaglandins
PGI2
Vasodilation
Antiaggregation
Trauma
TNEEL-NE
Thromboxane A2
platelet
aggregation
PGE2
Fever
Pain
PGF2
Vasodilation
Uterine contraction
pain receptor
Slide 12
Comfort: Pain Management
NSAIDs:
Mechanisms of Actions
Copyright 1989 D.J. Wilkie
Arachidonic
cascade
Steroids
Ketoprofen
5-Lipoxygenase
ASA/NSAIDS
Phospholipids
released
Leukotrienes
Cyclo-oxygenase
Thromboxane A2
platelet
aggregation
Prostaglandins
Trilisate
PGI2
Vasodilation
Antiaggregation
Trauma
TNEEL-NE
PGE2
Fever
Pain
PGF2
Vasodilation
Uterine contraction
pain receptor
Slide 13
Comfort: Pain Management
NSAIDs:
Mechanisms of Actions
Copyright 1989 D.J. Wilkie
Arachidonic
cascade
5-Lipoxygenase
Cyclo-oxygenase
Phospholipids
released
Leukotrienes
Trauma
TNEEL-NE
Cox2 Prostaglandins
Thromboxane A2
platelet
aggregation
pain receptor
Slide 14
Comfort: Pain Management
NSAIDs:
Mechanisms of Actions
Copyright 1989 D.J. Wilkie
Arachidonic
cascade
Steroids
Ketoprofen
5-Lipoxygenase
Phospholipids
released
Leukotrienes
Cyclo-oxygenase
ASA/NSAIDS
Cox2, Prostaglandins
Thromboxane A2
platelet
aggregation
Celebrex
Vioxx
Trauma
TNEEL-NE
pain receptor
Slide 15
Comfort: Pain Management
NSAIDs:
Administration Routes
Oral
Aspirin, Nuprin, Advil, Motrin, Naprosyn, Orudis (OTC)
Feldene, Clinoril, Indocin, Tolectin, Trilisate, Celebrex,
Vioxx (Prescription)
Rectal
Aspirin & Indocin
Parenteral
Toradol (ketorolac)
TNEEL-NE
Slide 16
Comfort: Pain Management
NSAIDs:
Dosages & Dose Intervals
Aspirin Doses
•1000 mg every 6 hours does not provide
greater analgesia than 650 mg every 4 hours
•Duration of analgesia is greater
Diclofenac & Ibuprofen
May vary in effectiveness (metabolism)
Aspirin
650 mg PO - equipotent to about
2 mg IM morphine
TNEEL-NE
Slide 17
Comfort: Pain Management
Cox1 and Cox2 Drugs
• Celecoxib (Celebrex)
• Rofecoxib (Vioxx)
TNEEL-NE
Slide 18
Comfort: Pain Management
NSAIDs:
Side-Effects & Toxicity
GI
bloating, dyspepsia, nausea,
vomiting, bleeding, diarrhea,
& peptic ulceration
Renal
decreased blood flow,
interstitial nephritis,
papillary necrosis
TNEEL-NE
Slide 19
Comfort: Pain Management
NSAIDs:
Hypersensitivity
Increased incidence:
middle aged, women, nasal polyps
rhinitis
edema
urticaria
bronchial asthma
larengeal edema
TNEEL-NE
Slide 20
Comfort: Pain Management
NSAIDs:
Nursing Implications
Symptom
Assess relevant parameters
Drug Interactions
alcohol
antacids
diuretics
lithium
phenytoin
TNEEL-NE
antirheumatic agents
anticoagulants
antidiabetic agents
beta blockers
methotrexate
Slide 21
Comfort: Pain Management
Acetaminophen:
Mechanisms of Actions
What does this drug do?
How does this drug work?
Analgesic
Antipyretic
(Weak prostaglandin inhibition more in CNS than periphery)
TNEEL-NE
Slide 22
Comfort: Pain Management
Acetaminophen:
Administration Routes
Oral
Several different brands available
over the counter & with prescription
Rectal
Several different brands available
over the counter & with prescription
Parenteral
None
TNEEL-NE
Slide 23
Comfort: Pain Management
Acetaminophen:
Dosages & Dose Intervals
Doses
•Dose for children and small individuals
•6 mg/kg to 12 mg/kg every 4 hours
•Has a Ceiling effect
•Doses above 1000 every 6 hours do not
provide significantly greater analgesia
than 650 mg every 4 hours
•Duration of analgesia is greater
TNEEL-NE
Slide 24
Comfort: Pain Management
Acetaminophen:
Toxicity
Initial
24 hours
nausea & vomiting,
anorexia,
abdominal pain
liver enzyme changes
encephalopathy
coma
death
TNEEL-NE
Slide 25
Comfort: Pain Management
Nursing Implications
Other sources of Tylenol
Percocet
Tylox
Vicodin
Nyquil
Adult dose: 2,600-4,000 mg q day maximum
Child dose: 6-12 mg/kg q 4 hr
TNEEL-NE
Slide 26
Comfort: Pain Management
Analgesic Ladder:
Step One Drugs
Step 1
+/- Adjuvant Drug
PAIN
TNEEL-NE
Source: World Health Organization, 1992
Slide 27
Comfort: Pain Management
Adjuvant Drugs:
Mechanisms of Actions
What do these drugs do?
How do these drugs work?
Analgesic
TNEEL-NE
Slide 28
Comfort: Pain Management
Adjuvant Drugs:
Mechanisms of Actions
Analgesic effects
Capsaicin
Steroids
Antihistamines
Antidepressants
 Amitriptyline
 Imipramine
 Desipramine
• Nortriptyline
• Trazodone
• Prozac (no)
 Doxepin
TNEEL-NE
Slide 29
Comfort: Pain Management
5HT and Norepinephrine
Reuptake Inhibition
Synthesis
Presynaptic
Terminal
Storage
Reuptake
Synaptic
Cleft
Postsynaptic
Membrane
TNEEL-NE
Release
Receptor
Slide 30
Comfort: Pain Management
Adjuvant Drugs:
Mechanisms of Actions
Analgesic effects
Anticonvulsants
Lidocaine
Calcitonin
Clonidine
TNEEL-NE
Slide 31
Comfort: Pain Management
Adjuvant Drugs:
Mechanisms of Actions
myelin
K+
K+
Na+
nodes of ranvier
Lidocaine
Ad
K+
Na+
C
Na +
K+
K+
K+
K+
Na +
TNEEL-NE
K+
K+
Na +
Na +
Na +
Na +
Na +
Na+
Na+
K+
K+
Na +
K+
K+
Na +
K+
K+
Na +
Na +
Slide 32
Comfort: Pain Management
Adjuvant Drugs:
Mechanisms of Actions
myelin
Ad
nodes of ranvier
Lidocaine
C
TNEEL-NE
Slide 33
Comfort: Pain Management
Gabapentin
Mechanism:
Multiple effects via sodium channel blockade, GABA, calcium channel
interaction, and norepinephrine release
Indications:
Not clear but may be effective in neuropathic pain and in sympathetic
maintained pain
Dose-Interval:
Not established, current use is 300 mg q day increase q 2-3 days by 300
mg to effective dose (300 mg TID to 3000 mg)
TNEEL-NE
Slide 34
Comfort: Pain Management
Adjuvant Drugs:
Administration Routes
• Refer WHO Step 1 Adjuvant Analgesic Table
• Most drugs are administered as oral preparations
• Others include:
– Rectal
– Parenteral
– Topical
TNEEL-NE
Slide 35
Comfort: Pain Management
Adjuvant Drugs:
Dosages & Dose Intervals
Doses
See the typical doses listed on the WHO Step
1 Adjuvant Analgesic Table
Doses and dose intervals differ for each
different adjuvant drug
Doses that provide analgesia can be quite
variable for some drugs such as gabapentin
TNEEL-NE
Slide 36
Comfort: Pain Management
Analgesic Ladder:
Step One Drugs
Step 3
Step 2
Opioid for moderate to severe pain
Opioid for mild to moderate pain
PAIN
TNEEL-NE
Source: World Health Organization, 1992
Slide 37
Comfort: Pain Management
Opioids:
Administration Routes
WHO Analgesic Ladder
Recommends morphine as the drug of choice and oral
as the administration route of choice
If Oral Route is not Possible . . .
Transdermal, transmucosal, rectal, vaginal, intravenous,
epidural, & intrathecal
High-dose morphine (any route)
Associated with hyperalgesia (exaggerated pain
sensation) and myoclonus (muscle spasm)
TNEEL-NE
Slide 38
Comfort: Pain Management
Opioids:
Administration Routes
Routes
Pain can be effectively managed with oral, transdermal,
subcutaneous or IV routes
More invasive: Epidural or intrathecal analgesia
Intrathecal
Enters into the cerebral spinal fluid
Doses are lower than epidural because
entire dose reaches spinal cord
Helps control rapidly changing pain (better than oral)
TNEEL-NE
Slide 39
Comfort: Pain Management
Opioids:
Administration Routes
Epidural Analgesia
Demonstrated effectiveness in management of all
types of pain including acute, chronic nonmalignant,
and cancer pain
Common Sites of Catheter Placement (Epidural)
Lumbar region but can be cervical, thoracic, lumbar,
or caudal
ANA’s Practice Guidelines
RNs assist with analgesia by catheter techniques
TNEEL-NE
Slide 40
Comfort: Pain Management
Narcotic Definition
A drug that produces stupor or narcosis
(sleep)
An obsolete term for analgesics
Legal definition applies to all drugs that
cause dependence
TNEEL-NE
Slide 41
Comfort: Pain Management
Opiate Definition
A drug that is a derivative from opium
TNEEL-NE
Slide 42
Comfort: Pain Management
Opioid Definition
A drug that binds to opiate receptors and
produces morphine-like action (genericlike term for opium derivatives and
synthetic drugs)
Opiate and Opioid often are used
interchangeably in clinical practice and
much of the literature
TNEEL-NE
Slide 43
Comfort: Pain Management
Analgesia Definition
Absence of sensibility to pain
Not the same as suffering
TNEEL-NE
Slide 44
Comfort: Pain Management
Mechanism of Action:
Opioids
•
•
•
•
TNEEL-NE
Agonists
Mixed Agonists Antagonists
Partial Agonists
Antagonists
Administration
routes are many:
Oral is preferred
but parenteral,
transdermal,
spinal, and nasal
routes may be
used
Slide 45
Comfort: Pain Management
Opioid Mechanisms of Action:
Agonists
Agonists bind and produce morphinelike actions at mu, delta, and kappa
receptors
TNEEL-NE
Slide 46
Comfort: Pain Management
Dorsal Horn Receptors
PAN
NK-1
GABA A
delta
5-HT3
NMDA
mu
Excitatory
Inhibitory
Glu
5-HT2
AMPA
K
SP
GABA B
a2
mu/delta
a 2 mu/delta NK-1 5-HT1B
GABA A
Adn
Adn
GABA B
Receptors on Post Synaptic Neurons
TNEEL-NE
Slide 47
Comfort: Pain Management
Opioid Mechanisms of Action:
Mixed Agonists Antagonists
Mixed agonists antagonists bind and produce
morphine-like actions at kappa receptors
They bind, but do not produce morphine-like
effects at mu and delta receptors, (don't produce
full morphine-like effects; e.g., can cause
withdrawal symptoms in people dependent upon
agonists, potentially life-threatening)
TNEEL-NE
Slide 48
Comfort: Pain Management
Opioid Mechanisms of Action:
Partial Agonists
Partial Agonists bind and produce
morphine-like actions at mu receptors
TNEEL-NE
Slide 49
Comfort: Pain Management
Opioid Mechanisms of Action:
Antagonists
Antagonists bind to mu, delta, and kappa
receptors but do not produce morphinelike effects (competitive agonist)
TNEEL-NE
Slide 50
Comfort: Pain Management
Opioid Receptors
Naloxone
4.
Partial
Agonist
Action
2.
1. Antagonist
Agonist
Action
Action
3.
Agonist-antagonist
Action
D
K
M
Buprenorphine
Naloxone
Pentazocine
Morphine
D
D
K
K
Partial Antagonist
Antagonist
Agonist
Agonist-antagonist
TNEEL-NE
M
M
Not Activated
Activated
D = Delta Receptor
K = Kappa Receptor
M = Mu Receptor
Slide 51
Comfort: Pain Management
Tolerance Definition
Tolerance: increased dose required to produce the
same effects when pain stimulus remains unchanged
TNEEL-NE
Slide 52
Comfort: Pain Management
Cross Tolerance Definition
Cross Tolerance: refers to tolerance between drugs,
e.g., morphine and Dilaudid
Lack of analgesia should not be confused with
tolerance or drug seeking behavior until genetic issues
have been considered
TNEEL-NE
Slide 53
Comfort: Pain Management
Tolerance & Cross Tolerance
Example
Tolerance: increased dose required to produce the
same effects when pain stimulus remains unchanged
Cross Tolerance: refers to tolerance between drugs,
e.g., morphine and Dilaudid
Lack of analgesia should not be confused with tolerance or drug
seeking behavior until genetic issues have been considered
Example: Lack of analgesic effect from Codeine doses. About 10% of
people of Northern European heritage lack the genetic ability to metabolize
codeine to morphine via O-demethylation (requires spartine/debrisoquine
axygenation (CYP2D6). These people will obtain no analgesic effect from
codeine beyond a placebo effect. CHANGE in DRUG is REQUIRED.
TNEEL-NE
Slide 54
Comfort: Pain Management
Dependence Definition
A physical effect of using drug for about 10
days or longer
Abstinence from drug use produces physical
withdrawal syndrome (runny nose, sweating,
anxiety, irritability, abdominal cramps, diarrhea)
To withdraw from morphine without withdrawal syndrome:
•decrease the 24 hour dose by 50% and give 25% of this dose every 6
hours; after 2 days
•reduce daily dose by an additional 25% every 2 days until 24 hour dose
is 30 mg PO per day, then discontinue the morphine (APS 1999)
TNEEL-NE
Slide 55
Comfort: Pain Management
Addiction Definition
Psychological drive (desire) to take drug
(opioid) for euphoric effects
Less than 0.1% of patients using opioids of medical purposes
become addicted to them
Research findings show only 4 out of nearly 12,000 patients
treated with opioids for medically indicated purposes developed
a problem with addiction
TNEEL-NE
Slide 56
Comfort: Pain Management
Addiction Definition
Concern about addiction
should not interfere with
patients in pain being treated
Even patients with a former or current substance
abuse problem should be given analgesics,
including opioids, when they have pain
Especially pain from trauma,
injury, surgery, or cancer
TNEEL-NE
Slide 57
Comfort: Pain Management
Opioids:
Absorption & Distribution
Absorption
First pass effect
Distribution
Opioids are distributed throughout tissue
TNEEL-NE
Slide 58
Comfort: Pain Management
Opioids: Absorption Example
60-min Area Under the Curve (AUC) in 7 Patients
60-min Plasma Morphine Concentrations in 7 Patients
Taking 10 mg Morphine (Tablet)
Taking 10 mg Morphine (Tablet)
10
Mean ng/ml


8


Mean AUC


300

6
250
200


4
2
350







150

100

5
10
15
20
30
45
Time
Oral Dose
TNEEL-NE
60

0 
0






5
10
15




50
0
0


20
30
45
60
Time
SL Dose
Slide 59
Comfort: Pain Management
Opioids: Metabolism
Metabolism
Morphine is metabolized by glucuronidation in the liver
and the gut mucosa
Major Glucuronidation Products
Morphine-3-glucuronide (M3G) and morphine-6glucuronide (M6G)
Hepatic UDP-glucuronyl Transferase Activity
This result: Consistent with the large inter-individual
variation in morphine bioavailability
TNEEL-NE
Slide 60
Comfort: Pain Management
Opioids: Metabolism
Example--Subject #25
Morphine ng/ml
2.5
2
1.5
1
0.5
0
Pre
00
PO MS ng/ml
TNEEL-NE
05
10
SL MS ng/ml
15
20
30
45
60
Time
Slide 61
Comfort: Pain Management
Opioids: Metabolism
Example--Subject # 5
Morphine ng/ml
35
30
25
20
15
10
5
0
Pre
00
PO MS ng/ml
TNEEL-NE
05
10
SL MS ng/ml
15
20
30
45
60
Time
Slide 62
Comfort: Pain Management
Opioids: Metabolism
Example--Subject # 2
Morphine ng/ml
60
50
40
30
20
10
0
Pre
00
PO MS ng/ml
TNEEL-NE
05
10
SL MS ng/ml
15
20
30
45
60
Time
Slide 63
Comfort: Pain Management
Opioids: Metabolism
Example--Subject # 22
Morphine ng/ml
1600
1400
1200
1000
800
600
400
200
0
Pre
00
PO MS ng/ml
TNEEL-NE
05
10
SL MS ng/ml
15
20
30
45
60
Time
Slide 64
Comfort: Pain Management
Opioids: Excretion
Excretion
Excretion of most opioids, especially
morphine, hydromorphone, and meperidine,
is by the kidneys
Question:
What does this fact mean for the person with
renal failure or elders who may have
decreased renal function?
TNEEL-NE
Slide 65
Comfort: Pain Management
Opioids:
Desired Effects--Analgesia
Desired Effect is Analgesia:
Assess for the analgesic effect at the
ONSET, PEAK, & DURATION of the
drug effect
Therapeutic goal:
If present pain intensity is greater than
able to live with pain score, additional
analgesic effect is necessary: GIVE
LARGER DOSE to achieve the
desired effect (pain relief)
TNEEL-NE
Slide 66
Comfort: Pain Management
Opioids: Side-Effects
Side Effects: Undesired Effects
Constipation
Nausea and vomiting
Sedation
Respiratory depression (ventilatory depth & rate)
Awake patients do not succumb to respiratory depression!!
Itching
Orthostatic hypotension
(decreases cardiac work load by decreasing
venous return and arterial pressure [reducing
afterload] & has therapeutic in congestive heart
failure and pulmonary edema)
TNEEL-NE
Slide 67
Comfort: Pain Management
Assisted Suicide & Euthanasia
• Extremely controversial topic in healthcare circles
• Physicians hesitant to prescribe large doses of opioids:
– May think they’re helping someone perform euthanasia
• Relieving pain may hasten death, but it is not euthanasia
or assisted suicide!
• ANA: “Nurses should not hesitate to use full and effective
doses of pain medication for the proper management of
pain in the dying patient.”
• Some patients may try to seek assisted suicide
– ANA’s position: Nurses should NOT participate in euthanasia or
assisted suicide
TNEEL-NE
Slide 68
Comfort: Pain Management
Opioids:
Conscious Sedation
• Conscious sedation implies that the
patient can respond to verbal and physical
stimuli when sedatives are used
• ANA has established practice guidelines.
• Analgesics may produce sedation as a side
Yes, I
understand.
I am feeling
the effects of
the pills
now.
effect, but sedatives do NOT produce any
analgesia
• Conscious sedation may be helpful during
the active phase of dying if desired by the
patient and family
TNEEL-NE
Slide 69
Comfort: Pain Management
Opioids: Nursing Role
• Dose titration: Dose adjustment based on decision
making about the adequacy of analgesic effect vs.
side effects
– The goal is to titrate the opioid dose to the desired effect
(maximal analgesia with minimal side effects)
first pill
• Use the WHO Analgesic Ladder
• Percodan and titration
4 hours
• Doses of all step 3 agonist drugs, except
meperidine, can be safely escalated without a
ceiling effect by means of titration
– There is no set amount of an opioid that will produce
pain relief for every patient (it’s individual)
TNEEL-NE
8 hours
Slide 70
Comfort: Pain Management
Opioids: Nursing Role
• Titration requires some type of pain assessment
– Nurse’s give optimal dose; identify alternative drugs
• Titrate the morphine dose upward vs. downward
• Withdrawing morphine doses
– To withdraw from morphine, decrease the 24 hour dose by 50%
and give 25% of this dose every 6 hours; after 2 days, reduce daily
dose by an additional 25% every 2 days until 24 hour dose is 30mg
PO per day, then discontinue the morphine
• Dose required can always vary tremendously
• Patients with renal dysfunction are more sensitive
• Larger doses may be required
TNEEL-NE
Slide 71
Comfort: Pain Management
Opioids: Nursing Role

Persons who smoke may require larger
doses of morphine, meperidine, pentazocine,
and propoxyphene to obtain pain control

Genetic factors can also affect analgesic responses

10% of Caucasians with Northern European ancestry are
not able to metabolize spartine
–

TNEEL-NE
May not obtain any pain relief from codeine
Nurses administer the prescribed dose at time of peak
analgesic effect, continue until analgesia sufficient or side
effects limit further doses
Slide 72
Comfort: Pain Management
Opioids: Nursing Role
• Nurses should always know:
– Onset, peak, and duration of effect for drug and route by which it
was administered
– Patient's goal for pain therapy (0-10 scale rating). The patient’s
optimal goal and the able-to-tolerate goal
– Know patient's pain intensity at onset, peak, and duration of
analgesic effect


TNEEL-NE
Breakthrough doses: Needed when pain control is not
constantly sustained
Loading doses are needed when using parenteral infusions
(IV or subcutaneous)
Slide 73
Comfort: Pain Management
Opioids: Knowledge
Required for Nursing Role

Washington State research findings
–
Some nurses do not have sufficient
knowledge about the pharmacokinetic
properties of the opioids to provide
adequate analgesia
• Nurses need to know about:
–
–
–
–
–
–
TNEEL-NE
Opioid onset of action
Opioid peak effect of action
Opioid duration of action
Opioid dosing interval
Equianalgesic doses for various opioids
How to increase (titrate) doses to achieve maximal analgesia with
minimal side effects
Slide 74
Comfort: Pain Management
RN's Opioid Knowledge:
Dose Intervals
Percentage
Correct
50
Smaller
Larger
Don't Know/No Answer
42
38
40
31
30
39
38
28
28
39
28
31
21
20
13
12
8
10
3
1
0
IR MS (Min)
IR MS (Max)
MSContin (Min)
MSContin (Max)
Answer: Morphine Intervals
(N=131 RNs in Washington; Morris, Wilkie, & Fanslow, 1994)
TNEEL-NE
Slide 75
Comfort: Pain Management
RN’s Opioid Knowledge
Equianalgesic Doses
Percentage
50
40
Correct Dose
Smaller Dose
Larger Dose
Don't Know
30
24
42
23
23
17
20
13
10
2
2
0
PO MS to IM MS
IM Hydromorphone to PO MS
Answer: Type of Conversion
(N=131 RNs in Washington; Morris, Wilkie, & Fanslow, 1994)
TNEEL-NE
Slide 76
Comfort: Pain Management
Equianalgesic Doses:
Step 2 Opioids
Maximum degree of pain relief on % basis
100
Placebo
80
Aspirin 650 mg
60
Acetaminophen 650 mg
40
Pentazocine 50 mg
20
Codeine 65 mg
0
Drug
TNEEL-NE
Propoxyphene 65 mg
Slide 77
Comfort: Pain Management
Codeine: Step 2
• Analgesic effect of Codeine
– depends on metabolism of codeine to
morphine via O-demethylation
– requires spartine/debrisoquine
oxygenation (CYP2D6)
10% of people of Northern European heritage lack
spartine. They will obtain no analgesic
effect from codeine beyond a placebo effect
A CHANGE in DRUG is REQUIRED to give them pain relief
TNEEL-NE
Slide 78
Comfort: Pain Management
Case: Equianalgesic Dose
Conversions
•86 yr old male with pain located in the area of
an abdominal incision, rated as 9 on 0-10 scale
•His 2nd day postop IV MS hourly requirement
has been 2 mg
•He has bowel function
•Is eating without difficulty
•Has an order for Dilaudid 2 mg q 4-6 hr when
taking po
Q: What nursing actions are required
to relieve this man's pain?
TNEEL-NE
Slide 79
Comfort: Pain Management
Case: Equianalgesic Dose
Conversions
From an equianalgesic chart, we know 7.5 mg oral
Dilaudid is equivalent to 10 mg IM morphine
Set the conversion equation as follows:
48 mg IV MS divided by 10 mg IM MS
=
?
__ mg PO Dilaudid divided by 7.5 mg PO Dilaudid
Answer: 36 mg PO Dilaudid per 24 hours
TNEEL-NE
Slide 80
Comfort: Pain Management
Case: Equianalgesic Dose
Conversions
According to the orders, at most the patient can receive
4 to 6 doses in 24 hours
With the prescription, the maximum dose the patient can
receive is 12 mg of oral Dilaudid, a dose that is far too low
for the patient's predicted needs
According to equianalgesic dose conversions, patient should
receive 6 mg oral Dilaudid 6 times a day (every 4 hours)
Initially it is prudent to administer or to offer oral pain
medications around the clock even if the order is prn
(as needed basis)
TNEEL-NE
Slide 81
Comfort: Pain Management
Meperidine Pharmacokinetics
Analgesic Effectiveness: Onset, Peak, Duration
Minutes
200
180
Onset
Peak
Duration
150
120
100
90
90
60
60
50
15
0
Oral
NOT
Intramuscular
1 - 1.3 mg/kg Q 3 h
7
1
Intravenous
0.5 - 0.7 mg/kg 2 h
Administration Route and Recommended Dose
TNEEL-NE
Slide 82
Comfort: Pain Management
Morphine Pharmacokinetics
Analgesic Effectiveness: Onset, Peak, Duration
Minutes
350
300
300
Onset
240
250
Peak
Duration
240
200
150
120
120
100
60
20
20
50
60
60
30
5
20
0
Oral
0.15 - 0.3 mg/kg Q 4 h
Intramuscular
0.1 - 0.13 mg/kg Q 4 h
Subcutaneous
Intravenous
0.1 - 0.13 mg/kg Q 4 h
0.05 - 0.10 mg/kg 2 h
Administration Route and Recommended Dose
TNEEL-NE
Slide 83
Comfort: Pain Management
Hydromorphone Pharmacokinetics
Analgesic Effectiveness: Onset, Peak, Duration
Minutes
300
240
Onset
250
Peak
Duration
180
200
120
150
100
120
60
60
20
50
15
30
0
Oral
0.05 mg/kg Q 4 h
Intramuscular
0.02 - 0.025 mg/kg Q 4 h
Intravenous
0.01 - 0.015 mg/kg 2 h
Administration Route and Recommended Dose
TNEEL-NE
Slide 84
Comfort: Pain Management
Fentanyl Pharmacokinetics
Hours
Analgesic Effectiveness: Onset, Peak, Duration
72
80
Onset
Peak
Duration
60
40
18
20
6
0
Transdermal (Duragesic)
25-50 u\g/hr
TNEEL-NE
Slide 85
Comfort: Pain Management
Fentanyl Pharmacokinetics
•
•
•
•
TNEEL-NE
75-125 times more potent than morphine
Rapid onset
Short duration of effect
Contraindicated within 14 days of MAO
inhibitor use
Slide 86
Comfort: Pain Management
IV Opioids Pharmacokinetics
Analgesic Effectiveness: Onset, Peak, Duration
Minutes
140
120
Onset
120
Peak
Duration
120
90
100
80
60
45
60
40
20
20
5
20
10
1
7
1
5
1
5
0
Morphine
TNEEL-NE
Hydromorphone
Meperidine
Fentanyl
Sufentanil
Slide 87
Comfort: Pain Management
Safe & Effective Analgesia Dose Titration
Based on Pharmacokinetics
Example: Morphine IV q 20 minutes (peak effect) X 6 doses
70
Plasma Concentration
Doses
60
6
50
5
40
4
30
3
20
2
10
1
0
20
40
60
80
100
120
Minutes Since First Dose
TNEEL-NE
Slide 88
Comfort: Pain Management
Safe & Effective Analgesia Dose Titration
Based on Pharmacokinetics
70
60
50
40
30
20
10
0
First Dose
Second Dose
Third Dose
Fourth Dose
Fifth Dose
Sixth Dose
200
4
9
19
22
30
39
180
5
11
18
26
35
45
160
6
13
21
30
40
51
140
7
15
24
34
45
58
120
8
17
27
38
51
66
100
9
19
30
43
58
80
10
21
34
49
60
11
24
39
40
13
28
20
15
Example: Morphine IV q 20 minutes (peak effect) X 6 doses
TNEEL-NE
Slide 89
Comfort: Pain Management
Safe & Effective Analgesia Dose
Titration: Other Facts
• Patients with renal dysfunction
• Larger doses may be required if
–
–
–
–
the pain is out of control
pain is a neuropathic
person has a smoking history
genetic factors affect metabolism
• Plasma concentrations of opioids vary
tremendously
TNEEL-NE
Slide 90
Comfort: Pain Management
Opioids:
Changing Routes
How Should an Opioid be Changed to A Different Route?
Calculate the total 24-hour dose
Convert 24 hr dose to the equianalgesic dose for the new route
Administer appropriate fraction of 24-hour dose for new route
Example
180mg MS Contin every 12 hours plus 80mg IR MS for breakthrough
pain=440mg PO MS/24 hr
From the equianalgesic conversion chart, 10mg IM=30mg PO MS
Start a continuous subcutaneous infusion: 440mg divided by 3=147 IM
MS equivalents or 147mg/24 hr=6mg/hr
TNEEL-NE
Slide 91
Comfort: Pain Management
Nonpharmacological
Interventions
• Psychological and physical interventions
can be seen as an adjunct to
pharmacological therapies.
– May or may not be totally effective on their own.
• Choice of intervention is determined by:
1. The nature of each case
2. What works for a specific patient
3. The skills of the clinician
TNEEL-NE
Slide 92
Comfort: Pain Management
Psychological Modalities
Distraction
Controlled breathing
Active listening
Patient education
TNEEL-NE
Slide 93
Comfort: Pain Management
Psychological Modalities
Reinforce or modify pain
control behaviors
Relaxation strategies
Consultants
TNEEL-NE
Slide 94
Comfort: Pain Management
Physical Modalities
Beds
Massages
Heat
TNEEL-NE
Slide 95
Comfort: Pain Management
Physical Modalities
Cold
Positioning
Exercise programs
TNEEL-NE
Slide 96
Comfort: Pain Management
Summary
Add a nonpharmacological
therapy at any step!
Step 3
Pain relief
Opioid for moderate to severe pain
+/- Non-opioid
+/- Adjuvant
Pain persisting
Step 2
Opioid for mild to moderate pain
+/- Non-opioid
+/- Adjuvant
Pain persisting
Step 1
Non-opioid
+/- Adjuvant
PAIN
TNEEL-NE
Source: World Health Organization, 1992
Slide 97