Transcript 02 Pain Management

E LNE C
End-of-Life Nursing Education Consortium
International Curriculum
Pain Management In
Palliative Care
Pain Is...
• “An unpleasant sensory and
emotional experience associated
with actual or potential tissue
damage”
IASP, 1979
• “What the person says it is…”
Pasero & McCaffery, 2011
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Current Status of Pain
• Cancer patients at end-of-life – 54%
have pain
• AIDS with prognosis <6 months –
intense pain
APS, 2008; Paice, 2010
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Current Status of Pain (cont.)
• Less research conducted in other
chronic illness
• Inadequate pain relief hastens
death
• Pain relief is essential at end of
life
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Pain
An unpleasant sensory and
emotional experience associated
with actual or potential tissue
damage, or described in terms of
such damage.
International Association for the Study of Pain
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Clinical Terms For The Sensory
Disturbances Associated With Pain
• Dysesthesia – An unpleasant abnormal sensation,
whether spontaneous or evoked.
• Allodynia – Pain due to a stimulus which does not
normally provoke pain, such as pain caused by light
touch to the skin
• Hyperalgesia – An increased response to a stimulus
which is normally painful
• Hyperesthesia - Increased sensitivity to stimulation,
excluding the special senses. Hyperesthesia
includes both allodynia and hyperalgesia, but the
more specific terms should be used wherever they
are applicable.
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Approach To Pain Control in Palliative Care
1. Thorough assessment by skilled and knowledgeable
clinician
– History
– Physical Examination
2. Pause here - discuss with patient/family the goals of care,
hopes, expectations, anticipated course of illness. This
will influence consideration of investigations and
interventions
3. Investigations – X-Ray, CT, MRI, etc - if they will affect
approach to care
4. Treatments – pharmacological and non-pharmacological;
interventional analgesia (e.g.. Spinal)
5. Ongoing reassessment and review of options, goals,
expectations, etc.
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TYPES OF PAIN
NOCICEPTIVE
NEUROPATHIC
Visceral
Somatic
• bones, joints
• connective tissues
• muscles
• Organs –
heart, liver,
pancreas, gut,
etc.
Deafferentation
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Sympathetic
Maintained
Peripheral
Somatic Pain
•
•
•
•
Aching, often constant
May be dull or sharp
Often worse with movement
Well localized
Eg/
– Bone & soft tissue
– chest wall
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Visceral Pain
•
•
•
•
Constant or crampy
Aching
Poorly localized
Referred
Eg/
– CA pancreas
– Liver capsule distension
– Bowel obstruction
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FEATURES OF NEUROPATHIC PAIN
COMPONENT
Steady,
Dysesthetic
Paroxysmal,
Neuralgic
DESCRIPTORS
• Burning,
Tingling
• Constant,
Aching
• Squeezing,
Itching
• Allodynia
• Hypersthesia
• Stabbing
• Shock-like,
electric
• Shooting
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• Lancinating
EXAMPLES
• Diabetic
neuropathy
• Post-herpetic
neuropathy
• trigeminal
neuralgia
• may be a
component of any
neuropathic pain
Pain
Assessment
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“Describing pain only in
terms of its intensity is like
describing music only in
terms of its loudness”
von Baeyer CL; Pain Research and Management 11(3) 2006; p.157-162
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PAIN HISTORY
• Description: severity, quality,
location, temporal features,
frequency, aggravating & alleviating
factors
• Previous history
• Context: social, cultural, emotional,
spiritual factors
• Meaning
• Interventions: what has been tried?
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Example Of A Numbered Scale
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Medication(s) Taken
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•
•
•
•
•
Dose
Route
Frequency
Duration
Efficacy
Adverse effects
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Physical Exam In Pain Assessment
Inspection / Observation
“You can observe a lot just by watching”
• Overall impression… the “gestalt”?
Yogi Berra
• Facial expression: Grimacing; furrowed brow;
appears anxious; flat affect
• Body position and spontaneous movement: there
may be positioning to protect painful areas, limited
movement due to pain
• Diaphoresis – can be caused by pain
• Areas of redness, swelling
• Atrophied muscles
• Gait
• Myoclonus – possibly indicating opioid-induced
neurotoxicity
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Physical Exam In Pain Assessment
Palpation
• Localized tenderness to
pressure or percussion
• Fullness / mass
• Induration / warmth
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Physical Exam In Pain Assessment
Neurological Examination
•
Important in evaluating pain, due to the possibility of spinal
cord compression, and nerve root or peripheral nerve lesions
•
Sensory examination
– Areas of numbness / decreased sensation
– Areas of increased sensitivity, such as allodynia or
hyperalgesia
•
Motor (strength) exam - caution if bony metastases (may
fracture)
•
Deep tendon reflexes – intensity, symmetry
– Hyperreflexia and clonus: possible upper motor neuron
lesion, such as spinal cord compression or cerebral
metastases.
– Hyoporeflexia - possible lower motor neuron impairment,
including lesions of the cauda equina of the spinal cord or
leptomeningeal metastases.
•
Sacral reflexes – diminished rectal tone and absent anal
reflexes may indicate cauda equina involvement of by tumour
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Physical Exam In Pain Assessment
Other Exam Considerations
Further areas of focus of the
physical examination are
determined by the clinical
presentation.
Eg: evaluation of pleuritic chest
pain would involve a detailed
respiratory and chest wall
examination.
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Pain
Treatment
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Non-Pharmacological Pain
Management
• Acupuncture
• Cognitive/behavioral therapy
• Meditation/relaxation
• Guided imagery
• TENS
• Therapeutic massage
• Others…
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W.H.O. ANALGESIC LADDER
3
By the
Strong opioid
+/- adjuvant
2
Clock
Weak opioid
+/- adjuvant
1
Non-opioid
+/- adjuvant
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STRONG OPIOIDS
• most commonly use:
– morphine
– Hydromorphone (Dilaudid ®)
– transdermal fentanyl (Duragesic®)
– oxycodone
– Methadone
• DO NOT use meperidine (Demerol) long-term
– active metabolite normeperidine  seizures
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OPIOIDS and
INCOMPLETE CROSS-TOLERANCE
• conversion tables assume that tolerance to a
specific opioid is fully “crossed over” to other
opioids.
• cross-tolerance unpredictable, especially in:
– high doses
– long-term use
• divide calculated dose in ½ and titrate
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TITRATING OPIOIDS
• dose increase depends on the situation
• dose by 25 - 100%
EXAMPLE: (doses in mg q4h)
Morphine
Hydromorphone
5 10 15 20 25 30 40 50 60
1
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2
3
4
5
6
8 10 12
http://palliative.info
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http://palliative.info
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TOLERANCE
PSYCHOLOGICAL
DEPENDENCE /
ADDICTION
PHYSICAL
DEPENDENCE
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TOLERANCE
A normal physiological
phenomenon in which increasing
doses are required to produce
the same effect
Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3
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PHYSICAL DEPENDENCE
A normal physiological
phenomenon in which a withdrawal
syndrome occurs when an opioid
is abruptly discontinued or an
opioid antagonist is administered
Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3
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PSYCHOLOGICAL DEPENDENCE
and ADDICTION
A pattern of drug use characterized
by a continued craving for an opioid
which is manifest as compulsive
drug-seeking behaviour leading to
an overwhelming involvement in the
use and procurement of the drug
Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3
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Changing Route Of Administration
In Chronic Opioid Dosing
po / sublingual / rectal routes
reduce by ½
SQ / IV / IM routes
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Using Opioids for Breakthrough Pain
• Patient must feel in control, empowered
• Use aggressive dose and interval
Patient Taking Short-Acting Opioids:
• 50 - 100% of the q4h dose, given q1h prn
Patient Taking Long-Acting Opioids:
• 10 - 20% of total daily dose given, q1h prn
with short-acting opioid preparation
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Opioid Side Effects
• Constipation – need proactive laxative use
• Nausea/vomiting – consider treating with dopamine
antagonists and/or prokinetics (metoclopramide,
domperidone, prochlorperazine [Stemetil], haloperidol)
• Urinary retention
• Itch/rash – worse in children; may need low-dose naloxone
infusion. May try antihistamines, however not great
success
• Dry mouth
• Respiratory depression – uncommon when titrated in
response to symptom
• Drug interactions
• Neurotoxicity (OIN): delirium, myoclonus ® seizures
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Spectrum of Opioid-Induced Neurotoxicity
Opioid
tolerance
Mild myoclonus
(eg. with sleeping)
Delirium
Opioids
Increased
Severe myoclonus
Seizures,
Death
Hyperalgesia
Agitation
Misinterpreted
as Pain
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Opioids
Increased
Misinterpreted
as Disease-Related Pain
OIN: Treatment
• Switch opioid (rotation) or reduce
opioid dose; usually much lower than
expected doses of alternate opioid
required… often use prn initially
• Hydration
• Benzodiazepines for neuromuscular
excitation
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Adjuvant Analgesics
• first developed for non-analgesic
indications
• subsequently found to have analgesic
activity in specific pain scenarios
• Common uses:
– pain poorly-responsive to opioids (eg.
neuropathic pain), or
– with intentions of lowering the total opioid dose
and thereby mitigate opioid side effects.
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Adjuvants Used In Palliative Care
• General / Non-specific
– corticosteroids
– cannabinoids (not yet commonly used for
pain)
• Neuropathic Pain
– gabapentin
– antidepressants
– ketamine
– topiramate
– clonidine
• Bone Pain
– bisphosphonates
– (calcitonin)
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CORTICOSTEROIDS AS ADJUVANTS
 inflammation
 edema
}
tumor mass
effects
 spontaneous nerve depolarization
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CORTICOSTEROIDS: ADVERSE EFFECTS
IMMEDIATE
• Psychiatric
• Hyperglycemia
LONG-TERM
•
•
• risk of GI bleed
 gastritis
•
 aggravation of existing
•
lesion (ulcer, tumor)
• Immunosuppression
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Proximal myopathy often
< 15 days
Cushing’s syndrome
Osteoporosis
Aseptic / avascular
necrosis of bone
DEXAMETHASONE
• minimal mineralcorticoid effects
• po/iv/sq/?sublingual routes
• perhaps can be given once/day;
often given more frequently
• If an acute course is discontinued
within 2 wks, adrenal suppression
not likely
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Treatment of Neuropathic Pain
Pharmacologic treatment
• Opioids
• Steroids
• Anticonvulsants – gabapentin, topiramate
• TCAs (for dysesthetic pain, esp. if depression)
• NMDA receptor antagonists: ketamine,
methadone
• Anesthetics
Radiation therapy
Interventional treatment
• Spinal analgesia
• Nerve blocks
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Gabapentin
• Common Starting Regimen
– 300 mg hs Day 1, 300 mg bid Day2,
300 mg tid Day 3, then gradually
titrate to effect up to 1200 mg tid
• Frail patients
– 100 mg hs Day 1, 100 mg bid Day
2, 100 mg tid Day 3, then gradually
titrate to effect
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Incident Pain
Pain occurring as a direct and
immediate consequence of a
movement or activity
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Circumstances In Which
Incident Pain Often Occurs
• Bone metastases
• Neuropathic pain
• Intra-abd. disease aggravated by respiration
» “incident” = breathing
» ruptured viscus, peritonitis, liver hemorrhage
• Skin ulcer: dressing change, debridement
• Disimpaction
• Catheterization
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Having a steady level of enough opioid to treat
the peaks of incident pain...
Pain
...would result in
excessive dosing
for the periods
between
incidents
Incident
Incident
Time
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Incident
Fentanyl and Sufentanil
 synthetic µ agonist opioids
 highly lipid soluble
• transmucosal absorption; effect in approx 10 min
• rapid redistribution, including in / out of CSF; lasts
approx 1 hr.
 fentanyl » 100x stronger than morphine
 sufentanil » 1000x stronger than morphine
10 mg morphine
10 µg sufentanil
100 µg fentanyl
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INCIDENT PAIN PROTOCOL
(see also http://palliative.info)
Step Medication
#
(50 mg/ml)
# Micrograms
Sublingually
1
Fentanyl
50
2
Sufentanil
25
3
Sufentanil
50
4
Sufentanil
100
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INCIDENT PAIN PROTOCOL ctd...
• fentanyl or sufentanil is administered SL 10
min. prior to anticipated activity
• repeat q 10min x 2 additional doses if needed
• increase to next step if 3 total doses not
effective
• physician order required to increase to next
step if within an hour of last dose
• the Incident Pain Protocol may be used up to q
1h prn
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Barriers to Pain Relief
• Importance of discussing barriers
• Specific barriers
– Professionals
– Health care systems
– Patients/families
Miaskowski et al., 2005; Paice, 2010; Pasero & McCaffery, 2011
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Pain Assessment
• Pain history
• Pain terms
• Acute vs. chronic
Fink & Gates, 2010
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Pain History
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Location
Intensity
Quality
Temporal pattern
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Pain History
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•
•
Aggravating/alleviating factors
Medication history (recent and distant)
Meaning of pain
Cultural factors
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Physical Examination
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•
•
•
Observation
Palpation
Auscultation
Percussion
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Functional Assessment
• Ability to dress self
• Walking
• Cooking
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Laboratory/Diagnostic
Evaluation
• Rule out potentially treatable
causes
• Need for additional laboratory or
radiographic evaluation is
directed by the goals of care
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Reassess
• Changes in pain
• Assess pain relief
• Make pain visible
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Common Syndromes at the
End of Life
• Nociceptive
– Somatic
– Visceral
• Neuropathic
–
–
–
–
Post herpetic neuropathy
Diabetic neuropathy
HIV associated neuropathy
Chemotherapy related neuropathy
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Pain vs. Suffering at the
End of Life
• Existential distress
• Dimensions of quality of life
• Requires interdisciplinary
approach
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Patients at Risk for
Undertreatment
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Children and older adults
Non-verbal or cognitively impaired
Patients who deny pain
Patients who speak a different
language
• Different cultures
• History of addictive disease
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Communicating
Assessment Findings
• Communication improves pain
management
• Describe intensity, limitations,
and response to treatments
• Documentation
Gordon et al, 2005; Pasero & McCaffery, 2011
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Definitions
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•
•
•
Tolerance
Physiologic dependence
Psychological dependence
Opioids and death
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Pharmacological Therapies
• Nonopioids
• Opioids
• Adjuvants
APS, 2008; Pasero & McCaffery, 2011
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Nonopioids
• Paracetamol
• NSAIDs
APS, 2008;
Paice, 2010:
Pasero & McCaffery, 2011
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Nonopioids: NSAIDs
Adverse Effects
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Opioids
•
•
•
•
•
•
Morphine
Codeine
Fentanyl
Tramadol
Methadone
Pethidine
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Opioids: Adverse Effects
•
•
•
•
•
•
Respiratory depression
Constipation
Sedation
Urinary retention
Nausea/vomiting
Pruritus
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Adjuvant analgesics
•
•
•
•
Antidepressants
Anticonvulsants
Local anesthetics
Corticosteroids
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Antidepressants
• Block serotonin and
norepinephrine
• Administer at bedtime
• Side effects
• SSRIs have little analgesic effect
• Newer agents
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Anticonvulsants/Antiepilepsy
Drugs
• Older agents have significant adverse
effects
• Newer agents:
– Gabapentin
– Pregabalin
– Lamotrigine, levetiracetam, oxcarbazepine
and others
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Local Anesthetics
• Topical: Lidocaine gel or patch
(plaster)
• Intravenous
• Spinal
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Corticosteroids
• Dexamethasone has least
mineralocorticoid effect
• Psychosis
• Proximal muscle wasting
• Administer - q am
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Routes of Administration
•
•
•
•
•
Oral
Mucosal
Rectal
Transdermal
Topical
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Routes of Administration (cont.)
• Parenteral
– Intravenous
– Subcutaneous
– Intramuscular
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Routes of Administration (cont.)
• Spinal
– Epidural
– Intrathecal
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WHO 3 Step Analgesic Ladder
Pain Management
Step 1: Mild pain
Step 2: Moderate pain
Step 3: Severe pain
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Principles: Prevent and
Treat Side Effects
• Anticipate
• Prevent
• Treat
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Principles: Long Acting
Medications
• Sustained release medications
• Immediate release for breakthrough pain
• Distinguish types of breakthrough pain
–Episodic
–Idiopathic
–End of dose failure
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Principles of Equianalgesia
• Determine equal doses when
changing drugs or routes of
administration
• Oral to parenteral morphine 3:1 ratio
• Reduce by 25% when changing
drugs
• Use of morphine equivalents
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Principles: Use of Opioid
Rotation
• Use when one opioid is
ineffective even with adequate
titration
• Use when adverse effects are
unmanageable
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Placebos
• Not diagnostic
• Causes mistrust
• Never ethical
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Cancer Therapies to Relieve
Pain
•
•
•
•
•
Radiation
Surgery
Chemotherapy
Hormonal therapy
Others
Doyle et al., 2001;
Janjan et al., 2003; Jeremic, 2001
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Interventional Therapies
• Neurolytic blocks
• Neuroablative procedures
• Vertebroplasty
Furlan et al., 2001;
Mathias et al., 2001; Swarm et al., 2010
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Non-Pharmacologic
Techniques
• Cognitive - behavioral therapies
– Relaxation
– Imagery
– Distraction
– Support groups
– Pastoral counseling
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Non-Pharmacologic
Techniques (cont.)
• Physical measures (heat, cold,
massage)
• Complementary therapies
• Repositioning/ bracing
Ernst, 2004; Kravits & Berenson, 2010;
Smith et al., 2002
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Pain in HIV
•
•
•
•
•
Abdominal pain
Headache
Musculosketal pain
Neuropathy
Oral lesions
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Roles of the Healthcare Team
•
•
•
•
Direct clinical care
Patient/family teaching
Education of colleagues
Identify system barriers a work to
correct
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Conclusion
• Pain relief is contingent on adequate
assessment and use of both drug
and non-drug therapies
• Pain extends beyond physical
causes to other causes of suffering
and existential distress
• Interdisciplinary care
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Freedom
94
Give the answers to the
following questions please:
1. The definitions of Dysesthesia,
Allodynia, Hyperalgesia,
Hyperesthesia
2. Compare the nociceptive and
neuropathic pain. What are the
difference?
3. What are the main opioids used in
palliative care?
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