CHRONIC PAIN MANAGEMENT

Co-ordinator- Dr. Chavi Sethi (MD)Speaker- Dr. Sushil

Department of AnesthesiologyM.L.B. Medical College, Jhansi

Pain• Pain is not just a sensory modality but is an experience.• The International Association for the Study of Pain defines pain as

"an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.“

• response to pain can be highly variable among persons as well as in the same person at different times.

• term "nociception," which is derived from noci (Latin for harm or injury), is used to describe the neural response only to traumatic or noxious stimuli.

• All nociception produces pain, but not all pain results from nociception.

• Many patients experience pain in the absence of noxious stimuli. It is therefore clinically useful to divide pain into one of two categories

(1) acute pain, which is primarily due to nociception, and (2) chronic pain, which may be due to nociception but in which

psychological and behavioral factors often play a major role.• Pain can also be classified according to pathophysiology (eg, nociceptive

or neuropathic pain), etiology (eg, postoperative or cancer pain), or the affected area (eg, headache or low back pain). Such classifications are useful in the selection of treatment modalities and drug therapy

Chronic Pain

• Chronic pain is defined as pain that persists beyond the usual course of an acute disease or after a reasonable time for healing to occur;

this period can vary from 1 to 6 months.• Chronic pain may be nociceptive, neuropathic, or mixed.

• Patients with chronic pain often have an attenuated or absent neuroendocrine stress response and have prominent sleep and affective (mood) disturbances, differentiate from acute pain

• A distinguishing feature is that psychological mechanisms or environmental factors frequently play a major role.

most common forms of chronic pain include those associated with –• musculoskeletal disorders,• chronic visceral disorders,• lesions of peripheral nerves, nerve roots, or dorsal root ganglia

(including diabetic neuropathy, causalgia, phantom limb pain, and postherpetic neuralgia),

• lesions of the central nervous system (stroke, spinal cord injury, and multiple sclerosis), and

• cancer pain. The pain of most musculoskeletal disorders (eg, rheumatoid arthritis

and osteoarthritis) is primarily nociceptive, whereas pain associated with peripheral or central neural disorders is primarily neuropathic

Mechanisms of Pain: NeuroplasticityHow does a Chronic Pain State Develop?

• Peripheral Sensitization- Injury causes release of

“sensitizing soup” - Reduction in threshold and

increase response of nocioceptors

• Central Sensitization- Membrane excitability, synaptic

recruitment and decreased inhibition

- Uncoupling of pain from peripheral stimuli

Evaluating the Patient with Pain

• physician must first distinguish between acute and chronic pain. • management of acute pain is primarily therapeutic, whereas that of chronic pain

additionally involves investigative measures. • The former requires only a pertinent history and examination, including

quantitative evaluation of pain severity, whereas the latter requires a careful history and physical examination, a review of prior medical evaluations and treatments, and thorough psychological and sociological evaluations.

• physical examination should emphasize the musculoskeletal and neurological systems.

• Imaging studies are often necessary and may include plain radiographs, computed tomography (CT), magnetic resonance imaging (MRI), or bone scans.

• These studies can often detect unsuspected trauma, tumors, or metabolic bone disease. MRI is particularly useful for soft tissue analysis and can show nerve compression.

Pain Measurement• numerical rating scale, faces rating scale, visual analog scale (VAS), and

the McGill Pain Questionnaire (MPQ) are most commonly used.• Because chronic pain is so complex, there are often multiple treatment

goals• chronic pain often is best managed using what is called a

“multimodality” approach. A multimodality approach to chronic pain includes a combination of therapies selected from eight broad categories:

Drug therapies Psychological therapies Rehabilitative therapies Anesthesiological therapies Neurostimulatory therapies Surgical therapies Lifestyle changes Complementary and Alternative medicine therapies

Multimodal Pain Management

Traditional Step Approach

Pharmacological Interventions• Pharmacological interventions in pain management include COX inhibitors,

opioids, antidepressants, neuroleptic agents, anticonvulsants, corticosteroids, and systemic administration of local anesthetics.

Antidepressants- These agents demonstrate an analgesic effect that occurs at a dose lower than needed for their antidepressant action. Both actions are due to blockade of presynaptic reuptake of serotonin, norepinephrine, or both.

• Older tricyclic agents appear to be more effective analgesics than selective serotonin reuptake inhibitors (SSRIs).

• most useful in patients with neuropathic pain, eg, from postherpetic neuralgia and diabetic neuropathy. They potentiate the action of opioids and frequently normalize sleep patterns

nonselective norepinephrine/5-HT reuptake inhibitors (amitriptyline, imipramine, clomipramine, venlafaxine),

preferential norepinephrine reuptake inhibitors (desipramine, nortriptyline selective 5-HT reuptake inhibitors (citalopram, paroxetine, fluoxetine).

Anticonvulsants• Anticonvulsants have been found to be extremely useful in patients with

neuropathic pain, particularly trigeminal neuralgia and diabetic neuropathy.• These agents block voltage-gated sodium channels and can suppress the

spontaneous neural discharges that play a major role in these disorders. • Gabapentin may offer additional unique beneficial effects. It has also been shown

to be an effective adjuvant for postoperative pain. • The most commonly employed agents are phenytoin, carbamazepine, valproic acid,

clonazepam, and gabapentin . Lamotrigine and topiramate may also be effective. All are highly protein bound and have relatively long half-lives.

Neuroleptics• neuroleptics useful in patients with refractory neuropathic pain.• The most commonly used agents are fluphenazine, haloperidol, chlorpromazine,

and perphenazine• Their therapeutic action appears to be due to blockade of dopaminergic receptors

in mesolimbic sites.

Corticosteroids

• Glucocorticoids are extensively used in pain management for their antiinflammatory and possibly analgesic actions.

• They may be given topically, orally, or parenterally (intravenously, subcutaneously, intrabursally, intraarticularly, epidurally).

• Large doses or prolonged administration result in significant side effects.

• Excess glucocorticoid activity can produce hypertension, hyperglycemia, increased susceptibility to infection, peptic ulcers, osteoporosis, aseptic necrosis of the femoral head, proximal myopathy, cataracts, and, rarely, psychosis.

• Patients can also develop the physical features characteristic of Cushing's syndrome

• Excess mineralocorticoid activity causes sodium retention and hypokalemia, and can precipitate congestive heart failure.

• Dexamethasone, Betamethasone, Triamcinolone and Methyl-prednisolone are commonly used.

Systemic Local Anesthetics

• Local anesthetics are occasionally used systemically in patients with neuropathic pain.

• They produce sedation and central analgesia; the analgesia frequently outlasts the pharmacokinetic profile of the local anesthetic and breaks the "pain cycle.

• " Lidocaine, procaine, and chloroprocaine are the most commonly used agents.• They are given either as a slow bolus or by continuous infusion. Lidocaine is given

by infusion over 5–30 min for a total of 1–5 mg/kg. • Procaine 200–400 mg can be given intravenously over the course of 1–2 h,

whereas chloroprocaine (1% solution) is infused at a rate of 1 mg/kg/min for a total of 10–20 mg/kg.

• Monitoring should include the electrocardiogram (ECG), blood pressure, respirations, and mental status; full resuscitation equipment should also be immediately available. Signs of toxicity such as tinnitus, slurring, excessive sedation, or nystagmus necessitate slowing or discontinuing the infusion.

Alfha2Adrenergic Agonists

• The primary effect of 2-adrenergic agonists is activation of descending inhibitory pathways in the dorsal horn. Epidural and intrathecal 2-adrenergic agonists are particularly effective in neuropathic pain and opioid tolerance.

• Clonidine is most commonly used drug in this grup.

Botulinum Toxin • Botulinum toxin injections have been increasingly utilized in the treatment of

painful conditions associated with skeletal muscle. • use in the treatment of conditions associated with involuntary muscle contraction

(eg, focal dystonia and spasticity). • Some clinicians have used the drug in the management of headaches and

myofascial syndromes. • Botulinum toxin blocks acetylcholine released at the synapse in motor nerve

endings but not sensory nerve fibers. Proposed mechanisms of analgesia include improved local blood flow, relief of muscle spasms, and release of muscular compression of nerve fibers

Topical Analgesics• The topical application of various analgesics is an area of considerable interest because

many chronic pain syndromes depend to some degree on the peripheral activation of primary afferent neurons.

• Localized administration can potentially optimize drug concentrations at the site of pain generation while avoiding high plasma levels, systemic side effects, drug interactions, and the need to titrate doses into a therapeutic range.

• topical NSAIDs, tricyclic antidepressants, capsaicin, local anesthetics, and opioids are used .

topical tricyclic antidepressant (doxepin) has shown efficacy in a mixed group of patients with neuropathic pain and, as a mouthwash, in patients with chemotherapy-induced oral mucositis.

Capsaicin is the active pungent ingredient in chili peppers.• Capsaicin is available as 0.025% and 0.075% cream. It was shown to achieve pain relief in

patients with postherpetic neuralgia, postmastectomy syndrome, osteoarthritis, and a variety of neuropathic syndromes.

Topical formulations of local anesthetics block Na+ channels in primary afferent neurons• lidocaine patches and gels showed pain reduction in patients with postherpetic neuralgia

and allodynia.• patients with painful diabetic polyneuropathy, CRPS, postmastectomy syndrome, or post-

thoracotomy syndrome can achieve relief of pain.

Topically applied or locally injected opioids produce analgesia by activating opioid receptors on primary afferent neurons.

• This leads to inhibition of Ca2+, Na+, and TRPV1 currents, which are activated by inflammatory agents.

• Intra-articular morphine also produces analgesia in chronic rheumatoid and osteoarthritis, where its potency was shown to be similar to standard intra-articular steroids and long lasting (up to 7 days), possibly because of morphine's anti-inflammatory activity.

• opioids have been applied locally (e.g., in gels) to treat pain from skin ulcers, cystitis, cancer-related oral mucositis, corneal abrasion, and bone injury

Topical Opioids Provide Temporary Relief in Central Intractable Pain. Treatment consisted of one or more of the following agents in a range of strengths

dissolved in 1oz of cold cream: morphine 30–90mg; oxycodone 30–90mg; hydromorphone 8–24mg, or carisoprodol 350–1,050mg. Patients were instructed to use their topical preparations in a manner to maximize pain relief.

Nonsteroidal Anti-inflammatory Drugs and Antipyretic Analgesics

• The acidic NSAIDs and the nonacidic antipyretic analgesics (e.g., acetaminophen, phenazones) inhibit COXs, enzymes that catalyze the transformation of arachidonic acid (a ubiquitous cell component generated from phospholipids) to prostaglandins and thromboxanes.

• Less severe pain states (e.g., early arthritis, headache) are commonly treated with nonselective NSAIDs (e.g., aspirin, ibuprofen, indomethacin, diclofenac) or antipyretic analgesics (e.g., acetaminophen), mostly used orally.

• Some agents are available for parenteral, rectal, or topical application

Opioids

Pain management by rehabilitative approaches

Physical therapy (PT)-useful in teaching patients to controlpain, to move in safe and structurally correct ways, to improve range of motion, and to increase flexibility, strength and endurance.

• “Active” and “Passive” modalities can both be used, but active modalities, such as therapeutic exercise,are particularly important when the goal is to improve both comfort and function.

Bed rest - use of prolonged bed rest in the treatment of patients with neck and low back pain.

• For severe radicular symptoms, limited bed rest of less than 48 hours may be beneficial to allow for reduction of significant muscle spasm brought on with upright activity

Bracing- acute neck pain secondary to whiplash injury,Manipulation & mobilisation- treatment of patients with acute low

back pain.

Transcutaneous electrical nerve stimulation- has been used to treat patients with various pain conditions,including neck

and low back pain• TENS is generally used in chronic pain conditions and not indicated in the

initial management of acute cervical or lumbar spine pain.Thermal modalities- Thermal modalities include a variety of methods that

produce heating and cooling of the tissues to manage acute and chronic musculoskeletal pain.

• Superficial heat, such as moist hot packs, increases skin and joint temperature and blood flow, and may decrease joint stiffness and muscle spasms.

Diathermy- Diathermy involves the use of high-frequency oscillating current and ultrasound (inaudible sound wave vibrations) to create deep heating.

• The deep heating may reduce the perception of pain.

Ultrasound- Ultrasound is a deep-heating modality that is most effective in heating structures such as the hip joint, which superficial heat cannot reach

• It has been found to be helpful in improving the distensibility of connective tissue which facilitates stretching.

• It is perhaps best used in the region of the upper trapezius or lumbar paraspinals to

facilitate active stretching and strengthening.Cryotherapy - Cryotherapy can be achieved through the use of ice, ice packs, or

continuously via adjustable cuffs attached to cold water dispensers Intramuscular temperatures can be reduced by between 3 °C and 7 °C, which functions to reduce local metabolism, inflammation, and pain.

• Cryotherapy works by decreasing nerve conduction velocity, termed cold-induced neuropraxia, along pain fibers with a reduction of the muscle spindle activity responsible for mediating local muscle tone.

Psychological/Mind-Body therapies for chronic painmanagement

• Psychological factors are important contributors to the intensity of pain and to

the disability associated with chronic pain.• Pain and stress are intimately related. There may be a vicious cycle in which pain

causes stress, and stress, in turn, causes more pain• Mind/body approaches address these issues and provide a variety of benefits,

including a greater sense of control, improved coping skills, decreased pain intensity and distress, changes in the way.

Cognitive-Behavioral therapy - CBT has proven to be effective in reducing pain and disability when it is used as part of a therapeutic strategy for chronic pain.

• It can provide educational information and diffuse feelings of fear and helplessness

• CBT may include training in various types of relaxation approaches, which can help people in chronic pain lower their overall level of arousal, decrease muscle tension, control distress, and decrease pain, depression and disability.

Biofeedback-

Biofeedback- Biofeedback is the use of electronic monitoring instruments to provide patients with immediate feedback on heart rate, blood pressure, muscle tension, or brain wave activity.

• This allows the patient to learn how to influence these bodily responses through conscious control and regulation.

• Biofeedback has been shown to be effective in the management of migraine headaches, fibromyalgia, temporomandibular disorders, and rheumatoid arthritis, Raynaud’s disease, tension headaches, headaches in children and the pain associated with irritable bowel syndrome.

Spinal Cord Stimulation (SCS)- This technique is also called dorsal column stimulation because it was thought to produce analgesia by directly stimulating large A fibers in the dorsal columns of the spinal cord. Proposed mechanisms include activation of descending modulating systems and inhibition of sympathetic outflow.

• Spinal cord stimulation is most effective for neuropathic pain.

• Accepted indications include sympathetically mediated pain, spinal cord lesions with localized segmental pain, phantom limb pain, ischemic lower extremity pain due to peripheral vascular disease, and adhesive arachnoiditis.

• Patients with failed back surgery syndrome (FBSS), which is typically a mixed nociceptive–neuropathic disorder, also appear to benefit from SCS.

Deep brain stimulation • used for intractable cancer pain, and rarely for intractable neuropathic pain of

nonmalignant origin. • Electrodes are implanted stereotactically into the periaqueductal and

periventricular gray areas for nociceptive pain (primarily cancer and chronic low back pain); for neuropathic pain, the electrodes are implanted into specific sensory thalamic nuclei.

• The most serious complications are intracranial hemorrhage and infection

Interventional Methods Used for Chronic Pain

• Interventional pain management or interventional pain medicine is a subspecialty of the medical specialty - pain management, devoted to diagnosis & treatment of pain & related disorders by application of interventional techniques in managing subacute , chronic, persistent & intractable pain independently or in conjuction with

other modalities of treatment.• It fills the gap between pharmacological management of pain and more invasive

operative procedures.

1) Diagnostic & Therapeutic Neural Blockade- Neural blockade with local anesthetics can be useful in delineating pain mechanisms, but, more importantly, it plays a major role in the management of patients with acute or chronic pain .

• Selection of the type of block depends on the location of pain, its presumed mechanism, and the skills of the treating physician.

• Local anesthetic may be applied locally (infiltration), or at a peripheral nerve, somatic plexus, sympathetic ganglia, or nerve root. It can be applied centrally in the neuraxis(Spinal and epidural)

A )Somatic Blocks- Trigeminal Nerve Blocks- The two principal indications are trigeminal neuralgia

and intractable cancer pain in the face• these blocks may be performed on the gasserian ganglion Facial Nerve Block- Blockade of the facial nerve is occasionally indicated

to relieve spastic contraction of the facial muscles and to treat herpes zoster affecting this nerve.

Glossopharyngeal Block- Glossopharyngeal nerve block may be used for patients with pain due to malignant growths at the base of the tongue, the epiglottis, and palatine tonsils. It can also be used to distinguish glossopharyngeal neuralgia from trigeminal and geniculate neuralgia

Occipital Nerve Block- Occipital nerve block is useful diagnostically and therapeutically in patients with occipital headaches and neuralgias.

Phrenic Nerve Block- Blockade of the phrenic nerve may occasionally provide relief for pain arising from the central portion of the diaphragm. It can also be useful in patients with refractory hiccups (singultation

Suprascapular Nerve Block -This block is useful for painful conditions arising from the shoulder (most commonly arthritis and bursitis.

Cervical Paravertebral Nerve Block- Selective paravertebral blockade at the cervical level can be useful diagnostically and therapeutically for cancer patients with pain originating from the cervical spine or the shoulder.

Lumbar Paravertebral Somatic Nerve Block- Paravertebral block at this level is useful in evaluating pain due to disorders involving the lumbar spine or spinal nerves,

Lumbar Medial Branch & Facet Blocks- These blocks may establish the contribution of lumbar facet (zygapophyseal) joint disease in back pain. Corticosteroids are commonly injected with the local anesthetic when the intraarticular technique is chosen.

2)Sympathetic Blocks- Sympathetic blockade can be accomplished by a variety of techniques including subarachnoid, epidural, as well as paravertebral blocks.

• Unfortunately, these approaches usually block both somatic and sympathetic fibers. • most common indications include reflex sympathetic dystrophy, visceral pain, acute

herpetic neuralgia, postherpetic pain, and peripheral vascular disease.

StellateBlock- used in patients with head, neck, arm, and upper chest pain. Thoracic Sympathetic Chain Block – Celiac Plexus Block- indicated in patients with pain arising from the abdominal

viscera, particularly abdominal malignant growths. Splanchnic Nerve Block-

Neurolytics- Neurolytics employ injection of chemical agents such as alcohol, phenol, or glycerol to block pain messages.

– It is indicated for patients with limited life expectancy and patients who have recurrent or intractable pain after a series of analgesic blocks.

– Potential side effects of neurolytic agents include neuritis and deafferentation pain, motor deficit and unintentional damage to non-targeted tissue.

Ethyl alcohol,phenol, glycerol, Hypertonic or hypotonic saline , Ammonium salts ,Botulinum neurotoxins are commonly used neurolytics,

• Radiofrequency ablation

– High frequencies of 300–500 KHz are used

– A modern RF lesion generator has the following functions:

■ Continuous on-line impedance measurement

■ A nerve stimulator

■ Monitoring of voltage, current, and wattage during the RF procedure

■ Temperature monitoring

■ Pulsed current delivery mode

Contd…– Continuous Radio Frequency Lesioning

• The voltage of the generator is set up between the electrode and the ground plate. The body tissues complete the circuit and RF-current flows through the tissue, resulting in an electric field.

• Frictional dissipation of the ionic current within the fluid medium causes tissue heating. RF heat is therefore generated in the tissue, and the electrode is heated by the tissue.

• The size of the lesion depends on the tip temperature and the tip temperature depends on the power deposition.

• But there are other factors involved as well. Heat is also removed from the lesion area by conductive heat loss and blood circulation. This is referred to as heat “washout.”

• Maximum “volume” of a lesion is effectively obtained after 40 seconds, and that the lesion size strongly depends on tip temperature and on probe diameter.

Indications of RF neuroablation• Radiofrequency neuroablation is frequently carried out for following

conditions :• - Lumbar RF sympathectomy for peripheral vascular disorders and

complex regional pain syndrome (CRPS) of lower extremity• - RF ablation of Gasserian Ganglion or of individual branches for

trigeminal neuralgia• - Cervical, thoracic, lumbar facet joint RF denervation• - Stellate ganglion lesioning for CRPS of upper extremity• - Cervical thoracic lumbar, sacral rhizolysis• - Sacroiliac joint denervation• - Intervertebral disc annuloplasty in intervertebral disc• prolapse

• Cryoneurolysis – A technique in which the application of low temperatures produced by

cryosurgical equipment achieves anesthesia or analgesia by blocking peripheral nerves or destroying nerve endings.

– Expansion of gas enclosed in the cryoprobe results in Kelvin effects; that is, gas under pressure escaping through a small orifice expands and cools, achieving temperatures between -500C & -700C at the tip, and returns through an inner tube.

Contd…– For myelinated fibers, a direct lesion 3 mm in diameter with a freeze time of

1 minute produces a conduction block.

– Where the nerve is frozen amid other tissues, the duration of exposure should be approximately 90 to 120 seconds.

– A prolonged conduction block occurs when the nerve is frozen at temperatures between -5°C and -20°C. This causes axonal disintegration and breakdown of myelin sheaths.

– Wallerian degeneration occurs with the perineurium and epineurium remaining intact.

– The absence of external damage to the nerve and the minimal inflammatory reaction following freezing ensure that regeneration is accurate and complete.

• Intrathecal Drug Delivery Systems– In general, chronic intraspinal infusion therapy using implantable drug

administration systems has been reserved for patients whose condition is considered chronic, and have failed more conservative therapies.

– Patients must have either inadequate pain control or intolerable side effects on systemic opiates and adjuvant therapy.

– General guidelines for considering intrathecal therapy include an expected 3-month survival.

– Although percutaneous externalized epidural or even intrathecal catheter placement is feasible for short-term treatment, vulnerability to infection and economic considerations preclude serious considerations for long-term use (>3 months).

• Vertebroplasty – It is a minimally invasive procedure that is effective in the treatment of pain

resulting from pathologic compression fractures, osteolytic bone lesions, myelomas, hemangiomas and osteoporosis.

– The main indication is the symptomatic (painful) osteoporotic compression fracture of the thoracolumbar spine.

– It is essential to discriminate an acute event with sudden onset of pain and plain x-rays showing radiological signs of an acute fracture from chronic painful disorders of the spine.

• Balloon Kyphoplasty– The indications for balloon kyphoplasty are the same as in vertebroplasty.

– It is especially indicated in the presence of vertebral body deformity.

• General contraindications include uncorrectable coagulation disorders, infectious processes of the spine, and allergies against PMMA or contrast medium. Poor pulmonary status and difficulty lying prone are relative contraindications.

Contd…• Ozone Nucleolysis

– Ozone nucleolysis may be done in most kinds of disc related pain.

• degenerated disc without any prolapse and nerve root irritation.

• contained disc prolapse or disc bulge with root irritation.

• non-contained disc.

– 3-10 cc of oxygen-ozone mixture (at a concentration of 29-40 microgram/ml) is injected into the disc.

– There are few conditions when ozone therapy should not be performed. They are active bleeding from any site, pregnancy, G6PD deficiency, active hyperthyroidism, loss of control of urination & defecation, and progressive sensory & motor loss.

– Complications of ozone therapy are very rare. They include post-procedural muscle spasm & burning pain & discitis.

Cancer Pain

• Cancer pain can be managed with oral analgesics in most patients.• The World Health Organization recommends a three-step approach

Pain persisting orincreasingStep 1:Non narcotic – “around the clock” 2‐• Acetaminophen 650mg q4h or• ASA 650mg q4h or• Ibuprofen 400mg q4h or• other NSAIDs• +/- Adjuvants** Adjuvant therapy medications that can help to enhance the effects of non opioid and ‐ ‐opioid analgesics1) NSAIDs (non steroidal anti inflammatories) can be used as co analgesics and are useful in ‐ ‐ ‐ ‐reducing inflammation2) Tricyclic anti depressants Nortriptyline, Desipramine, and Amitriptyline are options, ‐ ‐although Amitriptyline can cause confusionin the elderly. Studies have confirmed their effectiveness in treating diabetic neuropathy and neuropathic pain from other sources3) Anticonvulsant medications – Gabapentin, Pregabalin, and Carbamazepine can relieve the shooting, electrical pains of peripheralnerve dysfunction.

Step 2:Add Opioid for Moderate Pain – “around the clock” 2• Acetaminophen 325mg + codeine 30mg q4h (Tylenol #3) or• Acetaminophen 325mg + codeine 60mg q4h (Tylenol #4) or• Acetaminophen 325/500mg + oxycodone 5mg q4h (Percocet / Roxicet)• +/- Adjuvants*Note: Consider stronger opioid if pain not controlled by thesecombinations at a total daily dose if 400mg/day of codeine or 80mg/day ofoxycodone Step 3:

Start strong oral opioid – “around the clock”ii• Morphine 5 10mg q4h titrate to pain‐• Dilaudid 1 4 mg q4h titrate to pain‐ (hydromorphone hydrochloride)• MS Contin or other long acting 30 60mg q8 12 h‐ ‐ ‐• Fentanyl 25ųg/ hour plus Morphine Sulphate 5 mg. q 2hours for breakthrough – *never to be administered toopioid naive clients• +/- Adjuvants* Notes: Use short acting preparation of same medicationincreasing for breakthrough pain. Consider lower dose in opioid naïveand elderly patients