coyne pain management
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Pain Management: Thethings you should know
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Questions RegardingPain Control
What about the 20% who do not get relief fromthe WHO ladder or the 46% of those whosefamilies stated we failed?*
Have the opioids been titrated aggressively?
Is the pain neuropathic?
Has a true pain assessment been accomplished?
Have invasive techniques been employed?
Have you examined the patient? Is the patient receiving their medication?
Is the medication schedule and route appropriate?
*Tolle 2001
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Physiological effects of Pain
Increased catabolic demands: poor wound
healing, weakness, muscle breakdown
Decreased limb movement: increased risk ofDVT/PE
Respiratory effects: shallow breathing,tachypnea, cough suppression increasing risk ofpneumonia and atelectasis
Increased sodium and water retention (renal)
Decreased gastrointestinal mobility
Tachycardia and elevated blood pressure
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Psychological effects of Pain
Negative emotions: anxiety, depression
Sleep deprivation
Existential suffering: may lead to patientsseeking active end of life.
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Immunological effects of Pain
Decrease natural killer cell counts
Effects on other lymphocytes not yetdefined.
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Procedure Related Pain
Common in all patients
Frequent source of pain and distress
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Therapeutic Procedures
Surgery
Only 50% of post-operative pain isadequately managed
Post-operative pain syndromes
Traumatic neuroma
Similar to other chronic pain syndromes
Psychological factors important
Treat symptoms
Maintain functional status
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Principles of Assessment
Assess and reassess
Use methods appropriate to cognitive status and context
Assess intensity, relief, mood, and side effects
Use verbal report whenever possible
Document in a visible place
Expect accountability
Include the family
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Patient Pain History Site(s) of pain?
Severity of pain?
Date of onset?
Duration?
What aggravates or relieves pain?
Impact on sleep, mood, activity?
Effectiveness of previous medication?
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What Does Pain Mean to
Patients?
Poor prognosis or impending death
Particularly when pain worsens
Decreased autonomy
Impaired physical and social function
Decreased enjoyment and quality of life
Challenges to dignity
Threat of increased physical suffering
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Neuropathic Pain
Neuropathic pain is pain transmitted over damagednerves.
Patient Description of Neuropathic Pain:
Burning, electric, searing, tingling, and migratingor traveling.
Causes of Neuropathic Pain:
Amputation, shingles (herpes zoster), AIDS
(peripheral neuropathy), diabetic neuropathy,
fibromyalgia, and cancers that affect the spinal
cord, among others.Westbrook 2005
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Opioids
Codeine
FentanylHydrocodone
Hydormorphone
Methadone
MorphineOxycodone
Oxymorphone
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Cost of Opioids(AWP 2003 Redbook )(Equianalgesic Dose (morphine 180-200mg / day ATC)
Brand Generic Dose Cost/30 days Cost/day
Roxanol morphine 30 mg q4h $186.84 ($58.75) $6.23 ($2.00)
Morphine IR morphine 30 mg q4h $147.62 $4.92*
Oramorph SR morphine 100 mg q12h $307.20 $10.24
MS Contin morphine 100 mg q12h $328.20 $10.94
Morphine SR morphine 100 mg q12h $293.75 $9.79*
Avinza Morphine 200mg q24h $433.80 $14.46
Kadian morphine 200 mg q24h $365.00 $12.18
Duragesic fentanyl 100 mcg q72h $482.72 $16.06
Oxydose oxycodone 30 mg q4h 309.78($259.97) $10.32*
Oxycontin oxycodone 80 mg q12h $514.85 $17.16
Dilaudid hydromorphone 8 mg q4h $219.60 $7.32
Dolophine methadone 20 mg q8h $ 30.26 $1.01($0.51-4.54)
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Principles of Opioid Analgesic
Use in Acute and Cancer Pain Individualize route, dosage, and schedule
Administer analgesics regularly (not PRN) if
pain is present most of day
Become familiar with dose / time course ofseveral strong opioids
Give infants / children adequate opioid dose
Follow patients closely, particularly when
beginning or changing analgesic regimens
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Principles of Opioid AnalgesicUse in Acute and Cancer Pain
(cont) When changing to a new opioid or different route Use equianalgesic dosing table to estimate new dose
Modify estimate based on clinical situation
Recognize and treat side effects
Be aware of potential hazards of meperidine / mixedagonist-antagonists - particularly pentazocine
Do not use placebos to assess nature of pain
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Principles of Opioid AnalgesicUse in Acute and Cancer Pain
(cont) Watch for development of:
Tolerance - treat appropriately
Physical dependence prevent withdrawal
Do not label a patient psychologically dependent,addicted, if you mean physically dependent on /
tolerant to opioids
Be alert to psychological side of patient (APS,2005)
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Equianalgesia
Determining equal doses when
changing drugs or routes of
administration
Use of morphine equivalents
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Practical Prescribing:
Equianalgesic Dosing
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Some Equianalgesic Doses
Common drugs with oral doses equianalgesic to650mg oral aspirin or acetaminophen
Pentaxocine (Talwin) 30mg
Codeine 32mg
Meperidine (Demerol) po 50mg
Propoxphene (Darvon) 65mg
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Calculation:
Baseline Pain = Extended
release morphine 200 mg/24hrs
Breakthrough - 10-20% =
20-40 mg
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Principles: Use of OpioidRotation
Use when one opioid ineffective or
for adverse effects
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Methadone Acute pain: methadone morphine (1:1)
Chronic pain: ratio depends upon previous opioiddose (methadone:morphine)
< 90 mg (1:5) 91-299 mg (1:10)
>300 mg (1:12 or 20)
Torsade de Pointes in high parenteral dosesBruera &Sweeney, 2002;
Kranz et al., 2002
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Properties of Methadone
Well absorbed from all routes of administration oral
rectal
subcutaneous
IV
Sublingual
Rapid onset of analgesia effect ( 30 60 min.)
No significant cognitive impairment.
No euphoria.
Safe in renal and liver failure.
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Over 50% of patients requiredmore than one route of drug
administration during the last fourweeks of life.
N. Coyle 12/90
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Co Analgesics
Definition
Agents which enhance analgesic efficacy, have
independent analgesic activity for specific types ofpain, and / or relieve concurrent symptoms whichexacerbate pain
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Co Analgesics Commonly Used
For Pain NSAIDS
Acetaminophen
Antidepressants
Anticonvulsants
Corticosteroids
Neuroleptics
Antihistamines
Analeptics
Benzodiazepines
Antispasmodics
Muscle relaxants
Systemic localanesthetics
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Systemic Local Anesthetics
Indications
Neuropathic pain
Toxicities
Dizziness, nausea, tremor, nervousness,incoordination, headaches, paresthesias
Drugs
Lidocaine, mexiletine
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Local Anesthetics
Lidocaine Infusion
More effective in neuropathic pain but can be usedfor all pain syndromes. Starting dose 0.5mg-2 mg/kgper hr IV or SC. Some studies demonstrate long-
lasting pain relief even after drug has been stopped.Need to decrease opioids when starting. (Ferrini,Paice, 2004)
Lidocaine Patch (Lidoderm)
On 12hrs off 12 hours (but can leave on 24)
Expensive (great indigent program however)
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Miscellaneous Adjuvant
Analgesics Pamidronate (Aredia)
Zoledronic acid (Zometa)
Strontium-89(Metastron)
Calcitonin (Calcimar) Not in cancer ? arthritis
Capsaicin (Zostrix) scheduled in neuropathic pain
Clonidine (Catapres) all forms
Cannabinoid (Marinol)
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Analgesics for Neuropathic
Pain Tricyclic antidepressants nortriptaline (1st choice)
Anticonvulsants
Gabapentin, Carbamazepine, Pregaba
Local anesthetics
Parenteral, oral, topical
Topical capsaicin
Opioids for selected patients
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Ketamine
N-methyl-D-aspartate receptor antagonist(NMDA)
Used as an anesthetic for years
Case reports show effectiveness when traditionaland invasive techniques fail
Starting IV dose 150mg qd (0.1-0.2mg/kg) withreduction of opioid achieved or 10-15 mg q6increasing by 10 mg dose each day
Appears to have a synergistic effect with opioids
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Making PCA Work for your Patient
PCA History; dosing,bolus; basalrates
Always remember SC PCA
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Pain
Step 1NonopioidAdjuvant
Pain persisting or increasing
Step 2Opioid for mild to moderate pain
Nonopioid Adjuvant
Pain persisting or increasing
Pain persisting or increasing
Step 3
Opioid for moderate to severe painNonopioid Adjuvant
Invasive treatments
Opioid Delivery
Quality of Life
Modified WHO Analgesic Ladder
Proposed 4th Step
The WHO
Ladder
Deer, et al., 1999
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Role of Invasive (Anesthetic)
Procedures Intractable pain*
Intractable side effects*
*Symptoms that persists despite carefullyindividualized patient management
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Role of Invasive Procedures
Optimal pharmacologic managementcan achieve adequate pain control in80-85% of patients
The need for more invasive modalitiesshould be infrequent
When indicated, results may be gratifying
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Other techniques ...
Lidocaine
Ketamine Methadone
Sedation
Spinal cordstimulator
Chemotherapy,radiation
Surgery
Biphosphates
Others
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Q&A