CLINICAL REVIEW FOR THE

GENERALIST HOSPICE & PALLIATIVE NURSE

Pain ManagementWEEK 2

Objectives

1. Describe the prevalence of pain in the hospice and P.C. setting

2. Recognize the impact of pain on pts./families/and the healthcare system

3. Identify common barriers to effective pain management.

4. Define types of pain experienced by pts.

5. State principles of effective pain mgmt.

6. I.D. the components of a thorough pain assessment

7. Demonstrate the ability to do equi-analgesic conversions

Definition of Pain:

An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (APS)

Pain is SUBJECTIVE

“Pain is whatever the person says it is, experienced whenever they say they are experiencing it.” (McCaffery & Passero, 1999).

Self-Report is the most valid measure of pain.

Under-treatment of Pain

70-90% of pts. w/ advanced disease have pain

50% of hospitalized pts. experience pain

80% of pts. In LTC experience pain

Only 40-50% of them are given analgesics

Pain scores > or = 5 (on a 1-10 scale) greatly impact QOL

It’s Estimated That—

98-99% of all pain could be controlled, using current tools and knowledge.

The other 1-2% could be offered palliative sedation with good results.

Ethical Considerations

Patient rights—to good pain management

Joint Commission/ANA value pain relief

Double Effect—ethical if dose is needed to treat pain, and that effect is the intended one.

Nurses have a duty to relieve pain & suffering

Is given with the intent to relieve refractory suffering (physical, psychological, or spiritual). It is NOT “euthanasia” or “assisted suicide”.

Palliative Sedation

Uncontrolled Pain Impacts

Physical

Psychosocial

Emotional

Financial

Spiritual

Elements of a person

Costs of Poor Pain Management

40 million Dr. visits/yr. for pain

25% of all lost work days are due to pain

Costs $100 Billion/yr. Chronic pain is our

most expensive health problem

Pain Co-Morbidities

Depression Anxiety Diabetes Chronic Fatigue

Syndrome

Pain is Multi-Dimensional

Each member of the IDT can address it Nurse

Aide Physician Chaplain SW Volunteer

Patients’ attitudes are sometimes barriers to good pain management

Fear of addiction

Good patients don’t complain

Fear of side effects

Afraid to use strong pain medicines too soon

Another Barrier: Clinicians Attitudes

Doubt patients’ reports of pain

Fear of causing resp. depression

Confusion: addiction /dependence/ tolerance

Belief opioids shorten life

• Low Priority• Poor reimbursement• Restrictive regulations• Availability/Access to treatment

Institutional Barriers

Types of Pain

Acute—short-term, observable, signs (MI, appendicitis, surgery, toothache, labor pains), accompanied by physiological signs

Chronic—long-lasting, no purpose, often no observable signs (arthritis, chronic back pain, diabetic neuropathy)

Types of Pain (continued)

Nociceptive—arises from stim. of nerves in skin, soft tissue, or viscera.

Somatic—musculo-skeletal (ex. sprain, bone mets) (well-localized)

Visceral—involving internal organs+ structures (ex. SBO, liver capsule pain, menstrual cramps) (NOT well-localized-radiates or refers)

Neuropathic—results from actual injury to nerves (“sharp, shooting, burning”—ex. Phantom limb pain, sciatica, shingles)

Types of Pain

Mixed Nociceptive/Neuropathic—common in life-threatening illnesses (chronic low back pain, cancer pain)

Referred pain—usually visceral pain referred to skin, bone, muscle (ex. Gall bladder or liver pain referred to R. shoulder, pancreas or stomach pain referred to back)

How does it Feel?

Which type of pain is it?

“Cramps”“Pressure”

“Deep, squeezing”

“Around this area-it radiates”

“aching/throbbing”“dull/sore”

“It hurts right here”

“Burning”“Numbness/

Tingling”“Shooting/Stabbing”“Pins and Needles”

“Radiating/Electrical”

How to treat each type

Somatic—Non-opioids, opioids

Visceral—non-opioids, opioids

Neuropathic—adjuvants (anti-dep., anti-convulsants, steroids, NMDA antag. etc.)

NMDA Receptor Antagonists

Work well for nerve pain

Also used in veterinary medicine

APS—12 Principles of Pain Mgmt.

1. Individualize dose, route, + schedule

2. ATC dosing

3. Selection of opioids

4. Adequate dosing for infants/children

5. Follow pts. closely (do not stereotype)

6. Use equi-analgesic dosing

APS—12 Principles of Pain Management

7. Recognize and treat side effects (constip.!!)

8. Be aware of hazards of mixed agonist-antagonists and Demerol

9. Watch for development of tolerance (use combo., switch to ½ equi-analgesic dose)

10. Be aware of physical dependence11. Do not label a patient addicted (if tol./dep.)12. Be aware of psychological state (anxiety,

dep. may co-exist. Treat pain 1st)

W.H.O. PAIN LADDER

W.H.O. Recommendations

START LOW—GO SLOW with dosing

Preference for routes is: #1 PO #2 Transdermal #3 IV or SQ

•Prevent and treat side effects—constipation and nausea

W.H.O. RECOMMENDS Immediate-release meds. for

Breakthrough

Continuous pain is always there—steady Treat it with long-acting meds.

Breakthrough pain is one of 3 types

End-of Dose Failure (pain prior to next dose) Incident-Related (dressing changes, coughing) Idiopathic (unknown cause)

Treat it with immediate-release meds.

W.H.O. RECOMMENDS USING BOTH LONG AND SHORT-ACTING PAIN MEDICATIONS

Start with short-acting or IR pain meds.

Example: Percocet, codeine, morphine IR, oxycodone IR. These are dosed every 3-4 hours.

Once pain relief is achieved for 24-48 hours with stable dose of short-acting pain meds., calculate the total mg. taken in 24 hours, and convert to a long-acting formulation. (LABELLED SA, SR, LA, CR, Contin)

WORLD HEALTH ORGANIZATIONRECOMMENDATIONS

Treat Cancer Pain By the MOUTH

By the CLOCK, not prn

By the LADDER

Pain Assessment

**Accept pt’s c/o pain

History of pain

Non-Verbal signs

Patient-Centered Goals

Psychological impact

Diagnostic workup

Effectiveness + side effects of medication

Pain Assessment

Onset/Activity Other symptoms Site(s) (point to it) Intensity (use appropriate scale)

Quality (sharp, shooting, etc.)

Duration Exacerbating/Relieving factors

At rest/With movement Effects on QOL (“What can’t you do?”)

Medication History

Current regimen?

Effective?

Side Effects?

Past regimen?

The Checklist of Non-Verbal Pain Indicators Measures:

•Vocal Complaints (moaning, crying)•Facial Grimaces and Winces•Bracing During Movement•Restlessness•Rubbing•Verbal Complaints (“Ouch” “That hurts”)

*** Observations are made at rest AND with movement.

Physical Exam

Examine site Consider disease

process/progression Consider referral sites Consider

Culture Age Gender Environment

*note: often patients show no change in V.S. or facial expression w/chronic pain

COMMUNICATION TOOLS (w/physician, family, team, LTC staff)

BASI CS

Background

Assessment

Symptoms/Situation

Interpretation

Communication

Successful outcome

Situation

Background

Assessment

Recommendation

Factors influencing pain perception

Physical Psycho-social Emotional Spiritual Financial Cultural

(Careful not to stereotype)

ADDICTION is characterized by:

Using a drug for psychic benefits

Compulsive behavior to acquire the drug

Continued use despite harm

Tolerance

Dose loses effectiveness over time

End-of-Dose failure occurs first

Then pain relief becomes inadequate

Titrate dose up to effectiveness or rotate opioid (incomplete cross-tolerance)

DEPENDENCE

A state of neuro-adaptation that develops with repeated opioid use.

If drug is stopped or decreased abruptly, pt. will have withdrawal symptoms.

Taper drug to avoid this.

Pseudo-Addiction

Iatrogenic Due to inadequate treatment of pain Patient behaves as though addicted—

problems disappear when dose is increased

Pain Syndromes Cancer Pain (poss. associated with tumor,

tx,. or unrelated) HIV pain (poss. associated with virus, tx., or

unrelated) Sickle cell disease pain (due to vascular-

occlusive episodes) MS pain (neuralgia-follows nerve path,

dysthesias-abnormal sense of touch,”pain”) Post-CVA pain (often delayed for several

years after stroke—hyperalgesia, allodynia)

Side Effects

Aspirin /NSAIDS GI distress/bleeding/ulcers

Renal insufficiency Bleeding/anti-platelet Hypersensitivity rxns. CNS effects (dizziness,

tinnitus) Dose limit (“analgesic

ceiling”)

Acetaminophen (Tylenol)

Hepato-toxic at large doses

Dose limited to 4g/day (lower for alcoholics, AIDS pts., those w/liver disease

Look out for “hidden doses”. Why?

Combos. have limited use. Why?

Opioids (morphine, dilaudid, oxycodone, codeine)

Side effects (tolerance3 day) Sedation Nausea (due 2 ctz, GI motil.,

effect on inner ear) Dizziness, dysphoria Pruritis (often on

face/neck/chest only), urticaria Respiratory depression (only

after sedation) Side effects may be reported as

“allergies” **Constipation (treat

proactively! NO Tolerance)

The hand that orders an opioid and does NOT order a laxative, is the hand that does the dis-

impaction!

With Opioids, expect physical dependence

To avoid withdrawal symptoms, taper dose

Taper by about 25% every 2 -3 days

Ex.: A patient is ready to start tapering off her Vicodin tabs after surgery. She now takes 2 tabs q 6 hours (8 tablets per day).

Option A: Rapid taper (duration 10 days) Option A: Rapid taper (duration 10 days) 1 tab every 6 hrs x 1 day (4/day), then… 1 tab every 6 hrs x 1 day (4/day), then… 1 tab every 8 hrs x 3 days (3/day), then… 1 tab every 8 hrs x 3 days (3/day), then… 1 tab every 12 hrs x 3 days (2/day), then… 1 tab every 12 hrs x 3 days (2/day), then… 1 tab every daily x 3 days (1/day), then… 1 tab every daily x 3 days (1/day), then… Discontinue Discontinue

Option B: Slow taper (duration 3 weeks) •Reduce by 1 tablet/ day q 3 days until off

Adverse Effects--Morphine

Active metabolites may cause myoclonus + hyperexcitability, esp. in the elderly and w/low renal function

Dilaudid, hydromorphone may be safer choices

Respiratory Depression

Mechanism—Opioids render CO2 receptors gradually less sensitive to CO2 levels

Very rare, especially when doses are titrated up in appropriate steps— START LOW—GO SLOW

Pt. at risk—opioid-naïve and taking other sedating drugs at the same time

True respiratory depression can be treated w/dilute naloxone/narcan—also reverses analgesia!

Drugs to Avoid

Demerol (meperidine)—should NOT be used for cancer pain, due to poor oral bio-availability and long-lived excitatory metabolite

Propoxyphene—(Darvon, Darvocet)—Not recommended for long-term use or use in the elderly, due to long-lived toxic metabolites, ineffective analgesic action, and large amt. of acetaminophen.

ADJUVANT PAIN MEDICINES

Anti-Convulsants—Used to treat nerve pain (lancinating, paroxysmal)

carbamazepine (Tegretol)

gabapentin (Neurontin)

phenytoin (Dilantin)

valproic Acid (Depakote)

ADJUVANT PAIN MEDICINES

Local Anesthetics — for neuropathic pain (post-herpetic neuralgia)

Can give topically (Lidoderm Patch, EMLA cream)

or by spinal route—epidural or intrathecal (lidocaine, marcaine)

Muscle relaxer Baclofen

ADJUVANT PAIN MEDICINES --

CORTICOSTEROIDS dexamethasone (Decadron)

Anti-inflammatory effect Given for pain caused by

swelling or bone pain Side Effects

Increased appetite Improved mood Increased energy (or insomnia)

* Recommended for bone pain, liver capsule pain)

Delivery Route

Oral/SL is preferred Rectal useful w/N/V SQ or IV infusion,

useful for rapid titration

IM injections not recommended—pain, unreliable absorption

More Delivery Routes

Trans-mucosal (fentanyl pops)

Trans-dermal (not the same as topical)(delayed onset 12-24 h, not good for all pts.—why not?)

Spinal (intrathecal or epidural) expensive—use for carefully selected pts.

Equi-Analgesic Conversions

1. Charts are considered estimates —good way to determine starting dose

2. Titration is best way to dose (based on pt. goals, breakthru, pain intensity, side-effects, function, QOL)

3. Start with 100% dose listed for “severe pain” ( 20-50% in the elderly). 50% for moderate. 25% for mild.

Sample Equianalgesic Chart

Drug Dose (mg.)Parenteral

Dose(mg.)Oral

Duration(hours)

Morphine (IR) 5 15 3-4

Hydromorphone(Dilaudid)

1.5 4 3-4

Oxycodone (Long-Acting)

____ 10 8-12

Titrating Opioids

Make dose increases at peak effect. (see if current dose in effective)

Give the smallest dose that gives the greatest relief with the fewest side-effects.

Titrate in increments of 25% to 100%

TITRATION

Based on Pt. Goals (wants to be awake/aware, or to

sleep) Pain intensity (would rather deal with mild

pain) Severity of side effects (constipation or

nausea) Functional status (driving? working?) Sleep QOL—as reported by pt. and family

Method of Titrating

1. Add total 24 hour dose (LA + Break thru)

2. Increase by 50% if initial dose not effective.

3. Divide by dose interval (if q 12 hrs., divide 24 hour dose by 2)

4. Provide appropriate breakthru dosing

LONG-ACTING + BREAKTHROUGH

Long-acting medicine covers baseline pain P.R.N. dose covers breakthrough pain May give together, if needed. [just like insulin]

Calculating a Long Acting DoseExample:

Mrs. Bernardo takes Percocet 5/325 mg. 2 tabs q 6 hrs.

=8 tabs in 24 hours=40 mg. Oxycodone in 24 hours=20 mg. Oxycontin BID= or 40 mg. Kadian or Avinza q 24

hoursAdvantage: Steady pain relief, and pt. Is able to

sleep for 8 hours and not wake up in pain.

Breakthrough Dose A breakthrough dose breakthrough dose is ALWAYS ordered

with long-acting opioids.

It’s best to match the long-acting with the match the long-acting with the short-acting short-acting (e.g. MS contin w/MSIR). Only ONE breakthrough med should be ordered.

If >3 breakthrough doses If >3 breakthrough doses are used in 24h (or pt. wakes up + needs a nighttime dose), increase the baseline long-acting dose.

Calculating Breakthrough Dosing

(aka “rescue dosing”, “supplemental dosing”)

Breakthrough dose + 1/10 to 1/6 of the 24h dose (so divide 24 hr. dose by 10 or 6)

Give breakthrough dose q1-2h prn May give ATC + breakthru dose together If pt. on opioid inf., BT dose is 25-50% of hourly dose q 30 mins. Remember to increase BT dose when ATC dose increases

Example

A patient is taking 120 mg. of MS Contin q12h.

That’s 240 mg/24h 1/10 of 240 = 1/6 of 240 = Appropriate dose

would be

24 mg.

40 mg.

30 mg. q1-2h prn

If Reducing Opioid Dose

Do a gradual taper gradual taper to avoid “abstinence syndrome” or withdrawal symptoms

If switching from IV to PO or vice versa, keep in mind the “first “first pass effect”pass effect”– Gut filters out 2/3 of opioids given by mouth. So multiply IV dose by 3 to get PO. Divide PO dose by 3 to get IV.

For patients with intractable (refractory) pain and suffering at the end

Palliative sedation is an option Opioids Barbiturates Neuroleptics (Haldol, Thorazine,

etc.) Benzodiazepines IV Ketamine

ADJUVANT PAIN MEDICINES—non-pain meds. w/analgesic effects on certain types of pain

Tricyclic Anti-depressants Used to treat nerve pain (up to 1 wk.’ til effect) Inhibits neurotransmitters Ex. amitriptyline (Elavil) nortriptyline (Pamelor)SIDE EFFECTS These can be sedating—give at HS Orthostatic Hypotension Anti-cholinergic—dry mouth, constipation

Other Adjuvants

SSRI’s—Fluoxetine, Venlafaxine, Paraxetine, etc.

Anti-Convulsants—Gabapentin (Neurontin), Carbamazepine (Tegretol)

1st line drugs for chronic, lancinating, neuropathic pain

Works by lessening conduction of pain signals along nerve fibers (same mechanism as anti-seizure action.)

Other Adjuvants

Local Anesthetics Lidocaine, Mexiletine (Mexitil) Local action w/minimal systemic side

effects Avoid use in pts. w/cardiac dyrhythmias

Psychostimulants Caffeine (P.O.), Dextramphetamine,

Methylphenidate Side effects: insomnia, anorexia, anxiety,

agitation

Other Adjuvants CorticosteroidsCorticosteroids

Dexamethasone #1 Prednisone, MethylprednislonePrednisone, Methylprednislone

Analgesic mechanism unknown Multi-purpose

appetite mood/energy

Long-term side effects: blood sugar, bone loss, cushing’s, HTN, edema, immuno-supression

Special Populations

GeriatricGeriatric (metabolism, renal funct., GIB Risk) PediatricPediatric (develop. level, believe report, calc.

dose by wt., learn child’s words for pain) DyingDying (pain is a priority, pall. sedation if needed) Cognitively Impaired Cognitively Impaired (hi-risk 4 under treatment

of pain, 0-5 scale, learn pain behaviors) VeteransVeterans (stoicism, pain=weakness, use

interdiscipl. approach)

Non-Pharmacological Techniques

Repositioning/Bracing

Relaxation/Distraction

Exercise Guided Imagery Massage Heat/Cold