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Pain Management: The things you should know. For additional advice see Dale Carnegie Training® Presentation Guidelines. Questions Regarding Pain Control. What about the 20% who do not get relief from the WHO ladder or the 46% of those whose families stated we failed? *

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Pain Management: The things you should know

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Pain Management: The things you should know

For additional advice seeDale Carnegie Training® Presentation Guidelines

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Questions Regarding Pain Control

  • What about the 20% who do not get relief from the WHO ladder or the 46% of those whose families 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 of DVT/PE

  • Respiratory effects: shallow breathing, tachypnea, cough suppression increasing risk of pneumonia 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 patients seeking active end of life.

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Immunological effects of Pain

  • Decrease natural killer cell counts

  • Effects on other lymphocytes not yet defined.

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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 is adequately 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 is pain transmitted over damaged nerves.

Patient Description of Neuropathic Pain:

  • Burning, electric, searing, tingling, and migrating or 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

Neuropathic Pain

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  • Methadone

  • Morphine

  • Oxycodone

  • Oxymorphone

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Cost of Opioids (AWP 2003 Redbook )(Equianalgesic Dose (morphine 180-200mg / day ATC)

BrandGeneric DoseCost/30 daysCost/day

Roxanolmorphine30 mg q4h$186.84 ($58.75) $6.23 ($2.00)

Morphine IRmorphine30 mg q4h$147.62$4.92*

Oramorph SR®morphine100 mg q12h$307.20$10.24

MS Contin ® morphine100 mg q12h$328.20$10.94

Morphine SRmorphine100 mg q12h$293.75$9.79*

Avinza ®Morphine200mg q24h$433.80$14.46

Kadian ® morphine200 mg q24h$365.00$12.18

Duragesic®fentanyl100 mcg q72h$482.72$16.06

Oxydose ® oxycodone30 mg q4h309.78($259.97)$10.32*

Oxycontin ® oxycodone80 mg q12h$514.85$17.16

Dilaudid ® hydromorphone 8 mg q4h$219.60$7.32

Dolophine ® methadone20 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 of several 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 Analgesic Use 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 / mixed agonist-antagonists - particularly pentazocine

  • Do not use placebos to assess nature of pain

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Principles of Opioid Analgesic Use 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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  • Determining equal doses when

    changing drugs or routes of


  • 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 to 650mg oral aspirin or acetaminophen

  • Pentaxocine (Talwin)30mg

  • Codeine32mg

  • Meperidine (Demerol) po50mg

  • Propoxphene (Darvon)65mg

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Baseline Pain = Extended release morphine 200 mg/24 hrs

Breakthrough - 10-20% = 20-40 mg

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Principles: Use of Opioid Rotation

  • Use when one opioid ineffective or

    for adverse effects

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  • Acute pain: methadone  morphine (1:1)

  • Chronic pain: ratio depends upon previous opioid dose (methadone:morphine)

    • < 90 mg (1:5)

    • 91-299 mg (1:10)

    • >300 mg (1:12 or 20)

  • Torsade de Pointes in high parenteral doses

    Bruera &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 required more than one route of drug administration during the last four weeks 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 of pain, and / or relieve concurrent symptoms which exacerbate pain

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    Muscle relaxants

    Systemic local anesthetics

    Co Analgesics Commonly Used For Pain

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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 used for all pain syndromes. Starting dose 0.5mg-2 mg/kg per 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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    • N-methyl-D-aspartate receptor antagonist (NMDA)

    • Used as an anesthetic for years

    • Case reports show effectiveness when traditional and invasive techniques fail

    • Starting IV dose 150mg qd (0.1-0.2mg/kg) with reduction of opioid achieved or 10-15 mg q6 increasing 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; basal rates Always remember SC PCA

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    Quality of Life

    Invasive treatments

    Opioid Delivery

    Pain persisting or increasing

    Step 3

    Opioid for moderate to severe pain





    Pain persisting or increasing

    Step 2

    Opioid for mild to moderate pain





    Pain persisting or increasing

    Step 1






    Modified WHO Analgesic Ladder

    Proposed 4th Step

    The WHOLadder

    Deer, et al., 1999

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    Role of Invasive (“Anesthetic”) Procedures

    • Intractable pain*

    • Intractable side effects*

      *Symptoms that persists despite carefully

      individualized patient management

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    Role of Invasive Procedures

    • Optimal pharmacologic management can achieve adequate pain control in 80-85% of patients

      • The need for more invasive modalities should be infrequent

      • When indicated, results may be gratifying

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    Spinal cord stimulator

    Chemotherapy, radiation




    Other techniques ...

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