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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 l.jpg

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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Opioids

Codeine

Fentanyl

Hydrocodone

Hydormorphone

  • Methadone

  • Morphine

  • Oxycodone

  • 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 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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Equianalgesia (cont)

  • Determining equal doses when

    changing drugs or routes of

    administration

  • Use of morphine equivalents



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Some Equianalgesic Doses (cont)

Common drugs with oral doses equianalgesic to 650mg oral aspirin or acetaminophen

  • Pentaxocine (Talwin) 30mg

  • Codeine 32mg

  • Meperidine (Demerol) po 50mg

  • Propoxphene (Darvon) 65mg


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Calculation: (cont)

Baseline Pain = Extended release morphine 200 mg/24 hrs

Breakthrough - 10-20% = 20-40 mg


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Principles: Use of Opioid Rotation (cont)

  • Use when one opioid ineffective or

    for adverse effects


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Methadone (cont)

  • 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 (cont)

  • 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.


  • Slide24 l.jpg

    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 administration during the last four weeks of life.

    • 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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    NSAIDS administration during the last four weeks of life.

    Acetaminophen

    Antidepressants

    Anticonvulsants

    Corticosteroids

    Neuroleptics

    Antihistamines

    Analeptics

    Benzodiazepines

    Antispasmodics

    Muscle relaxants

    Systemic local anesthetics

    Co Analgesics Commonly Used For Pain


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    Systemic Local Anesthetics administration during the last four weeks of life.

    • Indications

      • Neuropathic pain

    • Toxicities

      • Dizziness, nausea, tremor, nervousness, incoordination, headaches, paresthesias

    • Drugs

      • Lidocaine, mexiletine


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    Local Anesthetics administration during the last four weeks of life.

    • 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 administration during the last four weeks of life.

    • 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)


    Analgesics for neuropathic pain l.jpg
    Analgesics for Neuropathic Pain administration during the last four weeks of life.

    • 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 administration during the last four weeks of life.

    • 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 administration during the last four weeks of life.

    PCA History; dosing,bolus; basal rates Always remember SC PCA


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    Quality of Life administration during the last four weeks of life.

    Invasive treatments

    Opioid Delivery

    Pain persisting or increasing

    Step 3

    Opioid for moderate to severe pain

    ±

    ±

    Nonopioid

    Adjuvant

    Pain persisting or increasing

    Step 2

    Opioid for mild to moderate pain

    ±

    ±

    Nonopioid

    Adjuvant

    Pain persisting or increasing

    Step 1

    ±

    Nonopioid

    ±

    Adjuvant

    Pain

    Modified WHO Analgesic Ladder

    Proposed 4th Step

    The WHOLadder

    Deer, et al., 1999


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    Role of Invasive (“Anesthetic”) Procedures administration during the last four weeks of life.

    • Intractable pain*

    • Intractable side effects*

      *Symptoms that persists despite carefully

      individualized patient management


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    Role of Invasive Procedures administration during the last four weeks of life.

    • 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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    Lidocaine administration during the last four weeks of life.

    Ketamine

    Methadone

    Sedation

    Spinal cord stimulator

    Chemotherapy, radiation

    Surgery

    Biphosphates

    Others

    Other techniques ...


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    Q&A administration during the last four weeks of life.


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