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Dr. Stacie Levine, University of Chicago

Acknowledgement. Dr. Stacie Levine, University of Chicago Pain Module, Curriculum for the Hospitalized Aged Medical Patient champ.bsd.uchicago.edu. Objectives. Understand the major categories of pain Implement the WHO pain ladder to manage patients with pain

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Dr. Stacie Levine, University of Chicago

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  1. Acknowledgement Dr. Stacie Levine, University of Chicago Pain Module, Curriculum for the Hospitalized Aged Medical Patient champ.bsd.uchicago.edu

  2. Objectives • Understand the major categories of pain • Implement the WHO pain ladder to manage patients with pain • Perform safe and effective opiate dosing, escalation, and conversions

  3. Why Pain? • Extremely common and undertreated • 50% of community dwelling older persons • Only 40% of oncology and 30% of hip fracture patients report “adequate” pain control • Education in pain assessment and management mandated by ACGME/RCCs and Joint Commission • Undertreated pain leads to functional decline, prolonged length of stay, increased healthcare utilization

  4. Bedside Assessment of Pain Patient centered approach is the key • ASK the patient, regardless of mental status • Identify preferred pain terminology • Hurting, aching, stabbing, discomfort, soreness • Type: visceral, nocioceptive, neuropathic • Functional impact: How is their life changed? • Use a pain scale that works for the patient • Physiologic measures (eg, HR, BP) not reliable indicators

  5. Pain in non-verbal pts • Unique pain signature – • Use baseline behavior as frame of reference • Pain can cause hypo- or hyper-activity • Ask caregivers how they know when pt is in pain • Possible indicators • Facial expression: frown, blinking, sad/frightened • Vocalizations: grunting, calling out, noisy breathing • Movements: rigid, tense, fidgeting, resistance to being moved, pacing

  6. Managing Pain • WHO pain ladder: • Non-opioids • Adjuvants • Opioids

  7. Step 1 - mild to moderate Pain • Non-opioids • APAP • NSAIDs • COX-2 inhibitors • Adjuvants • Topicals – capsaicin cream, lidoderm patch • Anticonvulsants: GABA-nergics • Antidepressants: Cymbalta, tricyclics, SNRIs • Steroids • Non-medication: massage, TENS, PT/OT

  8. Step 2- moderate Pain • Mild opioids • Codeine: GI upset common • Hydrocodone (Vicodin): no paper Rx needed • Oxycodone (Percocet): actually more potent than morphine, reason for low doses with APAP • Opioid-like • Tramadol: analgesia ~ same as T3; max 200 mg/day in elderly

  9. Step 3- Severe Pain Strong Opioids • Morphine • Oxycodone • Hydromorphone (Dilaudid) • Fentanyl • Oxymorphone (Opana, Numorphan) • Methadone

  10. Avoid • Meperidine (Demerol) • Pentazocine (Talwin) • Combination with antihistamine (Vistaril)

  11. Morphine Equianalgesia • Key to dosing and changing opiods • Use calculators Conversion: http://www.epocrates.com/products/medtools/opioidanalgesicconverter.html

  12. Dosing • Load • Start low, short-acting: 2-5 mg PO morphine equivalent (~ 1 Percocet q 4 hr) • Dose q peak: • po, pr ~ 1 hr • SC, IM ~ 30 min • IV ~ 6-15 min • Regular dosing, not “prn” • Re-eval in 4 hrs

  13. Escalating Doses • Use percentage increase irrespective of starting dose • Mild-mod pain: increase by 25 - 50% • Severe: increase by 50 - 100% • Frequency of escalation: • Short-acting, single agent – q 2 hr • Long-acting – every 24 hr • Fentanyl patch – q 72 hr • Methadone – every 4-7 days

  14. Break-through Pain • Use immediate release opioids only • Start: 10% of total 24 hr dose or 33% of one ER dose • Frequency: offer after peak effect • PO/ PR - ~ 1 hr • SC/IM ~ 30 min • IV ~ q10-15 min

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