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Pain Management: Practicing the Art

Pain Management: Practicing the Art. M. Rachel McDowell, RN, MSN, ACNP-BC Cancer Supportive Care Nurse Practitioner Vanderbilt-Ingram Cancer Center. Goals of presentation. Provide steps for developing treatment plan Approach to titration (upward and downward) Patient education

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Pain Management: Practicing the Art

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  1. Pain Management: Practicing the Art M. Rachel McDowell, RN, MSN, ACNP-BC Cancer Supportive Care Nurse Practitioner Vanderbilt-Ingram Cancer Center

  2. Goals of presentation • Provide steps for developing treatment plan • Approach to titration (upward and downward) • Patient education • Consent for treatment • Utilization of controlled substance databases • Urine drug screens use and interpretation

  3. Benefits of pain control Earlier mobilization Shortened hospitalization Reduced cost Improved QOL Decrease in patient suffering

  4. Pain Assessment • Location • Character • Achy • Sharp • Jabbing • Deep or Superficial • Burning, tingling, numbness • Duration: when did this begin? • Frequency: constant, intermittent, am, pm?

  5. Lorne B. Yudcovitch, OD, MS, FAAO; College of Optometry, Pacific University; 2043 College Way; Forest Grove, OR 97116 “The Use of Anesthetics, Steroids, Non-Steroidals, and Central-Acting Analgesics in the Management of Ocular Pain” Retrieved from http://www.google.com/imgres?imgurl=http://pacificu.edu/optometry/ce/courses/22746/images/clip_image002.jpg&imgrefurl=http://www.pacificu.edu/optometry/ce/courses/22746/ocularpainpg1.cfm&h=274&w=564&sz=37&tbnid=BdvVnqYJnZHq3M:&tbnh=65&tbnw=134&prev=/images%3Fq%3DPain%2BAssessment%2Bscales&hl=en&usg=__TdhB-pWbp_ouIYHvwQ4FJ1dHzgw=&ei=BBR2S6T_IMGXtgeCnqSlCg&sa=X&oi=image_result&resnum=7&ct=image&ved=0CCEQ9QEwBg Intensity: Pain Scale

  6. Treatment Plan • Goal of Therapy: • Decrease pain level • Pain is mostly controlled, most of the time • Increase level of function • Minimal side effects from regimen • Time frame – acute or chronic

  7. Important Factors • Etiology of pain, prognosis • Stage of disease – how aggressive do you want to be? • What kind of pain or combo do they have? • What have they been tried on in the past? • How did it work for them, side effects, adverse events? • Age, performance status • History or current issue with drug misuse/abuse • What kind of insurance do they have or not? • How capable is the patient in understanding plan?

  8. Treatment Options • Treat underlying cause • Non-pharmacological measures • Pharmacological measures • No single modality done in isolation will be effective for most patients with chronic noncancer pain (CNCP) (Ashburn, Staats, Lancet 1999)

  9. Nonpharmacologic Options • Biofeedback • Relaxation therapy • Physical and occupational therapy • Cognitive/behavioral strategies • Guided imagery • Acupuncture • Transcutaneous electrical nerve stimulation • Positioning • Rest, activity • Massage • Heat and cold

  10. Treatment for pain • Identify the cause of the pain • Primary treatment if indicated • Radiation • Surgery • Hyperbaric treatment • Interventions: Nerve Block, Kyphoplasty • Medications

  11. Interventional Techniques • Interventional Therapies • Trigger points • Acupuncture • Nerve blocks • Facet denervation • Intrathecal pumps

  12. Medications • Somatic/Nociceptive Pain • Opioids • NSAIDS • Neuropathic Pain • Anticonvulsants • Antidepressants - SNRIs • Bony Pain • NSAIDS • Steroids

  13. Pharmacotherapeutics and the Nervous System Brain Descending Modulation Anticonvulsants Tricyclics, SNRI Opioids CNS Central Sensitization Anticonvulsants Opioids NMDS-Receptor Antagonists Tricyclic/SNRI Antidepressants PNS Spinal Cord Peripheral Sensitization Local Analgesics Topical Analgesics Anticonvulsants Antidepressants Opioids

  14. Guidelines for opioids • WHO ladder combined with etiology-specific therapies for syndromes • pharmacologic and nonpharmacologic interventions • long-acting + short-acting opioids • adjuvant medications for neuropathic pain • NSAIDs and steroids can be helpful when there is an inflammatory component to pain

  15. Step 3: Opioids for moderate-to-severe pain +/- non-opioid +/-adjuvant therapy Step 2: Opioids for mild- to-moderate pain +/- non-opioid +/- adjuvant therapy Step 1: Non-opioid +/- adjuvant therapy GOAL: Freedom From Pain STEP 3 Pain Persists STEP 2 Pain Persists STEP 1 WHO Guidelines for Cancer Pain (Adapted from Portenoy et al, 1997)

  16. Opioid Selection • No perfect opioid • Pre-treat likely side effects • Must recognize individual responses to opioids may vary • Response and side effects • Hydrocodone vx. Oxycodone • Sequential trials of different opioids – alone or in combination – may be necessary to optimize therapy

  17. Common Analgesics • Demerol • Morphine Sulfate IR • Percocet • Dilaudid • Lortab • Opana IR • Oxycodone • Tramadol • Butrans • Morphine Sulfate ER • OxyContin • Exalgo • Fentanyl patches • Opana ER • Methadone

  18. Pure Opioid Agonists • Pure Opioid agonist • No ceiling effect for analgesia • Single-entity for moderate to severe pain • May be a role for combined opioids in certain subsets of patients

  19. Current Regimen • Opioid Naïve: • Never been on opioids before • Only been on opioids for a short time period or intermittently • Opioid Tolerant • Taking pain medications on a regular basis • Dependent on amount of pain medication

  20. Differences in older adult • Experience higher peak and longer duration of drug action • Age-related changes in drug distribution and elimination make more sensitive to sedation and respiratory distress • Pain perceived differently • Physiologic • Psychological • Cultural changes • Altered presentations • Aging does NOT increase Pain threshold • Older adults (esp frail and old-old) at risk for too little or too much

  21. General Approach • Start pt on short acting • Titrate up for pain relief • Once stable convert to long acting • Add amount of short acting for 24 hours • Convert to long acting • Continue short acting for breakthrough pain • 10-15 % of 24 hour total narcotic

  22. Advantages of Long-Acting Opioids • More predictable serum levels • More predictable pain relief • Avoids mini-withdrawals • Easier to use; improved compliance • Greater Patient satisfaction • Less reinforcement of drug-taking behavior

  23. Titration of Opioids • Titrate to adequate pain control. Appropriate dose adjustments are critical to adequate pain control. Adjustments are indicated under the following circumstances • If the patient has been taking more than 4 rescue doses per day • If the patient rates pain as greater than 4/10 • If the patient complains the pain is inadequately controlled

  24. Dose Titration • Based on two pieces of information: • Calculation of the 24-hour narcotic total (this should be averaged over several days unless the patient has had a marked increase in pain in the prior 24-hour period of time) • The stated average pain level (this should be averaged over several days unless the patient has had a marked increase in pain in the prior 24-hour period of time)

  25. 24-hour narcotic total: = 24o fixed dose + 24o rescue doses a patient is taking MSER 60 mg po bid with MSIR 15 mg po q1-2hrs prn for breakthrough. On history, he indicates that he is taking the sustained-release formulation as directed and 8 rescue doses in a 24-hour period of time.

  26. The 24-hour narcotic total is: (60 mg x 2 doses) + (15 mg x 8 doses) = 120 mg + 120 mg = 240 mg.

  27. Dose Titration Dose titration by a fixed percentage Moderate pain (5/6): increase 24 hour narcotic total by 25% Severe pain (7+): increase narcotic total by 50% Rescue dose: 10-15%of total dose offered Q 1-2 hours PRN Accommodate increase if pt frail, sick, or elderly

  28. Case Study Pt reports 6/10 pain, therefore he requires a 25 % increase in medication. 2. Pt’s 24 hour narcotic total = ___ mgmorphine

  29. Step 1: Increase dose by 25% 24 NT mg + (24 NT x .25) = New long acting dose

  30. Step 2: Determine the new fixed dose New fixed dose / 2 doses per day = X mg bid

  31. Step 3 Calculate the rescue dose 10% of NT mg = X mg New rescue order = MSIR X mg q2h prn

  32. Old regimen MSER 60 mg bid MSIR 15 mg q 2 prn New regimen MSER 150 mg bid MSIR 30 mg q 2 prn

  33. Case Study Pt reports 8/10 pain. What do you do?

  34. Pt reports 8/10 pain, therefore he requires a 50 % increase in his medication. Pt’s 24 hour narcotic total = 240 mg morphine

  35. Step 1: Increase dose by 50% 24 NT mg + (24 NT x .50) = 240 mg + ___ = ___ mg

  36. Step 2: • Determine the new fixed dose • ? mg / 2 doses per day = ? mg

  37. Step 3: Calculate the rescue dose 10% of new 24 NT = ___ mg New rescue order = MSIR ___ mg q2h prn

  38. Old regimen MSER 60 mg bid MSIR 15 mg q 2 prn New regimen MSER 180 mg bid MSIR 30 mg q 2 prn

  39. Equianalgesia

  40. Fentanyl Doses based on Daily Oral Morphine Dosage Or The ratio is 2:1 2 mg oral morphine per DAY ~ 1 mcq fentanyl patch

  41. Fentanyl Patch In pts currently on opioids, conversion factor for Morphine to Fentanyl is 2:1 Fentanyl patch is 2X more potent than morphine PO If the 24 hr narcotic total= 180 mg morphine Fentanyl dose= ___ mg (use nearest fentanyl patch size)

  42. IV to PO conversion Now your patient is ready to go home but need to be converted to PO medication. Pt is on a morphine pain pump at a continuous infusion of 7.5 mg/hour and uses the bolus of 1 mg 6 times in the past 24 hours.

  43. Case Study 7.5 mg/hr X 24 = 180 mgmorphine IV/24 IV Narcotic total = 186 mg IV PO Narcotic total = 558 Opioid naïve: IV is 6X more potent than PO (1:6) Currently on opioid: IV is 3X more potent than PO (1:3)

  44. 4. Rescue dose is 10% = 60 mgmorphine q 2 hours prn 5. Long acting dose = 280 mg morphine bid

  45. Old regimen: 7.5 mg/hour CIV, with 1 mg q 10 minutes prn New Regimen: MSER 280 mg bid MSIR 60 mg q 2 prn

  46. Case Study A patient with a pathologic fracture had satisfactory relief of pain with an IV dilaudid infusion of 3 mg per hour. You want to send her home on an equianalgesic dose of sustained release oral morphine (MS Contin or OraMorph SR given q12h, or Kadian q day). What is the correct dose?

  47. Calculations 1. 3 mg/hr dilaudid = 72 mg IVdilaudid/24 hrs 2. Convert from dilaudid to morphine: 72 mg dilaudidIV X 5 = 360 mg IV morphine 3. Narcotic total = 360 mg IVmorphine/24 hours

  48. 3. Narcotic total = 360 mg IVmorphine/24 hours 4. Multiply IV by 3 to obtain PO dose 360 x 3 = 1080 mg morphine in 24 hours PO 5. Breakthrough dose = 10 % of 24 hour narcotic total MSIR 30 mg, 3 tabs po q 2 prn Dilaudid8 mg, 2 tab po q 2 prn

  49. 6. The q12h dose = 500 mg morphine SR PO q12h MS Contin100 mg, 5 tabs po BID MS Contin100 mg, 3 tabs po TID

  50. Old regimen: 3 mg/hr dilaudidIV New regimen: MS Contin 100 mg, 5 tabs po BID MS Contin 100 mg, 3 tabs po TID Rescue dosing MSIR 30 mg, 3 tabs po q 2 prn or Dilaudid8 mg, 2 tabs po q 2 prn

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