Pain Talk for Nurses June 2014-2

Pain Management Strategies

Mark Kantrow MD

OR, Everything a nurse (and doctor!)

should knowabout pain management

Objectives

Know basic steps of analgesic management

Know basic conversions between common opioids

Know adverse effects of analgesics, their management

understand pain management at the end of life

Pain•Neuropathic

•Visceral

•Somatic

•direct tissue damage

•direct nerve damage

Acute Pain

Short duration usually from trauma, surgery or other injury

Variations in intensity

Pain behaviors—moaning, rubbing

Anxiety

Sympathetic hyperactivity—sweating, tachycardia, hypertension

Chronic Pain

Variable onset with variable duration

Variable intensity

Behavior may not “give away pain”

Patient may be depressed or irritable or “stiff”--unpleasant

Often the physical findings one sees in acute pain are absent

Pain equationTissue damage

+emotional + spiritual + social =

THE PAIN EXPERIENCE

WHO (World Health Organization) Recs for

Pain TreatmentBy the mouth

By the clock

By the ladder

For the individual

With attention to detail

WHO 3-stepLadder

1 mild1 mild

2 moderate2 moderate

3 severe3 severe

Morphine

Hydromorphone

Methadone

Levorphanol

Fentanyl

Oxycodone

± Adjuvants

Morphine

Hydromorphone

Methadone

Levorphanol

Fentanyl

Oxycodone

± Adjuvants

A/Codeine

A/Hydrocodone

A/Oxycodone

A/Dihydrocodeine

Tramadol

± Adjuvants

A/Codeine

A/Hydrocodone

A/Oxycodone

A/Dihydrocodeine

Tramadol

± Adjuvants

ASA

Acetaminophen

NSAIDs

± Adjuvants

ASA

Acetaminophen

NSAIDs

± Adjuvants

Adjuvant Analgesics

Medications that supplement primary analgesics

--Often have another primary use: anticonvulsants, steroids, antidepressants

May themselves be the primary analgesics

May use at any step of the WHO ladder

Dyspnea

• Treatment is similar to pain.

• Pay attention to patient’s experience as much as the “numbers”

• Dyspnea is a subjective experience

• Be careful about IVF if patient’s dyspnea is worsening or if patient is dying

Opioid pharmacology . . .

CCmax max afterafter

po po ≈≈ 1 h 1 h

SC, IM SC, IM ≈≈ 30 min 30 min

IV IV ≈≈ 6 min 6 min

Pla

sma C

once

ntr

ati

on

0 Half-life (t1/2) Time

IV

po / pr

SC / IM

Cmax

Routine Oral Dosing

Hydrocodone, Oxycodone, Morphine, Hydromorphone

Dose q 4

Adjust dose daily

Mild to moderate pain increase by 25-50%

Severe/ uncontrollable pain increase by 50-100%

Bolus Effect

Swings in plasma concentration

Drowsiness ½ - 1 hour after ingestion

Pain before next dose due

Should move to extended release preparation or continuous SC, IV infusion with PCA

Extended Release Improves compliance and pain relief- reduces bolus effect

provides background pain relief

Orally can dose q8, 12 or 24 (product specific)

don’t crush or chew tablets

May flush time-release granules down feeding tubes (Kadian, Avinza)

Adjust q 2-4 days as steady state is reached

Transdermal patchFentanyl

Peak effect after application in 12-24 hours

Patch lasts 48-72 hours

NOT for the opioid naïve

Ensure adherence to skin

Must have subcutaneous fat to allow absorption—not for the cachectic patient

Fever makes absorption unpredictable

Breakthrough dosing

Use immediate release opioids

Approximately 10% of the 24-h dose

May offer again after Cmax is reached for previous dose

PO/PR q 1 hr

SC, IM q 30 minutes

IV q 15 minutes

Alternative Routes of Administration

Enteral Feeding Tubes/ Oral

Transmucosal

Rectal

Transdermal

Parenteral (IV, SubQ, IM)

Intraspinal

Equianalgesic Chart

DrugDose(mg)Parenteral

Dose (mg)Oral

DurationHours

Morphine (IR) 10 30 3-4

Hydromorphone 1.5 7.5 3-4

Oxycodone ____ 20 3-4

Equianalgesic Survival Skills

IV morphine is THREE times as strong as oral morphine

10 mg IV morphine equals 30 mg p.o. morphine

Equianalgesic Survival Skills

IV Dilaudid is 5 times as strong as oral

1 mg Dilaudid IV equals 5 mg Dilaudid p.o.

Little known fact:

1 mg Dilaudid IV = 7.5 mg Morphine IV

Equianalgesic Survival Skills

Morphine 5mg IVP = Percocet 10 (oxycodone)

Morphine 3mg IVP = Lortab 10 (hydrocodone)

Equinanalgesic Survival Skills

Case 1Your patient has been receiving Morphine 5mg IVP q 4 hours prn and now has lost her IV. The physician you call orders a dose of oral Morphine liquid 5mg q 4 hours.

DO THE MATH!

What do you say when you hear this?

Case #2Mrs. Bourgeois is a 37y/o housewife who has suffered from chronic back pain for 10 years following an MVA. She had a laminectomy 2 years ago with only minimal improvement in pain.

She takes MS Contin 60 BID as prescribed by her pain management physician as an outpatient and has tolerable chronic pain.

She is admitted to your unit with a retropharyngeal abscess and cannot swallow.

Case #2 cont’dThe admitting physician writes for Morphine 5 mg IV q 4 PRN pain.

DO THE MATH!

How do you expect this will manage her pain?

How do you think this patient will be regarded by the nursing and physician staff?

Be careful of “story” we tell ourselves

PSEUDO-ADDICTION*DRUG SEEKING

BEHAVIOR

Case 3

Mr. Sampson is a 45 y/o WM with bone pain related to newly discovered metastatic prostate CA. He is admitted for poorly controlled pain. He is tachycardic, diaphoretic and grimacing, describing his pain as 10/10

There are several PRN medication choices

Oxycodone 10mg, ii po q 4 prn

Morphine 5 mg IVP q 3 prn

Dilaudid 1 mg IVP q 3 prn

STRONGEST

LONGEST ACTING

FASTEST ACTING

Opioid adverse effects

Common-Constipation-Dry Mouth

-Nausea/Vomiting-Sedation-Pruritis

Uncommon-hallucinations

-delirium-Myoclonus/seizures

-urticaria-Respiratory Depression

-urinary retention

Opioid allergy

Anaphylactic reactions are very rare with opioids

Bronchospasm

Urticaria

Nausea / vomiting, constipation, drowsiness, confusion

adverse effects, not allergic reactions

PRURITIS

Mast cell destabilization with all opioids causing itching

Treat with routine long-acting, nonsedating antihistamines

Fexofenadine (Allegra), 60 mg po bid, or

Loratadine (Claritin)

Sedating antihistamines or doxepin if sleep desired

Constipation . . .

Common to all opioids

One does not develop tolerance to this!

Opioid effects on CNS, spinal cord, myenteric plexus of gut

Easier to prevent than treat

. . . Constipation

Diet usually insufficient to relieve

Bulk forming agents not recommended (no metamucil!)

Stool Softener: senna, bisacodyl, glycerine, casanthranol, etc

Stimulant laxative: Docusate sodium

senna + docusate sodium is best combo

Constipation . . .

Prokinetic agent

metoclopramide

Osmotic laxative

MOM, lactulose, sorbitol

Other measures

Nausea / vomiting . . .

Onset with start of opioids- opioid naive

usually improves within days

Prevent or treat with dopamine-blocking antiemetics or prokinetics

prochlorperazine, (Compazine) 10 mg q 6 h

haloperidol, 1 mg q 6 h

metoclopramide,(Reglan) 10 mg q 6 h

Sedation . . .*Onset with start of opioids*distinguish from exhaustion due to pain* usually improves within days

. . . Sedation

If persistent and undesired, rotate to another opioid or change route of administration

Psychostimulants may be useful

methylphenidate, 5 mg q am and q noon, titrate

Respiratory depression . . .

Opioid effects differ for patients treated for extreme pain and at the end of life

pain is a potent stimulus to breathe

Depressed level of consciousness precedes respiratory depression!!

• pharmacologic tolerance develops rapidly to respiratory effects of opioids

• take care if combining with benzos

. . . Respiratory depression

• Management

• identify, treat contributing causes

• reduce opioid dose

• observe

• if stable vital signs but unarousable use Narcan gently: naloxone, 0.1-0.2 mg IV q 1-2 min

May be difficult in patient with dementia or terminal delirium;Vital signs not reliable indicator;Moaning & groaning;Objective signs:Facial grimacing, frowning, furrowed browIncreased agitationClenched jawGuarding

Pain Assessment at end of life

Death

dying patient

receiving suboptimal treatment

death

dying patient receiving adequate symptom control

•Any action which has foreseen harmful effects which are inseparable from the good effect is considered justifiable if the following conditions are satisfied: Intent is good effect— no intent to harmAct is good, morally acceptableGood outweighs bad

Rule of Double Effect

Summary:

• WHO ladder of pain management

• Equianalgesic Dosing

• Common Side Effects of Opioids

• Pain treatment at the end of life

Quiz:

• Dilaudid 1mg IV equals how much Morphine IV?

• Percocet 10 (oxycodone) equals how much IV morphine?

• What always preceeds respiratory depression from opioids?

• What important side effect of opioids does one not develop a tolerance to?

Thank You