Top Banner

Click here to load reader

of 97

Diana J. Wilkie, PhD, RN, FAAN © 2001 D.J. Wilkie.

Jan 18, 2018

Download

Documents

Suzan Nash

Slide 3 Comfort: Pain Management TNEEL-NE Nociceptive Pain Definition Pain resulting from activation of primary afferent nociceptors by mechanical, thermal or chemical stimuli Thermal Mechanical Chemical Stimuli
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript

Diana J. Wilkie, PhD, RN, FAAN 2001 D.J. Wilkie Slide 2 Comfort: Pain Management TNEEL-NE Neurophysiology of Pain: Physiological & Sensory Responses Most patients facing the end-of-life transition have pain Selection of effective pharmacological and nonpharmacological therapies requires consideration of the holistic nature of pain, which is a multidimensional experience Pharmacological Nonpharmacological x Slide 3 Comfort: Pain Management TNEEL-NE Nociceptive Pain Definition Pain resulting from activation of primary afferent nociceptors by mechanical, thermal or chemical stimuli Thermal Mechanical Chemical Stimuli Slide 4 Comfort: Pain Management TNEEL-NE Pain resulting from damage to peripheral nervous or central nervous system tissue or from altered processing of pain in the central nervous system Neuropathic Pain Definition Slide 5 Comfort: Pain Management TNEEL-NE Multiple Dimensions of Pain The ABCs of Pain A ffective Dimension B ehavioral Dimension C ognitive Dimension P hysiological-Sensory Dimension Slide 6 Comfort: Pain Management TNEEL-NE Source: World Health Organization, 1992 Analgesic Ladder PAIN Non-opioid +/- Adjuvant Step 1 Pain persisting Opioid for mild to moderate pain +/- Non-opioid +/- Adjuvant Step 2 Pain persisting Opioid for moderate to severe pain +/- Non-opioid +/- Adjuvant Step 3 Pain relief Slide 7 Comfort: Pain Management TNEEL-NE Pharmacology Concepts Side effects Pharmacokinetics Pharmacodynamics Desired effects Slide 8 Comfort: Pain Management TNEEL-NE Source: World Health Organization, 1992 Analgesic Ladder: Step One Drugs PAIN NSAIDs Acetaminophen Step 1 Slide 9 Comfort: Pain Management TNEEL-NE NSAIDs: Mechanisms of Actions What do these drugs do?How do these drugs work? Anti-inflammatory Analgesic Antipyretic Slide 10 Comfort: Pain Management TNEEL-NE Anti-inflammation peripheral effect Analgesic peripheral effect (probable central effect) Antipyretic central effect NSAIDs: Mechanisms of Actions Slide 11 Comfort: Pain Management TNEEL-NE Afferent Fiber Tissue 5HT H BK PGE Trauma NSAIDs: Mechanisms of Actions Slide 12 Comfort: Pain Management TNEEL-NE NSAIDs: Mechanisms of Actions Leukotrienes Copyright 1989 D.J. Wilkie Thromboxane A2 platelet aggregation Vasodilation Uterine contraction Fever Pain PGI2PGE2PGF2 Prostaglandins Vasodilation Antiaggregation Phospholipids released Trauma Arachidonic cascade Cyclo-oxygenase 5-Lipoxygenase pain receptor Slide 13 Comfort: Pain Management TNEEL-NE NSAIDs: Mechanisms of Actions Copyright 1989 D.J. Wilkie Thromboxane A2 platelet aggregation Vasodilation Uterine contraction Fever Pain PGI2PGE2PGF2 Prostaglandins Vasodilation Antiaggregation Phospholipids released Trauma Steroids ASA/NSAIDS Trilisate Leukotrienes Arachidonic cascade Cyclo-oxygenase 5-Lipoxygenase pain receptor Ketoprofen Slide 14 Comfort: Pain Management TNEEL-NE NSAIDs: Mechanisms of Actions Cox2 Prostaglandins Thromboxane A2 platelet aggregation Copyright 1989 D.J. Wilkie Phospholipids released Trauma Leukotrienes Arachidonic cascade Cyclo-oxygenase 5-Lipoxygenase pain receptor Slide 15 Comfort: Pain Management TNEEL-NE NSAIDs: Mechanisms of Actions pain receptor Copyright 1989 D.J. Wilkie Phospholipids released Trauma Leukotrienes Cox2, Prostaglandins Thromboxane A2 platelet aggregation Arachidonic cascade Cyclo-oxygenase 5-Lipoxygenase Ketoprofen ASA/NSAIDS Celebrex Vioxx Steroids Slide 16 Comfort: Pain Management TNEEL-NE NSAIDs: Administration Routes Oral Aspirin, Nuprin, Advil, Motrin, Naprosyn, Orudis (OTC) Feldene, Clinoril, Indocin, Tolectin, Trilisate, Celebrex, Vioxx (Prescription) Parenteral Toradol (ketorolac) Rectal Aspirin & Indocin Slide 17 Comfort: Pain Management TNEEL-NE NSAIDs: Dosages & Dose Intervals Aspirin 650 mg PO - equipotent to about 2 mg IM morphine 1000 mg every 6 hours does not provide greater analgesia than 650 mg every 4 hours Duration of analgesia is greater Aspirin DosesDiclofenac & Ibuprofen May vary in effectiveness (metabolism) Slide 18 Comfort: Pain Management TNEEL-NE Celecoxib (Celebrex) Rofecoxib (Vioxx) Cox1 and Cox2 Drugs Slide 19 Comfort: Pain Management TNEEL-NE Renal decreased blood flow, interstitial nephritis, papillary necrosis GI bloating, dyspepsia, nausea, vomiting, bleeding, diarrhea, & peptic ulceration NSAIDs: Side-Effects & Toxicity Slide 20 Comfort: Pain Management TNEEL-NE NSAIDs: Hypersensitivity Increased incidence: middle aged, women, nasal polyps rhinitis edema urticaria bronchial asthma larengeal edema Slide 21 Comfort: Pain Management TNEEL-NE Drug Interactions alcohol antirheumatic agents antacids anticoagulants diuretics antidiabetic agents lithium beta blockers phenytoin methotrexate Symptom Assess relevant parameters NSAIDs: Nursing Implications Slide 22 Comfort: Pain Management TNEEL-NE Acetaminophen: Mechanisms of Actions What does this drug do?How does this drug work? Analgesic Antipyretic (Weak prostaglandin inhibition more in CNS than periphery) Slide 23 Comfort: Pain Management TNEEL-NE Acetaminophen: Administration Routes Parenteral None Oral Several different brands available over the counter & with prescription Rectal Several different brands available over the counter & with prescription Slide 24 Comfort: Pain Management TNEEL-NE Acetaminophen: Dosages & Dose Intervals Dose for children and small individuals 6 mg/kg to 12 mg/kg every 4 hours Has a Ceiling effect Doses above 1000 every 6 hours do not provide significantly greater analgesia than 650 mg every 4 hours Duration of analgesia is greater Doses Slide 25 Comfort: Pain Management TNEEL-NE nausea & vomiting, anorexia, abdominal pain Initial 24 hours liver enzyme changes encephalopathy coma death Acetaminophen: Toxicity Slide 26 Comfort: Pain Management TNEEL-NE Other sources of Tylenol Percocet Tylox Vicodin Nyquil Adult dose: 2,600-4,000 mg q day maximum Child dose: 6-12 mg/kg q 4 hr Nursing Implications Slide 27 Comfort: Pain Management TNEEL-NE Source: World Health Organization, 1992 Analgesic Ladder: Step One Drugs PAIN +/- Adjuvant Drug Step 1 Slide 28 Comfort: Pain Management TNEEL-NE Adjuvant Drugs: Mechanisms of Actions What do these drugs do?How do these drugs work? Analgesic Slide 29 Comfort: Pain Management TNEEL-NE Adjuvant Drugs: Mechanisms of Actions Analgesic effects Capsaicin Steroids Antihistamines Antidepressants Amitriptyline Nortriptyline Imipramine Trazodone Desipramine Prozac (no) Doxepin Slide 30 Comfort: Pain Management TNEEL-NE 5HT and Norepinephrine Reuptake Inhibition Presynaptic Terminal Synaptic Cleft Postsynaptic Membrane Storage Synthesis Receptor Release Reuptake Slide 31 Comfort: Pain Management TNEEL-NE Adjuvant Drugs: Mechanisms of Actions Analgesic effects Anticonvulsants Lidocaine Calcitonin Clonidine Slide 32 Comfort: Pain Management TNEEL-NE Adjuvant Drugs: Mechanisms of Actions A C myelin K+ Na + K+ Na+ K+ Na+ K+ Na + K+ Na + K+ Na + K+ Na + K+ Na + K+ Na+ K+ Na + K+ Na + nodes of ranvier Lidocaine Slide 33 Comfort: Pain Management TNEEL-NE Adjuvant Drugs: Mechanisms of Actions A C myelin nodes of ranvier Lidocaine Slide 34 Comfort: Pain Management TNEEL-NE Mechanism: Indications: Dose-Interval: Multiple effects via sodium channel blockade, GABA, calcium channel interaction, and norepinephrine release Not clear but may be effective in neuropathic pain and in sympathetic maintained pain Not established, current use is 300 mg q day increase q 2-3 days by 300 mg to effective dose (300 mg TID to 3000 mg) Gabapentin Slide 35 Comfort: Pain Management TNEEL-NE Adjuvant Drugs: Administration Routes Refer WHO Step 1 Adjuvant Analgesic Table Most drugs are administered as oral preparations Others include: Rectal Parenteral Topical Slide 36 Comfort: Pain Management TNEEL-NE Adjuvant Drugs: Dosages & Dose Intervals See the typical doses listed on the WHO Step 1 Adjuvant Analgesic Table Doses and dose intervals differ for each different adjuvant drug Doses that provide analgesia can be quite variable for some drugs such as gabapentin Doses Slide 37 Comfort: Pain Management TNEEL-NE Source: World Health Organization, 1992 Analgesic Ladder: Step One Drugs PAIN Opioid for mild to moderate pain Opioid for moderate to severe pain Step 2 Step 3 Slide 38 Comfort: Pain Management TNEEL-NE Opioids: Administration Routes High-dose morphine (any route) Associated with hyperalgesia (exaggerated pain sensation) and myoclonus (muscle spasm) Recommends morphine as the drug of choice and oral as the administration route of choice WHO Analgesic LadderIf Oral Route is not Possible... Transdermal, transmucosal, rectal, vaginal, intravenous, epidural, & intrathecal Slide 39 Comfort: Pain Management TNEEL-NE Opioids: Administration Routes Pain can be effectively managed with oral, transdermal, subcutaneous or IV routes More invasive: Epidural or intrathecal analgesia RoutesIntrathecal Enters into the cerebral spinal fluid Doses are lower than epidural because entire dose reaches spinal cord Helps control rapidly changing pain (better than oral) Slide 40 Comfort: Pain Management TNEEL-NE Opioids: Administration Routes ANAs Practice Guidelines RNs assist with analgesia by catheter techniques Demonstrated effectiveness in management of all types of pain including acute, chronic nonmalignant, and cancer pain Epidural AnalgesiaCommon Sites of Catheter Placement (Epidural) Lumbar region but can be cervical, thoracic, lumbar, or caudal Slide 41 Comfort: Pain Management TNEEL-NE Narcotic Definition A drug that produces stupor or narcosis (sleep) An obsolete term for analgesics Legal definition applies to all drugs that cause dependence Slide 42 Comfort: Pain Management TNEEL-NE Opiate Definition A drug that is a derivative from opium Slide 43 Comfort: Pain Management TNEEL-NE A drug that binds to opiate receptors and produces morphine-like action (generic- like term for opium derivatives and synthetic drugs) Opiate and Opioid often are used interchangeably in clinical practice and much of the literature Opioid Definition Slide 44 Comfort: Pain Management TNEEL-NE Analgesia Definition Absence of sensibility to pain Not the same as suffering Slide 45 Comfort: Pain Management TNEEL-NE Mechanism of Action: Opioids Agonists Mixed Agonists Antagonists Partial Agonists Antagonists Administration routes are many: Oral is preferred but parenteral, transdermal, spinal, and nasal routes may be used Slide 46 Comfort: Pain Management TNEEL-NE Agonists bind and produce morphine- like actions at mu, delta, and kappa receptors Opioid Mechanisms of Action: Agonists Slide 47 Comfort: Pain Management TNEEL-NE Receptors on Post Synaptic Neurons Dorsal Horn Receptors Glu SP Excitatory AMPA delta NMDANK-1 5-HT 2 NK-1 GABA A A PAN K GABA B mu/delta a 2 5-HT 1B mumu/delta Adn 5-HT 3 GABA B Adn a 2 Inhibitory Slide 48 Comfort: Pain Management TNEEL-NE Mixed agonists antagonists bind and produce morphine-like actions at kappa receptors They bind, but do not produce morphine-like effects at mu and delta receptors, (don't produce full morphine-like effects; e.g., can cause withdrawal symptoms in people dependent upon agonists, potentially life-threatening) Opioid Mechanisms of Action: Mixed Agonists Antagonists Slide 49 Comfort: Pain Management TNEEL-NE Partial Agonists bind and produce morphine-like actions at mu receptors Opioid Mechanisms of Action: Partial Agonists Slide 50 Comfort: Pain Management TNEEL-NE Antagonists bind to mu, delta, and kappa receptors but do not produce morphine- like effects (competitive agonist) Opioid Mechanisms of Action: Antagonists Slide 51 Comfort: Pain Management TNEEL-NE Opioid Receptors 1. Agonist Action Morphine Agonist Activated D K M Naloxone D K M D = Delta Receptor K = Kappa Receptor M = Mu Receptor Naloxone 2. Antagonist Action Antagonist Not Activated D K M Morphine D K M D = Delta Receptor K = Kappa Receptor M = Mu Receptor Pentazocine 3. Agonist-antagonist Action Agonist-antagonist Activated D K M D = Delta Receptor K = Kappa Receptor M = Mu Receptor Buprenorphine 4. Partial Agonist Action Partial Antagonist Activated D K M D = Delta Receptor K = Kappa Receptor M = Mu Receptor Slide 52 Comfort: Pain Management TNEEL-NE Tolerance Definition Tolerance: increased dose required to produce the same effects when pain stimulus remains unchanged Slide 53 Comfort: Pain Management TNEEL-NE Cross Tolerance Definition Cross Tolerance: refers to tolerance between drugs, e.g., morphine and Dilaudid Lack of analgesia should not be confused with tolerance or drug seeking behavior until genetic issues have been considered Slide 54 Comfort: Pain Management TNEEL-NE Example: Lack of analgesic effect from Codeine doses. About 10% of people of Northern European heritage lack the genetic ability to metabolize codeine to morphine via O-demethylation (requires spartine/debrisoquine axygenation (CYP2D6). These people will obtain no analgesic effect from codeine beyond a placebo effect. CHANGE in DRUG is REQUIRED. Tolerance & Cross Tolerance Example Tolerance: increased dose required to produce the same effects when pain stimulus remains unchanged Cross Tolerance: refers to tolerance between drugs, e.g., morphine and Dilaudid Lack of analgesia should not be confused with tolerance or drug seeking behavior until genetic issues have been considered Slide 55 Comfort: Pain Management TNEEL-NE A physical effect of using drug for about 10 days or longer Abstinence from drug use produces physical withdrawal syndrome (runny nose, sweating, anxiety, irritability, abdominal cramps, diarrhea) Dependence Definition To withdraw from morphine without withdrawal syndrome: decrease the 24 hour dose by 50% and give 25% of this dose every 6 hours; after 2 days reduce daily dose by an additional 25% every 2 days until 24 hour dose is 30 mg PO per day, then discontinue the morphine (APS 1999) Slide 56 Comfort: Pain Management TNEEL-NE Psychological drive (desire) to take drug (opioid) for euphoric effects Less than 0.1% of patients using opioids of medical purposes become addicted to them Research findings show only 4 out of nearly 12,000 patients treated with opioids for medically indicated purposes developed a problem with addiction Addiction Definition Slide 57 Comfort: Pain Management TNEEL-NE Even patients with a former or current substance abuse problem should be given analgesics, including opioids, when they have pain Addiction Definition Especially pain from trauma, injury, surgery, or cancer Concern about addiction should not interfere with patients in pain being treated Slide 58 Comfort: Pain Management TNEEL-NE Opioids: Absorption & Distribution Distribution Opioids are distributed throughout tissue Absorption First pass effect Slide 59 Comfort: Pain Management TNEEL-NE Opioids: Absorption Example Oral Dose SL Dose Slide 60 Comfort: Pain Management TNEEL-NE Opioids: Metabolism Hepatic UDP-glucuronyl Transferase Activity This result: Consistent with the large inter-individual variation in morphine bioavailability Morphine is metabolized by glucuronidation in the liver and the gut mucosa MetabolismMajor Glucuronidation Products Morphine-3-glucuronide (M3G) and morphine-6- glucuronide (M6G) Slide 61 Comfort: Pain Management TNEEL-NE Pre Time Morphine ng/ml PO MS ng/mlSL MS ng/ml Opioids: Metabolism Example--Subject #25 Slide 62 Comfort: Pain Management TNEEL-NE Pre Morphine ng/ml Opioids: Metabolism Example-- Subject # 5 Time PO MS ng/mlSL MS ng/ml Slide 63 Comfort: Pain Management TNEEL-NE Opioids: Metabolism Example-- Subject # 2 Pre Morphine ng/ml Time PO MS ng/mlSL MS ng/ml Slide 64 Comfort: Pain Management TNEEL-NE Opioids: Metabolism Example-- Subject # 22 Pre Morphine ng/ml Time PO MS ng/mlSL MS ng/ml Slide 65 Comfort: Pain Management TNEEL-NE Opioids: Excretion Excretion of most opioids, especially morphine, hydromorphone, and meperidine, is by the kidneys ExcretionQuestion: What does this fact mean for the person with renal failure or elders who may have decreased renal function? Slide 66 Comfort: Pain Management TNEEL-NE Desired Effect is Analgesia: Assess for the analgesic effect at the ONSET, PEAK, & DURATION of the drug effect Therapeutic goal: If present pain intensity is greater than able to live with pain score, additional analgesic effect is necessary: GIVE LARGER DOSE to achieve the desired effect (pain relief) Opioids: Desired Effects--Analgesia Slide 67 Comfort: Pain Management TNEEL-NE Side Effects: Undesired Effects Constipation Nausea and vomiting Sedation Respiratory depression (ventilatory depth & rate) Opioids: Side-Effects Itching Orthostatic hypotension (decreases cardiac work load by decreasing venous return and arterial pressure [reducing afterload] & has therapeutic in congestive heart failure and pulmonary edema) Awake patients do not succumb to respiratory depression!! Slide 68 Comfort: Pain Management TNEEL-NE Assisted Suicide & Euthanasia Extremely controversial topic in healthcare circles Physicians hesitant to prescribe large doses of opioids: May think theyre helping someone perform euthanasia Relieving pain may hasten death, but it is not euthanasia or assisted suicide! ANA: Nurses should not hesitate to use full and effective doses of pain medication for the proper management of pain in the dying patient. Some patients may try to seek assisted suicide ANAs position: Nurses should NOT participate in euthanasia or assisted suicide Slide 69 Comfort: Pain Management TNEEL-NE Opioids: Conscious Sedation Conscious sedation implies that the patient can respond to verbal and physical stimuli when sedatives are used ANA has established practice guidelines. Analgesics may produce sedation as a side effect, but sedatives do NOT produce any analgesia Conscious sedation may be helpful during the active phase of dying if desired by the patient and family Yes, I understand. I am feeling the effects of the pills now. Slide 70 Comfort: Pain Management TNEEL-NE Opioids: Nursing Role Dose titration: Dose adjustment based on decision making about the adequacy of analgesic effect vs. side effects The goal is to titrate the opioid dose to the desired effect (maximal analgesia with minimal side effects) Use the WHO Analgesic Ladder Percodan and titration Doses of all step 3 agonist drugs, except meperidine, can be safely escalated without a ceiling effect by means of titration There is no set amount of an opioid that will produce pain relief for every patient (its individual) first pill 4 hours 8 hours Slide 71 Comfort: Pain Management TNEEL-NE Opioids: Nursing Role Titration requires some type of pain assessment Nurses give optimal dose; identify alternative drugs Titrate the morphine dose upward vs. downward Withdrawing morphine doses To withdraw from morphine, decrease the 24 hour dose by 50% and give 25% of this dose every 6 hours; after 2 days, reduce daily dose by an additional 25% every 2 days until 24 hour dose is 30mg PO per day, then discontinue the morphine Dose required can always vary tremendously Patients with renal dysfunction are more sensitive Larger doses may be required Slide 72 Comfort: Pain Management TNEEL-NE Opioids: Nursing Role Persons who smoke may require larger doses of morphine, meperidine, pentazocine, and propoxyphene to obtain pain control Genetic factors can also affect analgesic responses 10% of Caucasians with Northern European ancestry are not able to metabolize spartine May not obtain any pain relief from codeine Nurses administer the prescribed dose at time of peak analgesic effect, continue until analgesia sufficient or side effects limit further doses Slide 73 Comfort: Pain Management TNEEL-NE Opioids: Nursing Role Nurses should always know: Onset, peak, and duration of effect for drug and route by which it was administered Patient's goal for pain therapy (0-10 scale rating). The patients optimal goal and the able-to-tolerate goal Know patient's pain intensity at onset, peak, and duration of analgesic effect Breakthrough doses: Needed when pain control is not constantly sustained Loading doses are needed when using parenteral infusions (IV or subcutaneous) Slide 74 Comfort: Pain Management TNEEL-NE Opioids: Knowledge Required for Nursing Role Washington State research findings Some nurses do not have sufficient knowledge about the pharmacokinetic properties of the opioids to provide adequate analgesia Nurses need to know about: Opioid onset of action Opioid peak effect of action Opioid duration of action Opioid dosing interval Equianalgesic doses for various opioids How to increase (titrate) doses to achieve maximal analgesia with minimal side effects Slide 75 Comfort: Pain Management TNEEL-NE IR MS (Min)IR MS (Max)MSContin (Min)MSContin (Max) Answer: Morphine Intervals Percentage CorrectSmallerLargerDon't Know/No Answer (N=131 RNs in Washington; Morris, Wilkie, & Fanslow, 1994) RN's Opioid Knowledge: Dose Intervals Slide 76 Comfort: Pain Management TNEEL-NE PO MS to IM MSIM Hydromorphone to PO MS Answer: Type of Conversion Percentage Correct DoseSmaller Dose Larger DoseDon't Know (N=131 RNs in Washington; Morris, Wilkie, & Fanslow, 1994) RNs Opioid Knowledge Equianalgesic Doses Slide 77 Comfort: Pain Management TNEEL-NE Equianalgesic Doses: Step 2 Opioids Drug Placebo Aspirin 650 mg Acetaminophen 650 mg Pentazocine 50 mg Codeine 65 mg Propoxyphene 65 mg Maximum degree of pain relief on % basis Slide 78 Comfort: Pain Management TNEEL-NE Codeine: Step 2 Analgesic effect of Codeine depends on metabolism of codeine to morphine via O-demethylation requires spartine/debrisoquine oxygenation (CYP2D6) 10% of people of Northern European heritage lack spartine. They will obtain no analgesic effect from codeine beyond a placebo effect A CHANGE in DRUG is REQUIRED to give them pain relief Slide 79 Comfort: Pain Management TNEEL-NE Q: What nursing actions are required to relieve this man's pain? 86 yr old male with pain located in the area of an abdominal incision, rated as 9 on 0-10 scale His 2nd day postop IV MS hourly requirement has been 2 mg He has bowel function Is eating without difficulty Has an order for Dilaudid 2 mg q 4-6 hr when taking po Case: Equianalgesic Dose Conversions Slide 80 Comfort: Pain Management TNEEL-NE Case: Equianalgesic Dose Conversions Answer: 36 mg PO Dilaudid per 24 hours From an equianalgesic chart, we know 7.5 mg oral Dilaudid is equivalent to 10 mg IM morphine Set the conversion equation as follows: 48 mg IV MS divided by 10 mg IM MS __ mg PO Dilaudid divided by 7.5 mg PO Dilaudid = ? Slide 81 Comfort: Pain Management TNEEL-NE Case: Equianalgesic Dose Conversions With the prescription, the maximum dose the patient can receive is 12 mg of oral Dilaudid, a dose that is far too low for the patient's predicted needs According to equianalgesic dose conversions, patient should receive 6 mg oral Dilaudid 6 times a day (every 4 hours) Initially it is prudent to administer or to offer oral pain medications around the clock even if the order is prn (as needed basis) According to the orders, at most the patient can receive 4 to 6 doses in 24 hours Slide 82 Comfort: Pain Management TNEEL-NE Meperidine Pharmacokinetics Analgesic Effectiveness: Onset, Peak, Duration OralIntramuscularIntravenous Minutes Onset PeakDuration mg/kg Q 3 h mg/kg 2 h NOT Administration Route and Recommended Dose 60 90 Slide 83 Comfort: Pain Management TNEEL-NE mg/kg Q 4 h mg/kg Q 4 h mg/kg 2 h Administration Route and Recommended Dose Morphine Pharmacokinetics Analgesic Effectiveness: Onset, Peak, Duration OralIntramuscularSubcutaneousIntravenous Minutes OnsetPeakDuration Slide 84 Comfort: Pain Management TNEEL-NE OralIntramuscularIntravenous Minutes 0.05 mg/kg Q 4 h mg/kg Q 4 h mg/kg 2 h Administration Route and Recommended Dose Hydromorphone Pharmacokinetics Analgesic Effectiveness: Onset, Peak, Duration OnsetPeakDuration Slide 85 Comfort: Pain Management TNEEL-NE Transdermal (Duragesic) Hours u\g/hr Fentanyl Pharmacokinetics Analgesic Effectiveness: Onset, Peak, Duration OnsetPeakDuration Slide 86 Comfort: Pain Management TNEEL-NE Fentanyl Pharmacokinetics times more potent than morphine Rapid onset Short duration of effect Contraindicated within 14 days of MAO inhibitor use Slide 87 Comfort: Pain Management TNEEL-NE IV Opioids Pharmacokinetics MorphineHydromorphoneMeperidineFentanylSufentanil Minutes Analgesic Effectiveness: Onset, Peak, Duration OnsetPeakDuration Slide 88 Comfort: Pain Management TNEEL-NE Safe & Effective Analgesia Dose Titration Based on Pharmacokinetics Example: Morphine IV q 20 minutes (peak effect) X 6 doses Minutes Since First Dose Plasma Concentration Doses Slide 89 Comfort: Pain Management TNEEL-NE Safe & Effective Analgesia Dose Titration Based on Pharmacokinetics Example: Morphine IV q 20 minutes (peak effect) X 6 doses First DoseSecond DoseThird DoseFourth DoseFifth DoseSixth Dose Slide 90 Comfort: Pain Management TNEEL-NE Safe & Effective Analgesia Dose Titration: Other Facts Patients with renal dysfunction Larger doses may be required if the pain is out of control pain is a neuropathic person has a smoking history genetic factors affect metabolism Plasma concentrations of opioids vary tremendously Slide 91 Comfort: Pain Management TNEEL-NE Opioids: Changing Routes Calculate the total 24-hour dose Convert 24 hr dose to the equianalgesic dose for the new route Administer appropriate fraction of 24-hour dose for new route How Should an Opioid be Changed to A Different Route? 180mg MS Contin every 12 hours plus 80mg IR MS for breakthrough pain=440mg PO MS/24 hr From the equianalgesic conversion chart, 10mg IM=30mg PO MS Start a continuous subcutaneous infusion: 440mg divided by 3=147 IM MS equivalents or 147mg/24 hr=6mg/hr Example Slide 92 Comfort: Pain Management TNEEL-NE Nonpharmacological Interventions Psychological and physical interventions can be seen as an adjunct to pharmacological therapies. May or may not be totally effective on their own. Choice of intervention is determined by: 1. The nature of each case 2. What works for a specific patient 3. The skills of the clinician Slide 93 Comfort: Pain Management TNEEL-NE Psychological Modalities Patient education Active listening Controlled breathing Distraction Slide 94 Comfort: Pain Management TNEEL-NE Psychological Modalities Reinforce or modify pain control behaviors Relaxation strategies Consultants Slide 95 Comfort: Pain Management TNEEL-NE Physical Modalities Heat Massages Beds Slide 96 Comfort: Pain Management TNEEL-NE Physical Modalities Cold Positioning Exercise programs Slide 97 Comfort: Pain Management TNEEL-NE Source: World Health Organization, 1992 Summary PAIN Non-opioid +/- Adjuvant Step 1 Pain persisting Opioid for mild to moderate pain +/- Non-opioid +/- Adjuvant Step 2 Pain persisting Opioid for moderate to severe pain +/- Non-opioid +/- Adjuvant Step 3 Pain relief Add a nonpharmacological therapy at any step!