Pain Management Strategies Mark Kantrow MD
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