Chpn hpna ppt #2 pain management
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Pain management info for Palliative Nurses
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Chpn hpna ppt #2 pain management
- 1. Clinical Review for the Hospice and Palliative Nurse Pain Management
- 70. Sample Equianalgesic Chart 8-12 20 ---- Oxycodone (long acting) 3-4 7.5 1.5 Hydromorphone 3-4 30 10 Morphine (IR) Duration (hours) Dose (mg) Oral Dose (mg) Parenteral Drug
Notes de l'éditeur
- Patient/Family Teaching Sheets (available in Spanish) Managing Pain TIPS SHEETS TIPS www.hpna.org
- Pain Management Objectives Describe the prevalence of pain in the hospice and palliative care setting Recognize the impact of pain on patients, families and the healthcare system Identify common barriers to effective pain management 4. Define the types of pain experienced by the hospice and palliative care patient 5. State the principles of effective pain management 6. Identify the components of a thorough pain assessment 7. Demonstrate the ability to do equianalgesic conversions
- Pain Management Prevalence of pain and its impact on patients and families Under treatment of pain in all practice areas continues to be documented Pain is experienced by 70-90% of patients with advanced disease, with 40-50% of patients experiencing moderate pain, and 25-30% experiencing severe pain 1 The SUPPORT study found that 50% of conscious patients who died in the hospital experienced moderate to severe pain at least half of the time 2 42% of patients admitted to hospice programs reported scores of 5 or less (1 = no relief; 10 = complete relief) 3 weeks after admission; only 50% of pain relieved 3 80% of postoperative patients experiencing pain in one study experienced moderate to severe pain; 31% reported severe to extreme pain; 71% reported continued pain after first dose of medication 4 Although as many as 45-85% of nursing home residents report pain 5,6 only 40-50% are given analgesics 6 50% of hospitalized patients experience pain in the last 3 days of life Pain scores (on a 0-10 scale) greater than or equal to “5” greatly impact on quality of life It is estimated that 85-90% of patients could be free of pain and 98-99% pain controlled using the knowledge and tools currently available. The remaining 1-2% of patients at the end of life can be offered palliative sedation in addition to analgesics
- Pain Management Impact of poorly controlled pain 1 Physical: Decreased ability to perform activities of daily living (ADL’s); Decreased strength and endurance; Nausea; Anorexia; Insomnia; Impaired immune response Psychosocial: Alteration in social and close relations; Isolation; Inability to work; Loss of self esteem, self worth; Increased caregiver burden; Disruptions of social support of both patient and family Emotional: Diminished leisure; Increased fear and anxiety; Depression (often associated with uncontrolled chronic pain); Loss of control; Consideration of suicide if pain not controlled Financial: Inability to work and earn income; Loss of health insurance; Cost of pain medications and treatments; Increased hospitalization Spiritual: Increased suffering; Re-evaluation or doubt regarding past religious foundations and beliefs; Questioning the meaning of suffering
- Pain Management Use of interdisciplinary resources for treatment of total pain 7 Pain affects the multiple dimensions of the human being No one discipline can address all of the issues of the individual in pain Interdisciplinary team approaches bring together the experience and education of many disciplines to address the multidimensional aspects of the total pain experience Interdisciplinary team approach to pain management can also assist in identifying and addressing multiple institutional barriers to effective pain management Team members: physicians; nurses, including those in advanced practice; pharmacists; social workers; counselors (including spiritual care providers); assistive personnel; rehabilitation therapists Ongoing communication among team members essential in maintaining Continuity of care Involvement of patient and family in decision making Collaboration in meeting patient/family goals
- Pain Management Costs of poor pain management 8 U.S. healthcare system spends $100 billion per year in pain management Chronic pain is the most expensive health problem in the United States today at $40 billion annually 40 million physician visits per year for pain related complaints 25% of all work days lost are due to pain Average chronic pain patient has Suffered seven years Undergone 3 major surgeries Incurred medical bills of $50,000-$100,000 82% of patients seeking care in a pain clinic continued to suffer at a two year follow up Improving pain management is more cost efficient than continuing practices that result in inadequate relief of pain 7
- Pain Management Costs of poor pain management 8 Co-morbidities, increase treatment costs substantially, are associated with chronic pain Co-morbidities include Depression Anxiety disorder Diabetes Chronic fatigue syndrome
- Pain Management Barriers to Effective Pain Management 9 Patient/Family Barriers Reluctance to report pain Fear that pain means the disease is worse Concern that distracting physicians from treatment of underlying disease Concern about not being a good patient Reluctance to take pain medications Fear of addiction or being thought of as an addict Worries about unmanageable side effects Concern about becoming tolerant to pain medications Pressure from family members to remain awake Reluctance of patient to show pain/weakness to family members Healthcare Provider Barriers Inadequate knowledge of pain management Poor assessment of pain Concern about regulation of controlled substances Fear of patient addiction Concern about side effects of analgesics Concern about patients becoming tolerant to analgesics Reluctance to accept recommendations from qualified palliative care individuals Institutional Barriers Low priority given to pain treatment Inadequate reimbursement Restrictive regulation of controlled substances Problems of availability of treatment or access to it Inadequate reimbursement
- Pain Management Definitions of Pain American Pain Society (APS) 10 : “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Describes pain as a phenomenon with multiple components: psychosocial and physical functioning Recognizes the complexity of pain experience However, pain not caused by tissue damage alone Patients self report may not be proportionate to tissue damage Patients with chronic nonmalignant pain (CNP) may have reports of severe pain with little or no tissue damage 7
- Pain Management Definition “Pain is whatever the experiencing person says it is, existing whenever he/she says it does” 7,11 Captures the subjective experience of pain Patient’s self report of pain is the single most reliable indicator of pain 7,10,12 Does not capture the pain experience of the nonverbal person such as infants or persons with cognitive impairment 13 √ See Appendix A, TYPES OF PAIN (GRID)
- Pain Management Types of Pain 10.14 Acute pain is usually of sudden onset with a precipitating cause, i.e., MI and acute appendicitis Accompanied by physiological signs of the CNS: tachycardia, hypertension, diaphoresis, pallor; non-verbal signs: facial expression, tense muscles Usually self limited and responds to analgesic treatment May be subacute - progressing over time May be episodic or intermittent - confined periods of pain with regular or irregular pattern, (i.e., at the time of a dressing change or another activity - providing analgesic prior to the event can have a significant impact to decrease the painful episode) Where cause of acute pain not immediately known, treatment of pain should proceed even during the investigation; waiting for definitive diagnosis to treat pain in inadvisable Patient with appropriate pain management may be more cooperative during diagnostic work-up Cancer pain may be acute, chronic or intermittent & often has a definable etiology, usually related to tumor recurrence or treatments 10 Unlike acute pain, rarely see signs of sympathetic nervous system arousal with chronic cancer pain Inexperienced clinician may misinterpret lack of noticeable objective signs of pain, such as those seen in acute pain situations Prevalence of pain increases with progression of disease Assessment and interventions vary based on primary site, extent of disease, progression, and disease treatments employed Chronic pain - pain that persists for more than 3 months and is ongoing, for example, arthritis Adaption of autonomic nervous system, patient does not exhibit objective signs of pain Poorly relieved chronic pain at end-of-life contributes to fatigue, depression, insomnia Associated with significant changes in personality, lifestyle, functional ability Treatment includes both pain and complications, including psychological distress Breakthrough pain - transient increase in pain to greater that moderate intensity Patient may have a combination of different types of pain. Noting the patients pattern of pain is an essential component of pain assessment
- Pain Management Classification of Pain 7,13 Nociceptive pain The normal processing of stimuli that damages normal tissues or has the potential to do so if prolonged Usually responsive to non-opioids and/or opioids Stimuli from somatic or visceral structures
- Pain Management Type of nociceptive pain Somatic Pain - pain resulting from stimulating pain activating sensitive Structures. Originating from Bone Joints Muscle Skin Connective tissue Quality described as: aching, throbbing, dull, sore Usually well localized
- Pain Management Type of nociceptive pain Visceral Pain - pain from infiltration, compression, distention, or stretching of the visceral organs Described as Squeezing, cramping, pressure; distention; deep, stretching, bloated feeling Poorly localized May be associated with nausea and vomiting, diaphoresis Referred to cutaneous sites distant from site of origin, for example shoulder pain associated with diaphragmatic irritation of the gall bladder Further divided into Tumor involvement of organ capsule Quality: aching Well localized Obstruction of hollow viscus Quality: intermittent cramping Poorly localized
- Pain Management Neuropathic pain Arises from an abnormal processing of sensory input by the central or peripheral nervous system Mechanisms not as well understood Characteristically described as burning, shooting, tingling, numbness, radiating, electrical shock-like, stabbing Responds to adjuvant therapy: anti-depressants, anticonvulsants, steroids, local anesthetics, N-Methyl-D-receptor antagonists (NMDA) such as ketamine 7
- Pain Management Neuropathic pain Centrally Generated Pain - divided into deafferentation pain and sympathetically maintained pain Deafferentation pain Caused by injury to either central or peripheral nervous system Central nervous system example: pain experienced below the level of a spinal cord lesion, i.e., quality: burning Peripheral nervous system example: phantom limb pain, i.e., quality: sharp, stabbing (lancinating) Sympathetically maintained pain: associated with dysregulation of the autonomic nervous system, i.e., reflex sympathetic dystrophy; complex regional pain syndrome, type I, type II Peripherally Generated Pain Painful polyneuropathies Pain is experienced along the route of the involved nerves, i.e., diabetic neuropathy, alcohol-nutritional neuropathy, Guillain-Barré syndrome Painful mononeuropathies Associated with known peripheral nerve injury Pain felt along the route of the injured nerve Examples: nerve root compression, nerve entrapment, trigeminal neuralgia
- American Pain Society principles of Pain Management 10 Believe/accept self report of pain 7 American Pain Society established the following principles of pain management to guide the clinician in providing appropriate pain control measures 10 Individualize the route, dosage, and schedule Consider the most appropriate route for the patient Be aware that optimal analgesic doses vary from person to person-be aware of dosing in elderly patients (start low go slow) Give each analgesic an adequate trial by increasing the dose up to the appearance of limiting side effects before switching to another drug 2. Around the clock dosing (not only PRN) if pain is present most of the day Establish optimal dose through titration - increase or decrease the dose according to the degree of pain relief and side effects experienced by the patient Once optimal dose established, provide it on scheduled, around-the-clock basis Provide supplementary dosing for breakthrough pain “ PRN only” takes several hours and higher doses to relieve pain PRN dosing leads to cycle of under-medication of pain alternating with periods of over-medicating and potential drug toxicity
- American Pain Society principles of Pain Management 10 3. Become familiar with the dose and time course of several strong opioids Morphine viewed as the standard strong opioid Other agonists provide similar qualities of analgesia & similar side effects Individual patients respond differently to different opioids Selection of opioid based on Favorable prior experience with a particular drug Preference for a long duration of action Avoiding a limiting adverse effect of a particular opioid Circumventing tolerance to one opioid in a patient who is getting progressively less relief with that drug Need for rapid onset of action Availability of a more desirable dosage form 4. Give infants and children adequate opioid doses Clinical and pharmacokinetics of opioids in children and infants over 6 months are approximately the same as in adults Dosing based on weight Infants under 6 months (especially premature or ill) at risk of apnea when given opioids
- American Pain Society principles of Pain Management 10 5. Follow patients closely, particularly when beginning or changing analgesic regimens Monitor patient for pain relief and side effects frequently Adjust pain regimen accordingly Monitor closely when starting new regimen, changing opioids or changing routes - at least daily when outpatient Individual responses will vary 6. When changing to a new opioid or different route, first use equianalgesic doses to estimate the new dose. Then, modify the estimate based on the clinical situation & the specific drugs Use standardized equianalgesic charts - entire institution is using same chart Charts usually based on morphine 10 mg as standard for comparison Charts based on single-dose studies therefore may be limited in application Chart provides dosing of other opioids to equal morphine in either route For IV bolus, APS suggests that half the IM dose will give the same peak effect (largely because of delayed absorption of the IM drug) For continuous IV 24 hour infusion, APS recommends assuming that IV and IM total dosages will be equivalent (eventually almost all of the IM drug is absorbed) See Equianalgesia for more detailed overview
- American Pain Society principles of Pain Management 10 Recognize and treat side effects Most common side effects of opioids: sedation, constipation, nausea, vomiting, itching, respiratory depression Assess patient (ask) for possible side effects Treatments of side effects Change the dosing regimen or route of the same drug Try a different opioid Add another drug that counteracts the adverse effects (i.e., bowel protocol for constipation) Use a route of administration that minimizes drug concentrations at the site producing the side effect (i.e., changing from oral to SC or transdermal on a patient with partial bowel obstruction)
- American Pain Society principles of Pain Management 10 8. Be aware of the potential hazards of meperidine (Demerol ) and mixed agonist-antagonists, particularly pentazocine (Talwin ) Meperidine (Demerol ) - Normeperidine, a metabolite of meperidine, can produce CNS excitotoxicity leading to anxiety, tremors, myoclonus, and generalized seizures Oral doses of Meperidine (Demerol ) have about ¼ of the analgesic effectiveness of similar parenteral doses but still produce same amount normeperidine Patients with compromised renal function are particularly at risk Naloxone (Narcan ) does not reverse this hyperexcitability, and may make it worse Meperidine (Demerol ) not recommended for use greater than 48 hours for acute pain in patients without renal or CNS disease or at doses greater than 600 mg/24 hours Meperidine should not be prescribed for chronic pain - especially worrisome in patients with sickle cell disease who may have renal disease and low seizure threshold; they are at particular risk for seizures If meperidine given to patients taking monoamine oxidase inhibitors, a hyperpyrexic syndrome with delirium can occur and may be lethal Mixed agonist-antagonists - Mixed agonists-antagonist drugs such as pentazocine (Talwin ), nalbuphine (Nubain ) or butorphanol (Stadol ) produce analgesia by binding to their receptor sites However, they antagonize the action of morphine-like agonists at the mu receptor The antagonist actions lessen both the analgesic & respiratory depressant effects seen at higher doses No convincing evidence that agonist-antagonists offer any advantage over morphine-like agonists in the treatment of pain (possible exceptions: less risk for respiratory depression; fewer regulatory controls) May cause confusion and hallucinations (particularly pentazocine) (Talwin ) May cause acute withdrawal symptoms when given to patients taking chronic morphine-like agonists Not recommended as first-line drugs May be useful in individuals unable to tolerate other opioids
- American Pain Society principles of Pain Management 10 9. Watch for the development of tolerance and treat appropriately Tolerance refers to a larger dose of opioid analgesic that is required to maintain the original analgesic effect Common in all groups taking opioids chronically First signs: decrease in duration of effective analgesia To delay tolerance: consider combination opioids with non-opioids or switch to an alternative opioid & select one-half of the predicted equianalgesic dose found on equianalgesic table as starting dose since cross-tolerance among opioids is not complete 10. Be aware of the development of physical dependence & prevent withdrawal Physical dependence occurs in patients taking chronic opioids when the abrupt discontinuation of the administration of an opioid antagonist produces an abstinence syndrome Abstinence syndrome: anxiety, irritability, chills alternating with hot flashes, salivation, lacrimating, rhinorrhea, diaphoresis, piloerection, nausea, vomiting, abdominal cramps, insomnia Time course of abstinence syndrome depends on half-life of opioid Avoid abstinence syndrome by weaning patient slowly from chronic opioid use: one-half of the previous daily dose may be given in every 6 hour doses for 2 days and then reduced by 25% every 2 days Continue this until reach a 24-hour dose equivalent to 30 mg oral morphine in adult or 0.6 mg/kg/day in child. Discontinue after 2 days on this dose Use of transdermal clonidine (Catapres TTS 0.1-0.2 mg/day delivery) can lessen symptoms of anxiety, tachycardia, sweating, & other autonomic symptoms
- American Pain Society principles of Pain Management 10 Do not label a patient addicted (i.e., psychologically dependant) if you merely mean physically dependent on or tolerant to opioids Addiction is defined as a pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief. The patient exhibits drug-seeking behavior and becomes overwhelmingly involved with using & procuring the drug Educate patient and family on distinction between addiction, tolerance and physical dependence Educate patient and family on low risk of addiction and fear of addiction should not be primary concern in treating acute or chronic pain 12. Be aware of the psychological state of the patient Patient anxiety can be reduced when pain is relieved with analgesics If anxiety persists, consider anti-anxiety agents Anxiety and depression are common in chronic malignant and chronic nonmalignant pain Antidepressants can help elevate mood, improve appetite and sleep and relieve some types of pain
- Pain Management World Health Organization (WHO) Ladder 7,15,16 The WHO ladder portrays a progression in the doses and types of analgesic drugs for effective pain management. The best choice of modality often changes as the patient’s condition and the characteristics of the pain change. Historically, was proposed in the 1980’s to address management of chronic cancer pain Subsequently adopted by the United States Agency for Health Care Policy and Research (AHCPR) in 1994 Studies indicate that WHO Ladder approach has improved management of chronic cancer pain over the last 10 years Used as a guide to selecting the initial analgesic and dosing WHO ladder recommends that analgesics be administered Orally whenever possible “ By the clock” to prevent the return of pain As described in the ladder Based on assessment of the individual’s pain experience Administered with attention to detail
- Pain Management WHO analgesic recommendations WHO analgesic recommendations based on pain intensity ratings on 1-10 scale: mild (1-3); moderate (4-6); or severe pain (7-10) (Note: while the WHO analgesic ladder is not used by many services, it can be a useful teaching tool) Step 1 ( mild pain): recommend non-opioid analgesic with possible adjuvant based on other assessment aspects Note 1: Adjuvant in WHO Ladder refers to both adjuvant analgesics and adjuvant drugs that are added to analgesics to reduce side effects, i.e., laxatives for opioid-induced constipation
- Pain Management WHO analgesic recommendations Step 2 (moderate pain): add opioids in low doses. Non-opioids and adjuvants may be continued based on assessment and reassessment Note 2: Historically in Step 2 use of weak opioids (i.e., codeine) or fixed combination opioids (i.e., Percocet ) were recommended. Now recommending strong opioids in smaller doses due to increased efficacy and lack of need to switch medications as pain escalated to Step 3 recommendations. Additionally, fixed combination opioids with acetaminophen are limited by total acetaminophen dose of 4 gms per 24 hours (greater doses leading to hepatic toxicity)
- Pain Management WHO analgesic recommendations Step 3 (severe pain): add higher doses of opioids. Non-opioids and adjuvants may be continued based on assessment and reassessment Oral routes recommended, but using opioid with multiple route availability preferable to avoid having to change medication Opioids should have short half life so can be titrated quickly and safely for severe, escalating pain Preferable to use opioid with sustained release formulation available for patients with chronic pain after appropriate ATC dose established using initial immediate release use (i.e., 24-48 hour total dosing of immediate release converted to sustained release given every 12 hour) Opioids with breakthrough pain for patients on sustained release ATC dosing short half life used in immediate release formulation Selection based on patient report - if reports severe pain, not advisable to start as a step one - titrate safely to effect
- Pain Management Pain Assessment Principles 7,17 Accept the patient’s complaint of pain Patient’s self report is considered mainstay of pain assessment Captures the subjective, personal experience of pain Healthcare professional has professional responsibility to accept the patient’s report of pain All reports taken seriously and acted upon At times, can be difficult to accept patient’s report of pain Healthcare providers feel vulnerable to being fooled by persons they perceive as “drug seekers” Healthcare providers will at times provide analgesics to patients who may lie about reports of pain, but will be providing effective analgesia to all who do have pain Take a careful history of the pain complaint, consider it within the context of diagnosis, medical history, goals of care Assessment for non-verbal patients, obtain information from persons most involved in care such as family members or other healthcare providers Scales such as the FLACC scale may be useful to teach to family (www.childcancerpain.org/content.cfm?content=assess08) Establish patient centered goals of pain management. Use a consistent pain scale. Include acceptable intensity level and relate to functional abilities
- Pain Management Pain Assessment Principles 7,17 Monitor nonverbal signs of pain, such as grimacing, guarding, wincing and moaning or crying with movement Recognize that patients near the end of life may have multiple syndromes complicating pain assessment Clarify the temporal pattern of patient’s pain: acute, chronic, baseline, intermittent, breakthrough, incident Assess the psychological impact of pain on the patient and family Assess for the meaning of pain within the patients stated spiritual context Examine the site of the pain Facilitate an appropriate diagnostic work up when indicated and ensure patient’s pain is controlled during work up Provide ongoing communication to patient and family during assessment and intervention. Give a time frame of when to see evidence of patient comfort Assess/reassess effectiveness of pain management treatment plan Assess and reassess for evidence of adverse side effects related to pain treatment plan
- Pain Management - Assessment Assessment When conducting a pain assessment, the following should be included in the initial assessment of pain Adapt assessment for individuals who have difficulty communicating as needed Areas to assess with questions to solicit necessary information include Onset/duration When did the pain first begin? Was it associated with a particular activity or known medical event? Do you experience other symptoms (such as nausea, vomiting, sleep interruption) with the onset of pain? Do you have other medical conditions that cause pain (arthritis, chronic low back pain) different from the pain you are now having? Site(s) More than 75% of persons with cancer pain have pain in 2 or more sites Ask patient , “Please point to all of the areas on your body where you are currently experiencing pain” When using a documentation tool: please place a mark on the drawing of this body where you currently have pain Assess each site for pain intensity, quality, duration
- Pain Management - Assessment Severity or intensity of pain Although numerical estimates are the most frequently used method of assessing the severity of pain and adequacy of pain relief, some patients cannot use the numerical estimate and one of the other tools may be appropriate. It is most important that the staff is consistent in using a particular assessment tool. Some patients do not want to use a pain scale. In these cases, the team should use a consistent approach to address that patient’s pain Select the pain intensity scale appropriate to patient and recognized by practice setting: 0 to 10 scale, word descriptors (mild, moderate, severe); visual analogue scales; faces scales Verify that use of the pain rating scale is acceptable to the patient: “Are you comfortable using this scale?” , ”Do you understand how to use the scale?” Ask, if 0 is no pain and 10 is the worst pain you can imagine, how would you rate your pain right now? At its worst over last 24 hours? At its best over last 24 hours? “ What would be an acceptable level of pain”, or “What are your goals in terms of pain rating using same scale?” Quality of pain Ask, “What words would you use to describe the pain?” Not all patients use the word ‘pain’ to describe what they are feeling. They may use ‘discomfort’, ‘soreness’, ‘ache’ If patient struggles with descriptors, ask patient if any of the following words describe their pain: throbbing, shooting, sharp, cramping, aching, tender, pricking, burning, pulling If patient continues to struggle, ask, “What could you do to make me feel the pain you have?” Exacerbating or relieving factors What makes the pain worse or what causes the pain? (may include activities, body position) Is there anything you do or take that makes the pain better? What relieves the pain? (may include over the counter medications or non-drug interventions) Assess the pain at rest, with movement, and in relation to daily activity Ask the caregivers how patient is doing with activities
- Pain Management - Assessment Effects of pain on quality of life What does the pain mean to the patient and family? The meaning of pain can extend beyond the physical suffering, for example, worsening of the disease, loss of independence, being closer to death How has the pain affected the patient’s quality of life? Does the pain keep the patient from doing activities he/she enjoys? Ask, “What does this pain mean to you?” Ask, “What do you think is causing the pain?” Ask, “Has the pain ever been so bad that you considered harming yourself?” Medication History Ask “ What medications have you taken in the past for general aches and pains, such as headache?” “ Did that medication provide you relief?” “ Did you have any side effects or problems from that medication?” “ If you have had surgery in the past, do you remember what medications you were given for pain?” “ What medications have you found helpful for pain relief in the past for chronic pain problems, such as arthritis or backache?” “ Do those medications continue to provide you acceptable pain relief?” “ Do you have any side effects or problems from the medication that you take for chronic pain?”
- Pain Management - Assessment Physical assessment Examine site(s) of pain, including referral sites. Note: skin color, warmth, irritation, integrity, etc. Consider disease process, extent of progression. Consider pain within context of other assessment findings (auscultation, palpation, observation, lab values, radiographic findings) Cultural assessment and implications Avoid cultural stereotyping and conduct a culturally sensitive assessment. Be aware of cultural generalities and determine individual differences. i.e., we can not assume that all Japanese & Native Americans are stoic, or that all Filipinos & Puerto Ricans are expressive Pain assessment tools used in the United States can be used by other cultures Work closely with patient/family to identify pain management goals that are incorporate cultural preferences/values, including use of non-drug pain management interventions, use of herbs or home remedies as appropriate Secure teaching materials in patient’s own language / Obtain translator as needed Explore cultural implications of pain with patient and family. / How does the patient express pain? Is the family involved in pain treatment decisions? Are there any religious/spiritual practices related to pain management, i.e., prayer, meditation, pain as penance? Are there any culturally specific beliefs about pain, i.e., should be endured, should not be verbalized? Other considerations - Socioeconomic factors may influence pain assessment Age – Elderly - May be more stoic. Generally have inadequate pain assessment and management. Poor historians - cognitive limits may effect appropriate and adequate reporting. More likely not to report pain, they do not want to bother the nurse or doctor, or distress their family. Likely to have multiple medical problems that can cause the pain Gender - Men are generally more stoic. Women may exhibit lower pain thresholds & less tolerance. Become more upset when pain prevents them from doing things they enjoy / they seek care sooner than men, and respond better than men to analgesic. Women experience more visceral pain, men more somatic pain Martial status - Patient may minimize pain when spouse present Spiritual - Some patients believe pain and suffering are meaningful signs of the presence of a higher being and must endure, others are outraged by the pain and suffering. Accept patient’s belief and give permission for patient to verbalize point of view. Elderly women and elderly patients of minority background use religious coping strategies (prayer and spiritual comfort) to manage pain more often than Caucasian men Environmental factors - Creating a peaceful environment from bright lights, extreme noise, and extensive heat or cold may assist in alleviating patients pain
- Pain Management Physician/nurse communication 7 Effective communication between the physician and nurse is critical in providing excellent patient care The use of specific techniques/tools provides a framework for communication between members of the healthcare team about a patient's condition. Focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety BASICS - Background, Assessment, Symptoms/Situation, Interpretation, Communication, Successful outcome SBAR - situation, background, assessment, recommendation Use physician’s name when calling and tell physician your name Provide the information, why you are calling, include the patient name and diagnosis Include pain management goal: rating and activities Summarize current pain ratings and effects on activities Provide current medication regimen and side effects Suggest possible alternatives (based on clinical practice guidelines)
- Pain Management Team communication: to ensure collaboration among team members addressing pain management 7 Establish common goals Set goals with individual Acknowledge right of every patient with pain Communicate patient pain goals to all members of the team, i.e., pain rating of 3 out of 10 Associated activities goals, i.e., 5 hours uninterrupted sleep; 10 minutes of mobility Patient goal should be communicated/reviewed during each team meeting or interaction Use common language Ensure all members of team speaking same pain language Standardize throughout institution: intensity scales, equianalgesic charts, documentation Common knowledge base Acknowledgment by all members that all members must accept patient’s report of pain Clinical guidelines 10,15 Patient education Regular communication Predictable or scheduled Based on patient need and/or clinical setting Progress notes, standardized report form
- Pain Management Non-opioids 7 Characteristics Used in acute and chronic pain Used in both nociceptive (somatic and visceral) and neuropathic pain Most effective with nociceptive pain (muscle and joint pain) Alone, provide adequate relief for mild pain (acetaminophen, NSAIDs) or moderate pain (NSAIDs) Combined with opioid analgesics for both additive analgesic effects or opioid dose-sparing effects (allows possibility of opioid dose to be decreased) √ See Appendix B, Dosing Information √ Go back to Appendix A, TYPES OF PAIN GRID and discuss treatment for each type of pain (pharmacological and non-pharmacological
- Pain Management - Non-opioids 7 Acetaminophen Mechanism of analgesia not well understood Can be effective in inflammatory conditions though has very little anti-inflammatory effect Dosing Acetaminophen may be given on PRN basis for occasional pain or around-the-clock (ATC) for ongoing pain Acetaminophen has short half life - give every 4 hours for ongoing pain Analgesia has ceiling - daily dose restriction Adults = 4000mg/24 hours, decrease dose for patients with impaired hepatic metabolism Remember ceiling when using fixed combination (opioid/non-opioid) analgesia (Lortab , Lorcet , Percocet , Tylenol #3 , Tylox , Vicodin , Vicoprofen ) Available without prescription Evaluate analgesic effectiveness within 2 hours Not affected by physical dependence or tolerance as these do not develop in continuous administration Routes of Administration - Acetaminophen available orally in pill and liquid forms and rectally 7
- Pain Management - Non-opioids 7 Acetaminophen Side effects No effect on platelet aggregation. Does not cause gastrointestinal problems, may cause stomach upset in chronic use May cause severe hepatotoxicity even at recommended doses in patients with chronic alcoholism, malnourishment, recent fasting, or preexisting liver disease Toxicity more likely in children Hepatoxicity usually develops 2-4 days after intake: jaundice, increased plasma bilirubin and plasma transaminase; prolonged prothrombin time May be reversible over weeks or months Fatality due to hepatic necrosis Questions remain if acetaminophen use associated with renal disease Considerations Be aware of hidden doses, i.e., APAP in combination products
- Pain Management - Non-opioids 7 NSAIDs Characteristics Exert analgesic effects through the inhibition of prostaglandin production. Prostaglandin is an inflammatory mediator released when cells are damaged that sensitize nerves that carry information about pain Multipurpose analgesia - rheumatoid arthritis, postoperative pain, cancer pain, headache, menstrual cramps Can provide pain relief for mild or moderate pain when used alone Usually not sufficient alone for severe pain Some available without prescription: aspirin, ibuprofen, ketoprofen (Orudis ), naproxen sodium (Naprosyn ) Choice of drug NSAIDs - whatever worked best for individual in past with fewest side effects NSAIDS - if no response after 3 days of adjustment, consider switching to different NSAID (“sequential trials”) If patient is hypersensitive or allergic to ASA or other NSAID, all NSAIDs should be considered contraindicated Acetaminophen considered safest non-opioid analgesic unless history of liver disease or history of regular moderate to heavy ethanol intake NSAIDs side effects more problematic when taken for chronic pain than for short period of time (e.g., postoperatively) Misoprostol (Cytotec ), a prostaglandin analog, can reduce risk of gastric ulcers caused by NSAIDs
- Pain Management - Non-opioids 7 NSAIDs Dosing NSAIDs may be given on PRN basis for occasional pain or around-the-clock (ATC) for ongoing pain Half life differs: 4 hours to once daily Acute pain: use recommended starting dose Frail elderly, high risk for side effects or chronic use: start at 50% recommended starting dose and increase by 50% increments weekly; do not exceed 200% of recommended daily dose Evaluate for analgesic effectiveness within 3 hours; for chronic use, monitor over 2-7 days depending on NSAID half-life Consider infrequent dosing (once or twice per day) in patients with chronic pain or patients taking in addition to opioid Ceiling exists for NSAIDs = varies from individual Analgesic dose usually less than anti-inflammatory dose Consider giving ½ the recommended dose and increase every 2-3 days until pain relief reported or undesirable side effects present Dosing of NSAIDs not affected by physical dependence or tolerance as these do not develop in continuous administration Routes of Administration All NSAIDs available orally Topical NSAIDs may be use for localized pain, may have equal effectiveness and fewer side effects Only few available rectally, but most oral dose forms can be given rectally 7 Only ketorolac (Toradol ) available for parenteral administration (IM, IV) in United States. Indicated for short term use only. IM route not recommended at the end of life due to pain with injection
- Pain Management - Non-opioids 7 NSAIDs Side Effects Hematologic Platelet aggregation - caution in patients with bleeding diatheses such as hemophilia; caution in some patients undergoing surgery or cancer treatment Side effect treatment considerations: if bleeding a concern, consider acetaminophen, or NSAIDS with minimal or no effect on platelet aggregation such as choline magnesium (Trilisate ), salsalate (Disalcid ), and nabumetone (Relafen ). However, none safe in setting of bleeding diatheses GI Side effects Local: irritation from oral NSAIDs (heartburn-like complaint) Usually not indicative of severe injury, may resolve with continued administration Side effect treatment considerations: lower dose, switching NSAID, enteric coated NSAID, taking NSAID with food or large glass of water; use H 2 blocker, i.e., ranitidine Zantac ; antacids may cause decreased absorption Misoprostol (Cytotec ), a prostaglandin analog, can reduce risk of gastric ulcers Systemic: regardless of route, NSAIDs interfere with prostaglandin synthesis which impairs protective barrier of the GI tract; patient may be asymptomatic until bleed or perforation occurs Side effect treatment considerations: select NSAID with lower risk for bleeding (ibuprofen, diclofenac, choline magnesium trisalicylate, salsalate; nabumetone) use of lowest effective dose Consider administrating proton pump inhibitor as omeprazole (Prilosec ) or lansoprazole (Prevacil ) when using non-selective NSAIDs, to prevent gastrointestinal complications Renal Chronic use of NSAIDS at high doses may cause end-stage renal disease (renal insufficiency and acute renal failure is rare) Side effect treatment considerations: avoid use of indomethacin (Indocin ), consider aspirin, use low doses, monitor kidney function Cognitive Impairment Mild dizziness and drowsiness relatively common Other symptoms: decreased attention span, short term memory loss (note: elderly may not report these symptoms as may be associated with aging process) Side effect treatment considerations: lower the dose, discontinue the NSAID, switch NSAID Cardiovascular and cerebrovascular disease Use non-selective agents COX-2 agents cautiously
- Pain Management Teaching points for non-opioids 7 Patients at risk for GI bleed associated with NSAID therapy: history of NSAID - induced ulcer, prior ulcer diseases, age greater than 60 years, concomitant use of corticosteroid therapy, concomitant anticoagulant therapy, high doses of NSAIDs, poor prognosis for survival of GI complication For surgical patients, consult with surgeon about stopping ASA treatment and NSAIDs before surgery Education regarding non-opioid medications should include Name Type of medication (nonsteroidal anti-inflammatory drug) Description (what medication looks like in dose ordered) Uses (pain control) Dosage and administration schedule Possible side effects (stomach irritation) Precautions (call healthcare provider if pain unrelieved) Brand names (Advil ) Instructions on stopping medications (do not stop suddenly; call healthcare provider before stopping) Never take medication on an empty stomach, take medication with food or full glass of water Antacids may be helpful if indigestion occurs Not advisable to take two NSAIDs together; however, daily ASA may be continued for prevention of heart attack Read all labels of over the counter medications to check for ASA contents Report to healthcare provider immediately Nausea and vomiting - report immediately if vomitus has coffee grounds appearance or frank blood Breathing problems - report to healthcare provider immediately Dark stool Other possible side effects Headache, Dizziness, Ringing in ears, Blurred vision, Ankle swelling, Diarrhea/ constipation, Rash Patient/Family Teaching Sheet - Managing Pain
- Pain Management Opioids Characteristics Provide pain relief primarily through CNS action - binding to opioid receptor sites in brain and spinal cord Receptor sites include mu, kappa and delta receptor sites Pain relief occurs when opioid binds to one or more of these receptors as an agonist Two groups: agonists and agonist-antagonists √ See Appendix B, Dosing Information
- Pain Management Pure agonists opioids Characteristics Pure agonists have broader application for both acute and chronic pain management Expect physical dependence after receiving opioids for several days Physical dependence manifested by withdrawal syndrome will occur when abruptly stopped or antagonist administered naloxone (Narcan ) given Prevent withdrawal by reducing opioid dose over 7-10 days or by decreasing dose by 25% of previous dose Tolerance to certain side effects (sleepiness, nausea) will occur within few days No tolerance to constipation Tolerance to analgesia occurs but is rare - consider disease progression if present. Managed by increasing dose or shortening interval between doses Tolerance to respiratory depression occurs if opioid increased slowly Indications Foundation for analgesia in acute and chronic cancer pain; increasingly accepted in chronic nonmalignant pain Most types of pain respond to pure agonists, but some more than others: nociceptive pain more responsive than neuropathic Pure agonists drug of choice for breakthrough medication
- Pain Management Choice of opioid drug Principle of selection and administration of drug is patient related, comparable with pain severity, age, dosing, routing requirements, underlying illness, and metabolic state Use one pure agonists with one route If one pure agonists not relieving pain after appropriate titration, may be necessary to switch medications - continue titration with same opioid until side effects become limiting or manageable before switching or initiating sequential trials Switch pure agonists if occurrence or likelihood of accumulation of active metabolites cause unmanageable or unacceptable effects, i.e., CNS stimulation secondary to normeperidine build up Two main reasons for switching pure agonists: unmanageable side effects or potential toxicity from metabolite accumulation Choice of opioid drug All pure agonists have same side effects; however, patient variability will occur in relation to side effects Side effects may be often reported as “allergies” by patients who previously experienced adverse reactions - true allergy to pure agonists rare If true allergy present (i.e., morphine), consider another opioid (fentanyl, hydromorphone) For breakthrough, pure agonists must have rapid onset of action and short duration; if possible, should be same as long acting opioid
- Pain Management Morphine (MS Contin ® , Roxanol ® , Duramorph ® and others) 9 Morphine Considered “gold standard’ of opioid analgesics and used for comparison in opioid use Some patients cannot tolerate because of the side effects: itching, headache, sedation, nausea Usually resolve in a few days Now being reevaluated in terms of first line use Recent research demonstrates limitations of use Two main metabolites Morphine-3-glucuronide (M3G) = primary metabolite, but not active at receptor site Morphine-6-glucuronide (M6G) = active at opioid receptor site and responsible in part for analgesic effects and side effects M6G levels usually exceed morphine levels in chronic use Accumulation leads to toxic build up: profound nausea and respiratory depression M6G levels elevated in oral route, age 70 years or greater, renal failure M6G levels decreased in males and concurrent use of rifampin Morphine half life = 2-4 hours; M6G half life is longer 40% of morphine available for therapeutic use due to first pass effect - PO doses therefore higher than IV, SL is not absorbed under the tongue - it trickles down into GI tract
- Pain Management Codiene 9 Usually most appropriate for mild pain - limited use in severe pain Combination products with codeine and acetaminophen or aspirin limit their use 60% therapeutic availability after first pass effect Metabolized by liver to active form of morphine Wide variations in individual response to IM and peak levels Fentanyl (Duragesic Patch ) 9 Initially used for anesthesia Administered IV and epidurally for acute pain With development of patch, found use in cancer pain and chronic nonmalignant pain Metabolized in liver - no active metabolites Hydrocodone 9 Found in combination therapy with acetaminophen in differing strengths per 500 mg of acetaminophen: 2.5, 5, 7.5 and 10 mg 650 mg acetaminophen with 10 mg hydrocodone (Vicodin HP ); 7.5 mg elixir Limited by acetaminophen ceiling Not available as single entity medication Used for mild to moderate pain only
- Pain Management Hydromorphone (Dilaudid ) 9 Considered by many practitioners to be first line for postoperative pain management May be considered first line opioid in postoperative PCA use; however, cost is greater than morphine Appropriate for some cancer pain As yet, no clinically relevant metabolites Short half life and lack of metabolite problems make it preferable to morphine in patients with renal insufficiency, particularly the elderly 30-40% bioavailability Oral to parenteral ratio of 5:1 More potent than morphine, but exact equianalgesic ratio is considered unknown and variable by route: most equianalgesic charts show 7:1 based on single dose studies No controlled release formulation currently available in the United States - may limit use in cancer pain and chronic nonmalignant pain Concentration of 10mg/ml make it viable option for parenteral administration: SC or SC infusion
- Meperidine (Demerol ) Contraindicated in chronic pain management, long-term care, palliative care Evidence to support that should NOT be used as a first line analgesic for any type of pain Active metabolite: normeperidine; CNS stimulant: irritability, tremors, muscle twitching, jerking, agitation, seizures. Due to accumulation of metabolite, do not use in long-term therapy such as cancer or chronic nonmalignant pain Contraindicated in patients receiving MAO inhibitors and in patients with untreated hypothyroidism, Addison’s disease, benign prostatic hypertrophy, urethral stricture, renal failure, geriatric population, sickle cell anemia Caution in patients with preexisting seizure disorders, atrial flutter or other supraventricular tachycardias More likely than other opioids to cause postoperative delirium Contradicted for repeated dosing Assess patients taking meperidine every 8-12 hours for CNS irritability: restlessness, shakiness, tremors, twitching, jerking If CNS signs present, discontinue meperidine immediately as normeperidine accumulation evident and could lead to seizures - may need to consider addition of depressant or anticonvulsant when reducing doses Naloxone (Narcan ) does not reverse the effects of normeperidine Doses required to produce analgesia in patients with moderate to severe pain is 75-100 mg every 2-4 hours - maximum 24 hour dose of 600 mg reached or exceeded quickly with subsequent normeperidine build up Oral meperidine is not recommended for any type of pain management as this route is one fourth as effective compared to parenteral - maximum daily dose of 600 mg reached or exceeded quickly with subsequent normeperidine build-up Meperidine is painful when administered by injection. Dilute when given IV
- Pain Management Methadone Appears to act as an antagonist in the N-methyl-D-aspartate (NMDA) receptor, in addition to opioid receptor binding Useful in neuropathic pain syndromes Now used by some clinicians in situations where costs of first line opioids are prohibitive or if patient displays true allergy to morphine Less expensive than morphine or hydromorphone with lower abuse potential Perceived negative connotation as it is used in drug abuse detoxification treatments Extensively metabolized by liver with 85% bioavailability Lower parenteral/oral ration of 1:2 Long and variable half life (12-190 hours) Takes longer time to reach steady state and maximum analgesic effect Days or weeks of accumulation may occur during titration, especially if rapid. Titration changes may need to no sooner than 7 days This may lead to delayed onset of adverse effects Not recommended in patients who cannot be closely monitored or predisposed to opioid side effects: elderly, noncompliant patients, major organ failure Consider initial dosing on PRN basis to minimize accumulation associated with initial titration. The onset and half life of PRN dosing may be variable. Every 8 hour dosing may be better Use a second short acting opioid for breakthrough (morphine, hydromorphone) - decrease rescue dosing as patient reaches steady state of methadone Caution in equianalgesic conversion - methadone may be up to 10 times more potent than indicated on most equianalgesic charts. There are several different conversion tables Recommend beginning initial methadone dosing at 10-25% of equianalgesic dose Higher doses (>400mg/day) may lead to potential fatal arrhythmia related QT intervals
- Pain Management Oxycodone Available alone or in combination with acetaminophen (Percocet ® ) or aspirin (Percodan ® ) Used in acute, cancer and chronic nonmalignant pain Mild to severe intensity Previously in combination with acetaminophen or aspirin which limited maximum daily dose Now available as single entity in controlled release or short acting formulations Metabolized in liver - 50-80% bioavailability Active metabolite: oxymorphone Twice the amount is needed orally than intramuscularly Oral preparations can be administered rectally with bioavailability of 45-60% Variations in pharmacodynamics lead to individualization of dosing Propoxyphene Used in combination with acetaminophen (Darvocet ) or aspirin (Darvon Compound ) Considered a weak analgesic, widely prescribed for mild to moderate pain Not recommended for chronic pain, cancer pain, end-of-life care Same side effects as codeine at equianalgesic doses Active metabolite: norpropoxphene that can accumulate with in kidneys causing tremors and seizures Because of potential for norpropoxphene accumulation recommended use for short term mild, intermittent pain Not recommended in elderly (renal insufficiency) as propoxyphene and norpropoxphene eliminated by kidneys In combination with diazepam (Valium ), can increase adverse effects such as respiratory depression, sedation, cognitive impairment leading to increase risk for falls and subsequent complications More costly than codeine
- Mixed Agonist-antagonists 7 Indications Limited to parenteral (exceptions: oral pentazocine (Talwin ), butorphanol (Stadol ) nasal spray. May be given PRN for intermittent pain or ATC for ongoing pain Pure agonists considered better choices for all types of pain compared to agonist-antagonist analgesics Ceiling effects exists on analgesia and respiratory depressant effects. Limited by ceiling effect to analgesia: an increase in dose will not produce an increase in analgesia when ceiling reached - inappropriate for severe escalating pain. Does have a ceiling effect on respiratory depression; however, at equianalgesic doses, all opioids can produce respiratory depression Increase dose by 25-50% if previous dose safe but ineffective until pain relieved, ceiling effect reached or side effects unmanageable or unacceptable May be appropriate for acute moderate to severe nociceptive pain (visceral or somatic); however, never recommended as first line analgesic for any type of pain Do not use in patients receiving pure agonists - may cause reduction in analgesia from pure agonists or withdrawal-like symptoms may be precipitated in patients who are physically dependent on pure agonists (after several days of treatment) Create a high rate of psychotomimetic effects - disorientation/hallucinations
- Pain Management Butorphanol (Stadol ) Parenteral used for labor and postpartum pain, pre-anesthesia sedative and analgesic, anesthetic supplement. Should not be used in patients taking ATC opioid Butorphanol (Stadol ) nasal spray may be appropriate for outpatient treatment of moderate to severe acute migraine pain or some types of postoperative pain Adverse effects Headache, vertigo, lethargy, a floating feeling, confusion, light-headedness, sedation, psychiatric effects: hallucinations, unusual dreams, depersonalization. Respiratory depression equal to pure agonists (doses of 30 to 60 g/kg). Multiple adverse cardiac effects (increased pulmonary arterial pressure and cardiac workload) - not recommended for treatment of myocardial infarction or patients with hypertension Buprenorphine (Buprenex ) 7,18 Only partial agonist opioid available. Not available in oral formulation due to significant first pass effect. Does not produce adverse cardiac side effects - may be appropriate analgesia if myocardial infarction suspected Adverse effects Sedation, nausea, vomiting, dizziness, sweating, headache are most common. Respiratory depression usually not a problem Difficult to reverse side effects, including respiratory depression with naloxone (Narcan ) (may need high doses of up to 10-12 mg)
- Nalbuphine (Nubain ) Available in parenteral route only. Frequently used for managing labor pains Adverse effects Does not produce adverse cardiac effects - useful in pain associated with suspected myocardial infarction Produces same degree of respiratory depression at equianalgesic doses Pentazocine (Talwin ) Considered of little value in pain management, Should not be considered for end-of-life care Recognized as medication with abuse potential, Can be given orally, but parenteral dosing not recommended Adverse effects Sedation, sweating, nausea, dizziness Respiratory depression occurs at high doses: reversible with naloxone (Narcan ) Psychiatric effects: dysphoria, anxiety, nightmares, hallucinations, depersonalization Do not stop abruptly after prolonged use: severe withdrawal symptoms may occur
- Pain Management Routes and dosing 7,10 General dosing Multiple routes available for pure agonists Most available orally and parenterally Some used for intrathecal, epidural or subcutaneous administration Intrathecal and epidural routes require preservative free preparations Controlled release formulations and transdermal May be given PRN for occasional pain or ATC for ongoing or chronic pain If current dose safe but ineffective, increase by 25-50% until pain relief occurs or unmanageable side effects present No ceiling effect for pure agonists; however, some pure agonists (propoxyphene and meperidine) have active metabolite that can accumulate at higher doses All opioids have side effects that eventually limit dose escalation If dose effectively relieves pain, but causes unacceptable or unmanageable side effects, consider lower dose by 25%, adding another type of analgesic (acetaminophen, NSAID), or switching opioid
- Pain Management Routes and dosing 7,10 Route - administer medications by least invasive and safest route capable of producing adequate analgesic Oral (PO)/ Sublingual (SL) route Usually preferred for chronic treatment due to convenience, flexibility, relatively steady blood levels Consider liquid formulations if difficulty swallowing tablets Peak effects for most opioids occurs 1 ½ to 2 hours after administration (sustained release exception) Patients may take second dose 2 hours after first if side effects mild at that time This may be drawback in rapidly escalating pain or pain crisis Sublingual route (considered oral) may be used with a specially prepared concentrated form Intramuscular (IM) route Least recommended. Considered painful with wide fluctuations in absorption from muscle 30-60 minute lag to peak effect; rapid fall off of action Starting dose depends on opioid used - see equianalgesic chart for starting dose recommendations Absorption may be quicker through deltoid muscle vs. gluteal injection, especially in lipid soluble opioids such as methadone Repeated administration via IM route is not recommended: consider IV or SC route In chronic pain, repeated IM administration may cause sterile abscess or muscle fibrosis Subcutaneous (SC) route Viable option for cancer patients who are unable to swallow and who do not have central venous access Not used in acute pain situations - slow onset Hydromorphone and morphine most common opioid analgesics used in continuous SC infusion Absorption and distribution vary depending on placement of needle and adipose tissue - can be used in patients with cachexia Conversion from oral morphine to SC is 3:1 (same for conversion from oral to IV) Not the preferred route due to limitations of painful injections, time consuming, sterile technique, equipment use by caregivers, costs Limited volume of infusion to prevent irritation, pain, necrosis, and sloughing at site Most patients can tolerate 2-3 ml per hour; some up to 5 ml per hour - may need to use more than one site if large volume required Rescue doses provided via SC PCA
- Pain Management Intravenous (IV) route Bolus provides most rapid onset of effect Peak times vary among opioids Starting doses may be one-half the oral route Starting doses vary among medications - use equianalgesic chart for initial dose; consider using ½ recommended Duration of action shorter so bolus availability necessary followed by establishment of maintenance infusion in acute pain or chronic exacerbations In acute pain or chronic exacerbations, may need to titrate with repeated bolus administration to establish baseline (or basal) rate for continuous infusion For opioid naïve patient consider IV morphine at 0.03 mg/kg, or equianalgesic dose of similar opioid, every 10 minutes until 50% reduction of pain or acceptable pain rating reported by patient Opioids with long elimination half-lives not recommended (methadone, levorphanol) as blood level may remain too high for many hours infusions provide steadier blood levels Continuous infusions provide steadier blood levels Goal: most effective analgesia with fewest side effects Estimate hourly maintenance dose = loading dose elimination half life (hours) X 2 Monitor closely first few hours as elimination half lives in individuals may vary Include provision for bolus every 15 minutes to every 30 minutes Bolus set at same dose as hourly rate Adjust continuous rate based on frequency of bolus administration Monitor vital signs continuously during titration SC infusion will produce equivalent blood levels at same dose as IV, but SC bolus have slower onset and offset and low peak effect than IV bolus
- Pain Management Transdermal Fentanyl (Duragesic ) available in patch in which medication is delivered continuously through skin Skin under patch absorbs fentanyl and depots of the drug concentrate in the upper skin layers, fat and skeletal muscles - gradually released into systemic circulation May produce less constipation than sustained-release oral opioid formulations as it may bypass the opioid receptors of the GI tract 72 hour dosing interval Recommended for chronic cancer pain. Not recommended for acute postoperative pain or procedural pain due to potential for accumulation after pain stimulus decreases leading to increased risk for respiratory depression There is a lag in absorbing fentanyl through the skin May take 12-16 hours to see effects and 48 hours to achieve steady state blood concentrations Therefore, recommended that patients titrated to relief using short-acting opioids and then switched to transdermal fentanyl based on equianalgesic conversion Use short acting opioid for breakthrough (see breakthrough dosing) Increase transdermal dose based on daily total of rescue opioid needed Caution patients that increased heat to patch or skin area may increase release of medication Best results when applied to skin without hair and adequate subcutaneous tissue
- Pain Management Rectal Route Suppositories available in United States for hydromorphone, oxymorphone, and morphine Alternative to patients who cannot swallow Onset of action may be within 10 minutes May need to consider decreasing starting dose by 25% of oral dosing due to excessive drowsiness Controlled released morphine given rectally or vaginally produces analgesia comparable to oral morphine when administered on a 12 hour schedule - do not crush or dissolve controlled-release formulations Disadvantages: individual or family/caregiver reluctance to administer rectal medications Not recommended for escalating pain or pain crises Stomal Ostomy administration is not equivalent to rectal administration Colostomies generally created in area of colon and are drained by vessels that go directly to portal vein - this subjects medications to direct hepatic metabolism Starting dose should be considered same as oral or rectal route Sigmoid colostomies (left-sided) produce formed stool and more likely to be effective alternative route for administering opioids Ensure that stomal mucosa is well hydrated - if dry, instill 10 ml warm water with syringe attached to catheter Insert drug a fingers depth into stoma and insert colostomy plug - leave in place until bowel function occurs or time for next dose Instruct patient to recline for 15-30 minutes to prevent expulsion Ostomies of jejunum, ileum, ascending, transverse, and high descending colon produce wet, liquid or semisolid effluent may push out medication before it can be absorbed
- Pain Management Intraspinal (epidural and intrathecal) 10 Used for postoperative pain and cancer pain primarily Opioid binds to receptors of spinal cord at level of injection Morphine and fentanyl most commonly used, but have different update and redistribution after spinal injection Morphine is poorly able to diffuse into capillaries - remains in cerebral spinal fluid for extended period and therefore longer analgesia Morphine spreads toward the cephalic end of the body into the cerebrospinal fluid up to the level of brainstem, may cause respiratory depression or sedation Fentanyl is more fat soluble - absorbed systemically with reduced duration of action and risk of central nervous system depression Respiratory depression is rare - avoid with close hourly monitoring of sedation and respiratory rate for first 24 hours Recommended that intraspinal analgesia be managed by skilled team members familiar with risks Monitoring supported by appropriate education and establishing protocols Dose related side effects: nausea, itching, urinary retention Intraspinal analgesia may be given in single dose, intermittent by scheduled bolus, patient controlled epidural, continuous opioid infusion alone, or continuous opioid infusion with local anesthetic Continuous infusion require indwelling or intrathecal catheter Continuous infusion used primarily where pain expected to outlast duration of single dose Long term intraspinal use suggested for cancer patients with regionalized pain below T1 who have failed with other systemic approaches Intraspinal may be alternative when side effects outweigh advantages of other systemic approaches Less effective route if intraspinal introduced after pain refractory to systemic approaches, may need to add titrated doses of epidural local anesthetic in these cases Infection of skin and subcutaneous tissue around the catheter exit site when the catheter is exposed
- Pain Management Patient Controlled Analgesia (PCA) 7,10 Small doses provided on demand using special microprocessing-controlled infusion pump via intravenous, subcutaneous or intraspinal routes Predetermined dose of opioid delivered based on time intervals, or lock out, since previous dose infused Primarily used in acute pain situations Adjusts to individual response to opioids and allows greater control over pain experience Can be used in any situation in which oral route use is not possible Maximum dosage is fixed at upper limit based on total dose/time Maximum cumulative dose usually based on 1 hour or 4 hour interval Doses, lockouts, and limits adjusted based on required loading dose, age, state of health, and presence of opioid tolerance Can be set based on demand dosing, or continuous dosing with demand dosing for breakthrough pain When using PCA, must ensure use of adequate loading dose based on equianalgesic charting recommendations If using continuous infusion, hourly limit of PCA should then be set to 3-5 times the projected hourly requirement to allow for possibility of redistribution of loading dose early in treatment Consider decreasing continuous infusion dose after 24 hours of therapy, if necessary Drug of choice is based on the patient, comfort of practitioner and one that provides appropriate pain relief with fewest side effects Increased risk of sedation and respiratory depression associated with continuous infusion with PCA Continuous infusion with PCA may therefore not be recommended in acute pain situations Continued infusion with PCA may be useful in treating patients with chronic cancer pain; however, oral route is preferred in chronic nonmalignant and cancer pain and should be used whenever possible
- Pain Management - Side Effects of Opioids - McCaffery & Pasero guidelines 7 Constipation Most common side effect of opioids, Tolerance to this side effect does NOT occur Opioids delay gastric emptying, slow bowel motility, decrease peristalsis May also reduce secretions from mucosa of colon, Results in slow moving hard stool All patients receiving ATC opioids must be placed on bowel protocol Diet and exercise continue to be important, if tolerated, but are not sufficient alone Bulk laxatives, natural roughage, and fluids are often not tolerated and not effective in prevention of opioid-induced constipation, and can cause fecal impaction or obstruction if fluid intake insufficient Management - Start all patients receiving opioids ATC on docusate Sodium/Cassanthranol (Peri-Colace ) 100 mg 1 PO BID (hold if loose stools) If no BM in 48 hour period, add one of following MOM 30-60 cc PO Daily Senna 187 mg 2 tabs at bedtime Bisacodyl (Dulcolax ) 5 mg PO Lactulose 15 to 60 ml Daily or BID If no BM in 72 hours, perform rectal exam for impaction If not impacted after 72 hours, try one of following Bisacodyl (Dulcolax ) suppository 1 per rectum daily Magnesium citrate 8 oz PO Senna Extract 2.5 oz PO Mineral oil 30 to 60 ml PO Milk of Magnesium 25 ml + cascara 5 ml suspension Fleet enema If impacted Consider pre-medication with rescue dose analgesia or antianxiety medication Manual disimpaction if stool soft If stool hard, insert glycerin suppository or mineral oil enema first to soften stool before manual disimpaction Administer enema (tap water) until clear after disimpacting Increase daily bowel regimen
- Pain Management - Side Effects of Opioids - McCaffery & Pasero guidelines 7 Nausea and Vomiting In opioid therapy, may be due to stimulation of chemoreceptor trigger zone in brain, slowing of GI motility, effects on balance and equilibrium of inner ear Most often associated with initial dosing of opioids - subsides within days to weeks Antiemetic should be available on PRN basis, but may need to treat patients routinely if on ATC dosing of opioids Management Titrate opioids slow and steady for prevention Explore cause of nausea Chemoreceptor trigger zone stimulation Ondansetron (Zofran ), Prochlorperazine (Compazine ), Thiethylperazine (Torecan ), Haloperidol (Haldol ) Slowed GI motility Metoclopramide (Reglan ) Inner ear stimulation DimenhyDRINATE (Dramamine ) Scopolamine patch (may cause confusion) - remove after 72 hours Chronic nausea in advanced cancer Metoclopramide (Reglan ) 10 mg every 4 hour SC or PO If nausea persists, add dexamethasone 10 mg BID, If nausea persists, add another antiemetic Other: switch opioids, consider intraspinal route, relaxation techniques
- Pain Management - Side Effects of Opioids - McCaffery & Pasero guidelines 7 Sedation Usually experienced when opioids started or dose increased Patient may actually be exhausted from lack of sleep due to pain The patient may be sleeping now due to good pain control Tolerance will occur over period of days to weeks Monitor for safety during periods of sedation (i.e., driving) Patients on short term opioids may experience sedation which interferes with therapies and increases risk of respiratory depression Monitor sedation (consider using sedation scale) every 1-2 hours for first 12-24 hours postoperatively Management Determine if sedation is due to starting of opioids or increase in dose Consider reducing opioids by 10-25%, then add non-opioid or adjuvant to maintain acceptable analgesia Consider providing lower dose of opioids more frequently (decreases peak concentration) Consider simple stimulants such as caffeine Consider adding psychostimulant methylphenidate (Ritalin ) or pemoline (Cylert ) if adjustment of opioids not recommended If sedation persists, consider switching opioids, intraspinal route Pruritus Can occur with any associated histamine release & commonly with morphine May be generalized, but usually localized to face, neck, chest Usually not accompanied by rash Management Consider reducing opioids by 25% if analgesia satisfactory then add non-opioid or adjuvant to maintain analgesia DiphenhydrAMINE (Benadryl ) 12.5-25mg IV or 25-50 mg PO (may be sedating) for symptom relief. Caution use in geriatric population
- Pain Management - Side Effects of Opioids - McCaffery & Pasero guidelines 7 Mental status changes Cause of increased anxiety and fear for patients, families, caregivers The patient may refer to being ‘mentally hazy’ or ‘not as sharp as before’ May occur when opioids initiated or increased Will usually resolve within days to weeks Assess to ensure that opioid is cause of mental status change and not an other medical reason such as sepsis, hypoxia, electrolyte imbalance Management Assess for underlying cause Eliminate nonessential CNS acting medications (e.g., steroids) Consider reducing opioid by 25% and adding non-opioid or adjuvant analgesic to maintain pain control Consider trial of haloperidol (Haldol ) (0.5-1 mg PO BID or TID or 0.25-0.5 IV or IM) if delirium persists Switch opioids or consider intraspinal route
- Pain Management - Side Effects of Opioids - McCaffery & Pasero guidelines 7 Respiratory depression Considered clinically significant when there is a decrease in rate and depth of respirations from baseline Do not use specific numbers of respirations per minute as only assessment in respiratory depression - assess for level of responsiveness and pinpoint pupils also Tolerance develops over period of days to weeks Longer patient on opioid, less likely to develop Most at risk in first 24-48 hours after initiation of opioid, particularly epidural route At risk populations: infants less than 6-mths-old, elderly, opioid naïve, coexisting chronic lung diseases/ organ failure Pain considered respiratory stimulant - monitor patient with previous long period of poor pain management now well controlled More opioid required to induce respiratory depression than sedation Prevention by appropriate titration, monitoring of sedation levels Monitor sedation levels respiratory status, every 1-2 hours for first 24 hours in opioid naïve Decrease opioid dose by 25% when excessive sedation assessed; add non-opioid or adjuvant analgesic for pain control Stop opioid / consider naloxone (Narcan ) administration if patient minimally responsive or non-responsive to stimulus Naloxone (Narcan ) administration if in agreement with patient’s goals Meet three criteria: patient unresponsive to physical stimulation, shallow respirations or respiratory rate of less than 8 per minute and pinpoint pupils Stop opioid and other sedating medications Seek assistance Mix 0.4 mg (1 ampule) of naloxone & 10 ml of normal saline for IV administration Administer 0.5 ml over 2 minutes while monitoring patient response (titration to responsiveness) Should see patient response (eyes open and talking) within 1 to 2 minutes. If not, continue naloxone (Narcan ) titration at same rate up to 0.8 mg (2 ampules) in 20 ml of normal saline If no response, assess for other causes of sedation or decreased respiratory rate Discontinue naloxone (Narcan ) administration when patient can take deep breaths on command Keep naloxone (Narcan ) dose available as may need to repeat in 30-60 minutes as duration of action is less than most opioids Monitor respirations & sedation (encourage frequent deep breathing) until patient more alert Notify MD and document Consider non-opioid for pain relief Resume opioid at 50% original dose when respirations greater than 9 per minute and patient easily aroused
- Pain Management - Teaching points Discuss harmful effect of unrelieved pain - interrupted sleep, slower healing, impaired mobility Review and reinforce patient’s stated pain goal and use of opioids to achieve Administration If taking medications around the clock, reinforce need to take medications on scheduled basis as determined by patient and family If ordered, more than one pain medication can be taken at the same time Instruct not to dissolve or crush controlled release medications Record time and amount of all breakthrough medication taken Side effects Review side effects and management: bowel protocol for constipation, antiemetics for nausea and vomiting Instruct on tolerance of certain side effects: sedation in 48-72 hours Call healthcare provider if confusion occurs Provide written materials on each analgesic or medication used for management of side effects Fear of addiction Greatest most significant barrier for patient/ family in taking opioid Explore concerns about addiction and provide reassuring answers to concerns Advise patient not to “hold out” as long as possible due to misguided fears of addiction Provide written information that reinforces and explains aspects of opioid administration Brand name, i.e., MS Contin Type of pain medication (time released opioid or narcotic) Description (tablets) Uses (pain relief) Dosage and administration, i.e., every 12 hours by mouth Possible side effects (constipation) Precautions (driving) Stopping medication (do not stop abruptly - call healthcare provider) When to call physician, i.e., pain not relieved Patient/Family Teaching Sheet - Managing Pain
- Pain Management Equianalgesia 7 Means equal analgesia Refers to doses of various opioid analgesics that provide approximately the same pain relief Use equianalgesic charts available - numerous examples and all are considered estimates Titration is optimal way to achieve patient comfort Make sure same chart is consistently used throughout facility Provides list of analgesic doses (oral and parenteral) that are approximately equal to each other in ability to provide pain relief Most use Morphine 10 mg as basis for comparison Dosing based on 4 hour dosing schedule as basis Starting Doses √ Refer to Opioid Equianalgesic conversion process detailed in the Core Curriculum for the Generalist Hospice and Palliative Nurse
- Pain Management Example of an equianalgesic chart Equianalgesic chart provides a basis for selecting the appropriate starting dose when converting an opioid based on severe pain intensity Locate the prescribed opioid in column one of the chart , i.e., morphine Select the column with the appropriate route (column two for parenteral; column three for oral) This is the appropriate starting dose for opioid naïve patient If patient reports severe pain, use 100% of initial dose, i.e., morphine 10 mg IV every 4 hours or morphine 30 mg PO every 4 hours If patient reports moderate pain, use 50% of initial dose, i.e., morphine 5 mg IV every 4 hours or morphine 15 mg PO every 4 hours If patient reports mild pain, use 25% of initial dose, i.e., morphine 2.5 mg IV every 4 hours or morphine 7.5 mg PO every 4 hours Initial dosing may need to be decreased by 25% to 50% in elderly patients, based on physical assessment and previous history with opioid treatment
- Pain Management Titration of opioids 7,9,10 Titration refers to adjusting (usually upward) the amount or dose of an opioid and is based on the following Patient goals Need for supplemental or breakthrough doses Pain intensity Severity of adverse side effects Functional capacity of patient Sleep Emotional state Patient/caregiver reports of impact of pain on quality of life Dose increases typically made at the onset or peak effect of analgesic For IV, titration may occur as often as every 5 minutes For adjuvant therapies, such as tricyclics, may occur every 4-5 days Goal: provide smallest dose that provides greatest relief with fewest side effects Pure agonist do not have a ceiling and therefore can be safely titrated up based on patient response - focus on pain relief not milligrams Usually titrated in increments of 25-100% If pain is moderate increase dose by 25-50% If previous opioid dose is safe but pain remains severe, increase pure agonist by 50-100%
- Pain Management Methods of titration 7,9,10 Establish pain relief based on initial dosing If initial dosing effective, monitor amounts of immediate-release opioid taken in 24 hour period - add total of scheduled doses and immediate - release over 24 hour period Convert total 24 hour dosing to ATC dosing If initial dosing not effective, increase dose by 50% and monitor effectiveness Establish and provide breakthrough dosing Provide appropriate immediate-release opioid analgesic based on assessment, particularly patient report of intensity
- Pain Management Methods of titration Determine and provide breakthrough dosing 7,9 Also referred to as rescue dosing or supplemental dosing Refers pain that increases above the pain addressed by the ongoing analgesics Seen especially in chronic pain situations Occurs in 2/3 of patients receiving opioids for chronic malignant pain Assessing for breakthrough - no tool developed - rely on patient’s report of pain Patient and family should record frequency (numbers of occurrences in 24 hours) of breakthrough: include rating, patient activities and analgesic administration Episodes vary in duration (minutes to hours), occurrence (once, or many times per day), and onset (slow or sudden) Determine and provide breakthrough dosing 7,9 Three types of breakthrough pain Incident pain - usually predictable and elicited by specific activities Usually handled with quick acting analgesic of short duration 30-60 minutes before engaging in pain-eliciting activities Adjust and titrate breakthrough pain medication based on severity of anticipated breakthrough pain - based on past experience Spontaneous pain occurs unpredictably without warning nor as a result of an identifiable cause or activity Adjuvant medication in combination with ATC opioid may help diminish frequency and severity Use immediate release opioid analgesic as indicated End-of-dose failure - pain that returns toward the end of the dosing interval in a patient receiving around the clock analgesics, i.e., ATC opioid given every 12 hours, but patient experiences pain in 10 hours Eliminated by increasing the dose of analgesic (by 25-50%, if tolerated) or shortening the interval between doses, i.e., from every 12 hours to every 8 hours
- Pain Management Calculating Rescue Dosing 7,12,15 When possible, use same medication and route as around-the-clock (use immediate release morphine if using long acting morphine) Rescue dosing is usually calculated as a range from one tenth (1/10) to one sixth (1/6) of the total daily dose Also estimated at 10-15% of total 24 hour dose Breakthrough dosing must be adjusted according to above calculation when ATC dosing increases Provide rescue dosing on every 1-2 hours basis May be taken at same time as ATC dose Increase ATC dose if patient receives more than 3 rescue doses in 24 hour period
- Pain Management Examples of calculating rescue dosing Immediate release and controlled-release morphine or oxycodone Around the clock dose, in 24 hour period: 180 mg/24 hour 180 10 (1/10 or 10%) = 18 mg 180 6 (1/6 or 15%) = 30 mg Equals immediate release dose to be given every 3 hours as needed, 18 mg to 30 mg PO every 3 hours as needed
- Pain Management - Example oral transmucosal fentanyl citrate (OTFC) (Actiq ) Composed of fentanyl on an applicator to rub against oral mucosa for fast absorption Usually effective after 5 minutes, should be used over 15 minute period of time so is absorbed through oral mucosa and not swallowed Dispose of unused portion by running under hot water or insert in child-resistant temporary storage bottle provided when drug first dispensed Do not use breakthrough calculations for OTFC (Actiq ) based on 24 hour ATC dosing When using OTFC (Actiq ) for breakthrough pain, manufacturer recommends starting new patients with 200 g unit of OTFC (Actiq ) and finish it within 15 minutes If no relief, wait 15 minutes then finish a second 200 g unit over a 15 minute period If no relief, wait 15 minutes and finish a third 200 g unit over a 15 minute period (maximum of three 200 g units or 600 gs) For next episode, start with the total dose needed when starting OTFC (Actiq ) (example: patient received acceptable pain control with two units of 200 gs OTFC (Actiq ). Next breakthrough episode would start with 400 gs over 15-minute period If insufficient pain control, use same titration process, continue using 400 gs: wait 15 minutes, then use another 400 gs unit over 15 minutes If insufficient pain control, repeat same process up to 1600 gs totalImmediate release morphine usually recommended if controlled-release medication does not have an immediate release formulation Must convert opioid to morphine using equianalgesic chart or manufacturer recommendation 200 g transdermal fentanyl = 400 mg morphine (total fentanyl gs x 2 for morphine equivalent) 400 10 (1/10 or 10%) = 40 mg 400 6 (1/6 or 15%) = 70 mg Immediate release rescue dose = 40-70 mg PO every 1-2 hour PRN
- Pain Management Rescue dosing for parenteral opioid infusions Recommended rescue dose for patients receiving continuous parenteral or epidural opioid infusion is 25-50% of hourly opioid dose Should be offered every 30 minutes if not using Patient Controlled Analgesia (PCA) Ordinarily, total amount of parenteral rescue doses given in 1 hour may be equal to but usually do not exceed the hourly opioid dose If rescue dose need exceeds the hourly dose, need to increase hourly dose
- Pain Management Adjuvants 7 Characteristics Non pain medications with specific indications that have analgesic effects on certain types of pain No one mechanism of action identified for this group of analgesics Different classes of medications with variety of mechanisms of action Initially used in chronic neuropathic pain, now has applications for other pain situations Fewer patients respond adequately to adjuvants than to opioids Will produce analgesia to both neuropathic and nociceptive pain May be used as additional therapy to opioid therapy or as distinct primary therapy in certain painful disorders However, in palliative care usually administered with opioid to enhance pain relief, treat pain that is refractory or allow reduction of opioid to limit side effects General Indications Tricyclic antidepressants used primarily in continuous chronic neuropathic pain Not indicated for acute pain situations due to delayed analgesia (low dosing, slow titration, several days for accumulation) SSRI antidepressants not indicated as first line antidepressant in neuropathic pain management Corticosteroids primarily used for variety of cancer-related pain conditions (metastatic bone pain or neuropathic pain associated with tumor compression) Psychostimulants relieve a variety of types of pain (cancer-related to headache). May also be used to reduce sedation and increase pain relief Anticonvulsants are first line treatment options for chronic lancinating pain
- Pain Management Adjuvants 7 Choice of drug Depends on type of pain, patient age and other medical conditions Individual response will vary to each medication If one adjuvant in a drug group is not effective or causes unmanageable side effects, consider another in same group (sequential trials)
- Pain Management - Adjuvants Tricyclic antidepressants Mechanism of action: not certain, but thought to block the reuptake of neurotransmitters, for pain, such as serotonin and norepinephrine in the central nervous system increases activity in the endogenous pain-modulating pathways 9 Side effects limit usefulness, anticholinergic effects including grogginess, dry mouth, constipation and significant postural hypotension In co-administration with opioids, interaction may result in higher opioid concentrations Analgesia usually occurs within 1 week May be effective for both lancinating & continuous neuropathic pain Second line agents for paroxysmal (sudden onset) pain Indications Multipurpose analgesic considered for any type of chronic pain syndrome Not indicated for acute pain In palliative care, strongest indication in neuropathic pain not responding to opioids Usually more effective in neuropathic pain characterized as burning or lancinating In terminal care, patients may benefit from non-analgesic effects: treatment for sedation and insomnia √ See Appendix B, Dosing Information
- Pain Management - Adjuvants Tricyclic antidepressants Choice of drug 7,16,18 Historically, amitriptyline (Elavil ) recommended as first choice due to extensive clinical trials; however, desipramine (Norpramin ) has fewer side effects with excellent analgesia Failure of one drug should be followed by trial of another (sequential trials) No clear protocol for drug selection - trial and error Amitriptyline (Elavil ) Uses: migraines and other headaches, arthritis, chronic low back pain, fibromyalgia, painful diabetic polyneuropathy, chronic facial pain, cancer pain Imipramine (Tofranil ) Uses: arthritis, headache, painful diabetic polyneuropathy, low back pain, idiopathic chest pain Doxepin (Sinequan ) Uses: co-existent pain and depression, headache, low back pain Clomipramine (Anafranil ) Uses: varied neuropathic pains and idiopathic pain Desipramine (Norpramin ) Uses: post-herpetic neuralgia and painful diabetic neuropathy Nortriptyline (Aventyl , Pamelor ) Uses: mixed neuropathic pains Less anticholinergic side effects, should be taken at bedtime because of sedation
- Pain Management - Adjuvants Tricyclic Antidepressant dosing overview Start low: elderly 10 mg; younger 25 mg, increase by same amount as starting dose Evaluate and increase every 3-5 days Usual effective dose for amitriptyline (Elavil ) and desipramine (Norpramin ) is 50 -150 mg - some patients will benefit at doses lower or higher than this range Dose for analgesia usually not higher than or even as much as dosing for depression Titrate up to antidepressant dose if tolerated - especially if depression present Usual single dosing at nighttime Divide dose (early morning & late evening) if patient complains of “hangover” or double vision in morning or complains of increased pain in afternoon Monitor during titration: changes in pain, mood, cognitive status, sleep pattern, and other side effects Consider monitoring plasma levels Usually see effective analgesia within a week of effective dosing In some, maximal effect may be over days or weeks thereafter Due to delay in analgesia, days needed in titration to reach effect: and side effects place many patients at risk for discontinuing tricyclics Side effects Orthostatic hypotension More likely in elderly Nortriptyline (Pamelor ) less like to cause this side effect Sedation and mental clouding More likely in elderly Desipramine (Norpramin ) least likely to cause somnolence or confusion Anticholinergic effects of tricyclic antidepressants: dry mouth, blurred vision, constipation Cardiotoxicity: most severe side effect, but most uncommon; at risk are patients with significant heart disease including dysrhythmias or failure - increased risk for falls and subsequent complications
- Pain Management - Adjuvants Selective Serotonin Reuptake Inhibitors (SSRIs) Antidepressants Duloxetine (Cymbalta ) and Venlafaxine (Effexor ) have found to block pain neurotransmitters as well as improve mood Expensive, no generic available Particularly effective in the older patient for pain and depression Paroxetine (Paxil ) demonstrated effectiveness for analgesia in diabetic neuropathy Fluoxetine (Prozac ) demonstrated significant analgesic properties with fewer side effects than amitriptyline Other SSRIs have not been studied extensively for their analgesic effects, but due to low side effect profile clinical interest is strong Consider SSRI as alternative if side effects to tricyclic antidepressants intolerable, i.e., orthostatic hypertension SSRIs less likely to cause mental clouding, confusion or somnolence Sexual dysfunction is most reported troubling side effect for SSRI antidepressants Drug holiday over weekend (omission of doses after Thursday morning until Sunday noon) demonstrated marked satisfaction in sexual functioning in patients taking sertraline (Zoloft ) and paroxetine (Paxil ) Depression did not relapse
- Pain Management - Adjuvants Anticonvulsants 7 Indications First line drugs for chronic lancinating neuropathic pain: sharp, shooting, stabbing, burning May be useful in other types of neuropathic pain Variability among drugs is great - sequential trials often required Gabapentin (Neurontin ) has low side effect profile and excellent anecdotal results in the treatment of neuropathic pain - now considered to be anticonvulsant of first choice for neuropathic pain Pregabalin (Lyrica ) approved for pain relief by FDA. Effective for pain from neuropathic pain and for partial seizures when taken together with other seizure medicines. May be at higher chance for dizziness and sleepiness if taken with any narcotic pain medicine (such as oxycodone), tranquilizers or medicines for anxiety (such as lorazepam) Mechanism of Action - not comprehensively known Analgesia is presumed to be similar to mechanisms that inhibit seizure activity Suppression of paroxysmal discharges and their spread from site of origin and reduction of neuronal hyperexcitability Reducing the conduction of pain signals along damaged peripheral nerves Anticonvulsants can cause unclear thinking, forgetfulness, and other CNS side effects Start low dose and titrate up slowly √ See Appendix B, D osing Information
- Pain Management - Adjuvants Anticonvulsants 7 - Medication Overview Gabapentin (Neurontin ® ) Considered first line drug of choice for all types of neuropathic pain due to effectiveness of analgesic action and low side effect profile Reflex sympathetic dystrophy HIV-related neuropathy Post-herpetic neuralgia Adverse effects Most common: sedation, dizziness, nausea or GI upset Usually decrease with continued use Occasional reports of mood changes (dysphoria) or cognitive impairment Low side effect profile indicates advantageous use in elderly Few drug interactions noted Start with low dose and gradually increase Withdraw should be gradual Carbamazepine (Tegretol ) Effective in lancinating neuropathic pain, i.e., trigeminal neuralgia, post-herpetic neuralgia, diabetic neuropathies, glossopharyngeal neuralgia, paroxysmal pain in multiple sclerosis, stabbing pains after laminectomy, lancinating pains from cancer, phantom limb pain Adverse effects Sedation, dizziness, nausea, unsteadiness Minimize by starting low and titrating up gradually Leukopenia or thrombocytopenia in 2% of patients; aplastic anemia rarely Obtain baseline CBC before initial therapy, several weeks after, and then every 3-4 months; obtain baseline liver and renal panels as well Leukocyte count of less than 4000 is considered contraindication - Discontinue if leukocyte count drops below 3000 or absolute neutrophil count of less than 1500 Rare side effects: hepatic damage, hyponatremia caused by SIADH, congestive heart failure
- Pain Management - Adjuvants Anticonvulsants 7 - Medication Overview Phenytoin (Dilantin ) Effective in following types of lancinating neuropathic pain; Painful diabetic neuropathies, Trigeminal neuralgia, Glossopharyngeal neuralgia, Paroxysmal pain in post-herpetic neuralgia IV dose used for rapidly escalating neuropathic pain Adverse effects Dose dependent and occur at plasma levels beyond therapeutic for treatment of seizures, Sedation or mental clouding, Dizziness, Unsteadiness, Diplopia, Toxic levels: ataxia, progressive encephalopathy, seizures Clonazepam (Klonopin ) Effective in following types of neuropathic pain; Trigeminal neuralgia, Paroxysmal post-laminectomy pain, Post-traumatic neuralgia, Lancinating phantom limb pain Adverse effects Most common: drowsiness - tolerance may occur within weeks after initiation, Occasional reports of ataxia at higher doses, Withdrawal syndrome may occur with abrupt discontinuation of relatively high doses Valproic acid (Depakene ) Effective in following types of neuropathic pain; Trigeminal neuralgia, Post-herpetic neuralgia Adverse effects Sedation, nausea, tremor, increased appetite, Start low and titrate slowly to decrease dose-dependent side effects, Interaction with ASA or antacids may cause valproic acid toxicity Baclofen (Lioresal ) Agonist at the GABA type B receptor site Primary use is for spasticity Non-anticonvulsant drug found effective for lancinating pain, shooting pain Useful for paroxysmal neuropathic pain Second line (after carbamazepine) for trigeminal neuralgia Adverse effects Dizziness, sedation, GI distress, Minimize by starting low and gradually titrate to effect, Do not discontinue abruptly - need to taper to avoid withdrawal syndrome including delirium
- Pain Management – Adjuvants Corticosteroids 7 Indications - Considered multipurpose adjuvant analgesic Epidural spinal cord compression, Increased intracranial pressure, Superior vena cava syndrome, Neuropathic pain caused by compression or infiltration of peripheral nerves or nerve plexus, Painful lymphedema, Cancer pain including bone pain, Arthralgia, Headache from increased intracranial pressure, Pain caused by obstruction (e.g., bowel or ureter), In co-administration with opioids to reduce opioid dose & associated side effects In palliative care, may also be used to improve appetite, nausea, malaise, and overall quality of life Mechanism of action - Mechanism of action of corticosteroids as analgesia is unknown. Possibly due to reduction of peri-tumoral edema in certain cancer sites or possibly by shrinkage of tumor masses themselves. Reduction of tissue concentration of some inflammatory mediators (prostaglandins and leukotrienes) may lessen activation of nociceptors. May temper aberrant electrical activity in damaged nerves Choice of drug - In United States dexamethasone (Decadron ) usually selected / Low mineralocorticoid effects (less fluid and electrolyte retention) / Prednisone and methylPREDNISolone also selected High dose and low dose regimens High dose: (dexamethasone 100 mg initially followed by 96 mg/day in divided doses) Acute episode of severe pain not immediately responsive to opioids Oncologic emergencies: superior vena cava syndrome, epidural spinal cord compression Reduce dose slowly over weeks in conjunction with other analgesic approaches (e.g., radiation) Low dose: dexamethasone 1-2 mg one or twice daily Often in co-administration with opioids with poor response – usually over long term Frequent assessment necessary to reach optimal analgesia with lowest potential for side effects Short term therapy Neuropsychologic effects usually seen in high doses early in treatment: delirium, mood changes (euphoria to depression), cognitive functioning, changes in perception, Hyperglycemia, Fluid retention, Gastrointestinal distress: dyspepsia, bowel perforation, Increase appetite Long term therapy Cushingoid appearance: moon face, buffalo hump, sSkin diseases, changes in subcutaneous/connective tissue Weight gain, Hypertension, Severe osteoporosis, Myopathy, Increased risk of infection, Hyperglycemia In palliative care, low dose therapy usually well-tolerated over long term Gastrointestinal toxicity greatly increased in co-administration with NSAIDS and is not recommended in either long term or short term therapy Withdrawal after long term therapy can cause syndrome of muscle/joint pain known as ‘pseudorheumatism’ During withdrawal, patient may also experience malaise, headache, mood disturbances or flare of symptoms for which steroid prescribed - taper slowly Decrease slowly to prevent adrenal insufficiency
- Pain Management - Adjuvants Local anesthetic agents 7 Indications Local action with minimal systemic side effects Considered second line analgesics due to limited information on long term safety and effectiveness Should be tried in burning pain when pain not responsive to antidepressants or not tolerated or for lancinating pain if anticonvulsant therapy not effective Efficacy of IV infusions is conflicting - may be useful in pain of post-herpetic neuralgia & diabetic neuropathy and possible neuropathic pain related to cancer Brief local anesthetic infusion may be useful in patients with crescendo pain - severe neuropathic pain not responding promptly to opioids and requiring immediate relief Oral formulation of flecainide (Tambocor ) may be effective in treatment of pain caused by tumor infiltration of nerves, trigeminal neuralgia, and diabetic neuropathy Used in three major ways Localized analgesia by injection into tissues, nerve blocks or intraspinal Localized analgesia by absorption of topical application Generalized analgesia by oral or parenteral route In palliative care, used for long term management of neuropathic pain refractory to opioids Mechanism of action Local anesthetic agents block sodium channels Impose a non-depolarizing conduction block of the action potential Produces profound conduction block in peripheral axons after instillation of these medications Systemic administration probably produce analgesic effects in neuropathic pain states through suppression of aberrant electrical activity or hypersensitivity in neural structures involved in causing pain Medications and dosing Low initial doses followed by titration - consider levels equal to treatment of cardiac dysrhythmias Can increase dose every three days as tolerated Mexiletine (Mexitil ) Tocainide (Tonocard ) Lidocaine 16 Appropriate for procedural pain or rapidly escalating neuropathic pain Topical patch 5%, approved by FDA, for post-herpetic neuralgic and clinical trials demonstrate effectiveness in other neuropathic pain syndromes. May be effect for osteoarthritis and myofascial back pain
- Pain Management – Adjuvants Local anesthetic agents 7 Adverse effects Central nervous system effects Usually occur at lower concentrations Dizziness, perioral numbness (numbness surrounding the mouth), abnormal sensations, tremor usually occur first At higher plasma concentrations encephalopathy and seizures may occur Toxic concentrations: cardiac conduction disturbances, myocardial depression Caution or avoid use with patients with preexisting heart disease such as cardiac dysrhythmias, those receiving antiarrhythmic drugs, cardiac insufficiency Mexiletine (Mexitil ) or tocainide (Tonocard ): nausea, dizziness, lightheadedness, tremors, palpitations, vomiting, paresthesias If topical route used, side effects include redness, edema, and abnormal sensation at the site of application
- Pain Management - Adjuvants Psychostimulants Multipurpose for acute or chronic pain Useful in nociceptive or neuropathic pain Often used to treat somnolence associated with opioid use particularly in palliative care Caffeine (PO) Used in combination products for relief of headache Dextroamphetamine: (Dexedrine ) (PO) Methylphenidate: (Ritalin ) (PO) Desired effects Adverse effects Insomnia, anorexia, tremulousness, anxiety, agitation, uncomfortable cognitive changes Toxicity: hallucinations, paranoid reactions
- Pain Management Teaching points on adjuvant medications Advise patient /family that frequent reassessment and ‘titration’ may be necessary It may take days to weeks for patient to feel pain relief using adjuvant treatments Keep taking the medication even if it does not provide immediate relief Review potential adverse effects of each medication. Note: this will not increase likelihood that adverse effects will occur Call health care provider regarding intolerable adverse effects Provide teaching on management of side effects for particular medication, such as drinking fluids or sucking on sugarless candies for dry mouth For each medication, provide a hand out with the following information Brand name Description (what the medicine looks like) Type of medicine: (antidepressant, anticonvulsant, etc) Uses (relief of pain) Dosage and administration (take as directed, with food, etc) Possible side effects (dry mouth, constipation, dizziness) Precautions (rise slowly from sitting position) Stopping medications (consult healthcare provider before stopping any medications; avoid sudden withdrawal) Review possible food and drug interactions for each medication prescribed Remind patient not to run out of medication and to call healthcare provider at least 3 days in advance if refill is needed
- Pain Management - Addiction Issues 7,10 Addiction : “a pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief” 10 Individuals become overwhelmingly involved with using or procuring the drug and may display drug seeking behaviors such as: missed office or clinic appointments with subsequent off-hour calls for prescription refills, theft or forgery of prescriptions, prescription-seeking from more than one physician, theft of drugs from family members or other patients, buying or selling drugs on the streets Other characteristics of addiction (DSM-IV, 1994) Substance taken in larger amounts over a longer period of time than intended Persistent desire or unsuccessful attempts to control substance use present Large amounts of time invested in procuring substance, using substance, or recovering from its effects Reduction or cessation of important social, occupational or recreational activities Substance use continues despite knowledge of associated physical or psychological problem Opioid use for pain control is therapeutically indicated use, not for psychic effects such as with addicted individual Research demonstrates that medical use of opioid medications rarely associated with addiction - less than 1%
- Pain Management - Pseudoaddiction Pseudoaddiction the patient who seeks additional medications appropriately or inappropriately secondary to significant under-treatment of the pain syndrome Individuals display behaviors that are indicative of uncontrolled pain Demanding behaviors: try to “manipulate” staff, clock watch, hoard analgesics, visit multiple physicians or clinics Behaviors often interpreted by clinicians as “drug seeking” or associated with substance abuse Demanding behaviors cease when pain is treated
- Pain Management – Tolerance Tolerance: a form of neuroadaptation to the effects of chronically administered opioids (or other medications) which is indicated by the need for increasing or more frequent doses of the medication to achieve the initial effects of the drug. Tolerance may occur to both the analgesic effects of opioids and to the unwanted side effects such as respiratory depression, sedation, or nausea. The occurrence of tolerance is variable, but it does not, in and of itself, imply addiction Describes change between dosage and response Continued exposure is primary cause of tolerance In opioid administration, occurs after several days or longer Often confused with increasing pathology of disease state Rule out disease progression when dosing increase needed First sign is usually decrease in analgesic effect Treat by increasing dose or decreasing interval Dose will stabilize as pathology stabilizes and pain is controlled; increases usually not necessary Clinicians should not fear tolerance in patients with extended life expectancy No ceiling on pure agonists analgesic group Tolerance to side effects varies among individuals Sedation, nausea, respiratory depression: days or weeks Tolerance to constipation never occurs - patients on long term Opioid use need bowel protocol Cross-tolerance: development of tolerance to effects of other drugs that act at the same receptor site (e.g., patient on morphine may be tolerant to other pure agonists) When switching opioids, assume that this cross-tolerance will be incomplete: start new opioid at 50% of equianalgesic dose of previous opioid Cross tolerance to side effects may not occur: (e.g., tolerance to nausea on morphine may have occurred, but be severe on new opioid)
- Pain Management - Physical Dependence Physical dependence: a physiologic state in which abrupt cessation of the opioid, or administration of an opioid antagonist, results in withdrawal syndrome. Physical dependency on opioids is an expected occurrence in all individuals in the presence of continuous use of opioids for therapeutic or for non-therapeutic purposes. It does not, in and of itself, imply addiction Usually seen in patients on long term, high dose opioid use, but not limited to that population Assume physical dependence in patients taking repeated opioid doses for 2-3 days Signs associated with opioid withdrawal: lacrimation, rhinorrhea, yawning, dilated pupils, gooseflesh, tremor, insomnia, diarrhea, vomiting, anorexia, irritability, elevated blood pressure, muscle cramps/spasm, dysphoria, drug craving Treat for withdrawal if symptoms occur or suspected by reducing dose over 7-10 days Reduce previous by ½ for 2 days, then subsequently by 25% every two days until reach equivalent of 30mg/day or PO morphine. Give this dose for two days then discontinue 16 Transdermal clonidine (Catapres ) (0.1-0.2 mg/day) may reduce associated symptoms: anxiety, tachycardia
- Pain management - Patients with substance abuse history 7 Acknowledge personal bias about addiction Place personal judgments and beliefs aside: use science and principles of pain management as guide Accept patient’s report of pain Persons with history of addictive disorders may be less pain tolerant compared to non-addicted: preexisting individual differences or drug-induced neuroadaptation Clinicians most likely to under medicate due to misconceptions and fear of being manipulated Clinicians advised to err on side of providing appropriate pain relief than on side of allowing pain and suffering
- Pain Management - General guidelines in managing pain in patients with active addiction 7 Discuss patients fears of staff treatment and interference with pain management, if acknowledged addiction problem Assess and intervene for pain based on patient’s report Manage pain aggressively - addiction treatment not priority Reassure patient of staff commitment to pain management of all patients Develop pain treatment plan and provide patient written copy, if possible Remind staff that prescribing opioids to active addict for pain management not illegal; patient with active addiction may be pain intolerant; detoxification is ineffective treatment for addictive disease Consult from pain management specialist and addiction specialist for support to patient and staff Begin treatment with non-drug or non-opioid analgesia; start opioids if pain becomes moderate to severe If patient is physically dependent on opioids, do not administer mixed agonist/antagonist for analgesia as it may precipitate withdrawal Assess patient’s motivation for drug treatment Inpatient setting 7 Consider IV PCA: gives patient control, avoids confrontation with staff, safely regulates dosing, including need for higher doses due to pain intolerance For persons physically dependent on alcohol, sedative-hypnotics, or opioids, provide long-acting formulations of substitution medications to prevent emergence of withdrawal symptoms Monitor for emergence of withdrawal from substances used by patient at least every 4 hours - treat aggressively and symptomatically Taper opioids very slowly when no longer required to minimize emergence or withdrawal symptoms; assess for signs of withdrawal at least every 4 hours during taper and treat symptomatically Outpatient setting 9 Use long formulations (transdermal patch or controlled release) when opioids needed - less frequent dosing increases compliance to treatment plan Schedule medications around the clock - provide a specific time schedule of when to take medications Carefully document pain treatment plan and give patient copy Provide written information on hours of operation, policies methods of obtaining refills, and phone number, especially when facility not open At each visit, include patient’s analgesic use, pain severity and quality, level of function and side effects Record and discuss with the patient any behavior suggestive of inappropriate opioid use
- Pain management - Guidelines for patient recovering from addiction 7 Acknowledge patient’s addiction history and encourage patient verbalization of fears or re-addiction Explain intent of using opioids or other psychoactive medications Explain health risks associated with unrelieved pain, including risk of relapse Offer non-pharmacologic and non-opioid pain management options Respect patient’s right to decide whether to take opioid analgesia Explain that known risk for addiction to opioids in the context of pain is minimal Differentiate between addiction and physical dependence and ensure patient understands distinction Suggest patient contact recovery program and/or sponsor for additional support Request consultation from addiction specialist for additional support to patient/staff Taper opioids very slowly to prevent emergence of withdrawal symptoms Assess for emergence of withdrawal symptoms at least every 4 hours during tapering - treat symptomatically If patient is on methadone, first cover with daily methadone dose, then order analgesic Include family in discussions - usually family members equally concerned about relapse potential If relapse occurs, intensify recovery effort - do not terminate pain care
- Pain management - Geriatric Population 7
- Pain management - Geriatric Population 7 Age classifications Younger old: age 65 to 75 years Older old: age 75 to 85 years Oldest old: over 85 years Elderly population at greater risk for painful conditions One of the most under treated populations for pain Pain should not be considered an inevitable part of aging No evidence to support the belief that pain perception is dulled with aging Elderly patient under report pain Belief that it is a natural part of aging Not wanting to concern family members or caregivers Fear of losing independence Not wanting to bother healthcare providers Opioids can be safely given to elderly population Rule of thumb: start low and go slow to prevent potentially dangerous side effects Frequent assessment and reassessment of patient response necessary at this age Adjust dose or intervals as necessary to avoid adverse effects
- Pain management - Geriatrics Common types of pain in elderly Acute pain Usually associated with disease or injury At higher risk for complications associated with unrelieved acute pain: atelectasis, pneumonia, thromboembolism Acute atypical pain more likely in elderly: silent myocardial infarction Surgery in elderly may be used to relieve pain or improve quality of life Cancer pain Typical cancer patient is over 60 years of age Most common types of cancer in elderly: breast and prostate Probability for developing neoplasms increases with age Nearly 50% of patients diagnosed with cancer present with moderate to severe pain at time of presentation Experience pain associated with cancer treatments, particularly surgery Chronic nonmalignant pain Usually in areas of joints, legs, back Typically from degenerative process: osteoarthritis Other types of chronic nonmalignant pain: diabetic neuropathies, osteoporosis with vertebral body collapse, temporal arteritis, polymyalgia rheumatica, post stroke, peripheral vascular disease, post-herpetic neuralgia, angina
- Pain management - Geriatrics Physiologic changes influencing analgesic therapy Organ function has a steady decline with aging These changes influence how the body will metabolize & eliminate medications Elderly more sensitive to both the analgesic and toxic effects of pain medications Absorption Decreased motility of GI tract may cause problems in absorption of NSAIDs Increased risk for bleeding and ulceration May have preexisting problems with malabsorption or diarrhea that may reduce medication absorption May also be taking medications, such as antacids that decrease absorption Distribution Age related changes may impact the distribution of drugs Decrease in lean body mass with increase in body fat by age 70 In oldest old, may see reduction of body fat in relation to lean body mass Other changes: muscle and soft tissue decrease by 25% to 30%; body water volume decreases by 18% Results of changes Lipid-soluble drugs (fentanyl, methadone) have larger distribution, delayed onset of action, accumulation with repeated doses Water soluble drugs (morphine, hydromorphone) have lower volume of distribution, higher peak (greater susceptibility to toxicity), slower decrease in plasma concentrations; onset and duration may be faster Protein binding: production of albumin generally declines with age In presence of chronic illness, immobility, malnutrition or co-administration of albumin-reducing medications, greater drug effect and toxicity are possible
- Metabolism With increasing age, hepatic changes occur: decreased functional liver tissue, decreased hepatic blood flow Diminished liver capacity to metabolize medications Greater risk for accumulation of analgesics Consider increasing interval between doses and observe for signs of toxicity in patients with greater risk factors: cancer, heart failure, malnutrition, cirrhosis and taking medications that slow drug metabolism (verapamil, diltiazem, allopurinol) Elimination Age related changes affecting elimination Decreased hepatic blood flow, decreased renal mass, decreased renal blood flow, decreased glomerular filtration rate, decreased tubular reabsorption Implications for analgesic use Decreased clearance Decreased elimination Increased half life Increased accumulation of drugs and metabolites Increased therapeutic effect Increased toxicity Consider half life of analgesic and clearance (ratio between rate of drug elimination and drug concentration in blood plasma)
- Pain Management - Geriatric - Considerations in analgesia selection Non-opioids Acetaminophen Most commonly prescribed analgesic in nursing homes Generally well-tolerated by elderly Rate of hepatic metabolism may decrease Monitor long term use: accumulation may increase risk for renal disease and liver damage NSAIDs Use cautiously in elderly population Increased risk of GI problems, renal insufficiency, platelet dysfunction Avoid piroxicam (Feldene ) because of long half life (50 hours) Elderly taking NSAIDs four times as likely to have peptic ulcer disease and five times as likely to die from GI bleed compared to those not taking NSAIDs Use lower doses of NSAIDs for both long and short term therapy in co-administration with misoprostol (Cytotec ) to reduce occurrence of gastric and duodenal ulcers Avoid doses greater than 300 mg/day and use for more than 12 weeks Always take NSAIDs with food and water Monitor hemoglobin and hematocrit; test for occult blood Monitor complete blood count, liver function test, renal function profile every 6-12 months if on long term NSAID therapy IV ketorolac (Toradol ) may be used safely in elderly postoperatively if not contraindicated, such as frail elderly with dehydration, preexisting renal dysfunction, cirrhosis, heart failure Decrease adult dose by 50% for patients over 65 years Daily IV dose should not exceed 60 mg Consider 8 hour dosing (versus 6 hour) in elderly Consider discontinuation after 24-48 hours postoperatively
- Pain Management - Geriatric - Considerations in analgesia selection Opioids Reluctance to provide elderly opioids continues: fear that elderly cannot tolerate due to higher peak and longer duration of effect Recommend reducing initial opioid dosing by 25-50% in elderly patient Titrate slowly and monitor closely Tolerance to respiratory depressant effect will occur after 72 hours Patient fears in opioid use: side effects (constipation, sedation, confusion), addiction Morphine may be opioid of choice in elderly, but plasma clearance decreases with age - may remain in body longer & at higher concentrations Increased risk for M6G and M3G accumulation in patients with impaired renal or hepatic function Hydromorphone (Dilaudid ) is also acceptable opioid of choice for elderly: short half life, no clinically significant metabolites Fentanyl has no significant metabolites, but is lipophilic and can accumulate over time in lipid storage In continuous use, slow release from lipid storage can increase half life and lead to prolonged sedation, respiratory depression Transdermal fentanyl (Duragesic ) may have appeal to elderly: reports of less constipation, less sedation, increased convenience; however, delivery via transdermal patch may be increased in elderly with accompanying respiratory depression, nausea, pruritus Oxycodone, controlled release, provides appropriate pain relief with minimal side effects - no special dose changes needed in healthy elderly Caution with opioids with long half life such as methadone: increased risk for accumulation and toxicity, especially in elderly with hepatic or renal insufficiency Avoid: meperidine (Demerol ) and propoxyphene (Darvon ) in elderly due to toxic build up of metabolites in patients with impaired renal function Avoid pentazocine (Talwin ) in elderly due to increased risk of delirium and agitation
- Pain Management - Geriatric - Considerations in analgesia selection Adjuvants Adjuvants with short half lives and minimal side effects best choice for elderly Responses will vary - may need to try more than one before well-tolerated analgesia achieved Low doses with gradual escalation will help avoid early side effects - onset of analgesia may be delayed Tricyclic antidepressants First line treatment for burning neuropathic pain Initial dose of 10 mg instead of 25 mg / Increase dose by 10 mg every 4-7 days Nortriptyline (Pamelor ) and desipramine (Norpramin ) may be best choices for elderly due to fewer side effects compared to amitriptyline (Elavil ) Elderly sensitive to anticholinergic effects: dry mouth, confusion, dizziness, blurred vision, tachycardia, constipation, urinary retention Consider bethanechol (Urecholine ) 10 mg TID to reduce side effects Caution when side effects impair safety: changes in vision and sensorium Orthostatic hypotension common side effect of tricyclic - instruct patient to “dangle” before standing or consider changing to SSRI antidepressant Anticonvulsants Usually first line treatment for lancinating, shooting neuropathic pain Gabapentin (Neurontin ) good choice for elderly due to minimal side effects and drug interactions Side effects of dizziness, drowsiness, sedation will decrease with use Corticosteroids Multipurpose adjuvant analgesic useful in variety of chronic pain syndromes, cancer, bone,and neuropathic pain In palliative care settings, also useful to improve appetite, nausea, malaise, and overall quality of life Adverse effects of chronic use of concern in elderly: hypertension, severe osteoarthritis, myopathy, increased risk of infection, hyperglycemia, gastrointestinal toxicity, late neurophysiological effects Local anesthetics Second line analgesics for some types of continuous neuropathic pain in elderly: burning pain in elderly who do not respond to antidepressants or anticonvulsants or who cannot tolerate them Mexiletine (Mexitil ) least likely to produce serious toxicity and therefore best choice for elderly If not effective, tocainide (Tonocard ) or flecainide (Tambocor ) should be tried Adverse effects of concern to elderly: CNS and cardiovascular, therefore caution in dose selection and titration Caution in patients with preexisting heart disease Avoid if history of cardiac dysrhythmias, taking antiarrhythmic drugs, or have cardiac insufficiency
- Pain Management - Cognitively Impaired Population 7,17 Cognitively Impaired Patient At high risk for under treatment of pain Analgesics held by caregivers due to belief that exacerbate confusion or impairment Opioids abruptly withdrawn from patients with no previous history of cognitive impairment who become disoriented while on opioids, assuming cause is opioid Assume that pain is present in pathological conditions or procedures that are known to be painful and intervene appropriately Assess patient’s ability to report pain and comply with pain management plan Assess patient’s ability to use pain scales - do not assume they cannot rate Provide ample time for patient to reply - at least 30 seconds 0 to 5 scale may be the most appropriate tool for these patients Obtain appropriate assessment tools and place at bedside Collaborate with family or caregiver to determine behaviors that indicate pain for individual patient: grimacing, pacing, restlessness, moaning, lying still, guarding, changes in usual behaviors (referred to as proxy pain ratings) Communicate these behaviors to other health care providers to ensure continuity of care Provide frequent assessment of pain management if patient not able to ask for pain medications If not contraindicated, cognitively impaired can be given acetaminophen or NSAID and an opioid on ATC basis with frequent assessment for side effects and safety hazards If confusion occurs, gradual reduction of dose is indicated, not abrupt discontinuation, with frequent assessment for safety and reorientation of patient to person, place and time If confusion continues, consider switching opioids Confusion during PCA use: reduce dose and switch to family-controlled or nurse-controlled analgesia Resume PCA when patient oriented and able to safely administer
- Pain Management – Dying Population 16 At the end of life, pain assessment continues to be a priority If nonverbal, consider behavioral cues such as furrowed brow, stiffened body posturing, grunting If no previous history of pain, but appears uncomfortable, assess for alternative reasons: full bladder, constipation, delirium - consider therapeutic trial of opioid to determine if behaviors diminish Dose of opioids given during the last hours of life should be based on assessment and response - not fear of expediting death by caregiver (see ethical discussion on Principle of Double Effect) Dose may decrease during final hours of life, possibly due to decrease renal function Decreased renal function of dying patient may increase accumulation of analgesic metabolites - assess for toxicity (i.e., hallucinations, myoclonus, irritable state) consider reducing dose or changing opioid as needed Intractable pain at the end of life: palliative sedation 16 also known as therapeutic sedation or sedation for intractable pain and symptom management Use of palliative sedation may be warranted in patients unresponsive to progressive titration of opioids Sedation may be only alternative in these situations First consider all possible etiologies and treatments for intractable pain or other symptoms Consider second opinion from palliative care specialist Second, inform the family, Health Care Power of Attorney, or surrogate decision maker of anticipated outcome during family meeting Obtain written consent Treatment Escalation of existing opioid may be sufficient, may cause unacceptable side effects at higher doses Consider midazolam (Versed ) protocol either IV or Subq with intermittent bolus doses available Consider ketamine protocol option, an N-methyl-D-asparate antagonists (NMDA) antagonist commonly used in operative procedures Rarely, propofol (Diprivan ) anesthetic agent may be used intravenous with intermittent bolus Provide ongoing comfort to patient: oral care, positioning Provide emotional support to family and encourage continued communication with patient throughout
- Pain Management - Pediatric population 19 Pediatric patient When developing the pain management plan consider age, developmental level, verbal capabilities, past experiences, cultural factors, types of pain Include patients parents, caregiver, and healthcare providers in pain management plan Pain assessment is dependent on childs age and cognitive developmental stage Child self report of pain considered most reliable and valid indicator for estimate of pain, location, and intensity Learn the childs word for pain, may be boo-boo, ouchy, hurt, ouch, owie Behavioral observation is the primary assessment measure for pre-verbal or the non-verbal child; facial expression, changes in daily activities, body movements, vocalization, unusual responses, appetite or sleep changes Medication dose determined by body weight, milligram or microgram per kilogram) Oral route desired route Non drug techniques may not reduce pain, but may make it more bearable, improve mood, reduce distress, provide patient with sense of control, and sometimes aid with sleep Should be used concurrently with medications - in most cases, non drug techniques are not used in place of appropriately titrated analgesics May be useful if patient having breakthrough pain and awaiting onset of action of short acting medication Important to assess patient’s attitude or previous experiences with non drug techniques Attempt to identify which technique is closest to patient’s coping style (i.e., distraction when experiencing pain) Assess patient’s level of fatigue, cognitive status and ability to concentrate and follow instructions Can be taught to both patient and family, but must consider ability of either or both to participate (fatigue, interest, belief systems) Ensure patient and family appropriate equipment & educational materials
- Pain Management - Pediatric population 19 Veteran The persisting stigma around pain and pain treatments is particularly pronounced in the military. Pain is often perceived as a sign of weakness—something military personnel are taught to grin and bear. Not surprisingly, many choose to suffer in silence, not telling others about the relentless pain that have from combat or non-combat injuries. Ensure that pain assessment is performed in a consistent manner. Ensure that pain treatment is prompt and appropriate. Include veterans and families as active participants in pain management. Listen to the veteran tell their story. They may not have shared the stories with their families before. The families may be shocked what the veteran experienced. If a veteran is on staff it may be helpful to have them talk with the patient. Provide for continual monitoring and improvement in outcomes of pain management. Provide for an interdisciplinary, multi-modal approach to pain management. PTSD may complicate/enhance the pain. See the module Care at the Time of Dying, for information on PTSD
- Pain management - Non-pharmacological interventions 1,7,17 Use concurrently with medications Methods 7,17,19 Cognitive-behavioral - focus on methods to improve coping and relaxation Relaxation Used to decrease anxiety and relax skeletal muscles Person can be taught behaviors to counteract the physical, emotional, and behavioral changes produced by painful stimuli Maximizes sense of patient control Not effective during periods of severe pain or pain crisis Teach techniques during periods when pain under control in quiet and calm environment Brief methods: deep breathing, focused breathing, paced respiration, self control Deep methods: progressive muscle relaxation (PMR), autogenic training, meditation Contraindicated in patient with psychosis and patients with respiratory compromise Guided imagery Process of imagining doing something or producing a desired outcome; creating a state of positive expectancy regarding a problem, such as pain Incompatible emotive imagery: images that evoke emotions such as anger, humor, or self-assertion that are incompatible with pain Incompatible sensory imaging: images of sensations that have no link to pain (imagining cold winter day while experiencing burning pain) Transformative imagery: designed to alter specific features of the pain experience Monitor patient for distress, restlessness or agitation during the use of imagery Contraindicated in patients with psychosis, dementia, or delirium Distraction Places less attention on the pain Passive distraction: listening to music, watching television or movies Active distraction: problem solving, singing, playing an instrument, playing video game Technique will depend on individual’s ability to concentrate or energy level Techniques should stimulate four major sensory modalities of sound, sight, touch, movement
- Pain management - Non-pharmacological Methods 7,17,19 Physical interventions - produce relaxation and relieve pain Superficial use of hot and cold May cause decrease sensitivity to pain - usually in areas of well-localized pain May be helpful in patients with aching muscles, muscle spasms/joint stiffness, low back pain, itching Cold modalities: commercial gel packs, plastic bags of 1/3 alcohol 2/3 water, bag of frozen vegetables Heat modalities: heating pads, hot packs, immersion in water, plastic wraps to retain body heat Protective layer between skin and modality: towel or pillowcase Inspect skin at regular intervals Avoid in: bleeding disorders, causalgia (hypersensitivity to touch), areas with recent injury, broken skin, open wounds, areas of skin where patient receiving radiation therapy Consider areas proximal, distal or contralateral if area of pain contraindicated Do not use cold if patient has history of peripheral vascular disease, connective tissue disease, or stated “allergy” to cold (may trigger asthma attack) Do not use heat on areas treated with topical menthol products (may increase tissue damage), areas of open wounds, or bleeding Vigilance/contraindication in patients with decreased sensation, impaired cognition, or unconscious Massage Use of touch in various forms of pressure, friction and vibration to the soft tissue to reduce pain Thought to reduce pain by increasing superficial circulation, and relax muscles in certain situations Massage at pain site may not decrease pain in the area Most effective if short in duration Massage at areas of neck, shoulders and back may promote comfort Massage of feet or hands may be less strenuous to patients Movements: rhythmic stroking, kneading or circular, distal to proximal movements, effleurage (slow, smooth, long strokes) to promote relaxation Position for patient should be easy to maintain: lying on side or prone, sitting in chair Keep one hand on the patient at all times - one hand completes a stroke as another starts one Use warm, alcohol-free lotion Avoid in sites of tissue damage (open rounds, radiation sites), bleeding disorders, thrombophlebitis, patients uncomfortable with touch, or if viewed by patient as sexual
- Pain management - Non-pharmacological Methods 7,17,19 Physical interventions - produce relaxation and relieve pain Positioning Patients may find themselves in positions for extended periods of time, especially if debilitated Can exacerbate pain or cause onset of new pain Assist patients and caregivers to promote positions or postures that maintain or facilitate normal physiologic function of musculoskeletal system Appropriate positioning places minimal stress on joint capsule, tendons and muscle structure Loose-packed positions: place the least amount of stress on a joint: elbow flexion or 45 degrees, hip flexion of 30 degrees, hip abduction of 20 degrees Rolled towels, small pillow or foam can help maintain positioning or alignment Premedicate if patient experiences pain with movement Caution in patients with bony disease and risk for pathological fractures Exercise - based on physical condition of patient Range of motion exercises may be appropriate if patient not close to death Active range of motion (AROM); Active assisted range of motion (AAROM); Passive range of motion (PROM) Promote comfort, restore integrity of muscles, ligaments, joints, bones, and nerves used in movement Used in prevention of complications
- Pain management - Non-pharmacological Methods 7,17,19 Complementary therapies Therapeutic touch Based on four premises Human being is an open energy field There is bilateral symmetry in human beings Illness is an imbalance in one’s energy fields Human beings have natural capacity to transform and transcend his/her condition of living Involves practitioner assessing energy fields of client Hands held four to six inches over client’s body surface Phase I: practitioner performs sweeping motion from head to foot to smooth-out the client’s energy fields - referred to as unruffling Phase II: practitioner channels energy to area of imbalance or void Phase III: energy field is reassessed for re-patterning of energy field Music therapy Used to affect change in both psychologic and physiologic state of the patient Assess for patient’s: medical situation, mood state, coping abilities, degree of isolation, prior musical experiences, and total pain experience Passive music therapy: listening to preferred musical styles leading to decrease in anxiety, depression, fear, anger and sadness Active music therapy: taping out rhythm, conducting, or performing Provides distraction, increases sense of control, provides relaxation Aromatherapy Plant extracts are inhaled or applied to skin to treat illness and promote beneficial changes in mood and outlook Plants are distilled into oils of exceptional potency Benefits derived from influence on limbic system that coordinates mind and body activity Limbic system is sensitive to odors - association made with past pleasant experiences and memories Lavender and capsicum most often used for pain
- Pain Management - Ethical Considerations Patient Rights 20 Patients fear that pain will not be appropriately addressed. Patients express that symptoms associated with disease may be more troublesome than the disease itself Unmanaged pain can strip patients of their dignity, cause unnecessary suffering, impose unnecessary burden on patient/family Unrelieved pain can lead to anxiety, irritation, restlessness, sleeplessness, depression, fatigue, emotional and spiritual distress. May lead patients to request assisted suicide Relief from pain must be defined by the patient The Joint Commission stated in 2000 that the patient’s right to appropriate pain management must be honored in all health care facilities and published pain accreditation standards for all settings 21 Fear that opioid analgesics will cause death (respiratory depression) is a continued barrier to appropriate pain control In the terminally ill patient, nurses should not hesitate to use effective doses of analgesics to relieve pain and suffering, even if the secondary effect is death of the patient This ethical stance was supported by the American Nurses Association in 1985, and reiterated by the Task Force on the Nurse’s Roles in End-of-Life Decisions (1991) 23 and by the Supreme Court of the United States in 1997 20
- Pain Management - Ethical Considerations - Principle of Double Effect 20,22 The Principle of Double Effect is applied in ethical situations when distinguishing between harming and benefiting patient Applied when found impossible to avoid all harmful actions - in situations where decision made as to whether one potentially harmful action is preferable to another Four conditions must be present for the Principle of Double Effect to justify claims that an act that causes evil consequences is not always morally prohibited 22 The action itself must be good or at least morally indifferent The individual must sincerely intend only the good effect and not the evil The evil effect cannot be the means to the good effect There must be a favorable balance between good & evil effects of the action Applied by nurses when performing an action to benefit a patient will also do harm Example: terminally ill pulmonary patient experiencing great pain Treatment of choice will improve comfort but will also significantly affect respiratory rate Nurse has moral duty to remove evil (pain) - conflicts with duty to benefit patient (protect life) Answer to moral dilemma is that nurse should provide morphine to relieve pain even though it may hasten death Application of above principles The action of providing morphine is morally indifferent The intention of the nurse is to relieve suffering - eliminate pain, not depress respirations Respiratory depression is not the means by which the pain relief is obtained The relief of pain and suffering balances the potential evil effect of morphine on the respiratory system (and potential death)
- Pain Management - Ethical Considerations Advocacy in Pain Management 20 Nurses have duty to relieve pain and suffering The nurses’ personal fears of causing respiratory depression prevents them from providing appropriate pain medication Nurse must anticipate and plan for pain and other symptoms associated within a specific disease trajectory Duty to discuss options with patient regarding pain management and potential side effects Knowledge reduces patient and caregiver burden Patient and family view nurse as advocate which increases trusting relationship Advocacy entails making suggestions regarding appropriate pain management interventions to other members of the healthcare team - such as physicians Continues to advocate until pain issues are resolved to patient’s satisfaction Nurse serves as role model in decision making and knowledge base about pain management Placebos 7,10,24 There are not individuals or conditions for which placebos are recommended treatment (possible exception: placebos as control in preliminary drug research) Placebos do not provide any useful information about the origin or severity of the pain Patients who have a documented organic basis for their pain obtain temporary relief when given a placebo Unethical to attempt to discredit the patient’s report of pain Involves deception - clinician is lying to patient; endangers patient’s trust in caregivers; threatens caregivers integrity Legal considerations: liability for fraud, breach of contract, medical negligence Nurses should check state nurse practice acts for legal/regulatory guidance - questionable violation of informed consent Cannot be used to diagnose malingering, psychogenic pain, or any psychological problem Use of placebos do not prevent addiction to opioids Use of placebos deprives the patient of appropriate treatment or diagnostic measures Tend to be used in vulnerable patient populations (e.g., substance abuse history; pain difficult to diagnose or treat) & constitutes a dual standard of care
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