Pain Management

1
Pain Management

• Robert B. Walker, M.D., M.S.
• DABFP, CAQ (Geriatrics)
• Robert C. Byrd Center
• for Rural Health
• Marshall University

2
Introduction
3
End of Life Pain

• 50 of elders report significant problems with
  pain in the last 12 months of life.
• One-third of nursing home patients complain daily
  pain.
• Predictable, explainable pain is under treated.

4

• Elders list pain control as one of their top 5
  quality of life concerns
• Patients have a legal right to proper pain
  assessment and treatment.

5
Common Misconceptions

• I should expect to have pain
• Ill hold off so the medicine will work when I
  really need it
• Pain is for wimps
• I dont want to get hooked

6
Barriers

• We assess pain poorly and erratically
•  
• We havent been well trained in pain management
•  
• Were afraid of addiction issues
•  
• Were afraid of mistreating the patient

7
Basic Approach to Pain Management

• Ask the patient about pain and believe them.
• Use a pain scale.
• Document what you know about the pain
• Reassess the pain

8
Diagnosing and Documenting Pain
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Examples of Pain Scales
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Documenting Pain

• Onset
• What relieves?
• Location
• What worsens?
• Intensity
• Effects on Daily Activities
• Quality
• Treatment History

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Neurological Classification

• Nociceptive Pain
• Neuropathic Pain

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Nociceptive Pain

• Damage is to other tissue and nerve fibers are
  stimulated.
• Travels along usual pain and temperature nerves
• Responds well to common analgesics and opioids
• Sharp, throbbing, aching

13
Neuropathic Pain

• The nervous system itself damaged
• Direct damage to nerves, plexes, spinal cord
  (shingles, diabetic neuropathy)
• Burning, tingling, shooting
• May not respond as well to usual analgesics
  including opioids

14
Physical Examination

• motor, sensory, reflexes
•  
• headaches intracranial mass
• zoster, pressure sores
• non-verbal communication

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Treating Pain
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Treatment of Pain

• Treat Causes if possible
• Remember Non-Drug Treatments
• Analgesics Narcotic, Non-narcotic
• Adjuvants Anti-convulsants, Anti-depressants

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Standard Approach

• Treat Quickly (Pain leads to more pain)
• Mild Pain acetaminophen, ASA, NSAIDS
• Moderate mixtures, weak opioid, maybe adjuvants
• Severe strong opioid and non-opioid, maybe
  adjuvant

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Non-Narcotic Analgesics

• Acetaminophen (lt 4 g / 24 hrs.)
• NSAIDS (bone pain or inflammation)
• Lots of side effects
• Newer are expensive

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Basics of Analgesic Use

• 1. By Mouth When Possible
• 2. Timed Doses
• 3. Whatever dose it takes
• 4. Watch for Expected Side Effects
• 5. Consider Adjuvants

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Narcotic Analgesics Morphine

• IV if gt50 Kg. Give 10 mg. IV Q3-4 h
• If child or lt50 kg. Give 0.1mg/kg. IV
• If Opioid Naïve, consider lower dose
• Oral Start 5-10 mg. Titrate Up

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Morphine

• Max Effect IV -15 minutes
• SC- 30 minutes
• PO -I hr.

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Using Concentrates

• Dying Patient Cant swallow
• MSIR 20 mg/ml .25 to .50 ml. Q 1 hr. sl. PRN
• Oxycodone conc. 20 mg/ml .25 to .50 ml. Q 1 hr.
  sl. PRN

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DOSING

• Titrate Up Slowly Until pain controlled or side
  effects occur
• Anticipate Next Dose tend to give a little early
  
• Use Breakthrough Doses When Needed

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Extended Release

• Better Compliance
• More Expensive
• Dose q 8,12, or 24

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Extended Release

• Dont Crush or Chew
• May flush through feeding tubes
• Dont Start with Extended Dose

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Breakthrough Pain

• Is it new incident (new cause? or end-of-dose?)
• Use 10 of total daily dose (rounded up) up to q
  1-2 h

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Continuing Use

• Can continue to increase (no real upper limit)
• Gradually increase Limited by Side effects
• Note that the effective rescue dose increases as
  total dose does

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Other Options Fentanyl Patch

• 25, 50, 75, 100 mcg/hr.
• Apply every 3 Days
• Divide Morphine Daily Dose in Half
• Rescue with Opioids

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Other Options Fentanyl Patch

• Initial Dose May Take 12- 24 hrs.
• May continue previous meds for 8 - 12 h
• If switching, remove and use rescue for 24 hrs.

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• Fentanyl is well absorbed across mucous membranes
• Lolly-pop
• approved only for breakthrough in already
  receiving opioids
• not to be chewed 200ug units
• not proven to be more effective than morphine
  concentrates

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Other Options Methadone

• Starts working in about 1 hr.
• Inexpensive
• Neuropathic Pain

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A patient with advanced lung cancer has severe
pain from a localized bony metastasis. He begins
to consistent feel pain about four hours after
his last dose of opioid medication.

• 1. According to the program which of the
  following would be most helpful?
• Increase medication dose
• Change medication
• Begin to give the medication at intervals of less
  than four hours 
• Add adjuvant medication.

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Answer C.

• Begin to give the medication at intervals of less
  than four hours

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2. The most likely classification of this pain
is

• Referred Pain
• Nociceptive Pain 
• Neuropathic Pain 
• Visceral Pain

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Answer B.

• Nociceptive Pain

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3. The oral morphine preparation given to this
patient will begin to take full effect in about

• 15 minutes 
• 30 minutes 
• 1 hour 
• 2 hours

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Answer C.

• 1 hour

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Problems with Pain Management
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Problems with Opiates Addiction

• Define compulsive use, lack of control, harmful
  use
• Iatrogenic may be as low as 1 if no previous
  history
• Avoid making this tricky diagnosis
• Have you used this drug five times in your
  life?

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Warning signals

• Dominating Concerns over Availability
• Non-Provider Sanctioned Increases
• Ignoring Major Side Effects

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Warning signals

• Altering, losing Prescriptions
• Multiple Sources
• Unaccounted Medication

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Problems with Opiates Dependence

• Defined by the occurrence of a withdrawal
  syndrome after reduction or cessation.
• May occur after only 2- 3 days of strong opioids
• Usually well controlled by tapering

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Problems with Opiates Tolerance

• Need for higher doses for same effect
• Can occur with effects other than analgesia
• Often develops faster for sedation, respiration,
  nausea than analgesia
• Slow tolerance to obstipation

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Problems with Opiates Obstipation

• Fluids, Bran
• Pericolace or Senicot-S
• No BM in 48 hrs MOM or Lactulose
• No BM in 72 hrs Rectal Exam Mag Citrate,
  Fleets, Oil

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Problems with Opiates Nausea/Vomiting

• Usually occurs initially
• Improves with Time
• May be Able to Prevent with other meds, no
  movement

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Problems with Opiates Respiratory Depression

• Remember, fairly rapid tolerance develops
• Almost always associated with sedation
• Follow Respiratory Rate
• Withhold Next 2 Doses

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Naloxone

• Dilute 1 Vial (0.4mg) in 10 cc. Normal Saline
• Give 1 cc. per minute until respiratory rate OK

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Problems with Opiates Sedation

• Look at Other Meds
• Look for Other Reasons
• Try Decrease Dose 25
• Try another Analgesic, Psychotropic

49
A patient with widespread cancer is being treated
with a mixed narcotic analgesic. Addition of
non-narcotic pain medication for breakthrough is
being considered.

• Which of the following is the most significant
  pharmacologic concern?
• Acetaminophen hepatic toxicity
• Addiction 
• Tolerance
• Respiratory depression

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Answer A.

• Acetaminophen hepatic toxicity

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If a decision is made to change to a strong
opioid alone, which starting dose of oral
morphine would be reasonable?

• 1 mg. 
• 5 mg. 
• 10 mg. 
• 50 mg.

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Answer C.

• 10 mg.

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To which of the following morphine effects will
tolerance probably develop most slowly?

• Sedation 
• Nausea 
• Pain relief 
• Obstipation/constipation

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Answer D.

• Obstipation/constipation

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Adjuvant Use

• Anticonvulsants (Shooting Pain)
• Gabapentin (expensive, 100 mg TID)
• Carbamazine 100 mg. PO TID
• Valproic Acid 250 mg. QHS
• Clonazepam 0.5 mg PO BID (sedating)

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Adjuvant Use

• Tricyclic Antidepressants (Burning, Tingling)
• Low Doses (10 - 25 mg.)
• Amitriptyline
• Anticholenergic (sedating, drying, cardiac
  effects)
• Gabapentin

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Special Situations
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Terminal Events

• Cant Swallow Go to Concentrate
• If No Urine Output Titrate to Pain (no routine
  dosing)

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Converting from IV to Oral

• Morphine, Oxycodone, Meperidine 3 X dose
• Hydromorphone (Dilaudid) up to 5 X dose
• Then Reduce by 25 (cross tolerance)

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West Virginia Schedule II. Regulations

• In Emergency May Telephone or Mail (60 doses)
• One Drug Per Prescription with MD/DO Name Printed
  on Blank
• May Fax to Long Term Care or Hospice
• Should Write Out Concentrations

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Non-Drug Treatments

• Blocks Infusions
• Surgery rhizotomy and nerve decompression
• Radiation localized
• Tumor Treatment
• Heat Cold
• TENS
• Relaxation

• Complementary Medicine acupuncture,
  chiropractic, massage
• Spiritual Therapy
• Diversions Pets, Music, Art, Humor

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SUMMARY

• Optimizing well-being of the patient and loved
  ones
• Improving control over ones life
• Can reduce uncontrolled pain to less than 1 in
  20.
• We primary care physicians can, and must, get
  better at this.

63
A patient with advanced, widespread cancer is at
end-stage of her disease. She begins to
experience breakthrough pain every 1 or 2 hours
between doses of OxyContin.

• What dose should be given for rescue or
  breakthrough pain?
• Regular interval dose
• 10 of total daily dose
• 20 of total daily dose
• 30 of total daily dose

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Answer B.

• 10 of total daily dose

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This patient lives many miles from the office and
the Hospice nurse wished to increase the regular
interval dose of medication. Which of the
following is a legal option?

1. Give doses of another patients medicine 
2. Fax a prescription for the regular medication to
   the local pharmacist.
3. Give a medication on-hand not previously
   prescribed
4. Wait until a written script can be obtained.

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Answer B.

• Fax a prescription for the regular medication to
  the local pharmacist.

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The patient begins to take no fluids and has
instructed no IV be started. Urine output
ceases. How should dosing be determined?

• Titrate to pain, using rescue dose only 
• Half the usual interval dose 
• Give 10 of the usual interval dose 
• Double the usual interval dose.

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Answer A.

• Titrate to pain, using rescue doses only