Pain Management

Robert B. Walker, M.D., M.S.DABFP, CAQ (Geriatrics)Robert C. Byrd Center

for Rural HealthMarshall University

Introduction

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.

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.

Common Misconceptions

• “I should expect to have pain”

• “I’ll hold off so the medicine will work when I really need it”

• “Pain is for wimps”

• “I don’t want to get hooked”

Barriers We assess pain poorly and erratically  We haven’t been well trained in pain

management  We’re afraid of addiction issues  We’re afraid of mistreating the patient

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

Diagnosing and Documenting Pain

Examples of Pain Scales

Documenting Pain Onset

• What relieves?

Location• What worsens?

Intensity• Effects on Daily Activities

Quality• Treatment History

Neurological Classification

Nociceptive Pain

Neuropathic Pain

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

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

Physical Examination motor, sensory, reflexes  headaches: intracranial mass

zoster, pressure sores non-verbal communication

Treating Pain

Treatment of Pain Treat Causes if possible

Remember Non-Drug Treatments

Analgesics: Narcotic, Non-narcotic

Adjuvants: Anti-convulsants, Anti-depressants

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

Non-Narcotic Analgesics

Acetaminophen (< 4 g / 24 hrs.)

NSAIDS (bone pain or inflammation)– Lots of side effects– Newer are expensive

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

Narcotic Analgesics: Morphine

IV: if >50 Kg. Give 10 mg. IV Q3-4 h

If child or <50 kg. Give 0.1mg/kg. IV

If Opioid Naïve, consider lower dose

Oral: Start 5-10 mg. Titrate Up

Morphine

Max Effect: IV -15 minutes

SC- 30 minutes

PO: -I hr.

Using Concentrates

Dying Patient; Can’t 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

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

Extended Release

Better Compliance

More Expensive

Dose q 8,12, or 24

Extended Release Don’t Crush or Chew

May flush through feeding tubes

Don’t Start with Extended Dose

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

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

Other Options: Fentanyl Patch

25, 50, 75, 100 mcg/hr.

Apply every 3 Days

Divide Morphine Daily Dose in Half

Rescue with Opioids

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.

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

Other Options: Methadone

Starts working in about 1 hr.

Inexpensive

Neuropathic Pain

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?

A. Increase medication doseB. Change medicationC. Begin to give the medication at intervals of

less than four hours D. Add adjuvant medication.

Answer C.

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

2. The most likely classification of this pain is:

A. Referred PainB. Nociceptive Pain C. Neuropathic Pain D. Visceral Pain

Answer B.

Nociceptive Pain

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

A. 15 minutes B. 30 minutes C. 1 hour D. 2 hours

Answer C.

1 hour

Problems with Pain Management

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?”

Warning signalsDominating Concerns over Availability

Non-Provider Sanctioned Increases

Ignoring Major Side Effects

Warning signals Altering, losing Prescriptions

Multiple Sources

Unaccounted Medication

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

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

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

Problems with Opiates: Nausea/Vomiting

Usually occurs initially

Improves with Time

May be Able to Prevent with other meds, no movement

Problems with Opiates: Respiratory Depression

Remember, fairly rapid tolerance develops

Almost always associated with sedation

Follow Respiratory Rate

Withhold Next 2 Doses

Naloxone Dilute 1 Vial (0.4mg) in 10 cc.

Normal Saline

Give 1 cc. per minute until respiratory rate OK