Pain Management: The things you should know

Questions Regarding Pain Control

What about the 20% who do not get relief from the WHO ladder or the 46% of those whose families stated we failed?*
Have the opioids been titrated aggressively? Is the pain neuropathic? Has a true pain assessment been accomplished? Have invasive techniques been employed? Have you examined the patient?

Is the patient receiving their medication?

Is the medication schedule and route appropriate?
*Tolle

2001

Physiological effects of Pain

Increased catabolic demands: poor wound healing, weakness, muscle breakdown Decreased limb movement: increased risk of DVT/PE Respiratory effects: shallow breathing, tachypnea, cough suppression increasing risk of pneumonia and atelectasis Increased sodium and water retention (renal) Decreased gastrointestinal mobility Tachycardia and elevated blood pressure

Psychological effects of Pain

Negative emotions: anxiety, depression Sleep deprivation

Existential suffering: may lead to patients seeking active end of life.

Immunological effects of Pain

Decrease natural killer cell counts Effects on other lymphocytes not yet defined.

Procedure Related Pain

Common in all patients

Frequent source of pain and distress

Therapeutic Procedures
Surgery
Only 50% of post-operative pain is adequately managed Post-operative pain syndromes
Traumatic neuroma

Similar to other chronic pain syndromes

Psychological factors important Treat symptoms Maintain functional status

Principles of Assessment
Assess and reassess

Use methods appropriate to cognitive status and context

Assess intensity, relief, mood, and side effects

Use verbal report whenever possible

Document in a visible place Expect accountability Include the family

Patient Pain History

Site(s) of pain?

Severity of pain?
Date of onset?

Duration?
What aggravates or relieves pain?

Impact on sleep, mood, activity?

Effectiveness of previous medication?

What Does Pain Mean to Patients?

Poor prognosis or impending death
Particularly when pain worsens

Decreased autonomy
Impaired physical and social function

Decreased enjoyment and quality of life Challenges to dignity Threat of increased physical suffering

Neuropathic Pain
Neuropathic pain is pain transmitted over damaged nerves. Patient Description of Neuropathic Pain: Burning, electric, searing, tingling, and migrating or traveling. Causes of Neuropathic Pain: Amputation, shingles (herpes zoster), AIDS (peripheral neuropathy), diabetic neuropathy, fibromyalgia, and cancers that affect the spinal cord, among others.
Westbrook 2005

Opioids
Codeine Fentanyl Hydrocodone Hydormorphone Methadone Morphine Oxycodone Oxymorphone

Cost of Opioids (AWP 2003 Redbook )

(Equianalgesic Dose (morphine 180-200mg / day ATC)
Brand
Roxanol

Generic
morphine

Dose
30 mg q4h

Cost/30 days
$186.84 ($58.75)

Cost/day
$6.23 ($2.00)

Morphine IR
Oramorph SR MS Contin Morphine SR Avinza Kadian Duragesic Oxydose Oxycontin Dilaudid

morphine
morphine morphine morphine Morphine morphine fentanyl oxycodone oxycodone

30 mg q4h
100 mg q12h 100 mg q12h 100 mg q12h 200mg q24h 200 mg q24h 100 mcg q72h 30 mg q4h 80 mg q12h

$147.62
$307.20 $328.20 $293.75 $433.80 $365.00 $482.72 $514.85 $7.32

$4.92*
$10.24 $10.94 $9.79* $14.46 $12.18 $16.06 $10.32* $17.16

309.78($259.97)

hydromorphone 8 mg q4h $219.60

Dolophine

methadone

20 mg q8h

$ 30.26

$1.01
($0.51-4.54)

Principles of Opioid Analgesic Use in Acute and Cancer Pain

Individualize route, dosage, and schedule
Administer analgesics regularly (not PRN) if pain is present most of day Become familiar with dose / time course of several strong opioids

Give infants / children adequate opioid dose

Follow patients closely, particularly when beginning or changing analgesic regimens

 When changing to a new opioid or different route

Use equianalgesic dosing table to estimate new dose Modify estimate based on clinical situation

Principles of Opioid Analgesic Use in Acute and Cancer Pain (cont)

Recognize and treat side effects

Be aware of potential hazards of meperidine / mixed agonist-antagonists - particularly pentazocine Do not use placebos to assess nature of pain

 Watch for development of:

Principles of Opioid Analgesic Use in Acute and Cancer Pain (cont)

Tolerance - treat appropriately Physical dependence prevent withdrawal

Do not label a patient psychologically dependent, addicted, if you mean physically dependent on / tolerant to opioids
Be alert to psychological side of patient

(APS,2005)

Equianalgesia
Determining equal doses when changing drugs or routes of administration Use of morphine equivalents

Practical Prescribing: Equianalgesic Dosing

Some Equianalgesic Doses

Common drugs with oral doses equianalgesic to 650mg oral aspirin or acetaminophen

Pentaxocine (Talwin)
Codeine

30mg
32mg

Meperidine (Demerol) po
Propoxphene (Darvon)

50mg
65mg

Calculation:

Baseline Pain = Extended release morphine 200 mg/24 hrs Breakthrough - 10-20% = 20-40 mg

Principles: Use of Opioid Rotation

Use when one opioid ineffective or for adverse effects

 Acute pain: methadone morphine (1:1)

Methadone

Chronic pain: ratio depends upon previous opioid dose (methadone:morphine)

< 90 mg (1:5)

91-299 mg (1:10)
>300 mg (1:12 or 20)

Torsade de Pointes in high parenteral doses

Bruera &Sweeney, 2002; Kranz et al., 2002

Properties of Methadone
Well absorbed from all routes of administration
oral rectal subcutaneous IV Sublingual

Rapid onset of analgesia effect ( 30 60 min.) No significant cognitive impairment. No euphoria.

Safe in renal and liver failure.

Over 50% of patients required more than one route of drug administration during the last four weeks of life. N. Coyle 12/90

Co Analgesics
Definition
Agents which enhance analgesic efficacy, have independent analgesic activity for specific types of pain, and / or relieve concurrent symptoms which exacerbate pain

Co Analgesics Commonly Used For Pain

NSAIDS
Acetaminophen Antidepressants

Analeptics
Benzodiazepines Antispasmodics

Anticonvulsants
Corticosteroids

Muscle relaxants
Systemic local anesthetics

Neuroleptics
Antihistamines

Systemic Local Anesthetics

Indications
Neuropathic pain

Toxicities
Dizziness, nausea, tremor, nervousness, incoordination, headaches, paresthesias

Drugs
Lidocaine, mexiletine

Local Anesthetics
Lidocaine Infusion
More effective in neuropathic pain but can be used for all pain syndromes. Starting dose 0.5mg-2 mg/kg per hr IV or SC. Some studies demonstrate longlasting pain relief even after drug has been stopped. Need to decrease opioids when starting. (Ferrini,Paice, 2004)

Lidocaine Patch (Lidoderm)

On 12hrs off 12 hours (but can leave on 24) Expensive (great indigent program however)

Miscellaneous Adjuvant Analgesics

Pamidronate (Aredia)

Zoledronic acid (Zometa)

Strontium-89 (Metastron) Calcitonin (Calcimar) Not in cancer ? arthritis Capsaicin (Zostrix) scheduled in neuropathic pain Clonidine (Catapres) all forms Cannabinoid (Marinol)

 Tricyclic antidepressants
nortriptaline (1st choice)

Analgesics for Neuropathic Pain

Anticonvulsants
Gabapentin, Carbamazepine, Pregaba

Local anesthetics
Parenteral, oral, topical

Topical capsaicin Opioids for selected patients

Ketamine
N-methyl-D-aspartate receptor antagonist (NMDA) Used as an anesthetic for years

Case reports show effectiveness when traditional and invasive techniques fail
Starting IV dose 150mg qd (0.1-0.2mg/kg) with reduction of opioid achieved or 10-15 mg q6 increasing by 10 mg dose each day Appears to have a synergistic effect with opioids

Making PCA Work for your Patient

PCA History; dosing,bolus; basal rates Always remember SC PCA

Modified WHO Analgesic Ladder

Quality of Life
Invasive treatments

Proposed 4th Step

Opioid Delivery
Pain persisting or increasing Step 3 Opioid for moderate to severe pain Nonopioid Adjuvant Pain persisting or increasing

The WHO Ladder

Step 2 Opioid for mild to moderate pain Nonopioid Adjuvant Pain persisting or increasing Step 1 Nonopioid Adjuvant

Pain
Deer, et al., 1999

Role of Invasive (Anesthetic) Procedures

Intractable pain*
Intractable side effects*
*Symptoms that persists despite carefully
individualized patient management

Role of Invasive Procedures

Optimal pharmacologic management can achieve adequate pain control in 80-85% of patients
The need for more invasive modalities should be infrequent When indicated, results may be gratifying

Other techniques ...

Lidocaine Ketamine Chemotherapy, radiation Surgery Biphosphates Others

Methadone
Sedation Spinal cord stimulator

Q&A