Pain Assessment & Pain Assessment & ManagementManagement

M3 Palliative Medicine M3 Palliative Medicine CurriculumCurriculum

Seema S. Limaye, MDSeema S. Limaye, MD

University of ChicagoUniversity of Chicago

GOALSGOALS

1.1. Describe methods of pain Describe methods of pain assessment in cognitively assessment in cognitively impaired older adults.impaired older adults.

2.2. Understand various types of Understand various types of pain.pain.

3.3. Describe the basic Describe the basic pharmacology of opioidspharmacology of opioids

4.4. Understand how to initiate and Understand how to initiate and titrate opioids.titrate opioids.

Self-Directed Learning Self-Directed Learning ModulesModules Basics of Neuropathic painBasics of Neuropathic pain Side Effects of Opiods and Side Effects of Opiods and

Management OptionsManagement Options Treatment of Pain in Persons with Treatment of Pain in Persons with

h/o Substance Abuseh/o Substance Abuse

Mrs. PMrs. P

70 y.o. female h/o Paget’s disease, 70 y.o. female h/o Paget’s disease, renal insufficiency, osteoporosis renal insufficiency, osteoporosis presents to clinic with new back presents to clinic with new back pain.pain.

What do you want to obtain from What do you want to obtain from the history?the history?

Pain History

•Pain Characteristics – onset, duration, location, quality, intensity, associated symptoms, exacerbating and relieving factors

•Past and current management therapies

•Relevant medical and family history

•Psychosocial history

•Impact of pain on daily life – work, daily activities, personal relationships, sleep, appetite, emotional state

•Patient (and family’s) expected goals for treatment

Pain: A Complex Pain: A Complex PhenomenonPhenomenon PainPain

– Sensory stimuli and/or neurologic Sensory stimuli and/or neurologic injury modified by an individual’s injury modified by an individual’s memory, expectations, emotionsmemory, expectations, emotions

Biocultural Model of Pain:Biocultural Model of Pain:– Society also influences an Society also influences an

individual’s pain experiencesindividual’s pain experiences

Pain Assessment is Pain Assessment is NOT….NOT…. Relying on changes in vital signsRelying on changes in vital signs Deciding a patient does not “look in Deciding a patient does not “look in

pain”pain” Knowing how much a procedure or Knowing how much a procedure or

disease “should hurt”disease “should hurt” Assuming a sleeping patient does not Assuming a sleeping patient does not

have painhave pain Assuming a patient will tell you they are Assuming a patient will tell you they are

in painin pain

Consequences of Consequences of Untreated PainUntreated Pain Acute pain: Acute pain:

– increase metabolic rate and blood increase metabolic rate and blood clotting,clotting,

– impair immune functionimpair immune function– induce negative emotionsinduce negative emotions

Without intervention, pain receptors Without intervention, pain receptors become sensitive and may have become sensitive and may have long lasting changes in the neuronslong lasting changes in the neurons

Consequences of Consequences of Untreated PainUntreated Pain

Chronic pain may lead to: Chronic pain may lead to: – fatigue, fatigue, – anxiety, anxiety, – depression, depression, – confusion,confusion,– increased falls, increased falls, – impaired sleep, and impaired sleep, and – decreased physical decreased physical

functioning/deconditioningfunctioning/deconditioning

Bedside AssessmentBedside Assessment

ASK the patient about painASK the patient about pain– Asking about ADL’s and IADL’sAsking about ADL’s and IADL’s– Asking about physical activity, mood, sleep, appetite, Asking about physical activity, mood, sleep, appetite,

energy levelenergy level

Identify Identify preferred pain preferred pain terminologyterminology-hurting, aching, stabbing, discomfort, soreness-hurting, aching, stabbing, discomfort, soreness

Use a pain scale that works for the Use a pain scale that works for the individualindividual-Insure understanding of its use-Insure understanding of its use-Modify sensory deficits-Modify sensory deficits

Ferrell et al. J Pain Symptom Manage 1995. Chinball and Tait Pain 2001.Ferrell et al. J Pain Symptom Manage 1995. Chinball and Tait Pain 2001.Herr and Garand. Pain Management in the Elderly 2001Herr and Garand. Pain Management in the Elderly 2001

Use a standard scale to Use a standard scale to track the course of paintrack the course of pain

Faces Pain Scale and Faces Pain Scale and Pain ThermometerPain Thermometer

What are some common What are some common barriers barriers to pain to pain treatment?treatment?

Remember the common patient-Remember the common patient-related barriers to pain related barriers to pain managementmanagement

Drugs ..Drugs ..– are addictingare addicting– should be saved should be saved

for when it is for when it is reallyreally needed needed

– have unpleasant have unpleasant or dangerous side or dangerous side effects effects

– pills are not as pills are not as effective as a shoteffective as a shot

– narcotics are only narcotics are only for dying peoplefor dying people

Pain assessment in a Pain assessment in a vulnerable group: vulnerable group:

Cognitively Impaired Cognitively Impaired Older AdultsOlder Adults

Assessing pain: Nonverbal, Assessing pain: Nonverbal, Moderate to Severe Moderate to Severe ImpairmentImpairment Formal assessment tools Formal assessment tools

available but not necessarily available but not necessarily useful in routine clinical settingsuseful in routine clinical settings

Unique Pain Signature Unique Pain Signature

Nonverbal Pain IndicatorsNonverbal Pain Indicators Kaasalainen et al Perspectives 1998. Herr and Garand Clinics in Geriatric Kaasalainen et al Perspectives 1998. Herr and Garand Clinics in Geriatric Medicine 2000Medicine 2000

Unique Pain Unique Pain SignatureSignature How does the patient usually act?How does the patient usually act? What changes are seen when What changes are seen when

they are in pain?they are in pain?– family membersfamily members– nursing staffnursing staff

Communication across caregiver Communication across caregiver settings is key!settings is key!

Kovach et al. J Pain Symptom Manage 1999. Kovach et al. J Pain Symptom Manage 1999. Feldt et al. JAGS 1998. Feldt et al. JAGS 1998. Weiner et al. Aging 1998.Weiner et al. Aging 1998.

Nonverbal Pain Nonverbal Pain IndicatorsIndicators Facial expressionsFacial expressions (grimacing) (grimacing)

-Less obvious: slight frown, rapid blinking, -Less obvious: slight frown, rapid blinking, sad/frightened, any distortionsad/frightened, any distortion

Vocalizations Vocalizations (crying, moaning, groaning) (crying, moaning, groaning) -Less obvious: grunting, chanting, calling out, -Less obvious: grunting, chanting, calling out, noisy breathing, asking for helpnoisy breathing, asking for help

Body movements Body movements (guarding)(guarding) -Less obvious: rigid, tense posture, fidgeting, -Less obvious: rigid, tense posture, fidgeting,

pacing, rocking, limping, resistance to movingpacing, rocking, limping, resistance to moving

Kaasalainen et al Perspectives 1998. Herr and Garand Clinics in Geriatric Kaasalainen et al Perspectives 1998. Herr and Garand Clinics in Geriatric Medicine 2000Medicine 2000

Selection of pain medsSelection of pain meds

Source/type of painSource/type of pain Duration/timing/frequencyDuration/timing/frequency History of medication useHistory of medication use Impact on quality of lifeImpact on quality of life Presence of associated factorsPresence of associated factors

Types of Pain: A Brief Types of Pain: A Brief ReviewReview

Nociceptive PainNociceptive Pain– VisceralVisceral– SomaticSomatic

Neuropathic PainNeuropathic Pain Mixed/Unspecified PainMixed/Unspecified Pain Psychologic causePsychologic cause

Quality: Visceral PainQuality: Visceral Pain

DescriptorsDescriptors: : cramping, squeezing, cramping, squeezing, pressurepressure

Distribution/ExamplesDistribution/Examples: : – ReferredReferred

heart attack, kidney stoneheart attack, kidney stone– ColickyColicky

Bowel obstruction, gallstoneBowel obstruction, gallstone– DiffuseDiffuse

PeritonitisPeritonitis AnalgesicsAnalgesics: : opioids; acetaminophenopioids; acetaminophen

Quality: Somatic pain

Descriptors: aching, deep, dull, gnawing Distribution/Examples:

– Well localized—patients can often point with one finger to the location of their pain

• bone mets, strained ankle, toothache

Analgesics: NSAIDS, acetaminophen opioids

General Principles of General Principles of ManagementManagement Set a goal of reduction of pain to Set a goal of reduction of pain to

tolerable levels, not a goal of tolerable levels, not a goal of complete reliefcomplete relief

““Start low and go slow”Start low and go slow” Make sure patient and family are Make sure patient and family are

aware of goalsaware of goals Frequent clinic visits at first for Frequent clinic visits at first for

assurance, validation, and monitoring assurance, validation, and monitoring of titrationof titration

WHO 3-Step ladderWHO 3-Step ladder

Source: World Health Organization. Technical Report Series No. 804, Figure 2. Geneva: World Health Source: World Health Organization. Technical Report Series No. 804, Figure 2. Geneva: World Health Organization; 1990. Reprinted with permission.Organization; 1990. Reprinted with permission.

WHO 3-STEP LADDER 3 SEVERE Morphine Hydromorphone Methadone Oxycodone Fentanyl +/- Adjuvants

2 MODERATE

A/Codeine A/Hydrocodone A/Oxycodone Tramadol +/- Adjuvants 1 MILD ASA/NSAIDS Acetaminophen Cox-2 +/- Adjuvants

Non-opioid Non-opioid medicationsmedications Acetominophen 650mg tid-qid : Acetominophen 650mg tid-qid :

concern for hepatic toxicity >3-4gramsconcern for hepatic toxicity >3-4grams NSAIDs including Ibuprofen, Naproxen, NSAIDs including Ibuprofen, Naproxen,

COX-2 inhibitors: concern for gastric / COX-2 inhibitors: concern for gastric / renal toxicity, platelet dysfunction, renal toxicity, platelet dysfunction, may inhibit anti-hypertensive medsmay inhibit anti-hypertensive meds

Opioid combination Opioid combination productsproducts The following opioids are available as The following opioids are available as

combination products with acetaminophen, combination products with acetaminophen, aspirin, or ibuprofenaspirin, or ibuprofen– Codeine; hydrocodone; oxycodone; propoxypheneCodeine; hydrocodone; oxycodone; propoxyphene

Typically used forTypically used for– Moderate episodic (PRN) painModerate episodic (PRN) pain– Breakthrough pain in addition to a long-acting Breakthrough pain in addition to a long-acting

opioid.opioid. Never prescribe more than one combination Never prescribe more than one combination

drug at any one time.drug at any one time.

Which combination Which combination product?product?Analgesic potency:Analgesic potency:

– hydrocodone and oxycodone are more hydrocodone and oxycodone are more potent than codeine, which is more potent potent than codeine, which is more potent than propoxyphene, which some studies than propoxyphene, which some studies suggest is equipotent to aspirinsuggest is equipotent to aspirin..

– there is little difference between there is little difference between hydrocodone products and oxycodone hydrocodone products and oxycodone products in terms of potencyproducts in terms of potency..

Note: Note: propoxyphene products are not recommended for pain in most national propoxyphene products are not recommended for pain in most national pain guidelines, due to side effects and unclear efficacy compared to other pain guidelines, due to side effects and unclear efficacy compared to other productsproducts

AdjuvantsAdjuvants

Non-pharmacologicNon-pharmacologic TopicalsTopicals TylenolTylenol NSAIDS, Celecoxib, steroidsNSAIDS, Celecoxib, steroids AnticonvulsantsAnticonvulsants AntidepressantsAntidepressants AntiarrhythmicsAntiarrhythmics

Opioid PharmacologyOpioid Pharmacology

Block the release of Block the release of neurotransmitters in the spinal neurotransmitters in the spinal cordcord

Agonist of Mu, delta, kappa Agonist of Mu, delta, kappa receptorsreceptors

Conjugated in liverConjugated in liver Excreted via kidney (90%–95%)Excreted via kidney (90%–95%)

Opioid pharmacologyOpioid pharmacology

Central and peripheral effects of Central and peripheral effects of opioidsopioids

This leads to desired effects, as This leads to desired effects, as well as side effectswell as side effects

Receptor Clinical Effects

Mu 1 Supraspinal analgesiaPeripheral analgesiaSedationEuphoriaProlactin release

Mu 2 Spinal analgesiaRespiratory depressionPhysical dependenceGI dysmotilityPruritisBradycardiaGH release

Receptor Clinical Effects

Kappa 1 Spinal analgesiaMiosisDiresis

Kappa 2 PsychotomimesisDysphoria

Kappa 3 Supraspinal analgesia

Delta Spinal and supraspinal analgesia

Nociceptin/orphanin AnxiolysisAnalgesia

Clearance concernsClearance concerns Conjugated by liverConjugated by liver 90%–95% excreted in urine90%–95% excreted in urine Dehydration, renal failure, severe Dehydration, renal failure, severe

hepatic failurehepatic failure dosing interval (extend time) dosing interval (extend time) oror dosage sizedosage size– if oliguria or anuriaif oliguria or anuria

STOP routine dosing of morphineSTOP routine dosing of morphine use ONLY prnuse ONLY prn

Opiod Pharmacology…Opiod Pharmacology…

What is the peak effect (C What is the peak effect (C max max ) of morphine:) of morphine:– PO? PO?

30-60 min30-60 min– IV?IV?

5-15 min5-15 min– SC/IM?SC/IM?

Variable…usually 30-60 minVariable…usually 30-60 min What is the duration of effect of morphine?What is the duration of effect of morphine?

– PO?PO? 3-4 hours3-4 hours

– IV?IV? Usually 1-2 hours, but we typically dose it q2-3 hoursUsually 1-2 hours, but we typically dose it q2-3 hours

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0000 Half-life (tHalf-life (t1/21/2))Half-life (tHalf-life (t1/21/2)) TimeTimeTimeTime

IVIVIVIV

po / prpo / prpo / prpo / pr

SC / IMSC / IMSC / IMSC / IM

CCmaxmaxCCmaxmax

. . . More Opioid . . . More Opioid PharmacologyPharmacology Steady state after 4–5 half-livesSteady state after 4–5 half-lives

– steady state after 1 day (24 hours)steady state after 1 day (24 hours) Side Effects:Side Effects:

– sedation, confusion, respiratory sedation, confusion, respiratory depression, constipation, urinary depression, constipation, urinary retention, nausea and vomiting retention, nausea and vomiting

Short Acting OpioidsShort Acting Opioids

Parenteral or Parenteral or OralOral– morphinemorphine– hydromorphone hydromorphone

(Dilaudid (Dilaudid ®®))– meperidine meperidine

(Demerol (Demerol ®®) ) – codeinecodeine

Oral onlyOral only– oxycodone (Percocet oxycodone (Percocet ®®

, Tylox , Tylox ®® ) )– hydrocodone (Vicodin hydrocodone (Vicodin

®® Lortab Lortab ®®, Lorcet , Lorcet ®®) ) – propoxyphene (Darvon propoxyphene (Darvon

®®, Wygesic , Wygesic ®®))– Note: hydrocodone is Note: hydrocodone is

only available as a only available as a combination product.combination product.

Routine oral dosingRoutine oral dosingextended-release preparationsextended-release preparations

Improve compliance, adherenceImprove compliance, adherence Dose q 8, 12, or 24 h (product Dose q 8, 12, or 24 h (product

specific)specific)– don’t crush or chew tabletsdon’t crush or chew tablets– may flush time-release granules may flush time-release granules

down feeding tubesdown feeding tubes Adjust dose q 2–4 days (once Adjust dose q 2–4 days (once

steady state reached)steady state reached)

Transdermal FentanylTransdermal Fentanyl

Duration 24-72 hoursDuration 24-72 hours 12-24 hours to reach full analgesic effect12-24 hours to reach full analgesic effect Not recommended as first-line in opiate Not recommended as first-line in opiate

naïve patientsnaïve patients LipophilicLipophilic Simple Conversion rule: Simple Conversion rule:

-1 mg po morphine = ½ mcg fentanyl-1 mg po morphine = ½ mcg fentanyl

-(60 mg morphine roughly 25 mcg patch)-(60 mg morphine roughly 25 mcg patch)

DOSE FINDINGDOSE FINDING

ADDING AN OPIOIDADDING AN OPIOID

To achieve quick To achieve quick pain relief: (LOAD)pain relief: (LOAD)

1. 1. Start low Start low dose, short-actingdose, short-acting

2. 2. Dose q peakDose q peak

3.3. Re-eval in 4 Re-eval in 4 hrs. to figure out hrs. to figure out what dose is what dose is neededneeded

Breakthrough dosingBreakthrough dosing

Use immediate-release opioidsUse immediate-release opioids– 10% of 24-h dose10% of 24-h dose (or 1/3 of one ER (or 1/3 of one ER

dose)dose)– offer after Coffer after Cmaxmax reached reached

po / pr po / pr q 1 h q 1 h SC, IM SC, IM q 30 min q 30 min IV IV q 10–15 min q 10–15 min

Do NOT use extended-release Do NOT use extended-release opioids for breakthroughopioids for breakthrough

Ongoing assessmentOngoing assessment

Increase analgesics until pain Increase analgesics until pain relieved or adverse effects relieved or adverse effects unacceptableunacceptable

Be prepared for sudden Be prepared for sudden changes in painchanges in pain– plan for breakthroughs (prior to plan for breakthroughs (prior to

dressing changes or patient care dressing changes or patient care activities)activities)

Opioid Dose EscalationOpioid Dose EscalationAlways increase by a percentage of the present dose based upon patient’s pain rating and current assessment

Mild pain 1-3/10

25% increaseModerate pain4-6/10

25-50% increase Severe pain7-10/10

50-100% increase

Incomplete cross-Incomplete cross-tolerancetolerance If a switch is being made from one opioid to If a switch is being made from one opioid to

another it is recommended to another it is recommended to start the new start the new opioid at ~50%opioid at ~50% of the equianalgesic dose. of the equianalgesic dose.

This is because the This is because the tolerancetolerance a patient has a patient has towards one opioid, may not completely transfer towards one opioid, may not completely transfer (“incomplete cross-tolerance”) to the new opioid.(“incomplete cross-tolerance”) to the new opioid.

from

100%

to

50%of new Opioid

Pain Problem #1Pain Problem #1

You started Mrs. T on 10 mg You started Mrs. T on 10 mg morphine every 4hrs around the morphine every 4hrs around the clock for her cancer pain with clock for her cancer pain with good effect. She says she’s tired good effect. She says she’s tired of taking a pill every 4 hours. of taking a pill every 4 hours. Convert her to long-acting Convert her to long-acting morphine with appropriate prn morphine with appropriate prn doses. doses.

Pain Problem #1: Pain Problem #1: AnswerAnswer 24 hour use:24 hour use:10mg PO morphine x 6 = 60 mg PO morphine10mg PO morphine x 6 = 60 mg PO morphine Convert to long-acting twice a day dosing:Convert to long-acting twice a day dosing:

60 mg PO morphine / 2 = 30mg PO morphine 60 mg PO morphine / 2 = 30mg PO morphine SR BIDSR BID

Calculate prn dosing of morphine sulfate-Calculate prn dosing of morphine sulfate-immediate release:immediate release:

60mg PO morphine in 24 h x 10% = 6mg PO 60mg PO morphine in 24 h x 10% = 6mg PO morphine q3h prn breakthrough painmorphine q3h prn breakthrough pain

Part 2Part 2

She is admitted to the hospital She is admitted to the hospital and unable to take oral and unable to take oral medications--convert Mrs. T to: IV medications--convert Mrs. T to: IV morphinemorphine

Part 2: AnswerPart 2: Answer

Ratio of IV:PO morphine sulfate:Ratio of IV:PO morphine sulfate:

1mg:3mg1mg:3mg

Therefore: 60/x = 3/1Therefore: 60/x = 3/1

X=20mg IV morphine in 24hr periodX=20mg IV morphine in 24hr period

Dose q 3h = 20mg/8 = 2.5mg IV q3hrDose q 3h = 20mg/8 = 2.5mg IV q3hr

PRN dose? PRN dose?

2mg IV morphine q 2hr prn breakthrough 2mg IV morphine q 2hr prn breakthrough painpain

Part 3Part 3

Mrs. T has uncontrolled pain of Mrs. T has uncontrolled pain of moderate intensity because of moderate intensity because of progression of her disease. How progression of her disease. How would you re-dose her IV would you re-dose her IV morphine?morphine?

Part 3-AnswerPart 3-Answer

Increase pain regimen by 25-50% Increase pain regimen by 25-50% for moderate uncontrolled painfor moderate uncontrolled pain

Let’s increase by 25%Let’s increase by 25%

25% of 20mg IV morphine = 25mg 25% of 20mg IV morphine = 25mg IV morphine in 24 hoursIV morphine in 24 hours

Dosing q3h= 25mg/8 = 3mg IV Dosing q3h= 25mg/8 = 3mg IV morphine q3hmorphine q3h

Pain Problem #2Pain Problem #2

Mr. T is a 73 yo man with lung cancer, a Mr. T is a 73 yo man with lung cancer, a malignant plueral effusion, and chronic chest malignant plueral effusion, and chronic chest pain. He has undergone therapuetic pain. He has undergone therapuetic thoracentesis and pleuradesis. He is currently thoracentesis and pleuradesis. He is currently receiving meperidine 75 mg IM q6h, for pain. You receiving meperidine 75 mg IM q6h, for pain. You want to switch him to oral morphine because you want to switch him to oral morphine because you are aware that:are aware that:

1. IM meds hurt!1. IM meds hurt!2. it’s metabolite, normeperidine, can 2. it’s metabolite, normeperidine, can

accumulate in pts (with renal failure) and cause accumulate in pts (with renal failure) and cause CNS toxicity such as tremulousness, CNS toxicity such as tremulousness,

dyphoria, dyphoria, myoclonus and sz.myoclonus and sz. Without adjustingWithout adjusting for incomplete cross-tolerance, for incomplete cross-tolerance,

what dose and schedule would you choose?what dose and schedule would you choose?

Pain Problem #2: Pain Problem #2: AnswerAnswer Ratio of IV meperidine: PO morphineRatio of IV meperidine: PO morphine50mg:15mg50mg:15mg75mg x 4 = 300mg75mg x 4 = 300mg300/x = 50/15300/x = 50/15X=90 mg PO morphine in 24hX=90 mg PO morphine in 24h Adjust for incomplete cross-tolerance:Adjust for incomplete cross-tolerance:Decrease by 1/3 = 60mgDecrease by 1/3 = 60mg Dosing PO morphine q4h:Dosing PO morphine q4h:10mg PO morphine q4h10mg PO morphine q4h