Pain Management Robert B. Walker, M.D., M.S. DABFP, CAQ (Geriatrics) Robert C. Byrd Center for Rural...
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Transcript of Pain Management Robert B. Walker, M.D., M.S. DABFP, CAQ (Geriatrics) Robert C. Byrd Center for Rural...
Pain Management
Robert B. Walker, M.D., M.S.
DABFP, CAQ (Geriatrics)
Robert C. Byrd Center
for Rural Health
Marshall 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 Pain
B. 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 signals
Dominating 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
Problems with Opiates: Sedation
Look at Other Meds
Look for Other Reasons
Try Decrease Dose 25%
Try another Analgesic, Psychotropic
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?
A. Acetaminophen hepatic toxicity
B. Addiction
C. Tolerance
D. Respiratory depression
Answer A.
Acetaminophen hepatic toxicity
If a decision is made to change to a strong opioid alone, which starting dose of oral morphine would be reasonable?
A. 1 mg.
B. 5 mg.
C. 10 mg.
D. 50 mg.
Answer C.
10 mg.
To which of the following morphine effects will tolerance probably develop most slowly?
A. Sedation
B. Nausea
C. Pain relief
D. Obstipation/constipation
Answer D.
Obstipation/constipation
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)
Adjuvant Use
Tricyclic Antidepressants (Burning, Tingling)
– Low Doses (10 - 25 mg.)– Amitriptyline– Anticholenergic (sedating, drying, cardiac
effects)
Gabapentin
Special Situations
Terminal Events
Can’t Swallow: Go to Concentrate
If No Urine Output: Titrate to Pain (no routine dosing)
Converting from IV to Oral
Morphine, Oxycodone, Meperidine: 3 X dose
Hydromorphone (Dilaudid): up to 5 X dose
Then Reduce by 25% (cross tolerance)
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
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
SUMMARY Optimizing well-being of the
patient and loved ones Improving control over one’s life Can reduce uncontrolled pain to
less than 1 in 20. We primary care physicians can,
and must, get better at this.
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?
A. Regular interval dose
B. 10% of total daily dose
C. 20% of total daily dose
D. 30% of total daily dose
Answer B.
10% of total daily dose
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?
A. Give doses of another patient’s medicine B. Fax a prescription for the regular
medication to the local pharmacist.C. Give a medication on-hand not previously
prescribedD. Wait until a written script can be obtained.
Answer B.
Fax a prescription for the regular medication to the local pharmacist.
The patient begins to take no fluids and has instructed no IV be started. Urine output ceases. How should dosing be determined?
A. Titrate to pain, using rescue dose only
B. Half the usual interval dose
C. Give 10% of the usual interval dose
D. Double the usual interval dose.
Answer A.
Titrate to pain, using rescue doses only