PAIN MANAGEMENT

1. PAIN MANAGEMENT Paula A. Caron MS, APRN, ACHPN New Hampshire Hospice and Palliative Care Organization Annual Conference November 10, 2011

2. Assumptions…………… • You know basic physiology about pain • You know the definition of pain • You know adjuncts to pharmacologic management of pain (massage, acupuncture, TENS, etc) • You have basic pain assessment skills

3. Pain Satisfaction(?type of pain) • More than 75% of a sample of 316 people reported being satisfied with their pain management • Nearly half rated their pain as moderate to severe • Dawson et al (2002) Journal of Pain and Symptom Management, 23, 211-221.

4. Pain Satisfaction • 81% of 191 patients reported satisfaction with pain management despite 76% of them describing their pain as moderate to severe • Svensson, et al (2001) European Journal of Pain, 5, 125-133

5. “being listened to” ranked most important over pain management which was ranked second in a survey asking patients to rank nursing interventions • Webb & Hope (1995), Clinical Journal of Oncology Nursing, 4, 101-108.

6. Research has shown that relief of pain is not as important to satisfaction as are communication, staff behavior and empathy • Hallstrom & Elander (2001), Nursing Ethics, 8, 409-418. • Corroborated by Dawson et al where the patient-provider relationship was an important predictor of patient satisfaction • Dawson et al (2002), Journal of Pain and Symptom Management, 23, 211-221.

7. Inadequate pain assessment is probably the most common barrier to successful management • Therefore, adequate assessment is key to successful management • AND……….patient satisfaction DUH

8. So in the process of conducting a thorough assessment, the nurse conveys a sense of caring which not only validates the pain experience but may actually be therapeutic to reduce pain levels

9. Opioid Therapy: Guidelines • Use a long-acting drug and a breakthrough medication • Increase breakthrough dose as the baseline dose increases • Treat side effects aggressively and proactively; some will extinguish (sedation, nausea)

10. Routes of administration • Transdermal • Fentanyl • Topical • EMLA, Lidoderm • Parenteral • IV/SQ/IM • IM worst way • Spinal • Epidural/Intrathecal • Oral • Immediate Release • Long Acting • Liquid • Mucosal • Actiq • Rectal • 90% concentration achieved

11. Where to start…… • If patient is opioid naive, start with oxycodone or morphine • Oxycodone 5 mg Sig: 1-2 tabs every 2 hours prn pain • Morphine 15 mg Sig: ½ to 1 tab every 2 hours prn pain Ask patient to keep a log (if outpatient) of use

12. Where to start……… • If a patient is using more than 4 doses of short acting medication a day to stay comfortable OR If pain is not well relieved Consider addition of a long acting opioid

13. So which one? • Long acting formulations available: • Morphine • Oxycodone • Fentanyl • Methadone

14. TOLERANCE PSYCHOLOGICAL DEPENDENCE / ADDICTION PHYSICAL DEPENDENCE

15. Tolerance • A state of adaptation in which exposure to a drug results in a decrease in the drugs effect over time. • Physiologic Dependence • A state of physical adaptation that is manifested by a specific withdrawal syndrome that is produced by rapid cessation of the drug. • Addiction • A primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors

16. TOLERANCE A normal physiological phenomenon in which increasing doses are required to produce the same effect Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

17. PHYSICAL DEPENDENCE A normal physiological phenomenon in which awithdrawal syndrome occurs when an opioid is abruptly discontinued or an opioid antagonist is administered Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

18. PSYCHOLOGICAL DEPENDENCE and ADDICTION A pattern of drug use characterized by a continued craving for an opioid which is manifest as compulsive drug-seeking behaviour leading to an overwhelming involvement in the use and procurement of the drug Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

19. Beware of the Pseudoaddict!! Pseudoaddiction is .. • The behavioral manifestations of addiction that occur as a result of under treated pain • Moaning/crying when you enter the room • Clock watching • Frequent requests for more medication • Pain that seems “excessive” for the stimulus • Patient has no other history to suggest addiction • Behaviors cease with adequate pain treatment

20. Pseudoaddiction Typically occurs in the hospitalized patient, in pain, who has opioids ordered: • At inadequate potency or dose • At excessive dosing intervals • And when the behavior is reinforced by MD or RN behavior that tends to limit opioid use: “you really shouldn’t be having this much pain” “you have to wait another two hours for your next dose of medication”

21. Opioids • Adverse Effects • Allergic Reactions - extremely rare • Respiratory Depression - extremely rare • Almost always preceded by sedation • Most common in an opioid naïve patient • RR of 6-8 may be normal if oxygenation is ok • Narcan can be given - mix one ampule (0.4mg) in 10cc of saline and push 1ml at a time. Duration is 30-60minutes • Constipation - expected and doesn’t get better • “The hand that writes the opioid order without writing a bowel prep is the hand that does the disimpaction” • EG: Senokot 1-2 po bid with MOM QHS, prn

22. Opioids • Adverse Effects • Sedation • Can occur, but tolerance usually develops • If a patient has been exhausted from pain, relieving the pain may finally allow them to rest • Urinary Retention • More common with opioid naïve patients and those receiving meds spinal route. Tolerance in a few days. • Nausea/Vomiting • Tolerance usually occurs • Pruritus • Tolerance usually occurs