1. Pain Management Robert B. Walker, M.D., M.S. DABFP, CAQ (Geriatrics) Robert C. Byrd Center for Rural Health Marshall University

2. Introduction

3. 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.

4. 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.

5. 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”

6. 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

7. 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

8. Diagnosing and Documenting Pain

9. Examples of Pain Scales

10. Documenting Pain • Onset • What relieves? • Location • What worsens? • Intensity • Effects on Daily Activities • Quality • Treatment History

11. Neurological Classification • Nociceptive Pain • Neuropathic Pain

12. 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

13. 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

14. Physical Examination • motor, sensory, reflexes • headaches: intracranial mass • zoster, pressure sores • non-verbal communication

15. Treating Pain

16. Treatment of Pain • Treat Causes if possible • Remember Non-Drug Treatments • Analgesics: Narcotic, Non-narcotic • Adjuvants: Anti-convulsants, Anti-depressants

17. 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

18. Non-Narcotic Analgesics • Acetaminophen (< 4 g / 24 hrs.) • NSAIDS (bone pain or inflammation) • Lots of side effects • Newer are expensive

19. 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

20. 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

21. Morphine • Max Effect: IV -15 minutes • SC- 30 minutes • PO: -I hr.

22. 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

23. 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

24. Extended Release • Better Compliance • More Expensive • Dose q 8,12, or 24

25. Extended Release • Don’t Crush or Chew • May flush through feeding tubes • Don’t Start with Extended Dose

26. 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

27. 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

28. Other Options: Fentanyl Patch • 25, 50, 75, 100 mcg/hr. • Apply every 3 Days • Divide Morphine Daily Dose in Half • Rescue with Opioids

29. 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.

30. 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

31. Other Options: Methadone • Starts working in about 1 hr. • Inexpensive • Neuropathic Pain

32. 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? • Increase medication dose • Change medication • Begin to give the medication at intervals of less than four hours • Add adjuvant medication.

33. Answer C. Begin to give the medication at intervals of less than four hours

34. 2. The most likely classification of this pain is: • Referred Pain • Nociceptive Pain • Neuropathic Pain • Visceral Pain

35. Answer B. Nociceptive Pain

36. 3. The oral morphine preparation given to this patient will begin to take full effect in about: • 15 minutes • 30 minutes • 1 hour • 2 hours

37. Answer C. 1 hour

38. Problems with Pain Management

39. 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?”

40. Warning signals Dominating Concerns over Availability Non-Provider Sanctioned Increases Ignoring Major Side Effects

41. Warning signals • Altering, losing Prescriptions • Multiple Sources • Unaccounted Medication

42. 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

43. 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

44. 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

45. Problems with Opiates: Nausea/Vomiting • Usually occurs initially • Improves with Time • May be Able to Prevent with other meds, no movement

46. Problems with Opiates: Respiratory Depression • Remember, fairly rapid tolerance develops • Almost always associated with sedation • Follow Respiratory Rate • Withhold Next 2 Doses

47. Naloxone • Dilute 1 Vial (0.4mg) in 10 cc. Normal Saline • Give 1 cc. per minute until respiratory rate OK

48. Problems with Opiates: Sedation • Look at Other Meds • Look for Other Reasons • Try Decrease Dose 25% • Try another Analgesic, Psychotropic

49. 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? • Acetaminophen hepatic toxicity • Addiction • Tolerance • Respiratory depression

50. Answer A. Acetaminophen hepatic toxicity