Pain Management: The things you should know

1. Pain Management: The things you should know For additional advice seeDale Carnegie Training® Presentation Guidelines

2. 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

3. 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

4. Psychological effects of Pain • Negative emotions: anxiety, depression • Sleep deprivation • Existential suffering: may lead to patients seeking active end of life.

5. Immunological effects of Pain • Decrease natural killer cell counts • Effects on other lymphocytes not yet defined.

6. Procedure Related Pain • Common in all patients • Frequent source of pain and distress

7. 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

8. 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

9. 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?

10. 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

11. 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 Neuropathic Pain

12. Opioids Codeine Fentanyl Hydrocodone Hydormorphone • Methadone • Morphine • Oxycodone • Oxymorphone

13. Cost of Opioids (AWP 2003 Redbook )(Equianalgesic Dose (morphine 180-200mg / day ATC) Brand Generic Dose Cost/30 days Cost/day Roxanol morphine 30 mg q4h $186.84 ($58.75) $6.23 ($2.00) Morphine IR morphine 30 mg q4h $147.62 $4.92* Oramorph SR® morphine 100 mg q12h $307.20 $10.24 MS Contin ® morphine 100 mg q12h $328.20 $10.94 Morphine SR morphine 100 mg q12h $293.75 $9.79* Avinza ® Morphine 200mg q24h $433.80 $14.46 Kadian ® morphine 200 mg q24h $365.00 $12.18 Duragesic® fentanyl 100 mcg q72h $482.72 $16.06 Oxydose ® oxycodone 30 mg q4h 309.78($259.97) $10.32* Oxycontin ® oxycodone 80 mg q12h $514.85 $17.16 Dilaudid ® hydromorphone 8 mg q4h $219.60 $7.32 Dolophine ® methadone 20 mg q8h $ 30.26$1.01 ($0.51-4.54)

14. 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

15. Principles of Opioid Analgesic Use in Acute and Cancer Pain (cont) • When changing to a new opioid or different route • Use equianalgesic dosing table to estimate new dose • Modify estimate based on clinical situation • 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

16. Principles of Opioid Analgesic Use in Acute and Cancer Pain (cont) • Watch for development of: • 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)

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

18. Practical Prescribing: Equianalgesic Dosing

19. Some Equianalgesic Doses Common drugs with oral doses equianalgesic to 650mg oral aspirin or acetaminophen • Pentaxocine (Talwin) 30mg • Codeine 32mg • Meperidine (Demerol) po 50mg • Propoxphene (Darvon) 65mg

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

21. Principles: Use of Opioid Rotation • Use when one opioid ineffective or for adverse effects

22. Methadone • Acute pain: methadone  morphine (1:1) • 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

23. 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.

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

25. 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

26. NSAIDS Acetaminophen Antidepressants Anticonvulsants Corticosteroids Neuroleptics Antihistamines Analeptics Benzodiazepines Antispasmodics Muscle relaxants Systemic local anesthetics Co Analgesics Commonly Used For Pain

27. Systemic Local Anesthetics • Indications • Neuropathic pain • Toxicities • Dizziness, nausea, tremor, nervousness, incoordination, headaches, paresthesias • Drugs • Lidocaine, mexiletine

28. 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 long-lasting 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)

29. 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)

30. Analgesics for Neuropathic Pain • Tricyclic antidepressants • nortriptaline (1st choice) • Anticonvulsants • Gabapentin, Carbamazepine, Pregaba • Local anesthetics • Parenteral, oral, topical • Topical capsaicin • Opioids for selected patients

31. 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

32. Making PCA Work for your Patient PCA History; dosing,bolus; basal rates Always remember SC PCA

33. Quality of Life Invasive treatments Opioid Delivery Pain persisting or increasing Step 3 Opioid for moderate to severe pain ± ± Nonopioid Adjuvant Pain persisting or increasing Step 2 Opioid for mild to moderate pain ± ± Nonopioid Adjuvant Pain persisting or increasing Step 1 ± Nonopioid ± Adjuvant Pain Modified WHO Analgesic Ladder Proposed 4th Step The WHOLadder Deer, et al., 1999

34. Role of Invasive (“Anesthetic”) Procedures • Intractable pain* • Intractable side effects* *Symptoms that persists despite carefully individualized patient management

35. 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

36. Lidocaine Ketamine Methadone Sedation Spinal cord stimulator Chemotherapy, radiation Surgery Biphosphates Others Other techniques ...

37. Q&A