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