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Pain Assessment & Management M3 Palliative Medicine Curriculum Seema S. Limaye, MD University of Chicago.

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Presentation on theme: "Pain Assessment & Management M3 Palliative Medicine Curriculum Seema S. Limaye, MD University of Chicago."— Presentation transcript:

1 Pain Assessment & Management M3 Palliative Medicine Curriculum Seema S. Limaye, MD University of Chicago

2 GOALS 1. Describe methods of pain assessment in cognitively impaired older adults. 2. Understand various types of pain. 3. Describe the basic pharmacology of opioids 4. Understand how to initiate and titrate opioids.

3 Self-Directed Learning Modules Basics of Neuropathic pain Basics of Neuropathic pain Side Effects of Opiods and Management Options Side Effects of Opiods and Management Options Treatment of Pain in Persons with h/o Substance Abuse Treatment of Pain in Persons with h/o Substance Abuse

4 Mrs. P 70 y.o. female h/o Pagets disease, renal insufficiency, osteoporosis presents to clinic with new back pain. What do you want to obtain from the history?

5 Pain History Pain Characteristics – onset, duration, location, quality, intensity, associated symptoms, exacerbating and relieving factors Past and current management therapies Relevant medical and family history Psychosocial history Impact of pain on daily life – work, daily activities, personal relationships, sleep, appetite, emotional state Patient (and familys) expected goals for treatment

6 Pain: A Complex Phenomenon Pain Pain –Sensory stimuli and/or neurologic injury modified by an individuals memory, expectations, emotions Biocultural Model of Pain: Biocultural Model of Pain: –Society also influences an individuals pain experiences

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8 Pain Assessment is NOT…. Relying on changes in vital signs Relying on changes in vital signs Deciding a patient does not look in pain Deciding a patient does not look in pain Knowing how much a procedure or disease should hurt Knowing how much a procedure or disease should hurt Assuming a sleeping patient does not have pain Assuming a sleeping patient does not have pain Assuming a patient will tell you they are in pain Assuming a patient will tell you they are in pain

9 Consequences of Untreated Pain Acute pain: Acute pain: –increase metabolic rate and blood clotting, –impair immune function –induce negative emotions Without intervention, pain receptors become sensitive and may have long lasting changes in the neurons Without intervention, pain receptors become sensitive and may have long lasting changes in the neurons

10 Consequences of Untreated Pain Chronic pain may lead to: Chronic pain may lead to: –fatigue, –anxiety, –depression, –confusion, –increased falls, –impaired sleep, and –decreased physical functioning/deconditioning

11 Bedside Assessment ASK the patient about pain ASK the patient about pain –Asking about ADLs and IADLs –Asking about physical activity, mood, sleep, appetite, energy level Identify preferred pain terminology Identify preferred pain terminology -hurting, aching, stabbing, discomfort, soreness Use a pain scale that works for the individual Use a pain scale that works for the individual -Insure understanding of its use -Modify sensory deficits Ferrell et al. J Pain Symptom Manage Chinball and Tait Pain Herr and Garand. Pain Management in the Elderly 2001

12 Use a standard scale to track the course of pain Use a standard scale to track the course of pain

13 Faces Pain Scale and Pain Thermometer

14 What are some common barriers to pain treatment?

15 Remember the common patient- related barriers to pain management Drugs.. Drugs.. –are addicting –should be saved for when it is really needed –have unpleasant or dangerous side effects –pills are not as effective as a shot –narcotics are only for dying people

16 Pain assessment in a vulnerable group: Cognitively Impaired Older Adults

17 Assessing pain: Nonverbal, Moderate to Severe Impairment Formal assessment tools available but not necessarily useful in routine clinical settings Formal assessment tools available but not necessarily useful in routine clinical settings Unique Pain Signature Unique Pain Signature Nonverbal Pain Indicators Nonverbal Pain Indicators Kaasalainen et al Perspectives Herr and Garand Clinics in Geriatric Medicine 2000

18 Unique Pain Signature Unique Pain Signature How does the patient usually act? How does the patient usually act? What changes are seen when they are in pain? What changes are seen when they are in pain? –family members –nursing staff Communication across caregiver settings is key! Communication across caregiver settings is key! Kovach et al. J Pain Symptom Manage Feldt et al. JAGS Weiner et al. Aging 1998.

19 Nonverbal Pain Indicators Facial expressions (grimacing) Facial expressions (grimacing) -Less obvious: slight frown, rapid blinking, sad/frightened, any distortion Vocalizations (crying, moaning, groaning) Vocalizations (crying, moaning, groaning) -Less obvious: grunting, chanting, calling out, noisy breathing, asking for help Body movements (guarding) Body movements (guarding) -Less obvious: rigid, tense posture, fidgeting, pacing, rocking, limping, resistance to moving -Less obvious: rigid, tense posture, fidgeting, pacing, rocking, limping, resistance to moving Kaasalainen et al Perspectives Herr and Garand Clinics in Geriatric Medicine 2000

20 Selection of pain meds Source/type of pain Source/type of pain Duration/timing/frequency Duration/timing/frequency History of medication use History of medication use Impact on quality of life Impact on quality of life Presence of associated factors Presence of associated factors

21 Types of Pain: A Brief Review Nociceptive Pain Nociceptive Pain –Visceral –Somatic Neuropathic Pain Neuropathic Pain Mixed/Unspecified Pain Mixed/Unspecified Pain Psychologic cause Psychologic cause

22 Quality: Visceral Pain Descriptors: cramping, squeezing, pressure Descriptors: cramping, squeezing, pressure Distribution/Examples: Distribution/Examples: –Referred heart attack, kidney stone heart attack, kidney stone –Colicky Bowel obstruction, gallstone Bowel obstruction, gallstone –Diffuse Peritonitis Peritonitis Analgesics: opioids; acetaminophen Analgesics: opioids; acetaminophen

23 Quality: Somatic pain Descriptors: aching, deep, dull, gnawing Distribution/Examples: –Well localizedpatients can often point with one finger to the location of their pain bone mets, strained ankle, toothache Analgesics: NSAIDS, acetaminophen opioids

24 General Principles of Management Set a goal of reduction of pain to tolerable levels, not a goal of complete relief Set a goal of reduction of pain to tolerable levels, not a goal of complete relief Start low and go slow Start low and go slow Make sure patient and family are aware of goals Make sure patient and family are aware of goals Frequent clinic visits at first for assurance, validation, and monitoring of titration Frequent clinic visits at first for assurance, validation, and monitoring of titration

25 WHO 3-Step ladder WHO 3-Step ladder Source: World Health Organization. Technical Report Series No. 804, Figure 2. Geneva: World Health Organization; Reprinted with permission. Source: World Health Organization. Technical Report Series No. 804, Figure 2. Geneva: World Health Organization; Reprinted with permission.

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27 Non-opioid medications Acetominophen 650mg tid-qid : concern for hepatic toxicity >3-4grams Acetominophen 650mg tid-qid : concern for hepatic toxicity >3-4grams NSAIDs including Ibuprofen, Naproxen, COX-2 inhibitors: concern for gastric / renal toxicity, platelet dysfunction, may inhibit anti-hypertensive meds NSAIDs including Ibuprofen, Naproxen, COX-2 inhibitors: concern for gastric / renal toxicity, platelet dysfunction, may inhibit anti-hypertensive meds

28 Opioid combination products The following opioids are available as combination products with acetaminophen, aspirin, or ibuprofen The following opioids are available as combination products with acetaminophen, aspirin, or ibuprofen –Codeine; hydrocodone; oxycodone; propoxyphene Typically used for Typically used for –Moderate episodic (PRN) pain –Breakthrough pain in addition to a long-acting opioid. Never prescribe more than one combination drug at any one time. Never prescribe more than one combination drug at any one time.

29 Which combination product? Analgesic potency: –hydrocodone and oxycodone are more potent than codeine, which is more potent than propoxyphene, which some studies suggest is equipotent to aspirin. –there is little difference between hydrocodone products and oxycodone products in terms of potency. Note: propoxyphene products are not recommended for pain in most national pain guidelines, due to side effects and unclear efficacy compared to other products

30 Adjuvants Non-pharmacologic Non-pharmacologic Topicals Topicals Tylenol Tylenol NSAIDS, Celecoxib, steroids NSAIDS, Celecoxib, steroids Anticonvulsants Anticonvulsants Antidepressants Antidepressants Antiarrhythmics Antiarrhythmics

31 Opioid Pharmacology Block the release of neurotransmitters in the spinal cord Block the release of neurotransmitters in the spinal cord Agonist of Mu, delta, kappa receptors Agonist of Mu, delta, kappa receptors Conjugated in liver Conjugated in liver Excreted via kidney (90%–95%) Excreted via kidney (90%–95%)

32 Opioid pharmacology Central and peripheral effects of opioids Central and peripheral effects of opioids This leads to desired effects, as well as side effects This leads to desired effects, as well as side effects

33 ReceptorClinical Effects Mu 1Supraspinal analgesia Peripheral analgesia Sedation Euphoria Prolactin release Mu 2Spinal analgesia Respiratory depression Physical dependence GI dysmotility Pruritis Bradycardia GH release

34 ReceptorClinical Effects Kappa 1Spinal analgesia Miosis Diresis Kappa 2Psychotomimesis Dysphoria Kappa 3Supraspinal analgesia DeltaSpinal and supraspinal analgesia Nociceptin/orphaninAnxiolysis Analgesia

35 Clearance concerns Conjugated by liver Conjugated by liver 90%–95% excreted in urine 90%–95% excreted in urine Dehydration, renal failure, severe hepatic failure Dehydration, renal failure, severe hepatic failure dosing interval (extend time) or dosing interval (extend time) or dosage size dosage size –if oliguria or anuria STOP routine dosing of morphine STOP routine dosing of morphine use ONLY prn use ONLY prn

36 Opiod Pharmacology… What is the peak effect (C max ) of morphine: What is the peak effect (C max ) of morphine: –PO? min min –IV? 5-15 min 5-15 min –SC/IM? Variable…usually min Variable…usually min What is the duration of effect of morphine? What is the duration of effect of morphine? –PO? 3-4 hours 3-4 hours –IV? Usually 1-2 hours, but we typically dose it q2-3 hours Usually 1-2 hours, but we typically dose it q2-3 hours

37 Plasma Concentration 00 Half-life (t 1/2 ) TimeTime IVIV po / pr SC / IM C max

38 ... More Opioid Pharmacology Steady state after 4–5 half-lives Steady state after 4–5 half-lives –steady state after 1 day (24 hours) Side Effects: Side Effects: –sedation, confusion, respiratory depression, constipation, urinary retention, nausea and vomiting

39 Short Acting Opioids Parenteral or Oral Parenteral or Oral –morphine –hydromorphone (Dilaudid ®) –meperidine (Demerol ®) –codeine Oral only Oral only –oxycodone (Percocet ®, Tylox ® ) –hydrocodone (Vicodin ® Lortab ®, Lorcet ®) –propoxyphene (Darvon ®, Wygesic ®) –Note: hydrocodone is only available as a combination product.

40 Routine oral dosing extended-release preparations Improve compliance, adherence Improve compliance, adherence Dose q 8, 12, or 24 h (product specific) Dose q 8, 12, or 24 h (product specific) –dont crush or chew tablets –may flush time-release granules down feeding tubes Adjust dose q 2–4 days (once steady state reached) Adjust dose q 2–4 days (once steady state reached)

41 Transdermal Fentanyl Duration hours Duration hours hours to reach full analgesic effect hours to reach full analgesic effect Not recommended as first-line in opiate naïve patients Not recommended as first-line in opiate naïve patients Lipophilic Lipophilic Simple Conversion rule: Simple Conversion rule: -1 mg po morphine = ½ mcg fentanyl -(60 mg morphine roughly 25 mcg patch)

42 DOSE FINDING

43 ADDING AN OPIOID To achieve quick pain relief: (LOAD) 1. Start low dose, short-acting 2. Dose q peak 3.Re-eval in 4 hrs. to figure out what dose is needed

44 Breakthrough dosing Use immediate-release opioids Use immediate-release opioids –10% of 24-h dose (or 1/3 of one ER dose) –offer after C max reached po / pr q 1 h po / pr q 1 h SC, IM q 30 min SC, IM q 30 min IV q 10–15 min IV q 10–15 min Do NOT use extended-release opioids for breakthrough Do NOT use extended-release opioids for breakthrough

45 Ongoing assessment Increase analgesics until pain relieved or adverse effects unacceptable Increase analgesics until pain relieved or adverse effects unacceptable Be prepared for sudden changes in pain Be prepared for sudden changes in pain –plan for breakthroughs (prior to dressing changes or patient care activities)

46 Opioid Dose Escalation Always increase by a percentage of the present dose based upon patients pain rating and current assessment Mild pain 1-3/10 25% increase Moderate pain 4-6/ % increase Severe pain 7-10/ % increase

47 Incomplete cross- tolerance If a switch is being made from one opioid to another it is recommended to start the new opioid at ~50% of the equianalgesic dose. If a switch is being made from one opioid to another it is recommended to start the new opioid at ~50% of the equianalgesic dose. This is because the tolerance a patient has towards one opioid, may not completely transfer (incomplete cross-tolerance) to the new opioid. This is because the tolerance a patient has towards one opioid, may not completely transfer (incomplete cross-tolerance) to the new opioid. from 100% to 50% of new Opioid

48 Pain Problem #1 You started Mrs. T on 10 mg morphine every 4hrs around the clock for her cancer pain with good effect. She says shes tired of taking a pill every 4 hours. Convert her to long-acting morphine with appropriate prn doses. You started Mrs. T on 10 mg morphine every 4hrs around the clock for her cancer pain with good effect. She says shes tired of taking a pill every 4 hours. Convert her to long-acting morphine with appropriate prn doses.

49 Pain Problem #1: Answer 24 hour use: 24 hour use: 10mg PO morphine x 6 = 60 mg PO morphine Convert to long-acting twice a day dosing: Convert to long-acting twice a day dosing: 60 mg PO morphine / 2 = 30mg PO morphine SR BID Calculate prn dosing of morphine sulfate- immediate release: Calculate prn dosing of morphine sulfate- immediate release: 60mg PO morphine in 24 h x 10% = 6mg PO morphine q3h prn breakthrough pain

50 Part 2 She is admitted to the hospital and unable to take oral medications-- convert Mrs. T to: IV morphine She is admitted to the hospital and unable to take oral medications-- convert Mrs. T to: IV morphine

51 Part 2: Answer Ratio of IV:PO morphine sulfate: Ratio of IV:PO morphine sulfate:1mg:3mg Therefore: 60/x = 3/1 X=20mg IV morphine in 24hr period Dose q 3h = 20mg/8 = 2.5mg IV q3hr PRN dose? 2mg IV morphine q 2hr prn breakthrough pain

52 Part 3 Mrs. T has uncontrolled pain of moderate intensity because of progression of her disease. How would you re-dose her IV morphine? Mrs. T has uncontrolled pain of moderate intensity because of progression of her disease. How would you re-dose her IV morphine?

53 Part 3-Answer Increase pain regimen by 25-50% for moderate uncontrolled pain Increase pain regimen by 25-50% for moderate uncontrolled pain Lets increase by 25% Lets increase by 25% 25% of 20mg IV morphine = 25mg IV morphine in 24 hours Dosing q3h= 25mg/8 = 3mg IV morphine q3h

54 Pain Problem #2 Mr. T is a 73 yo man with lung cancer, a malignant plueral effusion, and chronic chest pain. He has undergone therapuetic thoracentesis and pleuradesis. He is currently receiving meperidine 75 mg IM q6h, for pain. You want to switch him to oral morphine because you are aware that: Mr. T is a 73 yo man with lung cancer, a malignant plueral effusion, and chronic chest pain. He has undergone therapuetic thoracentesis and pleuradesis. He is currently receiving meperidine 75 mg IM q6h, for pain. You want to switch him to oral morphine because you are aware that: 1. IM meds hurt! 2. its metabolite, normeperidine, can accumulate in pts (with renal failure) and cause CNS toxicity such as tremulousness, dyphoria, myoclonus and sz. Without adjusting for incomplete cross-tolerance, what dose and schedule would you choose? Without adjusting for incomplete cross-tolerance, what dose and schedule would you choose?

55 Pain Problem #2: Answer Ratio of IV meperidine: PO morphine Ratio of IV meperidine: PO morphine50mg:15mg 75mg x 4 = 300mg 300/x = 50/15 X=90 mg PO morphine in 24h Adjust for incomplete cross-tolerance: Adjust for incomplete cross-tolerance: Decrease by 1/3 = 60mg Dosing PO morphine q4h: Dosing PO morphine q4h: 10mg PO morphine q4h


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