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AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals.

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Presentation on theme: "AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals."— Presentation transcript:

1 THE RESIDENT’S GUIDE TO PAIN MANAGEMENT Elizabeth Kvale, MD Palliative Medicine
AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. Topic

Nociceptive — arthritis, fracture, laceration Visceral — pancreatitis, MI, constipation Neuropathic — herpes zoster, diabetic neuropathy Complex regional pain syndromes (RSD) Central pain Topic

Acute pain Identified event, resolves in days–weeks Usually nociceptive Chronic pain Cause often not easily identified; multifactorial Indeterminate duration Nociceptive and/or neuropathic Topic

Pain is a subjective experience ― the patient is the best source of information about their pain Pain history ― site(s), intensity, temporality, character, exacerbating and alleviating factors Topic

Allows you to know and document whether you have helped the patient Topic

6 Pain Management Basics:
Match the medication to the amount of the patient’s discomfort 3 Severe 2 Moderate Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone ± Adjuvants A/Codeine A/Hydrocodone A/Oxycodone A/Dihydrocodeine Tramadol ± Adjuvants 1 Mild ASA Acetaminophen NSAIDs ± Adjuvants Topic

7 Pain Management Basics
Don’t delay for investigations or disease treatment Unmanaged pain  nervous system changes Permanent damage Amplification of pain Treat underlying cause (eg, radiation for a neoplasm) Topic

8 Pain Management Basics: Opioid pharmacology (1 of 2)
Conjugated in liver Excreted via kidney (90%–95%) First-order kinetics Time to Cmax PO dosing ― 1 hour SC or IM dosing ― 30 minutes IV dosing ― 6 minutes Topic

9 Pain Management Basics: Opioid pharmacology (2 of 2)
Steady state after 4–5 half-lives Steady state after 1 day (24 hours) Duration of effect of “immediate-release” formulations (except methadone) 3–5 hours PO or PR Shorter with parenteral bolus Topic

10 Pain Management Basics Oral dosing of immediate-release preparations
Codeine, hydrocodone, morphine, hydromorphone, oxycodone Dose q4h Adjust dose daily Mild or moderate pain: ↑ 25%–50% Severe or uncontrolled pain: ↑ 50%–100% Adjust more quickly for severe uncontrolled pain Topic

11 Pain Management Basics Oral dosing of extended-release preparations
Improve compliance, adherence Dose q8h, q12h, or q24h (product-specific) Don’t crush or chew tablets May flush time-release granules down feeding tubes Adjust dose q2–4 days (once steady state reached) Topic

12 Pain Management Basics Breakthrough pain
Use immediate-release opioids 5%–15% of 24-h dose Offer after Cmax reached PO or PR: ~ q1h SC or IM: ~ q30min IV: ~ q10–15min Do not use extended-release opioids Topic

13 Pain Management Basics
Ongoing assessment Increase analgesics until pain is relieved or adverse effects are unacceptable Be prepared for sudden changes in pain Driving is safe if pain is controlled, dose is stable, no adverse effects Topic

14 Concerns ABOUT opioid use: POOR RESPONSE
If dose escalation  adverse effects: Use more sophisticated therapy to counteract adverse effect Use an alternative: Route of administration Opioid (“opioid rotation”) Use a co-analgesic Use a nonpharmacologic approach Topic

15 Concerns ABOUT opioid use: Clearance
Conjugated in liver 90%–95% excreted in urine If dehydration, renal failure, severe hepatic failure develops:  dosing interval,  dosage size If oliguria or anuria develops: Stop routine dosing of morphine Use only PRN Topic

16 Concerns ABOUT opioid use: TOLERANCE
Reduced effectiveness to a given dose over time Not clinically significant with chronic dosing If dose requirement is increasing, suspect disease progression Topic

17 Concerns ABOUT opioid use: Addiction
Psychological dependence Compulsive use Loss of control over drugs Loss of interest in pleasurable activities Topic

18 Concerns ABOUT opioid use: Physical dependence
A process of neuroadaptation Abrupt withdrawal may  abstinence syndrome If dose reduction required, reduce by 50% q2–3 days Avoid antagonists Topic

19 Concerns ABOUT opioid use: Substance ABUSERS
Can have pain too Treat with compassion Protocols, contracting Consult with pain or addiction specialists Topic

20 Concerns ABOUT OPIOID USE: Things to avoid
Meperidine — accumulates toxic metabolite normeperidine Mixed agonists/antagonists – Nubain, Talwin Do not use naloxone (Narcan) unless true respiratory crisis (RR < 6) Topic

Ask the patient Palliative medicine corollary ― believe the patient Match the pain medicine to patient’s level of pain Increase pain medicine (with awareness of Cmax and half-life) until patient is comfortable Slide 21 Topic

22 Mrs Paine Very pleasant 68-year-old admitted with COPD exacerbation
Home meds include 2 tablets of oxycodone 5 mg/APAP “whenever my back acts up” — usually 4 tablets a day Appropriate pain medication order? Topic

23 Mrs Paine Readmitted months later with stage IV non-small cell lung cancer Taking 2 oxycodone/APAP tabs every 6 hours Rates her pain as 7/10 “most of the time” Topic

24 Key Points Maximum acetaminophen dose in 24 hours is 4 grams
Tylenol #3 (codeine 30 mg/APAP 325 mg)  24-hr maximum = 12 tablets Percocet (oxycodone 5 mg/APAP 325 mg)  24-hr maximum = 12 tablets Tylox (oxycodone 5 mg/APAP 500 mg)  24-hr maximum = 8 tablets Lortab 5 (hydrocodone 5 mg/APAP 500 mg)  24-hr maximum = 8 tablets How long does it take to get a PRN dose of pain medication once it is requested? Topic

25 Key Points Mrs Paine’s total daily oxycodone dose is 40 mg (8 tablets  5 mg) Topic

26 Thank you for your time! Visit us at:

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