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THE RESIDENT’S GUIDE TO PAIN MANAGEMENT Elizabeth Kvale, MD Palliative Medicine THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading.

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Presentation on theme: "THE RESIDENT’S GUIDE TO PAIN MANAGEMENT Elizabeth Kvale, MD Palliative Medicine THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading."— Presentation transcript:

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

2 PAIN PHYSIOLOGY BASICS: TYPES OF PAIN Nociceptive — arthritis, fracture, laceration Visceral — pancreatitis, MI, constipation Neuropathic — herpes zoster, diabetic neuropathy Complex regional pain syndromes (RSD) Central pain Slide 2

3 PAIN PHYSIOLOGY BASICS: ACUTE VS. CHRONIC PAIN Acute pain Identified event, resolves in days–weeks Usually nociceptive Chronic pain Cause often not easily identified; multifactorial Indeterminate duration Nociceptive and/or neuropathic Slide 3

4 PAIN ASSESSMENT BASICS: BELIEVE THE PATIENT 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 Slide 4

5 PAIN ASSESSMENT BASICS: USE AN ASSESSMENT INSTRUMENT Allows you to know and document whether you have helped the patient Slide 5

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

7 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) PAIN MANAGEMENT BASICS Slide 7

8 Conjugated in liver Excreted via kidney (90%–95%) First-order kinetics Time to C max  PO dosing ― 1 hour  SC or IM dosing ― 30 minutes  IV dosing ― 6 minutes PAIN MANAGEMENT BASICS: OPIOID PHARMACOLOGY (1 of 2) Slide 8

9 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 PAIN MANAGEMENT BASICS: OPIOID PHARMACOLOGY (2 of 2) Slide 9

10 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 PAIN MANAGEMENT BASICS Oral dosing of immediate-release preparations Slide 10

11 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) PAIN MANAGEMENT BASICS Oral dosing of extended-release preparations Slide 11

12 Use immediate-release opioids  5%–15% of 24-h dose  Offer after C max reached PO or PR: ~ q1h SC or IM: ~ q30min IV: ~ q10–15min Do not use extended-release opioids PAIN MANAGEMENT BASICS Breakthrough pain Slide 12

13 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 PAIN MANAGEMENT BASICS Slide 13

14 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 CONCERNS ABOUT OPIOID USE: POOR RESPONSE Slide 14

15 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 CONCERNS ABOUT OPIOID USE: CLEARANCE Slide 15

16 Reduced effectiveness to a given dose over time Not clinically significant with chronic dosing If dose requirement is increasing, suspect disease progression CONCERNS ABOUT OPIOID USE: TOLERANCE Slide 16

17 Psychological dependence Compulsive use Loss of control over drugs Loss of interest in pleasurable activities CONCERNS ABOUT OPIOID USE: ADDICTION Slide 17

18 A process of neuroadaptation Abrupt withdrawal may  abstinence syndrome If dose reduction required, reduce by 50% q2–3 days  Avoid antagonists CONCERNS ABOUT OPIOID USE: PHYSICAL DEPENDENCE Slide 18

19 Can have pain too Treat with compassion Protocols, contracting Consult with pain or addiction specialists CONCERNS ABOUT OPIOID USE: SUBSTANCE ABUSERS Slide 19

20 Meperidine — accumulates toxic metabolite normeperidine Mixed agonists/antagonists – Nubain, Talwin Do not use naloxone (Narcan) unless true respiratory crisis (RR < 6) CONCERNS ABOUT OPIOID USE: THINGS TO AVOID Slide 20

21 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 C max and half-life) until patient is comfortable SUMMARY: BASIC PRINCIPLES OF PAIN MANAGEMENT Slide 21

22 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? MRS PAINE Slide 22

23 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” MRS PAINE Slide 23

24 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? KEY POINTS Slide 24

25 Mrs Paine’s total daily oxycodone dose is 40 mg (8 tablets  5 mg) KEY POINTS Slide 25

26 Visit us at: Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics THANK YOU FOR YOUR TIME! linkedin.com/company/american-geriatrics- society Slide 26


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