Section IV: Principles of Pain Management Opioid dose titration Long-acting medications Opioid rotation/equianalgesia Addictive disease Interventional therapies Non-pharmacological techniques Nursing role

Principles of Opioid Dose Titration Sustained release medications Immediate-release for breakthrough pain Distinguish types of breakthrough pain

Principles: Use of Opioid Rotation Use when one opioid is ineffective, even with adequate titration Use when adverse effects are unmanageable

Principles of Equianalgesia Determine equal doses when changing drugs or routes of administration Reduce by 25% when changing drugs Use of morphine equivalents

Treatment of Pain in Persons With Addictive Behaviors Team meetings with interdisciplinary approach Set realistic goals Set limits Use nonopioids as able Consider tolerance

Treatment of Pain in Persons With Established Addictive Disease (cont Avoid parenteral injections, if possible Prevent withdrawal Treat depression and other psychiatric disorders Use alternate opioid if on methadone for maintenance

Other Issues Polypharmacy Cost Compounding

Cancer Therapies to Relieve Pain . Radiation Surgery Chemotherapy Hormonal therapy Bisphosphonates

Interventional Therapies Neurolytic blocks Neuroablative procedures Vertebroplasty/kyphoplasty

Non-Pharmacologic Strategies Physical Complementary & Integrative Psychosocial Rehabilitation Relaxation Acupuncture Exercise Meditation Qigong Heat or cold Hypnosis Therapeutic massage TENS (transcutaneous electrical nerve stimulation) Music Reiki Biofeedback Systematic desensitization Cognitive-behavioral therapy

Summary Pain relief is contingent on adequate assessment and use of both drug and non-drug therapies Pain extends beyond physical causes to other causes of suffering and existential distress Interdisciplinary care