1. The Consortium for Advancements in Health & Human Services, Inc. Educational Program Development Team: BC Farnham, MSW, MBA; Debbie Favel, RN, MSN, CHPN; Dr. Denise Green; Sheryl Matney, MS; Jenny Gilley Carpenter, LPN.; Karina Lemos, RN.; Elizabeth R. Pugh, LBSW. This program is made possible through a collaborative community-education partnership between The Consortium for Advancements in Health & Human Services, Inc. and the presenting agency. The primary goal of this effort is to increase public awareness and access to hospice care, through the provision of community-based education. Contact Hours are awarded to professionals who complete this program by The Consortium for Advancements in Health & Human Services, Inc. © 2011 The Consortium for Advancements in Health & Human Services, Inc.

2.  This education program for healthcare professionals was developed by The Consortium for Advancements in Health and Human Services, Inc. (CAHHS) and is facilitated by the presenting agency via a community education partnership agreement. CAHHS is a private corporation and is solely responsible for the development, implementation and evaluation of its educational programs. There is no fee associated with receiving contact hours for participating in this program titled, Improving Quality of Life Through Effective Pain and Symptom Management. However, participants wishing to receive contact hours must offer a signature on the sign-in sheet, attend the entire program and complete a program evaluation form.  The Consortium for Advancements in Health and Human Services, Inc. is an approved provider of continuing nursing education by the Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. The Consortium for Advancements in Health & Human Services, Inc., is approved as a provider of continuing education in Social Work by the Alabama Board of Social Work Examiners, #0356, Expiration Date: 10/31/2014.  In most states, boards providing oversight for nursing and social work recognize contact hours awarded by organizations who are approved by another state's board as a provider of continuing education. If you have questions about acceptance of contact hours awarded by our organization, please contact your specific state board to determine its requirements. Provider status will be listed on your certificate.  CAHHS does not offer free replacement certificates to participants. In the event that CAHHS elects to provide a replacement certificate, there will be a $20.00 administrative fee charged to the individual who requests it.

3.  The attendee will be able to: ◦ Assess patient pain and differentiate between types of pain. ◦ Identify appropriate medications for treatment of pain. ◦ Utilize equianalgesic table for titration of opioids.

4. “Pain is a more terrible lord of mankind than even death itself.” - Albert Schweitzer

5.  Pain is “whatever the experiencing person says it is, existing whenever s/he says it does”. (McCaffery, 1968)

6. PAIN DEFINED Unpleasant Somato-Psychic Experience No Fun It affects the mind It originates in the body (most of the time) It is what the patient says it is

7.  Problems related to ◦ Healthcare professionals ◦ Patients ◦ The health care system

8.  Behavioral signs of pain is more reliable than self-report.  Pain teaches a person to be more tolerant of pain.  Non-cancer pain is not as severe as cancer pain.  Use of opioids for pain causes addiction.  Infants have decreased pain sensation.

9.  Tolerance  Physical Dependence  Addiction  Pseudo-addiction

10.  Patients in pain do not get addicted  May develop tolerance

11.  Professional, Patient and Family Team  Assess pain and associated symptoms regularly and systematically.  Asking patient to identify most troublesome symptom.  Believe patient and family reports of pain and what relieves the pain.

12.  Choose pain-control appropriate for the patient, family and setting.  Deliver interventions in a timely, logical, coordinated fashion.  Empower patients and families.  Develop effective plan of care

13. PAIN CYCLE Pain Decreased Tolerance of Pain Increased Anxiety Feelings of Hopelessness Despair Loneliness Anxiety Sleeplessness Decreased Appetite Decreased Mobility Decreased Psychological Functioning

14.  JCAHO: Right to appropriate assessment and management of pain.  Self-report of pain is the single most reliable indicator of pain.  Use pain scales appropriate to patient population.  Chronic pain patient maybe more sensitive to pain  Unrelieved pain has adverse physical and psychological consequences

15.  ACUTE PAIN – “complex, unpleasant experience with emotional and cognitive, as well as sensory, features that occur in response to tissue trauma.”  Elevated pulse, blood pressure and respirations, diaphoresis, dilated pupils, moaning, crying, rubbing

16.  CHRONIC PAIN – a persistent pain that “disrupts sleep and normal living, ceases to serve a protective function, and instead degrades health and functional capability.”  After more than 4 months, adaptive mechanisms, no measurable indications of pain

17.  Somatic – ◦ Pain in the muscles, bones, ligaments or joints ◦ Described as aching, gnawing, constant and localized ◦ Examples: Bone metastasis, surgical pain ◦ Responds to opioids, but may require adjuvant medications such as anti-inflammatories or muscle relaxers

18.  Visceral – ◦ Pain in smooth muscles and organs ◦ Caused by infiltration, compression, distention, or the stretching of tissue ◦ Described as aching, constant, not localized, may radiate to other areas ◦ Examples: Pancreatic cancer, liver metastasis ◦ Responds to opioids, but may require corticosteroid or anti-spasmodic adjuvant therapy.

19.  Neuropathic – ◦ Painful nervous system discharges ◦ Caused by inflammation, damage or pressure around a nerve ◦ Described as burning, aching, shooting, shock- like ◦ Examples: Peripheral neuropathy, spinal cord compression ◦ Responds poorly to opioids alone, but opioids may be used with an anti-depressant, anti- convulsant, anti-arrhythmic or other adjuvant

20.  Site – Where is your pain?  Character – What does it feel like?  Onset – When did it start?  Duration – How long does it last?  Frequency – How often does it occur  Intensity – ◦ What is the worst your pain gets? ◦ What is the rate of your pain one hour after taking your pain medication?

21.  Exacerbation – What makes the pain worse?  Associated symptoms – Does your pain cause you to have nausea, fatigue, dyspnea or weakness?  Alleviation – What helps relieve your pain?  Effect on quality of life – Does your pain cause you to have anxiety, fear, depression or spiritual stress? What does the pain keep you from doing?

23.  Non verbal cues  Examine sites of pain  Palpation  Auscultation, percussion  Neuro exam

24.  Changes in pain  Assess pain relief  Make pain visible

25.  Children and elderly  Cognitively impaired  Patients who deny pain  Non English speaking  Different cultures  History of substance abuse

26.  Communication improves pain management  Describe intensity, limitations, and response to treatments

27. STEP 3, severe pain Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone + Nonopioid analgesics STEP 2, moderate pain Acet or ASA + Codeine Hydrocodone Oxycodone Dihydracodeine Tramadol (not available with ASA or Acet) + Adjuvants STEP 1, mild pain Aspirin (ASA) Acetaminophen (Acet) Nonsteroidal anti-inflammatory drugs (NSAIDS) + Adjuvants

28.  Acetaminophen (Tylenol) ◦ Toxicity ◦ Maximum 4,000mg qd short term ◦ Maximum 3,200mg qd long term ◦ Maximum 2,400mg qd in elderly or debilitated ◦ Mild pain, poor anti-inflammatory capacity

29.  Extra Strength Tylenol500mg8  Darvocet N 100650mg6  Vicodin ES750mg5  Lortab 2.5, 5, 7.5500mg8  Lorcet Plus 7.5650 mg6  Percocet 5325mg12

30.  Risk of GI Ulcer decreases 15% after 3 months continuous care  For long term use, protect with misosprostol (Cytotec), omeprazole (Prilosec), lansoprosole (Prevacid) or pantoprazole (Protonix) OR  Use Cox-2 inhibitor celecoxib (Celebrex) or rofecoxib (Vioxx) meloxicam (Mobic)

31.  Hydrocodone and Oxycodone combination products (Lortab, Tylox, Percocet, Vicoprofen, Percodan)  All have ceilings due to acetaminophen, aspirin or ibuprofen content  Considerations: skip this step and add acetaminophen, aspirin or ibuprofen separately

32.  BEST CHOICE- ◦ Morphine, oxycodone, hydromorphone (Dilaudid) ◦ No ceiling ◦ Morphine and oxycodone come in tablet, liquid, concentrate and suppository form

33. Morphine FormulationHalf-life (t ½ ) Typical Dosing Analgesia Immediate release (IR)2-3.5, q4hOnset: 0.5-1h Peak: 1.5-2h Duration: 3-5h Sustained-release (SR)2-4* q12hOnset: 1.5h Peak: ~ 4h Duration: 8-12h *Terminal elimination half-life for morphine SR

34.  Used for occasional moderate to severe pain  Used PRN to determine long acting dose (add amount needed in 24hrs, divide by 2, give q 12) Initially uses 80mg Oxylr in 24hrs, Oxtcontin 40mg q 12hrs with 10mg Oxylr q 4 hrs for breakthrough pain Current Oxycontin dose 40mg q 12hrs, Used 40mg Oxylr in last 24hrs. New Dose- Oxycontin 60mg q 12 hrs. New breakthrough dose- Oxylr 15-20mg q 4hrs.  Used to control pain that breaks through long- acting dose (dose should be 1/3 -1/4 12 hr dose)

35. SEDATION ANALGESIA PAIN 1 2 3 4 5 6 7 8 9 10 11 12

36.  ONLY TO BE USED FOR CONTINUOUS PAIN, NEVER GIVEN PRN ◦ M.S. Contin, OxyContin, Oramorph SR  12 hour relief  Cannot be crushed or cut ◦ Kadian  24 hour relief  Time-released sprinkles

37.  Duragesic (fentanyl patch)  Lasts 72 hours  Takes up to 24 hours to peak  Must have subcutaneous tissue to absorb  Fevers cause rapid absorption  Cost prohibitive  Slow and careful titration necessary

38.  By percentage  After peak effect  Morphine resistant pain versus psychological component

39.  Oral  Mucosal  Rectal  Transdermal  Topical  Parenteral ◦ Intravenous ◦ Subcutaneous ◦ Intramuscular

40.  Determining equal doses when changing drugs or routes of administration  Use of morphine equivalents

41. DRUG PARENTERAL ROUTE ENTERAL ROUTE Morphine 10mg 30mg Codeine 130mg 200mg (not recommended) Fentanyl *see below OTFC available Hydrocodone not available 30mg Hydromorphone 1.5mg 7.5mg Levorphanol 2mg acute 4mg acute 1mg chronic 1mg chronic Methadone 10mg acute 20mg acute 2-4 mg chronic 2-4 mg chronic Oxycodone not available 20-30 mg Fentanyl 100 mcg patch = 200mg oral morphine/24hrs = 4mg IV morphine/hour. To convert from Fentanyl 100mcg/hour patch to IV Fentanyl, begin at 100mcg/hour IV and titrate as needed

42.  Sedation, light-headaches, nausea, vomiting, itching, dry mouth, urinary retention, constipation and respiratory depression  Most side effects diminish 3 days after opioid started or increased  Minimal side effects noted if dose is correct  Bowel protocol should be initiated at the beginning of opioid therapy

43.  Mild vegetable laxative and softener routinely (Senekot S)  Stronger laxative if no BM by the end of the 2 nd day (Senekot Xtra)  Increase as needed to achieve soft, form BM q 2-3 days

44.  Nausea and Vomiting ◦ Use an anti-emetic prophylactically in patient who:  Currently has nausea and vomiting  Has nausea and vomiting from a weak opioid  Experienced nausea and vomiting in past with strong opioid ◦ Always rule out obstruction ◦ Haldol, Reglan, vestibular

45.  Catch up on sleep  Other medications  Other medical problems

46.  If opioid is at steady state, then think of other causes: ◦ Dehydration ◦ Infections ◦ CNS event ◦ Other medications

47.  A change in rate or depth  Sedation precedes respiratory depression  Level 3 – drifts off to sleep during conversation

48.  Immediate hypersensitivity

49.  In general, all strong opioids have similar side effects ◦ Strategies:  Different route  Different opioid  Decrease dose, increase frequency  Add a second drug

50. Adjuvant medication are not analgesics, but have properties that either assist in blocking pain impulses or potentiates the effects of analgesics.

51. Prevent re-uptake of serontonin and norepinephrine – block neuropathic pain  Amitryptyline (Elavil)S, doxepin (Sinequan)S, desipramine (Norpramin)  Start with small dose, titrate to ½ therapeutic dose for depression  SSRI’s have less effect on neuropathic pain but may be somewhat effective. (Effexor)

52. Block nerve impulses by limiting sodium ions  Carbamapezine (Tegretol) 200-1600 mg qd  Phenytoin (Dilantin) 300-600 mg qd  Gabapentin (Neurontin) up to 3200 mg qd

53.  Clonidine (Catapres) 0.1 mg qd-tid  Decadron 4mg qd-tid or 100mg IM x 1  Donnatal 1-2 tabs bid-tid (GI spasms)  Baclofen (Lioresal) up to 80mg qd  Lorazepam (Ativan) 4-6mg qd  Hydroxyzine (Vistaril) 25-50 mg tid  Promethazine (Phenergan) 25-50mg q4 prn  Dextromethorphan up to 1000 mg qd  Ketamine 2% ointment tid

54.  Choose the adjuvant that will benefit the patient’s other symptoms as well as the pain  For severe pain use, use an adjuvant out of several different categories  Remember that often using adjuvant therapy provides improved pain relief with smaller doses of opioids and fewer side effects

55.  Addiction – Psychological craving for the drug’s psychic effect  Dependence – Natural physical response to continue use of an opioid  Tolerance – The body’s legitimate need for larger doses of an opioid to produce the same effect during an extended period of use  Pseudo-addiction – drug seeking behavior caused by poor pain management

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

57.  Physical – ◦ Decreased functional capability ◦ Diminished endurance and strength ◦ Nausea, poor appetite ◦ Poor or interrupted sleep

58.  Psychological – ◦ Diminished leisure, enjoyment ◦ Increased anxiety, fear ◦ Depression, personal distress ◦ Difficulty concentrating ◦ Somatic preoccupation ◦ Loss of control

59.  Social – ◦ Diminished leisure, enjoyment ◦ Decreased sexual function and intimacy ◦ Altered appearance ◦ Increased caregiver burden

60.  Spiritual – ◦ Increase suffering ◦ Altered meaning ◦ Re-evaluation of religious beliefs

61.  Physical – Movement, Thermal, Touch, Relaxation, Environment, Aromatherapy, Acupuncture  Psychological – Distraction, Meditation, Visualization, Staying Attitude, Hope, Spiritual Support  Palliative Treatments – Radiation Therapy, Chemotherapy, Nerve Blocks, Surgery  Pharmacological – Analgesic and Adjuvant Medications

62. All patients admitted to hospice will receive the best level of pain control that can be safely provided.

63.  Assessment – ◦ At time of admission, a comprehensive pain assessment will be conducted, including use of numeric pain rating scale ◦ When pain is identified as a problem, individualized pain management goals will be established (some patients find a level of 4 acceptable in order to remain awake and alert while others wish to be pain free is possible). ◦ Pain assessments will be conducted on each nursing visit with reassessments occurring until pain goal is achieved.

64.  Interventions – ◦ If pain is scored at greater than 3 or if pain level is unacceptable to patient, there will be an intervention to reduce the pain. ◦ Follow up to determine the success of the intervention MUST be done within 24 hrs of the intervention. In many cases, follow up will be necessary in a much shorter time frame depending on the severity of the pain and the interventions required. Nursing judgment is crucial in determining the time frame. Follow up may be done via telephone call or by visit at the discretion of the nurse. Documentation must be evident on the medical record. Follow up via telephone should generate a progress note, while a visit should generate a nursing note.

65.  Interventions cont’d – ◦ If pain is not improved, additional interventions should be taken and documented. ◦ Follow up within the determined time frame will be conducted until pain goal is achieved. NOTE: Follow up MUST be done within 24hrs. Documentation of this must be evident in the medical record. ◦ Alternative pain relief measures may be implemented as well as pharmacological interventions. (Massage, relaxation techniques, guided imagery, etc.)

66.  Interventions cont’d – ◦ Unless pain is occurring occasionally, scheduled analgesics are indicated with additional medication available on demand for breakthrough pain. ◦ Oral meds are the preferred routes ◦ Opioids are considered the analgesic of choice for moderate to sever pain. ◦ Adjuvant therapies must be considered.

67.  Documentation – ◦ The initial pain assessment must be completed at time of admission. Pain sites are to be numbered with a designation of the probable cause of the pain at each site. ◦ Subsequent assessments/reassessments must be clearly documented ◦ Progress notes should clearly delineate the plan and the rationale for treatment

68. All patients and their families admitted to Hospice will receive the best level of individualized care and personalized service that may be safely provided, regardless of the time of day. Hospice staff is available 24 hours a day, 7 days a week, 365 days per year. All calls made to Hospice will be promptly answered. Those received after hours or on-call, will be responded to within thirty (30) minutes.

69.  Assessment – ◦ Once staff is notified by the service that a call has been made, a response to the call MUST be initiated within 30 minutes. ◦ If the call is of routine nature and at the staff’s discretion can be handled safely and effectively over the phone, it may be appropriate to do so. ◦ If a second call comes in regarding the same patient or family, even if the subject of the call is different, a visit must be made. ◦ If the on-call staff receive notification that the patient is going to or is in the emergency room, the staff member MUST either accompany the patient to or meet them at the emergency room. There should be no exceptions to this. ◦ All deaths will be attended without regard to location.

70.  Interventions – ◦ All calls will be documented on the on-call log and it should be notated if a visit was made or of the situation was resolved via telephone consultation ◦ If it was determined that the situation could appropriately be handled via telephone call, a Progress Note (if a non-clinical problem) or an On Call Note should thoroughly explain the reason for the call, the action or intervention taken in response to the call (keep a supply of Progress Notes and On Call Notes with you).

71.  Interventions cont’d – ◦ Follow up to determine the outcome of the intervention MUST be done within 24 hrs of the intervention (requires passing off to next on-call nurse). Follow up may be done via telephone call or by visit at the discretion of the nurse. Documentation must be evident on the medical record. ◦ If it was determined that a visit be made, an On Call Note should thoroughly explain the nature of the call and all pertinent information regarding the call should be documented. All interventions should be documented, the rationale for such interventions and a report of the nursing assessment/observations that prompted the intervention.

72.  Documentation – ◦ Follow up to ALL calls for a clinical nature received during the on-call hours require follow up within 24 hrs. ◦ Documentation of this must be evident in the medical record.

73. “If we know that pain and suffering can be alleviated, and we do nothing about it, then we ourselves become the tormentors” – Primo Levi

74. Meuser T, Pietruck C, Radbruch L, et al.: Symptoms during cancer pain treatment following WHO- guidelines: a longitudinal follow-up study of symptom prevalence, severity and etiology. Pain 93 (3): 247-57, 2001. Patrick DL, Ferketich SL, Frame PS, et al.: National Institutes of Health State-of-the-Science Conference Statement: Symptom Management in Cancer: Pain, Depression, and Fatigue, July 15-17, 2002. J Natl Cancer Inst 95 (15): 1110-7, 2003. Bruera E, Willey JS, Ewert-Flannagan PA, et al.: Pain intensity assessment by bedside nurses and palliative care consultants: a retrospective study. Support Care Cancer 13 (4): 228-31, 2005.

75. Miaskowski C, Dodd MJ, West C, et al.: Lack of adherence with the analgesic regimen: a significant barrier to effective cancer pain management. J Clin Oncol 19 (23): 4275-9, 2001.