1. Pain Management Robert B. Walker, M.D., M.S. DABFP, CAQ (Geriatrics) Robert C. Byrd Center for Rural Health Marshall University

2. Introduction

3. End of Life Pain  50% of elders report “significant problems with pain” in the last 12 months of life.  One-third of nursing home patients complain daily pain.  Predictable, explainable pain is under treated.

4.  Elders list pain control as one of their top 5 quality of life concerns  Patients “have a legal right” to proper pain assessment and treatment.

5. Common Misconceptions “I should expect to have pain” “I’ll hold off so the medicine will work when I really need it” “Pain is for wimps” “I don’t want to get hooked”

6. Barriers  We assess pain poorly and erratically  We haven’t been well trained in pain management  We’re afraid of addiction issues  We’re afraid of mistreating the patient

7. Basic Approach to Pain Management Ask the patient about pain and believe them. Use a pain scale. Document what you know about the pain Reassess the pain

8. Diagnosing and Documenting Pain

9. Examples of Pain Scales

10. Documenting Pain  Onset What relieves?  Location What worsens?  Intensity Effects on Daily Activities  Quality Treatment History

11. Neurological Classification  Nociceptive Pain  Neuropathic Pain

12. Nociceptive Pain  Damage is to other tissue and nerve fibers are stimulated.  Travels along usual pain and temperature nerves  Responds well to common analgesics and opioids  Sharp, throbbing, aching

13. Neuropathic Pain  The nervous system itself damaged  Direct damage to nerves, plexes, spinal cord (shingles, diabetic neuropathy)  Burning, tingling, shooting  May not respond as well to usual analgesics including opioids

14. Physical Examination  motor, sensory, reflexes  headaches: intracranial mass  zoster, pressure sores  non-verbal communication

15. Treating Pain

16. Treatment of Pain  Treat Causes if possible  Remember Non-Drug Treatments  Analgesics: Narcotic, Non-narcotic  Adjuvants: Anti-convulsants, Anti- depressants

17. Standard Approach  Treat Quickly (Pain leads to more pain)  Mild Pain: acetaminophen, ASA, NSAIDS  Moderate: mixtures, weak opioid, maybe adjuvants  Severe: strong opioid and non-opioid, maybe adjuvant

18. Non-Narcotic Analgesics  Acetaminophen (< 4 g / 24 hrs.)  NSAIDS (bone pain or inflammation) –Lots of side effects –Newer are expensive

19. Basics of Analgesic Use  1. By Mouth When Possible  2. Timed Doses  3. Whatever dose it takes  4. Watch for Expected Side Effects  5. Consider Adjuvants

20. Narcotic Analgesics: Morphine  IV: if >50 Kg. Give 10 mg. IV Q3-4 h  If child or <50 kg. Give 0.1mg/kg. IV  If Opioid Naïve, consider lower dose  Oral: Start 5-10 mg. Titrate Up

21. Morphine  Max Effect: IV -15 minutes  SC- 30 minutes  PO: -I hr.

22. Using Concentrates  Dying Patient; Can’t swallow  MSIR 20 mg/ml :.25 to.50 ml. Q 1 hr. sl. PRN  Oxycodone conc. 20 mg/ml :.25 to.50 ml. Q 1 hr. sl. PRN

23. DOSING  Titrate Up Slowly Until pain controlled or side effects occur  Anticipate Next Dose: tend to give a little early  Use Breakthrough Doses When Needed

24. Extended Release  Better Compliance  More Expensive  Dose q 8,12, or 24

25. Extended Release  Don’t Crush or Chew  May flush through feeding tubes  Don’t Start with Extended Dose

26. Breakthrough Pain  Is it new incident (new cause? or end-of-dose?)  Use 10% of total daily dose (rounded up) up to q 1-2 h

27. Continuing Use  Can continue to increase (no real upper limit)  Gradually increase – Limited by Side effects  Note that the effective rescue dose increases as total dose does

28. Other Options: Fentanyl Patch  25, 50, 75, 100 mcg/hr.  Apply every 3 Days  Divide Morphine Daily Dose in Half  Rescue with Opioids

29. Other Options: Fentanyl Patch  Initial Dose May Take 12- 24 hrs.  May continue previous meds for 8 - 12 h  If switching, remove and use rescue for 24 hrs.

30.  Fentanyl is well absorbed across mucous membranes  “Lolly-pop”  approved only for breakthrough in already receiving opioids  not to be chewed 200ug units  not proven to be more effective than morphine concentrates

31. Other Options: Methadone  Starts working in about 1 hr.  Inexpensive  Neuropathic Pain

32. A patient with advanced lung cancer has severe pain from a localized bony metastasis. He begins to consistent feel pain about four hours after his last dose of opioid medication.  1. According to the program which of the following would be most helpful? A. Increase medication dose B. Change medication C. Begin to give the medication at intervals of less than four hours D. Add adjuvant medication.

33. Answer C. A. Begin to give the medication at intervals of less than four hours

34. 2. The most likely classification of this pain is: A. Referred Pain B. Nociceptive Pain C. Neuropathic Pain D. Visceral Pain

35. Answer B. Nociceptive Pain

36. 3. The oral morphine preparation given to this patient will begin to take full effect in about: A. 15 minutes B. 30 minutes C. 1 hour D. 2 hours

37. Answer C. 1 hour

38. Problems with Pain Management

39. Problems with Opiates: Addiction  Define: compulsive use, lack of control, harmful use  Iatrogenic: may be as low as 1% if no previous history  Avoid making this tricky diagnosis  “Have you used this drug five times in your life?”

40. Warning signals Dominating Concerns over Availability Non-Provider Sanctioned Increases Ignoring Major Side Effects

41. Warning signals  Altering, losing Prescriptions  Multiple Sources  Unaccounted Medication

42. Problems with Opiates: Dependence  Defined by the occurrence of a withdrawal syndrome after reduction or cessation.  May occur after only 2- 3 days of strong opioids  Usually well controlled by tapering

43. Problems with Opiates: Tolerance  Need for higher doses for same effect  Can occur with effects other than analgesia  Often develops faster for sedation, respiration, nausea than analgesia  Slow tolerance to obstipation

44. Problems with Opiates: Obstipation  Fluids, Bran  Pericolace or Senicot-S  No BM in 48 hrs: MOM or Lactulose  No BM in 72 hrs: Rectal Exam; Mag Citrate, Fleets, Oil

45. Problems with Opiates: Nausea/Vomiting  Usually occurs initially  Improves with Time  May be Able to Prevent with other meds, no movement

46. Problems with Opiates: Respiratory Depression  Remember, fairly rapid tolerance develops  Almost always associated with sedation  Follow Respiratory Rate  Withhold Next 2 Doses

47. Naloxone  Dilute 1 Vial (0.4mg) in 10 cc. Normal Saline  Give 1 cc. per minute until respiratory rate OK

48. Problems with Opiates: Sedation  Look at Other Meds  Look for Other Reasons  Try Decrease Dose 25%  Try another Analgesic, Psychotropic

49. A patient with widespread cancer is being treated with a mixed narcotic analgesic. Addition of non-narcotic pain medication for breakthrough is being considered. Which of the following is the most significant pharmacologic concern? A. Acetaminophen hepatic toxicity B. Addiction C. Tolerance D. Respiratory depression

50. Answer A. Acetaminophen hepatic toxicity

51. If a decision is made to change to a strong opioid alone, which starting dose of oral morphine would be reasonable? A. 1 mg. B. 5 mg. C. 10 mg. D. 50 mg.

52. Answer C. 10 mg.

53. To which of the following morphine effects will tolerance probably develop most slowly? A. Sedation B. Nausea C. Pain relief D. Obstipation/constipation

54. Answer D. Obstipation/constipation

55. Adjuvant Use  Anticonvulsants (Shooting Pain) –Gabapentin (expensive, 100 mg TID) –Carbamazine 100 mg. PO TID –Valproic Acid 250 mg. QHS –Clonazepam 0.5 mg PO BID (sedating)

56. Adjuvant Use  Tricyclic Antidepressants (Burning, Tingling) –Low Doses (10 - 25 mg.) –Amitriptyline –Anticholenergic (sedating, drying, cardiac effects)  Gabapentin

57. Special Situations

58. Terminal Events  Can’t Swallow: Go to Concentrate  If No Urine Output: Titrate to Pain (no routine dosing)

59. Converting from IV to Oral  Morphine, Oxycodone, Meperidine: 3 X dose  Hydromorphone (Dilaudid): up to 5 X dose  Then Reduce by 25% (cross tolerance)

60. West Virginia Schedule II. Regulations  In Emergency May Telephone or Mail (60 doses)  One Drug Per Prescription with MD/DO Name Printed on Blank  May Fax to Long Term Care or Hospice  Should Write Out Concentrations

61. Non-Drug Treatments  Blocks & Infusions  Surgery: rhizotomy and nerve decompression  Radiation: localized  Tumor Treatment  Heat & Cold  TENS  Relaxation Complementary Medicine: acupuncture, chiropractic, massage  Spiritual Therapy  Diversions: Pets, Music, Art, Humor

62. SUMMARY  Optimizing well-being of the patient and loved ones  Improving control over one’s life  Can reduce uncontrolled pain to less than 1 in 20.  We primary care physicians can, and must, get better at this.

63. A patient with advanced, widespread cancer is at end-stage of her disease. She begins to experience breakthrough pain every 1 or 2 hours between doses of OxyContin. What dose should be given for rescue or breakthrough pain? A. Regular interval dose B. 10% of total daily dose C. 20% of total daily dose D. 30% of total daily dose

64. Answer B. 10% of total daily dose

65. This patient lives many miles from the office and the Hospice nurse wished to increase the regular interval dose of medication. Which of the following is a legal option? A. Give doses of another patient’s medicine B. Fax a prescription for the regular medication to the local pharmacist. C. Give a medication on-hand not previously prescribed D. Wait until a written script can be obtained.

66. Answer B. Fax a prescription for the regular medication to the local pharmacist.

67. The patient begins to take no fluids and has instructed no IV be started. Urine output ceases. How should dosing be determined? A. Titrate to pain, using rescue dose only B. Half the usual interval dose C. Give 10% of the usual interval dose D. Double the usual interval dose.

68. Answer A. Titrate to pain, using rescue doses only