1. Pain: Is It All In Your Head? International Myeloma Foundation Patient and Family Seminar May 14, 2005 Maureen A. Carling RN SCM, NDN, HV, FET (England) © 2000 Maureen A. Carling All Rights Reserved

2. The Tragedy of Needless Pain. Despite the fact that most pain can be managed effectively, the under- treatment, inappropriate treatment, and in some cases, failure to treat at all, is common. Do not accept poor pain management

3. Pain and Invalidation “Its all in your head.” “You’ll just have to learn to live with the pain.” “You have a low threshold for pain.”

4. Pain and Invalidation If you hurt, then you DO have pain. Do not allow others to invalidate you.

14. The Therapeutic Window

15. Titration and the Therapeutic Window Aim of titration is to obtain and maintain level which lies inside the therapeutic window. When level rises above upper parameter, you will begin to feel ‘hung-over.’ When level falls below lower parameter, you will experience ‘breakthrough pain.’

16. Titration and the Therapeutic Window Statistically, if the pain breaks through, it takes 25%-30% of the SAME drug in immediate release form, to raise the level back inside the window. If the pain breaks through 2-3 times per day or more, it suggests that the level of the long acting drug is at the lower margin of the window.

17. “Rule of Thumb” If the pain breaks through 2-3 times per day or more, it is an indication that the level is in the lower margin of the window and the 12 hour dosage needs to be increased by 50%, with a corresponding increase in the breakthrough dosage to represent 1/3 of the NEW dosage.

18. “Rule of Thumb” Conversely, if your pain comes down, eg after radiation therapy, then the medications will need to be reduced. If you wake up feeling ‘hung-over,’ especially if there has been no breakthrough pain the previous day or so, then this is an indication that your pain has come down.. The 12 hour dosage is reduced by 1/3 with a corresponding decrease in the breakthrough medication to represent 1/3of the NEW dosage.

19. Rule of Thumb Do not take breakthrough medication routinely every four hours to prevent pain. The long acting drug is for that. Keep your medication regimen simple. Take your medication with your breakfast and supper and then you are free for the day, to get on with your life. Just take your ‘rescue’ dose with you in case you need it.

20. Side effects Remember, there are side effects to pain as well as side effects of medication.

21. Side effects Constipation in EVERYONE taking opioids. You need a ‘pusher’ eg Senokot and a stool softener from the first dose of an opioid. Opioids slow the bowel down. Your ‘pusher’ speeds it up again. It puts the ‘push’ back that the opioid has taken out. Take it EVERY day.

22. Side Effects Nausea and vomiting. If this occurs, it is usually for the first 48 hours after starting on an opioid for the first time. Taking an anti-emetic with the opioid for the first couple of days can prevent this. The commonest cause of nausea and vomiting after this time, is poor bowel management. Prevent it happening in the first place by taking your ‘pusher’ and softener regularly

23. Calling for Help Call your doctor or nurses: If the medication you are taking is not controlling your pain. If you have breakthrough pain 2-3 times daily or more.

24. Calling for Help If you wake up feeling ‘hung-over’ and especially, if you have had no breakthrough pain the previous day or so. If you have not had your bowels moved for three days or more.

25. Calling for Help If you have nausea and /or vomiting If you develop new pains.

26. New Approaches for Controlling Neuropathic Pain Neuropathic pain can be controlled using antidepressants and/or anticonvulsants, which need to be titrated up slowly over several weeks. These are now available in topical form along with other drugs such as Guaifenesin, Clonidine, Ketamine, NSAIDs and other drugs.

27. New Approaches to Controlling Neuropathic Pain Advantages: Reduce side effects considerably. Relief is faster on considerably lower dosages. A Compounding Pharmacist would help you with this.

29. Pain CAN and SHOULD be controlled You have nothing to fear, but fear itself