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Introduction

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.

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.

Common
Misconceptions
I should expect to have pain
Ill hold off so the medicine will
work when I really need it
Pain is for wimps
I dont want to get hooked

Barriers

We assess pain poorly and erratically

We havent been well trained in pain


management

Were afraid of addiction issues

Were afraid of mistreating the patient

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

Diagnosing and
Documenting Pain

Examples of Pain
Scales

Documenting Pain

Onset
What relieves?

Location
What worsens?

Intensity
Effects on Daily Activities

Quality
Treatment History

Neurological
Classification

Nociceptive Pain

Neuropathic Pain

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

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

Physical Examination

motor, sensory, reflexes

headaches: intracranial mass

zoster, pressure sores


non-verbal communication

Treating Pain

Treatment of Pain

Treat Causes if possible

Remember Non-Drug Treatments

Analgesics: Narcotic, Non-narcotic

Adjuvants: Anti-convulsants, Antidepressants

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

Non-Narcotic
Analgesics

Acetaminophen (< 4 g / 24 hrs.)

NSAIDS (bone pain or


inflammation)
Lots of side effects
Newer are expensive

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

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 Nave, consider lower dose

Oral: Start 5-10 mg. Titrate Up

Morphine

Max Effect: IV -15 minutes

SC- 30 minutes

PO: -I hr.

Using Concentrates

Dying Patient; Cant 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

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

Extended Release

Better Compliance

More Expensive

Dose q 8,12, or 24

Extended Release

Dont Crush or Chew

May flush through feeding tubes

Dont Start with Extended Dose

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

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

Other Options: Fentanyl


Patch

25, 50, 75, 100 mcg/hr.

Apply every 3 Days

Divide Morphine Daily Dose in Half

Rescue with Opioids

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.

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

Other Options:
Methadone

Starts working in about 1 hr.

Inexpensive

Neuropathic Pain

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.

A.
B.
C.
D.

1. According to the program which


of the following would be most
helpful?
Increase medication dose
Change medication
Begin to give the medication at intervals of
less than four hours
Add adjuvant medication.

Answer C.
A.

Begin to give the


medication at intervals of
less than four hours

2. The most likely classification


of this pain is:
A.
B.
C.
D.

Referred Pain
Nociceptive Pain
Neuropathic Pain
Visceral Pain

Answer B.

Nociceptive Pain

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

Answer C.
1 hour

Problems with Pain


Management

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?

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

Warning signals

Altering, losing Prescriptions

Multiple Sources

Unaccounted Medication

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

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

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

Problems with Opiates:


Nausea/Vomiting

Usually occurs initially

Improves with Time

May be Able to Prevent with


other meds, no movement

Problems with Opiates:


Respiratory Depression

Remember, fairly rapid tolerance develops

Almost always associated with sedation

Follow Respiratory Rate

Withhold Next 2 Doses

Naloxone

Dilute 1 Vial (0.4mg) in 10 cc.


Normal Saline

Give 1 cc. per minute until


respiratory rate OK