Pain Assessment &

Management

M3 Palliative Medicine Curriculum

Seema S. Limaye, MD
University of Chicago
GOALS
1. Describe methods of pain
assessment in cognitively impaired
older adults.
2. Understand various types of pain.
3. Describe the basic pharmacology of
opioids
4. Understand how to initiate and titrate
opioids.
Self-Directed Learning
Modules
 Basics of Neuropathic pain
 Side Effects of Opiods and
Management Options
 Treatment of Pain in Persons with h/o
Substance Abuse
Mrs. P

70 y.o. female h/o Paget’s disease, renal

insufficiency, osteoporosis presents to
clinic with new back pain.

What do you want to obtain from the

history?
Pain History
•Pain Characteristics – onset, duration, location,
quality, intensity, associated symptoms,
exacerbating and relieving factors
•Past and current management therapies
•Relevant medical and family history
•Psychosocial history
•Impact of pain on daily life – work, daily activities,
personal relationships, sleep, appetite, emotional
state
•Patient (and family’s) expected goals for treatment
Pain: A Complex
Phenomenon
 Pain
– Sensory stimuli and/or neurologic injury
modified by an individual’s memory,
expectations, emotions
 Biocultural Model of Pain:
– Society also influences an individual’s pain
experiences
Pain Assessment is
NOT….
 Relying on changes in vital signs
 Deciding a patient does not “look in pain”
 Knowing how much a procedure or disease
“should hurt”
 Assuming a sleeping patient does not have
pain
 Assuming a patient will tell you they are in
pain
Consequences of
Untreated Pain
 Acute pain:
– increase metabolic rate and blood
clotting,
– impair immune function
– induce negative emotions
 Without intervention, pain receptors
become sensitive and may have long
lasting changes in the neurons
Consequences of Untreated
Pain
 Chronic pain may lead to:
– fatigue,
– anxiety,
– depression,
– confusion,
– increased falls,
– impaired sleep, and
– decreased physical functioning/deconditioning
 Bedside Assessment
 ASK the patient about pain
– Asking about ADL’s and IADL’s
– Asking about physical activity, mood, sleep, appetite, energy
level

 Identify preferred pain terminology

-hurting, aching, stabbing, discomfort, soreness
 Use a pain scale that works for the
individual
-Insure understanding of its use
-Modify sensory deficits
Ferrell et al. J Pain Symptom Manage 1995. Chinball and Tait Pain 2001.
Herr and Garand. Pain Management in the Elderly 2001
Use a standard scale to
track the course of pain
Faces Pain Scale and Pain
Thermometer
What are some common barriers
to pain treatment?
Remember the common patient-
related barriers to pain management
 Drugs ..
– are addicting
– should be saved for
when it is really
needed
– have unpleasant or
dangerous side
effects
– pills are not as
effective as a shot
– narcotics are only for
dying people
 Pain assessment in a
vulnerable group:
Cognitively Impaired Older
Adults
Assessing pain: Nonverbal,
Moderate to Severe
Impairment
 Formal assessment tools available but
not necessarily useful in routine clinical
settings

 Unique Pain Signature

 Nonverbal Pain Indicators

Kaasalainen et al Perspectives 1998. Herr and Garand Clinics in Geriatric Medicine 2000
 Unique Pain Signature
 How does the patient usually act?
 What changes are seen when they are
in pain?
– family members
– nursing staff
 Communication across caregiver
settings is key!

Kovach et al. J Pain Symptom Manage 1999.

Feldt et al. JAGS 1998.
Weiner et al. Aging 1998.
Nonverbal Pain Indicators
 Facial expressions (grimacing)
-Less obvious: slight frown, rapid blinking,
sad/frightened, any distortion
 Vocalizations (crying, moaning, groaning)
-Less obvious: grunting, chanting, calling out, noisy
breathing, asking for help
 Body movements (guarding)
-Less obvious: rigid, tense posture, fidgeting,
pacing, rocking, limping, resistance to moving
Kaasalainen et al Perspectives 1998. Herr and Garand Clinics in Geriatric Medicine 2000
Selection of pain meds

 Source/type of pain
 Duration/timing/frequency
 History of medication use
 Impact on quality of life
 Presence of associated factors
Types of Pain: A Brief Review

 Nociceptive Pain
– Visceral
– Somatic
 Neuropathic Pain
 Mixed/Unspecified Pain
 Psychologic cause
Quality: Visceral Pain
 Descriptors: cramping, squeezing,
pressure
 Distribution/Examples:
– Referred
 heart attack, kidney stone
– Colicky
 Bowel obstruction, gallstone
– Diffuse
 Peritonitis
 Analgesics: opioids; acetaminophen
Quality: Somatic pain

 Descriptors: aching, deep, dull, gnawing

 Distribution/Examples:
– Well localized—patients can often point with one
finger to the location of their pain
• bone mets, strained ankle, toothache
 Analgesics: NSAIDS, acetaminophen
opioids
General Principles of
Management
 Set a goal of reduction of pain to
tolerable levels, not a goal of complete
relief
 “Start low and go slow”
 Make sure patient and family are
aware of goals
 Frequent clinic visits at first for
assurance, validation, and monitoring
of titration
WHO 3-Step ladder

Source: World Health Organization. Technical Report Series No. 804,

Figure 2. Geneva: World Health Organization; 1990. Reprinted with
permission.
WHO 3-STEP
LADDER 3 SEVERE

Morphine
Hydromorphone
Methadone
Oxycodone
Fentanyl
+/- Adjuvants

2 MODERATE

A/Codeine
A/Hydrocodone
A/Oxycodone
Tramadol
+/- Adjuvants
1 MILD

A S A /N S A ID S
A cetam inophen
Cox-2
+/- Adjuvants
Non-opioid medications

 Acetominophen 650mg tid-qid : concern for

hepatic toxicity >3-4grams
 NSAIDs including Ibuprofen, Naproxen,
COX-2 inhibitors: concern for gastric / renal
toxicity, platelet dysfunction, may inhibit
anti-hypertensive meds
Opioid combination
products
 The following opioids are available as
combination products with acetaminophen,
aspirin, or ibuprofen
– Codeine; hydrocodone; oxycodone;
propoxyphene
 Typically used for
– Moderate episodic (PRN) pain
– Breakthrough pain in addition to a long-acting
opioid.
 Never prescribe more than one combination
drug at any one time.
Which combination
product?
Analgesic potency:
– hydrocodone and oxycodone are more
potent than codeine, which is more
potent than propoxyphene, which some
studies suggest is equipotent to aspirin.
– there is little difference between
hydrocodone products and oxycodone
products in terms of potency.

Note: propoxyphene products are not recommended for pain in most national
pain guidelines, due to side effects and unclear efficacy compared to
other products
Adjuvants
 Non-pharmacologic
 Topicals
 Tylenol
 NSAIDS, Celecoxib, steroids
 Anticonvulsants
 Antidepressants
 Antiarrhythmics
Opioid Pharmacology

 Block the release of neurotransmitters

in the spinal cord
 Agonist of Mu, delta, kappa receptors
 Conjugated in liver
 Excreted via kidney (90%–95%)
Opioid pharmacology

 Central and peripheral effects of

opioids
 This leads to desired effects, as well as
side effects
Receptor Clinical Effects

Mu 1 Supraspinal analgesia
Peripheral analgesia
Sedation
Euphoria
Prolactin release
Mu 2 Spinal analgesia
Respiratory depression
Physical dependence
GI dysmotility
Pruritis
Bradycardia
GH release
Receptor Clinical Effects
Kappa 1 Spinal analgesia
Miosis
Diresis

Kappa 2 Psychotomimesis
Dysphoria

Kappa 3 Supraspinal analgesia

Delta Spinal and supraspinal analgesia

Nociceptin/orphanin Anxiolysis
Analgesia
Clearance concerns
 Conjugated by liver
 90%–95% excreted in urine
 Dehydration, renal failure, severe
hepatic failure
 dosing interval (extend time) or
 dosage size
–if oliguria or anuria
 STOP routine dosing of morphine
 use ONLY prn
Opiod Pharmacology…
 What is the peak effect (C max ) of morphine:
– PO?
 30-60 min
– IV?
 5-15 min
– SC/IM?
 Variable…usually 30-60 min
 What is the duration of effect of morphine?
– PO?
 3-4 hours
– IV?
 Usually 1-2 hours, but we typically dose it q2-3 hours
 IV
Plasma Concentration

SC / IM

Cmax po / pr

0 Half-life (t1/2) Time

. . . More Opioid
Pharmacology
 Steady state after 4–5 half-lives
– steady state after 1 day (24 hours)
 Side Effects:
– sedation, confusion, respiratory
depression, constipation, urinary
retention, nausea and vomiting
Short Acting Opioids
 Oral only
 Parenteral or – oxycodone (Percocet
Oral ® , Tylox ® )
– morphine – hydrocodone (Vicodin
– hydromorphone ® Lortab ®, Lorcet
(Dilaudid ®) ®)
– meperidine – propoxyphene
(Demerol ®) (Darvon ®, Wygesic
®)
– codeine
– Note: hydrocodone is
only available as a
combination product.
Routine oral dosing
extended-release preparations

 Improve compliance, adherence

 Dose q 8, 12, or 24 h (product
specific)
– don’t crush or chew tablets
– may flush time-release granules down
feeding tubes
 Adjust dose q 2–4 days (once steady
state reached)
Transdermal Fentanyl

 Duration 24-72 hours

 12-24 hours to reach full analgesic effect

 Not recommended as first-line in opiate

naïve patients
 Lipophilic

 Simple Conversion rule:

-1 mg po morphine = ½ mcg fentanyl

-(60 mg morphine roughly 25 mcg patch)
DOSE FINDING
ADDING AN OPIOID

To achieve quick pain

relief: (LOAD)
1. Start low dose,
short-acting
2. Dose q peak
3. Re-eval in 4 hrs.
to figure out what
dose is needed
Breakthrough dosing
 Use immediate-release opioids
– 10% of 24-h dose (or 1/3 of one ER
dose)
– offer after Cmax reached
 po / pr q1h
 SC, IM  q 30 min
 IV  q 10–15 min
 Do NOT use extended-release opioids
for breakthrough
Ongoing assessment
 Increase analgesics until pain
relieved or adverse effects
unacceptable
 Be prepared for sudden changes in
pain
– plan for breakthroughs (prior to
dressing changes or patient care
activities)
 Opioid Dose Escalation
Always increase by a percentage of the present dose based
upon patient’s pain rating and current assessment

50-100% increase

25-50% increase Severe pain

7-10/10
Moderate pain
25% increase 4-6/10

Mild pain
1-3/10
Incomplete cross-
tolerance
 If a switch is being made from one opioid to another
it is recommended to start the new opioid at
~50% of the equianalgesic dose.
 This is because the tolerance a patient has towards
one opioid, may not completely transfer (“incomplete
cross-tolerance”) to the new opioid.

to

from 50%
of new
100% Opioid
Pain Problem #1

 You started Mrs. T on 10 mg morphine

every 4hrs around the clock for her
cancer pain with good effect. She says
she’s tired of taking a pill every 4
hours. Convert her to long-acting
morphine with appropriate prn doses.
Pain Problem #1: Answer

 24 hour use:
10mg PO morphine x 6 = 60 mg PO morphine
 Convert to long-acting twice a day dosing:

60 mg PO morphine / 2 = 30mg PO morphine

SR BID
 Calculate prn dosing of morphine sulfate-
immediate release:
60mg PO morphine in 24 h x 10% = 6mg PO
morphine q3h prn breakthrough pain
Part 2

 She is admitted to the hospital and

unable to take oral medications--
convert Mrs. T to: IV morphine
Part 2: Answer

 Ratio of IV:PO morphine sulfate:

1mg:3mg
Therefore: 60/x = 3/1
X=20mg IV morphine in 24hr period
Dose q 3h = 20mg/8 = 2.5mg IV q3hr
PRN dose?
2mg IV morphine q 2hr prn breakthrough pain
Part 3

 Mrs. T has uncontrolled pain of

moderate intensity because of
progression of her disease. How would
you re-dose her IV morphine?
Part 3-Answer

 Increase pain regimen by 25-50% for

moderate uncontrolled pain
 Let’s increase by 25%

25% of 20mg IV morphine = 25mg IV

morphine in 24 hours
Dosing q3h= 25mg/8 = 3mg IV
morphine q3h
Pain Problem #2
 Mr. T is a 73 yo man with lung cancer, a malignant
plueral effusion, and chronic chest pain. He has
undergone therapuetic thoracentesis and
pleuradesis. He is currently receiving meperidine 75
mg IM q6h, for pain. You want to switch him to oral
morphine because you are aware that:
1. IM meds hurt!
2. it’s metabolite, normeperidine, can
accumulate in pts (with renal failure) and cause
CNS toxicity such as tremulousness, dyphoria,
myoclonus and sz.
 Without adjusting for incomplete cross-tolerance,
what dose and schedule would you choose?
Pain Problem #2: Answer
 Ratio of IV meperidine: PO morphine
50mg:15mg
75mg x 4 = 300mg
300/x = 50/15
X=90 mg PO morphine in 24h
 Adjust for incomplete cross-tolerance:
Decrease by 1/3 = 60mg
 Dosing PO morphine q4h:
10mg PO morphine q4h