THE RESIDENT’S GUIDE TO PAIN MANAGEMENT - PowerPoint Presentation

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THE RESIDENT’S GUIDE TO PAIN MANAGEMENT

Elizabeth Kvale, MDPalliative Medicine

THE AMERICAN GERIATRICS SOCIETYGeriatrics Health Professionals.Leading change. Improving care for older adults.

AGS

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PAIN PHYSIOLOGY BASICS:TYPES OF PAINNociceptive — arthritis, fracture, lacerationVisceral

— pancreatitis, MI, constipationNeuropathic — herpes zoster, diabetic neuropathy Complex regional pain syndromes (RSD)Central painSlide 2

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PAIN PHYSIOLOGY BASICS:ACUTE VS. CHRONIC PAINAcute pain

Identified event, resolves in days–weeksUsually nociceptiveChronic painCause often not easily identified; multifactorialIndeterminate durationNociceptive and/or neuropathic

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PAIN ASSESSMENT BASICS:BELIEVE THE PATIENTPain is a subjective experience ― the patient is the best source of information about their pain

Pain history ― site(s), intensity, temporality, character, exacerbating and alleviating factorsSlide 4

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PAIN ASSESSMENT BASICS:USE AN ASSESSMENT INSTRUMENTAllows you to know and document whether you have helped the patient

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Match the medication to the amount of the patient’s discomfortPain Management Basics:

Slide 6ASAAcetaminophenNSAIDs± Adjuvants

1 MildA/CodeineA/HydrocodoneA/OxycodoneA/DihydrocodeineTramadol

± Adjuvants

2

Moderate

3 Severe

Morphine

Hydromorphone

Methadone

Levorphanol

Fentanyl

Oxycodone

± Adjuvants

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Don’t delay for investigations or disease treatmentUnmanaged pain  nervous system changesPermanent damageAmplification of painTreat underlying cause

(eg, radiation for a neoplasm)Pain Management BasicsSlide 7

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Conjugated in liverExcreted via kidney (90%–95%)First-order kineticsTime to CmaxPO dosing ― 1 hourSC or IM dosing ―

30 minutesIV dosing ― 6 minutesPain Management Basics:Opioid pharmacology (1 of 2)Slide 8

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Steady state after 4–5 half-livesSteady state after 1 day (24 hours)Duration of effect of “immediate-release” formulations (except methadone)3–5 hours PO or PRShorter with parenteral bolus

Pain Management Basics:Opioid pharmacology (2 of 2)Slide 9

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Codeine, hydrocodone, morphine, hydromorphone, oxycodoneDose q4hAdjust dose dailyMild or moderate pain: ↑ 25%–50%

Severe or uncontrolled pain: ↑ 50%–100%Adjust more quickly for severe uncontrolled painPain Management BasicsOral dosing of immediate-release preparationsSlide 10

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Improve compliance, adherenceDose q8h, q12h, or q24h (product-specific)Don’t crush or chew tabletsMay flush time-release granules down feeding tubes

Adjust dose q2–4 days (once steady state reached)Pain Management BasicsOral dosing of extended-release preparationsSlide 11

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Use immediate-release opioids5%–15% of 24-h doseOffer after Cmax reachedPO or PR: ~ q1hSC or IM: ~ q30min

IV: ~ q10–15minDo not use extended-release opioidsPain Management BasicsBreakthrough painSlide 12

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Ongoing assessmentIncrease analgesics until pain is relieved or adverse effects are unacceptableBe prepared for sudden changes in painDriving is safe if pain is controlled, dose is stable, no adverse effects

Pain Management BasicsSlide 13

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If dose escalation  adverse effects:Use more sophisticated therapy to counteract adverse effectUse an alternative:Route of administration

Opioid (“opioid rotation”)Use a co-analgesicUse a nonpharmacologic approachConcerns ABOUT opioid use:POOR RESPONSESlide 14

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Conjugated in liver90%–95% excreted in urineIf dehydration, renal failure, severe hepatic failure develops: dosing interval,

 dosage sizeIf oliguria or anuria develops:Stop routine dosing of morphineUse only PRNConcerns ABOUT opioid use:ClearanceSlide 15

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Reduced effectiveness to a given dose over timeNot clinically significant with chronic dosingIf dose requirement is increasing, suspect disease progressionConcerns ABOUT opioid use: TOLERANCE

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Psychological dependenceCompulsive useLoss of control over drugsLoss of interest in pleasurable activitiesConcerns ABOUT opioid use:

AddictionSlide 17

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A process of neuroadaptationAbrupt withdrawal may  abstinence syndromeIf dose reduction required, reduce by 50%q2–3 daysAvoid antagonists

Concerns ABOUT opioid use:Physical dependenceSlide 18

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Can have pain tooTreat with compassion Protocols, contractingConsult with pain or addiction specialistsConcerns ABOUT opioid use:

Substance ABUSERSSlide 19

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Meperidine — accumulates toxic metabolite normeperidineMixed agonists/antagonists – Nubain, TalwinDo not use naloxone (Narcan) unless true respiratory crisis (RR < 6)Concerns ABOUT OPIOID USE:

Things to avoidSlide 20

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Ask the patientPalliative medicine corollary ― believe the patientMatch the pain medicine to patient’s level of pain

Increase pain medicine (with awareness ofCmax and half-life) until patient is comfortableSUMMARY: BASIC PRINCIPLESOF PAIN MANAGEMENT

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Very pleasant 68-year-old admitted with COPD exacerbationHome meds include 2 tablets of oxycodone5 mg/APAP “whenever my back acts up” — usually 4 tablets a dayAppropriate pain medication order?Mrs Paine

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Readmitted months later with stage IV non-small cell lung cancer Taking 2 oxycodone/APAP tabs every 6 hoursRates her pain as 7/10 “most of the time”Mrs Paine

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Maximum acetaminophen dose in 24 hours is 4 gramsTylenol #3 (codeine 30 mg/APAP 325 mg)  24-hr maximum= 12 tabletsPercocet (oxycodone 5 mg/APAP 325 mg) 

24-hr maximum = 12 tabletsTylox (oxycodone 5 mg/APAP 500 mg)  24-hr maximum= 8 tabletsLortab 5 (hydrocodone 5 mg/APAP 500 mg)  24-hr maximum = 8 tabletsHow long does it take to get a PRN dose of pain medication once it is requested?Key PointsSlide 24

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Mrs Paine’s total daily oxycodone dose is40 mg (8 tablets  5 mg)Key Points

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