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EEPPEECC
EEPPEECC
PainManagement
PainManagement
Module 4Module 4Module 4Module 4
The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation
The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation
EEPPEECC
EEPPEECC Module 4, Part 1
Principles of Pain Management
Module 4, Part 1Principles of Pain Management
ObjectivesObjectives
Compare, contrast nociceptive, Compare, contrast nociceptive, neuropathic painneuropathic pain
Know steps of analgesic Know steps of analgesic managementmanagement
Compare, contrast nociceptive, Compare, contrast nociceptive, neuropathic painneuropathic pain
Know steps of analgesic Know steps of analgesic managementmanagement
General principles . . .General principles . . .
AssessmentAssessment
ManagementManagement
pharmacologicpharmacologic
nonpharmacologicnonpharmacologic
AssessmentAssessment
ManagementManagement
pharmacologicpharmacologic
nonpharmacologicnonpharmacologic
. . . General principles. . . General principles
Education – patient, family, all Education – patient, family, all caregiverscaregivers
Ongoing assessment of outcomes, Ongoing assessment of outcomes, regular review of plan of careregular review of plan of care
Interdisciplinary care, consultative Interdisciplinary care, consultative expertiseexpertise
Education – patient, family, all Education – patient, family, all caregiverscaregivers
Ongoing assessment of outcomes, Ongoing assessment of outcomes, regular review of plan of careregular review of plan of care
Interdisciplinary care, consultative Interdisciplinary care, consultative expertiseexpertise
Pain pathophysiologyPain pathophysiology
Acute painAcute pain
identified event, resolves days–weeksidentified event, resolves days–weeks
usually nociceptiveusually nociceptive
Chronic painChronic pain
cause often not easily identified, cause often not easily identified, multifactorialmultifactorial
indeterminate durationindeterminate duration
nociceptive and / or neuropathicnociceptive and / or neuropathic
Acute painAcute pain
identified event, resolves days–weeksidentified event, resolves days–weeks
usually nociceptiveusually nociceptive
Chronic painChronic pain
cause often not easily identified, cause often not easily identified, multifactorialmultifactorial
indeterminate durationindeterminate duration
nociceptive and / or neuropathicnociceptive and / or neuropathic
Nociceptive pain . . .Nociceptive pain . . .
Direct stimulation of intact Direct stimulation of intact nociceptorsnociceptors
Transmission along normal nervesTransmission along normal nerves
sharp, aching, throbbingsharp, aching, throbbing
somaticsomatic
easy to describe, localizeeasy to describe, localize
visceralvisceral
difficult to describe, localizedifficult to describe, localize
Direct stimulation of intact Direct stimulation of intact nociceptorsnociceptors
Transmission along normal nervesTransmission along normal nerves
sharp, aching, throbbingsharp, aching, throbbing
somaticsomatic
easy to describe, localizeeasy to describe, localize
visceralvisceral
difficult to describe, localizedifficult to describe, localize
. . . Nociceptive pain. . . Nociceptive pain
Tissue injury apparentTissue injury apparent
ManagementManagement
opioidsopioids
adjuvant / coanalgesicsadjuvant / coanalgesics
Tissue injury apparentTissue injury apparent
ManagementManagement
opioidsopioids
adjuvant / coanalgesicsadjuvant / coanalgesics
Neuropathic pain . . .Neuropathic pain . . . Disordered peripheral or central Disordered peripheral or central
nervesnerves
Compression, transection, Compression, transection, infiltration, ischemia, metabolic infiltration, ischemia, metabolic injuryinjury
Varied typesVaried types
peripheral, deafferentation, complex peripheral, deafferentation, complex regional syndromesregional syndromes
Disordered peripheral or central Disordered peripheral or central nervesnerves
Compression, transection, Compression, transection, infiltration, ischemia, metabolic infiltration, ischemia, metabolic injuryinjury
Varied typesVaried types
peripheral, deafferentation, complex peripheral, deafferentation, complex regional syndromesregional syndromes
. . . Neuropathic pain. . . Neuropathic pain
Pain may exceed observable injury Pain may exceed observable injury
Described as burning, tingling, Described as burning, tingling, shooting, stabbing, electrical shooting, stabbing, electrical
ManagementManagement
opioidsopioids
adjuvant / coanalgesics often requiredadjuvant / coanalgesics often required
Pain may exceed observable injury Pain may exceed observable injury
Described as burning, tingling, Described as burning, tingling, shooting, stabbing, electrical shooting, stabbing, electrical
ManagementManagement
opioidsopioids
adjuvant / coanalgesics often requiredadjuvant / coanalgesics often required
Pain managementPain management Don’t delay for investigations or Don’t delay for investigations or
disease treatmentdisease treatment
Unmanaged pain Unmanaged pain nervous system nervous system changeschanges
permanent damagepermanent damage
amplify painamplify pain
Treat underlying cause (eg, radiation Treat underlying cause (eg, radiation for a neoplasm)for a neoplasm)
Don’t delay for investigations or Don’t delay for investigations or disease treatmentdisease treatment
Unmanaged pain Unmanaged pain nervous system nervous system changeschanges
permanent damagepermanent damage
amplify painamplify pain
Treat underlying cause (eg, radiation Treat underlying cause (eg, radiation for a neoplasm)for a neoplasm)
PlacebosPlacebos
No role for placebos to assess or No role for placebos to assess or treat paintreat pain
No role for placebos to assess or No role for placebos to assess or treat paintreat pain
WHO 3-stepLadderWHO 3-stepLadder
1 mild1 mild
2 moderate2 moderate
3 severe3 severe
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
± Adjuvants
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
± Adjuvants
A/Codeine
A/Hydrocodone
A/Oxycodone
A/Dihydrocodeine
Tramadol
± Adjuvants
A/Codeine
A/Hydrocodone
A/Oxycodone
A/Dihydrocodeine
Tramadol
± Adjuvants
ASA
Acetaminophen
NSAIDs
± Adjuvants
ASA
Acetaminophen
NSAIDs
± Adjuvants
AcetaminophenAcetaminophen
Step 1 analgesic, coanalgesicStep 1 analgesic, coanalgesic
Site, mechanism of action unknownSite, mechanism of action unknown
minimal anti-inflammatory effectminimal anti-inflammatory effect
Hepatic toxicity if > 4 g / 24 hoursHepatic toxicity if > 4 g / 24 hours
increased riskincreased risk
hepatic disease, heavy alcohol hepatic disease, heavy alcohol useuse
Step 1 analgesic, coanalgesicStep 1 analgesic, coanalgesic
Site, mechanism of action unknownSite, mechanism of action unknown
minimal anti-inflammatory effectminimal anti-inflammatory effect
Hepatic toxicity if > 4 g / 24 hoursHepatic toxicity if > 4 g / 24 hours
increased riskincreased risk
hepatic disease, heavy alcohol hepatic disease, heavy alcohol useuse
NSAIDs . . .NSAIDs . . .
Step 1 analgesic, coanalgesicStep 1 analgesic, coanalgesic
Inhibit cyclo-oxygenase (COX)Inhibit cyclo-oxygenase (COX)
vary in COX-2 selectivityvary in COX-2 selectivity
All have analgesic ceiling effectsAll have analgesic ceiling effects
effective for bone, inflammatory paineffective for bone, inflammatory pain
individual variation, serial trialsindividual variation, serial trials
Step 1 analgesic, coanalgesicStep 1 analgesic, coanalgesic
Inhibit cyclo-oxygenase (COX)Inhibit cyclo-oxygenase (COX)
vary in COX-2 selectivityvary in COX-2 selectivity
All have analgesic ceiling effectsAll have analgesic ceiling effects
effective for bone, inflammatory paineffective for bone, inflammatory pain
individual variation, serial trialsindividual variation, serial trials
. . . NSAIDs. . . NSAIDs
Highest incidence of adverse eventsHighest incidence of adverse events
GastropathyGastropathy
gastric cytoprotectiongastric cytoprotection
COX-2 selective inhibitorsCOX-2 selective inhibitors
Highest incidence of adverse eventsHighest incidence of adverse events
GastropathyGastropathy
gastric cytoprotectiongastric cytoprotection
COX-2 selective inhibitorsCOX-2 selective inhibitors
NSAID adverse effectsNSAID adverse effects
Renal insufficiencyRenal insufficiency
maintain adequate hydrationmaintain adequate hydration
COX-2 selection inhibitorsCOX-2 selection inhibitors
Inhibition of platelet aggregationInhibition of platelet aggregation
assess for coagulopathyassess for coagulopathy
Renal insufficiencyRenal insufficiency
maintain adequate hydrationmaintain adequate hydration
COX-2 selection inhibitorsCOX-2 selection inhibitors
Inhibition of platelet aggregationInhibition of platelet aggregation
assess for coagulopathyassess for coagulopathy
Opioid pharmacology . . .Opioid pharmacology . . .
Conjugated in liverConjugated in liver
Excreted via kidney (90%–95%)Excreted via kidney (90%–95%)
First-order kineticsFirst-order kinetics
Conjugated in liverConjugated in liver
Excreted via kidney (90%–95%)Excreted via kidney (90%–95%)
First-order kineticsFirst-order kinetics
Opioid pharmacology . . .Opioid pharmacology . . .
CCmax max afterafter
po po 1 h 1 h
SC, IM SC, IM 30 min 30 min
IV IV 6 min 6 min
half-life at steady state half-life at steady state
po / pr / SC / IM / IV po / pr / SC / IM / IV 3-4 h 3-4 h
CCmax max afterafter
po po 1 h 1 h
SC, IM SC, IM 30 min 30 min
IV IV 6 min 6 min
half-life at steady state half-life at steady state
po / pr / SC / IM / IV po / pr / SC / IM / IV 3-4 h 3-4 h
. . . Opioid pharmacology. . . Opioid pharmacology
Steady state after 4–5 half-livesSteady state after 4–5 half-lives
steady state after 1 day (24 hours)steady state after 1 day (24 hours)
Duration of effect of “immediate-Duration of effect of “immediate-release” formulations (except release” formulations (except methadone)methadone)
3–5 hours po / pr3–5 hours po / pr
shorter with parenteral bolusshorter with parenteral bolus
Steady state after 4–5 half-livesSteady state after 4–5 half-lives
steady state after 1 day (24 hours)steady state after 1 day (24 hours)
Duration of effect of “immediate-Duration of effect of “immediate-release” formulations (except release” formulations (except methadone)methadone)
3–5 hours po / pr3–5 hours po / pr
shorter with parenteral bolusshorter with parenteral bolus
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0000 Half-life (tHalf-life (t1/21/2))Half-life (tHalf-life (t1/21/2)) TimeTimeTimeTime
IVIVIVIV
po / prpo / prpo / prpo / pr
SC / IMSC / IMSC / IMSC / IM
CCmaxmaxCCmaxmax
Routine oral dosingimmediate-release preparationsRoutine oral dosingimmediate-release preparations
Codeine, hydrocodone, morphine, Codeine, hydrocodone, morphine, hydromorphone, oxycodonehydromorphone, oxycodone
dose q 4 hdose q 4 h
adjust dose dailyadjust dose daily
mild / moderate pain mild / moderate pain 25%–50%25%–50%
severe / uncontrolled pain severe / uncontrolled pain 50%–100%50%–100%
adjust more quickly for severe adjust more quickly for severe uncontrolled painuncontrolled pain
Codeine, hydrocodone, morphine, Codeine, hydrocodone, morphine, hydromorphone, oxycodonehydromorphone, oxycodone
dose q 4 hdose q 4 h
adjust dose dailyadjust dose daily
mild / moderate pain mild / moderate pain 25%–50%25%–50%
severe / uncontrolled pain severe / uncontrolled pain 50%–100%50%–100%
adjust more quickly for severe adjust more quickly for severe uncontrolled painuncontrolled pain
Routine oral dosingextended-release preparationsRoutine oral dosingextended-release preparations
Improve compliance, adherenceImprove compliance, adherence
Dose q 8, 12, or 24 h (product Dose q 8, 12, or 24 h (product specific)specific)
don’t crush or chew tabletsdon’t crush or chew tablets
may flush time-release granules down may flush time-release granules down feeding tubesfeeding tubes
Adjust dose q 2–4 days (once steady Adjust dose q 2–4 days (once steady state reached)state reached)
Improve compliance, adherenceImprove compliance, adherence
Dose q 8, 12, or 24 h (product Dose q 8, 12, or 24 h (product specific)specific)
don’t crush or chew tabletsdon’t crush or chew tablets
may flush time-release granules down may flush time-release granules down feeding tubesfeeding tubes
Adjust dose q 2–4 days (once steady Adjust dose q 2–4 days (once steady state reached)state reached)
Routine oral dosinglong-half-life opioidsRoutine oral dosinglong-half-life opioids
Dose interval for methadone is Dose interval for methadone is variable (q 6 h or q 8 h usually variable (q 6 h or q 8 h usually adequate)adequate)
Adjust methadone dose q 4–7 daysAdjust methadone dose q 4–7 days
Dose interval for methadone is Dose interval for methadone is variable (q 6 h or q 8 h usually variable (q 6 h or q 8 h usually adequate)adequate)
Adjust methadone dose q 4–7 daysAdjust methadone dose q 4–7 days
Breakthrough dosingBreakthrough dosing Use immediate-release opioidsUse immediate-release opioids
5%–15% of 24-h dose5%–15% of 24-h dose
offer after Coffer after Cmaxmax reached reached
po / pr po / pr q 1 h q 1 h
SC, IM SC, IM q 30 min q 30 min
IV IV q 10–15 q 10–15 minmin
Do NOT use extended-release Do NOT use extended-release opioidsopioids
Use immediate-release opioidsUse immediate-release opioids
5%–15% of 24-h dose5%–15% of 24-h dose
offer after Coffer after Cmaxmax reached reached
po / pr po / pr q 1 h q 1 h
SC, IM SC, IM q 30 min q 30 min
IV IV q 10–15 q 10–15 minmin
Do NOT use extended-release Do NOT use extended-release opioidsopioids
Clearance concernsClearance concerns Conjugated by liverConjugated by liver
90%–95% excreted in urine90%–95% excreted in urine
Dehydration, renal failure, severe Dehydration, renal failure, severe hepatic failurehepatic failure
dosing interval, dosing interval, dosage size dosage size
if oliguria or anuriaif oliguria or anuria
STOP routine dosing of STOP routine dosing of morphinemorphine
use ONLY prnuse ONLY prn
Conjugated by liverConjugated by liver
90%–95% excreted in urine90%–95% excreted in urine
Dehydration, renal failure, severe Dehydration, renal failure, severe hepatic failurehepatic failure
dosing interval, dosing interval, dosage size dosage size
if oliguria or anuriaif oliguria or anuria
STOP routine dosing of STOP routine dosing of morphinemorphine
use ONLY prnuse ONLY prn
Not recommended . . .Not recommended . . . MeperidineMeperidine
poor oral absorptionpoor oral absorption
normeperidine is a toxic metabolitenormeperidine is a toxic metabolite
longer half-life (6 hours), no longer half-life (6 hours), no analgesiaanalgesia
psychotomimetic adverse psychotomimetic adverse effects, myoclonus, seizureseffects, myoclonus, seizures
if dosing q 3 h for analgesia, if dosing q 3 h for analgesia, normeperidine builds upnormeperidine builds up
accumulates with renal failureaccumulates with renal failure
MeperidineMeperidine
poor oral absorptionpoor oral absorption
normeperidine is a toxic metabolitenormeperidine is a toxic metabolite
longer half-life (6 hours), no longer half-life (6 hours), no analgesiaanalgesia
psychotomimetic adverse psychotomimetic adverse effects, myoclonus, seizureseffects, myoclonus, seizures
if dosing q 3 h for analgesia, if dosing q 3 h for analgesia, normeperidine builds upnormeperidine builds up
accumulates with renal failureaccumulates with renal failure
Not recommended . . .Not recommended . . .
PropoxyphenePropoxyphene
no better than placebono better than placebo
low efficacy at commercially low efficacy at commercially available dosesavailable doses
toxic metabolite at high dosestoxic metabolite at high doses
PropoxyphenePropoxyphene
no better than placebono better than placebo
low efficacy at commercially low efficacy at commercially available dosesavailable doses
toxic metabolite at high dosestoxic metabolite at high doses
. . . Not recommended. . . Not recommended
Mixed agonist-antagonistsMixed agonist-antagonists
pentazocine, butorphanol, nalbuphine, pentazocine, butorphanol, nalbuphine, dezocinedezocine
compete with agonists compete with agonists withdrawalwithdrawal
analgesic ceiling effectanalgesic ceiling effect
high risk of psychotomimetic high risk of psychotomimetic adverse effects with adverse effects with pentazocine, butorphanolpentazocine, butorphanol
Mixed agonist-antagonistsMixed agonist-antagonists
pentazocine, butorphanol, nalbuphine, pentazocine, butorphanol, nalbuphine, dezocinedezocine
compete with agonists compete with agonists withdrawalwithdrawal
analgesic ceiling effectanalgesic ceiling effect
high risk of psychotomimetic high risk of psychotomimetic adverse effects with adverse effects with pentazocine, butorphanolpentazocine, butorphanol
Addiction . . .Addiction . . .
Psychological dependencePsychological dependence
Compulsive useCompulsive use
Loss of control over drugsLoss of control over drugs
Loss of interest in pleasurable Loss of interest in pleasurable activitiesactivities
Psychological dependencePsychological dependence
Compulsive useCompulsive use
Loss of control over drugsLoss of control over drugs
Loss of interest in pleasurable Loss of interest in pleasurable activitiesactivities
Addiction . . . Addiction . . .
Continued use of drugs in spite of Continued use of drugs in spite of harmharm
A rare outcome of pain management A rare outcome of pain management
particularly, if no history of substance particularly, if no history of substance abuseabuse
Continued use of drugs in spite of Continued use of drugs in spite of harmharm
A rare outcome of pain management A rare outcome of pain management
particularly, if no history of substance particularly, if no history of substance abuseabuse
. . . Addiction. . . Addiction
ConsiderConsider
substance use (true addiction)substance use (true addiction)
pseudoaddiction (undertreatment of pseudoaddiction (undertreatment of pain)pain)
behavioral / family / psychological behavioral / family / psychological disorderdisorder
drug diversiondrug diversion
ConsiderConsider
substance use (true addiction)substance use (true addiction)
pseudoaddiction (undertreatment of pseudoaddiction (undertreatment of pain)pain)
behavioral / family / psychological behavioral / family / psychological disorderdisorder
drug diversiondrug diversion
ToleranceTolerance
Reduced effectiveness to a given Reduced effectiveness to a given dose over timedose over time
Not clinically significant with chronic Not clinically significant with chronic dosingdosing
If dose is increasing, suspect If dose is increasing, suspect disease progressiondisease progression
Reduced effectiveness to a given Reduced effectiveness to a given dose over timedose over time
Not clinically significant with chronic Not clinically significant with chronic dosingdosing
If dose is increasing, suspect If dose is increasing, suspect disease progressiondisease progression
Physical dependencePhysical dependence
A process of neuroadaptationA process of neuroadaptation
Abrupt withdrawal may Abrupt withdrawal may abstinence abstinence syndromesyndrome
If dose reduction required, reduce by If dose reduction required, reduce by 50% q 2–3 days50% q 2–3 days
avoid antagonistsavoid antagonists
A process of neuroadaptationA process of neuroadaptation
Abrupt withdrawal may Abrupt withdrawal may abstinence abstinence syndromesyndrome
If dose reduction required, reduce by If dose reduction required, reduce by 50% q 2–3 days50% q 2–3 days
avoid antagonistsavoid antagonists
Substance usersSubstance users
Can have pain tooCan have pain too
Treat with compassion Treat with compassion
Protocols, contractingProtocols, contracting
Consultation with pain or addiction Consultation with pain or addiction specialistsspecialists
Can have pain tooCan have pain too
Treat with compassion Treat with compassion
Protocols, contractingProtocols, contracting
Consultation with pain or addiction Consultation with pain or addiction specialistsspecialists
Pain poorly responsiveto opioidsPain poorly responsiveto opioids If dose escalation If dose escalation adverse effects adverse effects
more sophisticated therapy to more sophisticated therapy to counteract adverse effectcounteract adverse effect
alternativealternative
route of administrationroute of administration
opioid (“opioid rotation”)opioid (“opioid rotation”)
coanalgesiccoanalgesic
use a nonpharmacologic approachuse a nonpharmacologic approach
If dose escalation If dose escalation adverse effects adverse effects
more sophisticated therapy to more sophisticated therapy to counteract adverse effectcounteract adverse effect
alternativealternative
route of administrationroute of administration
opioid (“opioid rotation”)opioid (“opioid rotation”)
coanalgesiccoanalgesic
use a nonpharmacologic approachuse a nonpharmacologic approach
Ongoing assessmentOngoing assessment Increase analgesics until pain Increase analgesics until pain
relieved or adverse effects relieved or adverse effects unacceptableunacceptable
Be prepared for sudden changes in Be prepared for sudden changes in painpain
Driving is safe ifDriving is safe if
pain controlled, dose stable, no adverse pain controlled, dose stable, no adverse effectseffects
Increase analgesics until pain Increase analgesics until pain relieved or adverse effects relieved or adverse effects unacceptableunacceptable
Be prepared for sudden changes in Be prepared for sudden changes in painpain
Driving is safe ifDriving is safe if
pain controlled, dose stable, no adverse pain controlled, dose stable, no adverse effectseffects
EEPPEECC
EEPPEECC Principles of Pain Principles of Pain
Management Management
SummarySummary
Principles of Pain Principles of Pain Management Management
SummarySummary
EEPPEECC
EEPPEECC Module 4, Part 2
Equianalgesic Dosing
Module 4, Part 2Equianalgesic Dosing
ObjectivesObjectives
Know alternative routes for delivery Know alternative routes for delivery of opioid analgesicsof opioid analgesics
Demonstrate ability to convert Demonstrate ability to convert between opioids while maintaining between opioids while maintaining analgesiaanalgesia
Know alternative routes for delivery Know alternative routes for delivery of opioid analgesicsof opioid analgesics
Demonstrate ability to convert Demonstrate ability to convert between opioids while maintaining between opioids while maintaining analgesiaanalgesia
Alternative routesof administrationAlternative routesof administration Enteral feeding tubesEnteral feeding tubes
TransmucosalTransmucosal
RectalRectal
Transdermal Transdermal
ParenteralParenteral
IntraspinalIntraspinal
Enteral feeding tubesEnteral feeding tubes
TransmucosalTransmucosal
RectalRectal
Transdermal Transdermal
ParenteralParenteral
IntraspinalIntraspinal
Transdermal patchTransdermal patch
FentanylFentanyl
peak effect after application peak effect after application 24 hours 24 hours
patch lasts 48–72 hourspatch lasts 48–72 hours
ensure adherence to skinensure adherence to skin
FentanylFentanyl
peak effect after application peak effect after application 24 hours 24 hours
patch lasts 48–72 hourspatch lasts 48–72 hours
ensure adherence to skinensure adherence to skin
ParenteralParenteral
SC, IV, IMSC, IV, IM
bolus dosing q 3–4 hbolus dosing q 3–4 h
continuous infusioncontinuous infusion
easier to administereasier to administer
more even pain controlmore even pain control
SC, IV, IMSC, IV, IM
bolus dosing q 3–4 hbolus dosing q 3–4 h
continuous infusioncontinuous infusion
easier to administereasier to administer
more even pain controlmore even pain control
IntraspinalIntraspinal
EpiduralEpidural
IntrathecalIntrathecal
Morphine, hydromorphone, fentanylMorphine, hydromorphone, fentanyl
ConsultationConsultation
EpiduralEpidural
IntrathecalIntrathecal
Morphine, hydromorphone, fentanylMorphine, hydromorphone, fentanyl
ConsultationConsultation
Bolus effectBolus effect
Swings in plasma concentrationSwings in plasma concentration
drowsiness ½ –1 hour after ingestiondrowsiness ½ –1 hour after ingestion
pain before next dose duepain before next dose due
Must move to Must move to
extended-release preparationextended-release preparation
continuous SC, IV infusioncontinuous SC, IV infusion
Swings in plasma concentrationSwings in plasma concentration
drowsiness ½ –1 hour after ingestiondrowsiness ½ –1 hour after ingestion
pain before next dose duepain before next dose due
Must move to Must move to
extended-release preparationextended-release preparation
continuous SC, IV infusioncontinuous SC, IV infusion
Changing routesof administrationChanging routesof administration Equianalgesic tableEquianalgesic table
guide to initial dose selectionguide to initial dose selection
Significant first-pass metabolism of Significant first-pass metabolism of po / pr dosespo / pr doses
codeine, hydromorphone, morphinecodeine, hydromorphone, morphine
po / prpo / pr toto SC, IV, IMSC, IV, IM
2–32–3 11
Equianalgesic tableEquianalgesic table
guide to initial dose selectionguide to initial dose selection
Significant first-pass metabolism of Significant first-pass metabolism of po / pr dosespo / pr doses
codeine, hydromorphone, morphinecodeine, hydromorphone, morphine
po / prpo / pr toto SC, IV, IMSC, IV, IM
2–32–3 11
Equianalgesic dosesof opioid analgesicsEquianalgesic dosesof opioid analgesics
po / pr po / pr (mg)(mg) AnalgesicAnalgesic SC / IV / IM SC / IV / IM (mg)(mg)
100100 CodeineCodeine 6060
1515 HydrocodoneHydrocodone --
44 HydromorphoneHydromorphone 1.51.5
1515 MorphineMorphine 55
1010 OxycodoneOxycodone --
po / pr po / pr (mg)(mg) AnalgesicAnalgesic SC / IV / IM SC / IV / IM (mg)(mg)
100100 CodeineCodeine 6060
1515 HydrocodoneHydrocodone --
44 HydromorphoneHydromorphone 1.51.5
1515 MorphineMorphine 55
1010 OxycodoneOxycodone --
Changing opioids . . .Changing opioids . . .
Equianalgesic tableEquianalgesic table
Transdermal fentanylTransdermal fentanyl
25-25-g patch g patch 45–135 (likely 50–60) mg 45–135 (likely 50–60) mg morphine / 24 h morphine / 24 h
Equianalgesic tableEquianalgesic table
Transdermal fentanylTransdermal fentanyl
25-25-g patch g patch 45–135 (likely 50–60) mg 45–135 (likely 50–60) mg morphine / 24 h morphine / 24 h
. . . Changing opioids. . . Changing opioids
Cross-toleranceCross-tolerance
start with 50%–75% of published start with 50%–75% of published equianalgesic doseequianalgesic dose
more if pain, less if adverse more if pain, less if adverse effectseffects
MethadoneMethadone
start with 10%–25% of published start with 10%–25% of published equianalgesic doseequianalgesic dose
Cross-toleranceCross-tolerance
start with 50%–75% of published start with 50%–75% of published equianalgesic doseequianalgesic dose
more if pain, less if adverse more if pain, less if adverse effectseffects
MethadoneMethadone
start with 10%–25% of published start with 10%–25% of published equianalgesic doseequianalgesic dose
Case 1Case 1 Mrs D, 45 years old Mrs D, 45 years old
Breast cancer, metastases to boneBreast cancer, metastases to bone
Comfortable on morphine atComfortable on morphine at6 mg / h SC6 mg / h SC
Convert to oral medications before Convert to oral medications before dischargedischarge
Mrs D, 45 years old Mrs D, 45 years old
Breast cancer, metastases to boneBreast cancer, metastases to bone
Comfortable on morphine atComfortable on morphine at6 mg / h SC6 mg / h SC
Convert to oral medications before Convert to oral medications before dischargedischarge
Case 2Case 2 Mr T, 73 years old, lung cancer, Mr T, 73 years old, lung cancer,
malignant pleural effusion, chronic malignant pleural effusion, chronic chest painchest pain
Thoracentesis, pleurodesisThoracentesis, pleurodesis Meperidine, 75 mg IM q 6 hMeperidine, 75 mg IM q 6 h Convert to oral morphine (without Convert to oral morphine (without
correcting for cross-tolerance)correcting for cross-tolerance)
Mr T, 73 years old, lung cancer, Mr T, 73 years old, lung cancer, malignant pleural effusion, chronic malignant pleural effusion, chronic chest painchest pain
Thoracentesis, pleurodesisThoracentesis, pleurodesis Meperidine, 75 mg IM q 6 hMeperidine, 75 mg IM q 6 h Convert to oral morphine (without Convert to oral morphine (without
correcting for cross-tolerance)correcting for cross-tolerance)
Case 3Case 3 Ms M, 41 years old, ovarian cancer, Ms M, 41 years old, ovarian cancer,
ascitesascites
2 x acetaminophen / hydrocodone (500 / 5 mg) q 4 h2 x acetaminophen / hydrocodone (500 / 5 mg) q 4 h
1 x acetaminophen / oxycodone (325 / 5 mg) q 6 h1 x acetaminophen / oxycodone (325 / 5 mg) q 6 h
Pain controlled, worried about Pain controlled, worried about acetaminophen toxicityacetaminophen toxicity
Convert to hydromorphone (without Convert to hydromorphone (without correcting for cross-tolerance)correcting for cross-tolerance)
Ms M, 41 years old, ovarian cancer, Ms M, 41 years old, ovarian cancer, ascitesascites
2 x acetaminophen / hydrocodone (500 / 5 mg) q 4 h2 x acetaminophen / hydrocodone (500 / 5 mg) q 4 h
1 x acetaminophen / oxycodone (325 / 5 mg) q 6 h1 x acetaminophen / oxycodone (325 / 5 mg) q 6 h
Pain controlled, worried about Pain controlled, worried about acetaminophen toxicityacetaminophen toxicity
Convert to hydromorphone (without Convert to hydromorphone (without correcting for cross-tolerance)correcting for cross-tolerance)
EEPPEECC
EEPPEECC Equianalgesic Equianalgesic
DosingDosing
SummarySummary
Equianalgesic Equianalgesic DosingDosing
SummarySummary
EEPPEECC
EEPPEECC Module 4, Part 3
Adjuvants, Adverse Effects, Barriers
Module 4, Part 3
Adjuvants, Adverse Effects, Barriers
ObjectivesObjectives
Know use of adjuvant analgesic Know use of adjuvant analgesic agentsagents
Know adverse effects of analgesics, Know adverse effects of analgesics, their managementtheir management
List barriers to pain managementList barriers to pain management
Know use of adjuvant analgesic Know use of adjuvant analgesic agentsagents
Know adverse effects of analgesics, Know adverse effects of analgesics, their managementtheir management
List barriers to pain managementList barriers to pain management
Adjuvant analgesics Adjuvant analgesics
Medications that supplement primary Medications that supplement primary analgesicsanalgesics
may themselves be primary analgesicsmay themselves be primary analgesics
use at any step of WHO ladderuse at any step of WHO ladder
Medications that supplement primary Medications that supplement primary analgesicsanalgesics
may themselves be primary analgesicsmay themselves be primary analgesics
use at any step of WHO ladderuse at any step of WHO ladder
Burning, tingling, neuropathic painBurning, tingling, neuropathic pain Tricyclic antidepressantsTricyclic antidepressants
Gabapentin (anticonvulsant)Gabapentin (anticonvulsant)
SSRIs usually not so usefulSSRIs usually not so useful
Tricyclic antidepressantsTricyclic antidepressants
Gabapentin (anticonvulsant)Gabapentin (anticonvulsant)
SSRIs usually not so usefulSSRIs usually not so useful
Tricyclic antidepressants for burning pain . . .Tricyclic antidepressants for burning pain . . .
AmitriptylineAmitriptyline
most extensively studiedmost extensively studied
10–25 mg po q hs, titrate 10–25 mg po q hs, titrate (escalate q 4–7 d)(escalate q 4–7 d)
analgesia in days to weeksanalgesia in days to weeks
AmitriptylineAmitriptyline
most extensively studiedmost extensively studied
10–25 mg po q hs, titrate 10–25 mg po q hs, titrate (escalate q 4–7 d)(escalate q 4–7 d)
analgesia in days to weeksanalgesia in days to weeks
Tricyclic antidepressants for burning pain . . .Tricyclic antidepressants for burning pain . . .
AmitriptylineAmitriptyline
monitor plasma drug levels monitor plasma drug levels > 100 mg / 24 h for risk of toxicity> 100 mg / 24 h for risk of toxicity
anticholinergic adverse effects anticholinergic adverse effects prominent, cardiac toxicityprominent, cardiac toxicity
sedating limited usefulness in frail, sedating limited usefulness in frail, elderlyelderly
AmitriptylineAmitriptyline
monitor plasma drug levels monitor plasma drug levels > 100 mg / 24 h for risk of toxicity> 100 mg / 24 h for risk of toxicity
anticholinergic adverse effects anticholinergic adverse effects prominent, cardiac toxicityprominent, cardiac toxicity
sedating limited usefulness in frail, sedating limited usefulness in frail, elderlyelderly
. . . Tricyclic antidepressants for burning pain. . . Tricyclic antidepressants for burning pain
DesipramineDesipramine
minimal anticholinergic or sedating minimal anticholinergic or sedating adverse effectsadverse effects
10–25 mg po q hs, titrate10–25 mg po q hs, titrate
tricyclic of choice in seriously illtricyclic of choice in seriously ill
nortriptyline is an alternativenortriptyline is an alternative
DesipramineDesipramine
minimal anticholinergic or sedating minimal anticholinergic or sedating adverse effectsadverse effects
10–25 mg po q hs, titrate10–25 mg po q hs, titrate
tricyclic of choice in seriously illtricyclic of choice in seriously ill
nortriptyline is an alternativenortriptyline is an alternative
Gabapentin for burning painGabapentin for burning pain AnticonvulsantAnticonvulsant
100 mg po q d to tid, titrate100 mg po q d to tid, titrate
increase dose q 1–3 dincrease dose q 1–3 d
usual effective dose 900–1800 mg / d; usual effective dose 900–1800 mg / d; max may be > 3600 mg / dmax may be > 3600 mg / d
minimal adverse effectsminimal adverse effects
drowsiness, tolerance develops drowsiness, tolerance develops within dayswithin days
AnticonvulsantAnticonvulsant
100 mg po q d to tid, titrate100 mg po q d to tid, titrate
increase dose q 1–3 dincrease dose q 1–3 d
usual effective dose 900–1800 mg / d; usual effective dose 900–1800 mg / d; max may be > 3600 mg / dmax may be > 3600 mg / d
minimal adverse effectsminimal adverse effects
drowsiness, tolerance develops drowsiness, tolerance develops within dayswithin days
Shooting, stabbing, neuropathic painShooting, stabbing, neuropathic pain AnticonvulsantsAnticonvulsants
gabapentingabapentin
100 mg po tid, titrate100 mg po tid, titrate
carbamazepinecarbamazepine
100 mg po bid, titrate100 mg po bid, titrate
valproic acidvalproic acid
250 mg po q hs, titrate250 mg po q hs, titrate
monitor plasma levels for risk of toxicitymonitor plasma levels for risk of toxicity
AnticonvulsantsAnticonvulsants
gabapentingabapentin
100 mg po tid, titrate100 mg po tid, titrate
carbamazepinecarbamazepine
100 mg po bid, titrate100 mg po bid, titrate
valproic acidvalproic acid
250 mg po q hs, titrate250 mg po q hs, titrate
monitor plasma levels for risk of toxicitymonitor plasma levels for risk of toxicity
Complex neuropathic pain . . .Complex neuropathic pain . . . Primary neuronal deathPrimary neuronal death Loss of myelin sheathLoss of myelin sheath Central sensitizationCentral sensitization Changes in neurotransmitters, Changes in neurotransmitters,
neuroreceptorsneuroreceptors
Opioid receptor down-regulationOpioid receptor down-regulation
increased importance of NMDA increased importance of NMDA receptors, glutamatereceptors, glutamate
Primary neuronal deathPrimary neuronal death Loss of myelin sheathLoss of myelin sheath Central sensitizationCentral sensitization Changes in neurotransmitters, Changes in neurotransmitters,
neuroreceptorsneuroreceptors
Opioid receptor down-regulationOpioid receptor down-regulation
increased importance of NMDA increased importance of NMDA receptors, glutamatereceptors, glutamate
. . . Complex neuropathic pain. . . Complex neuropathic pain Sensory neuronal deathSensory neuronal death
Multiple other medicationsMultiple other medications
Consult pain expert earlyConsult pain expert early
Sensory neuronal deathSensory neuronal death
Multiple other medicationsMultiple other medications
Consult pain expert earlyConsult pain expert early
Case 7 . . .Case 7 . . .
John, 40-year-old accountantJohn, 40-year-old accountant
AIDS, T4 = 34AIDS, T4 = 34
Burning pain hands, feetBurning pain hands, feet
initially with ddC + AZTinitially with ddC + AZT
disappeared when stoppeddisappeared when stopped
John, 40-year-old accountantJohn, 40-year-old accountant
AIDS, T4 = 34AIDS, T4 = 34
Burning pain hands, feetBurning pain hands, feet
initially with ddC + AZTinitially with ddC + AZT
disappeared when stoppeddisappeared when stopped
. . . Case 7. . . Case 7
Burning pain hands, feetBurning pain hands, feet
now returned x 6 monthsnow returned x 6 months
severesevere
keeps awake at nightkeeps awake at night
numbness in feetnumbness in feet
trouble buttoning shirttrouble buttoning shirt
How to manage John’s pain?How to manage John’s pain?
Burning pain hands, feetBurning pain hands, feet
now returned x 6 monthsnow returned x 6 months
severesevere
keeps awake at nightkeeps awake at night
numbness in feetnumbness in feet
trouble buttoning shirttrouble buttoning shirt
How to manage John’s pain?How to manage John’s pain?
Bone pain . . .Bone pain . . .
Constant, worse with movementConstant, worse with movement
Metastases, compression or Metastases, compression or pathologic fracturespathologic fractures
Prostaglandins from inflammation, Prostaglandins from inflammation, metastasesmetastases
Rule out cord compressionRule out cord compression
Constant, worse with movementConstant, worse with movement
Metastases, compression or Metastases, compression or pathologic fracturespathologic fractures
Prostaglandins from inflammation, Prostaglandins from inflammation, metastasesmetastases
Rule out cord compressionRule out cord compression
Bone pain . . .Bone pain . . .
ManagementManagement
opioidsopioids
NSAIDsNSAIDs
corticosteroidscorticosteroids
bisphosphonatesbisphosphonates
calcitonincalcitonin
ManagementManagement
opioidsopioids
NSAIDsNSAIDs
corticosteroidscorticosteroids
bisphosphonatesbisphosphonates
calcitonincalcitonin
. . . Bone pain. . . Bone pain
ManagementManagement
radiopharmaceuticalsradiopharmaceuticals
external beam radiationexternal beam radiation
orthopedic interventionorthopedic intervention
external bracingexternal bracing
ConsultationConsultation
ManagementManagement
radiopharmaceuticalsradiopharmaceuticals
external beam radiationexternal beam radiation
orthopedic interventionorthopedic intervention
external bracingexternal bracing
ConsultationConsultation
Case 8Case 8
Sarah, 73-year-old attorneySarah, 73-year-old attorney
Breast cancer, metastases to boneBreast cancer, metastases to bone
Treated with Adriamycin, Treated with Adriamycin, cyclophosphamidecyclophosphamide
2 months tamoxifen2 months tamoxifen
How to manage Sarah’s pain?How to manage Sarah’s pain?
Sarah, 73-year-old attorneySarah, 73-year-old attorney
Breast cancer, metastases to boneBreast cancer, metastases to bone
Treated with Adriamycin, Treated with Adriamycin, cyclophosphamidecyclophosphamide
2 months tamoxifen2 months tamoxifen
How to manage Sarah’s pain?How to manage Sarah’s pain?
Pain from bowel obstruction . . .Pain from bowel obstruction . . . ConstipationConstipation
External compressionExternal compression
Bowel wall stretch, inflammationBowel wall stretch, inflammation
Associated symptomsAssociated symptoms
Definitive interventionDefinitive intervention
relief of constipationrelief of constipation
surgical removal or bypasssurgical removal or bypass
ConstipationConstipation
External compressionExternal compression
Bowel wall stretch, inflammationBowel wall stretch, inflammation
Associated symptomsAssociated symptoms
Definitive interventionDefinitive intervention
relief of constipationrelief of constipation
surgical removal or bypasssurgical removal or bypass
. . . Pain from bowel obstruction. . . Pain from bowel obstruction ManagementManagement
opioidsopioids
corticosteroidscorticosteroids
NSAIDsNSAIDs
anticholinergic medications anticholinergic medications eg, scopolamineeg, scopolamine
octreotideoctreotide
ConsultationConsultation
ManagementManagement
opioidsopioids
corticosteroidscorticosteroids
NSAIDsNSAIDs
anticholinergic medications anticholinergic medications eg, scopolamineeg, scopolamine
octreotideoctreotide
ConsultationConsultation
Corticosteroids . . .Corticosteroids . . .
Many usesMany uses
DexamethasoneDexamethasone
long half-life (>36 h), dose once / daylong half-life (>36 h), dose once / day
minimal mineralocorticoid effectminimal mineralocorticoid effect
doses of 2–20 + mg / ddoses of 2–20 + mg / d
Many usesMany uses
DexamethasoneDexamethasone
long half-life (>36 h), dose once / daylong half-life (>36 h), dose once / day
minimal mineralocorticoid effectminimal mineralocorticoid effect
doses of 2–20 + mg / ddoses of 2–20 + mg / d
. . . Corticosteroids. . . Corticosteroids
Adverse effectsAdverse effects
steroid psychosissteroid psychosis
proximal myopathyproximal myopathy
other long-term adverse effectsother long-term adverse effects
Adverse effectsAdverse effects
steroid psychosissteroid psychosis
proximal myopathyproximal myopathy
other long-term adverse effectsother long-term adverse effects
Case 9Case 9
David, 67-year-old farmerDavid, 67-year-old farmer
Colon cancer, metastases to liverColon cancer, metastases to liver
Right upper quadrant painRight upper quadrant pain
tender livertender liver
no shifting dullnessno shifting dullness
How to manage David’s pain?How to manage David’s pain?
David, 67-year-old farmerDavid, 67-year-old farmer
Colon cancer, metastases to liverColon cancer, metastases to liver
Right upper quadrant painRight upper quadrant pain
tender livertender liver
no shifting dullnessno shifting dullness
How to manage David’s pain?How to manage David’s pain?
Opioid adverse effectsOpioid adverse effects
CommonCommon UncommonUncommon
ConstipationConstipation Bad dreams / Bad dreams / hallucinationshallucinations
Dry mouthDry mouth Dysphoria / deliriumDysphoria / delirium
Nausea / vomitingNausea / vomiting Myoclonus / seizuresMyoclonus / seizures
SedationSedation Pruritus / urticariaPruritus / urticaria
SweatsSweats Respiratory depressionRespiratory depression
Urinary retentionUrinary retention
CommonCommon UncommonUncommon
ConstipationConstipation Bad dreams / Bad dreams / hallucinationshallucinations
Dry mouthDry mouth Dysphoria / deliriumDysphoria / delirium
Nausea / vomitingNausea / vomiting Myoclonus / seizuresMyoclonus / seizures
SedationSedation Pruritus / urticariaPruritus / urticaria
SweatsSweats Respiratory depressionRespiratory depression
Urinary retentionUrinary retention
Opioid allergyOpioid allergy Nausea / vomiting, constipation, Nausea / vomiting, constipation,
drowsiness, confusiondrowsiness, confusion
adverse effects, not allergic reactionsadverse effects, not allergic reactions
Anaphylactic reactions are the only Anaphylactic reactions are the only true allergiestrue allergies
bronchospasmbronchospasm
Urticaria, bronchospasm can be Urticaria, bronchospasm can be allergies; need careful assessmentallergies; need careful assessment
Nausea / vomiting, constipation, Nausea / vomiting, constipation, drowsiness, confusiondrowsiness, confusion
adverse effects, not allergic reactionsadverse effects, not allergic reactions
Anaphylactic reactions are the only Anaphylactic reactions are the only true allergiestrue allergies
bronchospasmbronchospasm
Urticaria, bronchospasm can be Urticaria, bronchospasm can be allergies; need careful assessmentallergies; need careful assessment
Urticaria, pruritusUrticaria, pruritus
Mast cell destabilization by Mast cell destabilization by morphine, hydromorphonemorphine, hydromorphone
Treat with routine long-acting, Treat with routine long-acting, nonsedating antihistaminesnonsedating antihistamines
fexofenadine, 60 mg po bid, or higherfexofenadine, 60 mg po bid, or higher
or try diphenhydramine, loratadine, or or try diphenhydramine, loratadine, or doxepindoxepin
Mast cell destabilization by Mast cell destabilization by morphine, hydromorphonemorphine, hydromorphone
Treat with routine long-acting, Treat with routine long-acting, nonsedating antihistaminesnonsedating antihistamines
fexofenadine, 60 mg po bid, or higherfexofenadine, 60 mg po bid, or higher
or try diphenhydramine, loratadine, or or try diphenhydramine, loratadine, or doxepindoxepin
Constipation . . .Constipation . . .
Common to all opioidsCommon to all opioids
Opioid effects on CNS, spinal cord, Opioid effects on CNS, spinal cord, myenteric plexus of gutmyenteric plexus of gut
Easier to prevent than treatEasier to prevent than treat
Common to all opioidsCommon to all opioids
Opioid effects on CNS, spinal cord, Opioid effects on CNS, spinal cord, myenteric plexus of gutmyenteric plexus of gut
Easier to prevent than treatEasier to prevent than treat
Constipation . . . Constipation . . .
Prokinetic agentProkinetic agent
metoclopramide, cisapridemetoclopramide, cisapride
Osmotic laxativeOsmotic laxative
MOM, lactulose, sorbitolMOM, lactulose, sorbitol
Other measuresOther measures
Prokinetic agentProkinetic agent
metoclopramide, cisapridemetoclopramide, cisapride
Osmotic laxativeOsmotic laxative
MOM, lactulose, sorbitolMOM, lactulose, sorbitol
Other measuresOther measures
. . . Constipation. . . Constipation Diet usually insufficientDiet usually insufficient
Bulk forming agents not Bulk forming agents not recommendedrecommended
Stimulant laxativeStimulant laxative
senna, bisacodyl, glycerine, senna, bisacodyl, glycerine, casanthranol, etccasanthranol, etc
Combine with a stool softenerCombine with a stool softener
senna + docusate sodiumsenna + docusate sodium
Diet usually insufficientDiet usually insufficient
Bulk forming agents not Bulk forming agents not recommendedrecommended
Stimulant laxativeStimulant laxative
senna, bisacodyl, glycerine, senna, bisacodyl, glycerine, casanthranol, etccasanthranol, etc
Combine with a stool softenerCombine with a stool softener
senna + docusate sodiumsenna + docusate sodium
Nausea / vomiting . . .Nausea / vomiting . . .
Onset with start of opioidsOnset with start of opioids
tolerance develops within daystolerance develops within days
Prevent or treat with dopamine-Prevent or treat with dopamine-blocking antiemeticsblocking antiemetics
prochlorperazine, 10 mg q 6 hprochlorperazine, 10 mg q 6 h
haloperidol, 1 mg q 6 hhaloperidol, 1 mg q 6 h
metoclopramide, 10 mg q 6 hmetoclopramide, 10 mg q 6 h
Onset with start of opioidsOnset with start of opioids
tolerance develops within daystolerance develops within days
Prevent or treat with dopamine-Prevent or treat with dopamine-blocking antiemeticsblocking antiemetics
prochlorperazine, 10 mg q 6 hprochlorperazine, 10 mg q 6 h
haloperidol, 1 mg q 6 hhaloperidol, 1 mg q 6 h
metoclopramide, 10 mg q 6 hmetoclopramide, 10 mg q 6 h
. . . Nausea / vomiting. . . Nausea / vomiting
Other antiemetics may also be Other antiemetics may also be effectiveeffective
Alternative opioid if refractoryAlternative opioid if refractory
Other antiemetics may also be Other antiemetics may also be effectiveeffective
Alternative opioid if refractoryAlternative opioid if refractory
Sedation . . .Sedation . . .
Onset with start of opioidsOnset with start of opioids
distinguish from exhaustion due to paindistinguish from exhaustion due to pain
tolerance develops within daystolerance develops within days
Complex in advanced diseaseComplex in advanced disease
Onset with start of opioidsOnset with start of opioids
distinguish from exhaustion due to paindistinguish from exhaustion due to pain
tolerance develops within daystolerance develops within days
Complex in advanced diseaseComplex in advanced disease
. . . Sedation. . . Sedation
If persistent, alternative opioid or If persistent, alternative opioid or route of administrationroute of administration
Psychostimulants may be usefulPsychostimulants may be useful
methylphenidate, 5 mg q am and q noon, methylphenidate, 5 mg q am and q noon, titratetitrate
If persistent, alternative opioid or If persistent, alternative opioid or route of administrationroute of administration
Psychostimulants may be usefulPsychostimulants may be useful
methylphenidate, 5 mg q am and q noon, methylphenidate, 5 mg q am and q noon, titratetitrate
Delirium . . .Delirium . . .
PresentationPresentation
confusion, bad dreams, hallucinationsconfusion, bad dreams, hallucinations
restlessness, agitationrestlessness, agitation
myoclonic jerks, seizuresmyoclonic jerks, seizures
depressed level of consciousnessdepressed level of consciousness
respiratory depressionrespiratory depression
PresentationPresentation
confusion, bad dreams, hallucinationsconfusion, bad dreams, hallucinations
restlessness, agitationrestlessness, agitation
myoclonic jerks, seizuresmyoclonic jerks, seizures
depressed level of consciousnessdepressed level of consciousness
respiratory depressionrespiratory depression
. . . Delirium. . . Delirium
Rare, unless multiple factors Rare, unless multiple factors contributing, if contributing, if
opioid dosing guidelines followedopioid dosing guidelines followed
renal clearance normalrenal clearance normal
Rare, unless multiple factors Rare, unless multiple factors contributing, if contributing, if
opioid dosing guidelines followedopioid dosing guidelines followed
renal clearance normalrenal clearance normal
Respiratory depression . . .Respiratory depression . . . Opioid effects differ for patients Opioid effects differ for patients
treated for paintreated for pain
pain is a potent stimulus to breathepain is a potent stimulus to breathe
loss of consciousness precedes loss of consciousness precedes respiratory depressionrespiratory depression
pharmacologic tolerance rapidpharmacologic tolerance rapid
Opioid effects differ for patients Opioid effects differ for patients treated for paintreated for pain
pain is a potent stimulus to breathepain is a potent stimulus to breathe
loss of consciousness precedes loss of consciousness precedes respiratory depressionrespiratory depression
pharmacologic tolerance rapidpharmacologic tolerance rapid
. . . Respiratory depression. . . Respiratory depression ManagementManagement
identify, treat contributing causesidentify, treat contributing causes
reduce opioid dosereduce opioid dose
observeobserve
if unstable vital signsif unstable vital signs
naloxone, 0.1-0.2 mg IV q 1-2 minnaloxone, 0.1-0.2 mg IV q 1-2 min
ManagementManagement
identify, treat contributing causesidentify, treat contributing causes
reduce opioid dosereduce opioid dose
observeobserve
if unstable vital signsif unstable vital signs
naloxone, 0.1-0.2 mg IV q 1-2 minnaloxone, 0.1-0.2 mg IV q 1-2 min
Nonpharmacologic pain management . . .Nonpharmacologic pain management . . . NeurostimulationNeurostimulation
TENS, acupunctureTENS, acupuncture
AnesthesiologicAnesthesiologicnerve blocknerve block
SurgicalSurgicalcordotomycordotomy
Physical therapyPhysical therapyexercise, heat, coldexercise, heat, cold
NeurostimulationNeurostimulationTENS, acupunctureTENS, acupuncture
AnesthesiologicAnesthesiologicnerve blocknerve block
SurgicalSurgicalcordotomycordotomy
Physical therapyPhysical therapyexercise, heat, coldexercise, heat, cold
. . . Nonpharmacologic pain management. . . Nonpharmacologic pain management Psychological approachesPsychological approaches
cognitive therapiescognitive therapies(relaxation, imagery, hypnosis)(relaxation, imagery, hypnosis)
biofeedbackbiofeedback
behavior therapy, psychotherapy behavior therapy, psychotherapy
Complementary therapiesComplementary therapies
massagemassage
art, music, aroma therapyart, music, aroma therapy
Psychological approachesPsychological approaches
cognitive therapiescognitive therapies(relaxation, imagery, hypnosis)(relaxation, imagery, hypnosis)
biofeedbackbiofeedback
behavior therapy, psychotherapy behavior therapy, psychotherapy
Complementary therapiesComplementary therapies
massagemassage
art, music, aroma therapyart, music, aroma therapy
Barriers . . .Barriers . . . Not importantNot important
Poor assessmentPoor assessment
Lack of knowledgeLack of knowledge
Fear ofFear of
addictionaddiction
tolerancetolerance
adverse effectsadverse effects
Not importantNot important
Poor assessmentPoor assessment
Lack of knowledgeLack of knowledge
Fear ofFear of
addictionaddiction
tolerancetolerance
adverse effectsadverse effects
. . . Barriers. . . Barriers
Regulatory oversightRegulatory oversight
Patients unwilling to report painPatients unwilling to report pain
Patients unwilling to take medicinePatients unwilling to take medicine
Regulatory oversightRegulatory oversight
Patients unwilling to report painPatients unwilling to report pain
Patients unwilling to take medicinePatients unwilling to take medicine
EEPPEECC
EEPPEECC Adjuvants, Adjuvants,
Adverse Effects, Adverse Effects, BarriersBarriers
SummarySummary
Adjuvants, Adjuvants, Adverse Effects, Adverse Effects, BarriersBarriers
SummarySummary
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