the resident’s guide to pain management elizabeth kvale, md palliative medicine the american...

THE RESIDENT’S GUIDE TO PAIN MANAGEMENT

Elizabeth Kvale, MDPalliative Medicine

THE AMERICAN GERIATRICS SOCIETY

Geriatrics Health Professionals.

Leading change. Improving care for older adults.

AGS

PAIN PHYSIOLOGY BASICS:TYPES OF PAIN

• Nociceptive — arthritis, fracture, laceration

• Visceral — pancreatitis, MI, constipation

• Neuropathic — herpes zoster, diabetic neuropathy

• Complex regional pain syndromes (RSD)

• Central pain

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PAIN PHYSIOLOGY BASICS:ACUTE VS. CHRONIC PAIN

Acute pain• Identified event, resolves

in days–weeks• Usually nociceptive

Chronic pain• Cause often not easily

identified; multifactorial• Indeterminate duration• Nociceptive and/or

neuropathic

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PAIN ASSESSMENT BASICS:BELIEVE THE PATIENT

• Pain 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 factors

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PAIN ASSESSMENT BASICS:USE AN ASSESSMENT INSTRUMENT

Allows 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 discomfort

PAIN MANAGEMENT BASICS:

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ASA

Acetaminophen

NSAIDs

± Adjuvants

1 Mild

A/Codeine

A/Hydrocodone

A/Oxycodone

A/Dihydrocodeine

Tramadol

± Adjuvants

2 Moderate

3 Severe

Morphine

Hydromorphone

Methadone

Levorphanol

Fentanyl

Oxycodone

± Adjuvants

• Don’t delay for investigations or disease treatment

• Unmanaged pain nervous system changesPermanent damageAmplification of pain

• Treat underlying cause (eg, radiation for a neoplasm)

PAIN MANAGEMENT BASICS

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• Conjugated in liver

• Excreted via kidney (90%–95%)

• First-order kinetics

• Time to Cmax

PO dosing ― 1 hourSC or IM dosing ― 30 minutes IV dosing ― 6 minutes

PAIN MANAGEMENT BASICS:OPIOID PHARMACOLOGY (1 of 2)

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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)

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Codeine, hydrocodone, morphine, hydromorphone, oxycodone

• Dose q4h

• Adjust dose daily

• Mild or moderate pain: ↑ 25%–50%

• Severe or uncontrolled pain: ↑ 50%–100%

• Adjust more quickly for severe uncontrolled pain

PAIN MANAGEMENT BASICSOral dosing of immediate-release preparations

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• Improve compliance, adherence

• Dose 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 preparations

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• Use immediate-release opioids5%–15% of 24-h doseOffer after Cmax reached

• PO or PR: ~ q1h• SC or IM: ~ q30min• IV: ~ q10–15min

• Do not use extended-release opioids

PAIN MANAGEMENT BASICSBreakthrough pain

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• Ongoing assessment

• Increase analgesics until pain is relieved or adverse effects are unacceptable

• Be prepared for sudden changes in pain

• Driving is safe if pain is controlled, dose is stable, no adverse effects

PAIN MANAGEMENT BASICS

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If dose escalation adverse effects:

• Use more sophisticated therapy to counteract adverse effect

• Use an alternative: Route of administration Opioid (“opioid rotation”)

• Use a co-analgesic

• Use a nonpharmacologic approach

CONCERNS ABOUT OPIOID USE:POOR RESPONSE

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• Conjugated in liver

• 90%–95% excreted in urine

• If dehydration, renal failure, severe hepatic failure develops: dosing interval, dosage size

• If oliguria or anuria develops: Stop routine dosing of morphine Use only PRN

CONCERNS ABOUT OPIOID USE:CLEARANCE

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• Reduced effectiveness to a given dose over time

• Not clinically significant with chronic dosing

• If dose requirement is increasing, suspect disease progression

CONCERNS ABOUT OPIOID USE: TOLERANCE

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• Psychological dependence

• Compulsive use

• Loss of control over drugs

• Loss of interest in pleasurable activities

CONCERNS ABOUT OPIOID USE:ADDICTION

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• A process of neuroadaptation

• Abrupt withdrawal may abstinence syndrome

• If dose reduction required, reduce by 50%q2–3 days

Avoid antagonists

CONCERNS ABOUT OPIOID USE:PHYSICAL DEPENDENCE

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• Can have pain too

• Treat with compassion

• Protocols, contracting

• Consult with pain or addiction specialists

CONCERNS ABOUT OPIOID USE:SUBSTANCE ABUSERS

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• Meperidine — accumulates toxic metabolite normeperidine

• Mixed agonists/antagonists – Nubain, Talwin

• Do not use naloxone (Narcan) unless true respiratory crisis (RR < 6)

CONCERNS ABOUT OPIOID USE:THINGS TO AVOID

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• Ask the patient Palliative medicine corollary ― believe the patient

• Match the pain medicine to patient’s level of pain

• Increase pain medicine (with awareness ofCmax and half-life) until patient is comfortable

SUMMARY: BASIC PRINCIPLESOF PAIN MANAGEMENT

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• Very pleasant 68-year-old admitted with COPD exacerbation

• Home meds include 2 tablets of oxycodone5 mg/APAP “whenever my back acts up” — usually 4 tablets a day

• Appropriate 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 hours

• Rates her pain as 7/10 “most of the time”

MRS PAINE

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• Maximum acetaminophen dose in 24 hours is 4 grams Tylenol #3 (codeine 30 mg/APAP 325 mg) 24-hr maximum

= 12 tablets Percocet (oxycodone 5 mg/APAP 325 mg) 24-hr maximum =

12 tablets Tylox (oxycodone 5 mg/APAP 500 mg) 24-hr maximum

= 8 tablets Lortab 5 (hydrocodone 5 mg/APAP 500 mg) 24-hr maximum

= 8 tablets

• How long does it take to get a PRN dose of pain medication once it is requested?

KEY POINTS

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• Mrs Paine’s total daily oxycodone dose is40 mg (8 tablets 5 mg)

KEY POINTS

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