The Resident`s Guide to Pain Management

Report
THE RESIDENT’S
GUIDE TO PAIN
MANAGEMENT
AGS
Elizabeth Kvale, MD
Palliative Medicine
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
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
Slide 2
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
Slide 3
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
Slide 4
PAIN ASSESSMENT BASICS:
USE AN ASSESSMENT INSTRUMENT
Allows you to know and document whether you
have helped the patient
Slide 5
PAIN MANAGEMENT BASICS:
Match the medication to the amount of the patient’s discomfort
3 Severe
2 Moderate
Morphine
A/Codeine
1 Mild
A/Hydrocodone
A/Oxycodone
ASA
Acetaminophen
A/Dihydrocodeine
Tramadol
NSAIDs
± Adjuvants
± Adjuvants
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
± Adjuvants
Slide 6
PAIN MANAGEMENT BASICS
• Don’t delay for investigations or disease
treatment
• Unmanaged pain  nervous system changes
 Permanent damage
 Amplification of pain
• Treat underlying cause (eg, radiation for a
neoplasm)
Slide 7
PAIN MANAGEMENT BASICS:
OPIOID PHARMACOLOGY (1 of 2)
• Conjugated in liver
• Excreted via kidney (90%–95%)
• First-order kinetics
• Time to Cmax
 PO dosing ― 1 hour
 SC or IM dosing ― 30 minutes
 IV dosing ― 6 minutes
Slide 8
PAIN MANAGEMENT BASICS:
OPIOID PHARMACOLOGY (2 of 2)
• Steady state after 4–5 half-lives
 Steady state after 1 day (24 hours)
• Duration of effect of “immediate-release”
formulations (except methadone)
 3–5 hours PO or PR
 Shorter with parenteral bolus
Slide 9
PAIN MANAGEMENT BASICS
Oral dosing of immediate-release preparations
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
Slide 10
PAIN MANAGEMENT BASICS
Oral dosing of extended-release preparations
• Improve compliance, adherence
• Dose q8h, q12h, or q24h (product-specific)
 Don’t crush or chew tablets
 May flush time-release granules down feeding tubes
• Adjust dose q2–4 days (once steady state
reached)
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PAIN MANAGEMENT BASICS
Breakthrough pain
• Use immediate-release opioids
 5%–15% of 24-h dose
 Offer after Cmax reached
• PO or PR: ~ q1h
• SC or IM: ~ q30min
• IV:
~ q10–15min
• Do not use extended-release opioids
Slide 12
PAIN MANAGEMENT BASICS
• 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
Slide 13
CONCERNS ABOUT OPIOID USE:
POOR RESPONSE
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
Slide 14
CONCERNS ABOUT OPIOID USE:
CLEARANCE
• 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
Slide 15
CONCERNS ABOUT OPIOID USE:
TOLERANCE
• Reduced effectiveness to a given dose over
time
• Not clinically significant with chronic dosing
• If dose requirement is increasing, suspect
disease progression
Slide 16
CONCERNS ABOUT OPIOID USE:
ADDICTION
• Psychological dependence
• Compulsive use
• Loss of control over drugs
• Loss of interest in pleasurable activities
Slide 17
CONCERNS ABOUT OPIOID USE:
PHYSICAL DEPENDENCE
• A process of neuroadaptation
• Abrupt withdrawal may  abstinence
syndrome
• If dose reduction required, reduce by 50%
q2–3 days
 Avoid antagonists
Slide 18
CONCERNS ABOUT OPIOID USE:
SUBSTANCE ABUSERS
• Can have pain too
• Treat with compassion
• Protocols, contracting
• Consult with pain or addiction specialists
Slide 19
CONCERNS ABOUT OPIOID USE:
THINGS TO AVOID
• Meperidine — accumulates toxic metabolite
normeperidine
• Mixed agonists/antagonists – Nubain, Talwin
• Do not use naloxone (Narcan) unless true
respiratory crisis (RR < 6)
Slide 20
SUMMARY: BASIC PRINCIPLES
OF PAIN MANAGEMENT
• Ask the patient
 Palliative medicine corollary ― believe the patient
• Match the pain medicine to patient’s level of
pain
• Increase pain medicine (with awareness of
Cmax and half-life) until patient is comfortable
Slide 21
MRS PAINE
• Very pleasant 68-year-old admitted with
COPD exacerbation
• Home meds include 2 tablets of oxycodone
5 mg/APAP “whenever my back acts up” —
usually 4 tablets a day
• Appropriate pain medication order?
Slide 22
MRS PAINE
• Readmitted months later with stage IV nonsmall cell lung cancer
• Taking 2 oxycodone/APAP tabs every 6 hours
• Rates her pain as 7/10 “most of the time”
Slide 23
KEY POINTS
• 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?
Slide 24
KEY POINTS
• Mrs Paine’s total daily oxycodone dose is
40 mg (8 tablets  5 mg)
Slide 25
THANK YOU FOR YOUR TIME!
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