Download Pain Management Module

Resident Version
Pain Management Module
Created by Dr. David Olson
Objectives:
1. Differentiate between somatic, visceral, and neuropathic pain by listing two unique
characteristics for each.
2. List 3 signs of pain.
3. Identify two appropriate indications and limitations of non-opioid therapy.
4. Convert three common narcotic medications between IV and orals, and long versus short
acting pharmacotherapy.
References:
1. Schneider, C; Yale, Steven H.; Larson, M. Principles of Pain Management. Clinical
Medicine & Research Volume 1, Number 4: 337-340; 2003.
2. Trescot, Andrea; Boswell, Mark. Opiod Guidelines in the Management of Chronic NonCancer Pain. Pain Physician, 2006; 9:1-40.
3. Krakowski, I; Theobald, S. Practice Guidelines: Summary version of the Standards,
Options and Recommendations for the use of analgesia for the treatment of nociceptive
pain in adults with cancer. British Journal of Cancer (2003) 89(Suppl 1) s67-s72.
Discussion Outline:
A. Pain: is a highly subjective experience, unique to each patient and defined individually based
on experience and perceptions.
I. Types of Pain: Symptoms
Visceral: Pain from internal organs – primarily from inflammation or distension of the organ
capsule
 Poorly Localized
 Referred pain to similarly enervated areas
 Pain waxes and wanes, pressure like “squeezing”
Neuropathic: Pain referred to the body region innervated by damaged nerves
 Burning, Tingling, Electric Shock quality
 Often triggered by light touch “hyperalgesia”
 Poorly localized
Somatic: Nociceptive pain from activation of pain receptors in surface or deep tissue
 Highly localizable
 Sharp, focal pain
 Often more constant, increasing with evaluation of the affected area
II. Signs: On Physical Exam
Although none of these signs are highly sensitive or specific, they can be used as guides
before and during therapy.
 Overall appearance: The patient can appear very comfortable or be writhing. The
presentation depends on the patient.
 Multiple pain rating scales are available, commonly used are scales with evenly
spaced 1-10 numbers and the patient visually grades their pain. There are also
categorical scales using facial expressions for severity.
Tachycardia
Tachypnea
High Blood Pressure
III. Pharmacotherapeutic options:
IV. Starting Therapy:
A. Oral: If patient tolerating PO then start oral if pain is not severe:
1. Tylenol → NSAIDS → Codeine/Ultram → Hydrocodone → Oxycodone →
Morphine
2. Start patient on home therapy, unless they are having side effects.
3. Begin with short acting medications
4. Remember withdrawal is dangerous; never stop a chronic narcotic without
good reasons.
B. IV: For patients not tolerating PO, or in severe pain:
1. Morphine → Dilaudid → Fentanyl → PCA
2. PRN meds: remember to start low and titrate up (2mg q2hrs versus 10mg
q4hrs)
3. Remember parameters: hold for sleeping, low respiratory rate, low blood
pressure.
C. Bowel Regimen: Always remember to start a bowel regimen:
1. Ducosate/Senna, Lactulose if severe constipation, Enemas for pt’s not taking
PO.
D. Neuropathic pain: use Gabapentin or low dose tricyclic antidepressant as initial
Regimen.
E. Functional Chronic Pain (i.e. Fibromyalgia): does not respond to opiod management;
consider using SSRI or TCAs.
IV. Escalating Therapy and Long Term Treatment:
A. Escalating for short term pain relief:
 Goal is pain relief with few side effects
 Monitor daily usage and adjust as needed
 Treat the underlying cause of pain
 If no pain control is obtained, consider whether pain is somatic, visceral or
neuropathic (neuropathic pain rarely responds to opioid management)
B. Long acting medications
 Consider if patient not controlled with high doses of short acting OR
 If patient will require long term pain control OR
 If patient is cycling between sedation and severe pain
C. Converting to long acting
 Determine the total 24 hour usage for the patient
 Start long acting orals to equal 2/3 of the 24 hour use of short acting medications
o Consider the differing dosing schedule of the long acting meds
o Oxycontin q12 hrs
o MSContin; Morphine SR q8 or q12 hours
o Methadone q6, q8 or q12hrs
o Fentanyl Patch q72hrs
 Start short acting breakthrough at 10-15% of the total long acting dose at an
appropriate interval (q4 to q6hrs)
D. Adjusting long acting medications
o Make sure you have given the long acting time to reach steady state, which takes
4 to 5 half-lives
o Add long acting medication equivalent to 50% of breakthrough usage
o Reassess patient regularly for overuse and continue adjusting for pain control
VI. Converting IV to Oral and Back:
Oral
Drug
Parenteral (IV)
100
Codeine
60
n/a
Fentanyl
0.1
15
Hydrocodone
n/a
4
Dilaudid
1.5
150
Demerol
50
10
Methadone
5
15
Morphine
5
10
Oxycodone
n/a
Conversions are equivalent horizontally and vertically.
Fentanyl Patch: 25mcg/72hrs = 45-60mg oral morphine in 24 hrs
VII. Contraindications:
1. Liver problems: maximum 2gms Tylenol/24h, consider the longer half-life in liver
disease
2. GI bleeding: Avoid NSAIDs
3. Elderly: more affected by opioids, consider starting at 50% of short acting doses to
prevent overdose
VIII. Reversing Pain Meds:
1. Narcan to reverse opioids
2. Flumazenil to reverse benzodiazepines (do not reverse in chronic users, high risk of
seizure)
CASE
81 yo male who is admitted for severe pain from spinal stenosis. His past medical history is
significant for CRI, DM, HTN and BPH. The patient was converted from a PCA to morphine
sustained release yesterday and has been complaining of increased pain in the R hip and lower
back. He has used 10mg of oxycodone in the last 24 hours as breakthrough.
His PCA usage shows: total 24 hour use of 29 mg morphine
His current regimen is:
Morphine SR 30mg q8hrs
Oxycodone 5mg q4hrs PRN
Cyclobenzaprine 10mg bid
Ibuprofen 600mg TID
1. Was the conversion to Oral from IV appropriate?
2. Should the long acting or short acting be increased due to pain?
3. No changes to the regimen were made. The next day the patient is poorly arousable,
breathing 4 times per minute. Why? What should you do?
Review Questions:
1. 47 yo female presents to your clinic for the first evaluation. At this time the patient states she
is in continual pain and her previous doctor had been treating her chronic pain, but she recently
changed insurance carriers. She has been doing well on Morphine 90mg bid, and states she only
uses oxycodone a few times a day. Her main concern today is getting her medications refilled.
Physical exam:
Vitals: Pain 6/10, HR 54, BP 102/45, RR 8
Gen: well-groomed, although slow to respond and without stimulus falls asleep easily
M/S: multiple tender areas over trapezius, posterior cervical musculature, upper gluteal region
and costochondral junctions; symmetric and bilateral.
Joints: full range of motion, no synovitis and no pain with active or passive movement.
What is the most appropriate action?
A. Refill her medications
B. Refill her medications; begin an evaluation of her pain
C. Refill her medications at a lower dose and begin a taper of her dosage; begin an evaluation of
her pain
D. Do not refill her medications
E. Do not refill her medications and begin an evaluation of her pain
2. 65 yo male with a history DM, CAD and chronic back pain presents after witnessed aspiration
with respiratory distress. The patient is stabilized in the ICU overnight then transferred to the
floor. His respiratory distress has improved and his wbc count is responding to the antibiotics
well. Speech therapy has seen the patient and has determined that the patient continues to
aspirate anything oral. While you are working up the cause of his aspiration the patient needs to
remain NPO.
72 hours after admission the vitals are: HR 112, Tc 100.6, RR 23, Bp 170/96 Pain 9/10. He also
complains of anxiety, and is having muscular tremors. You review the chart and discover he was
using methadone at 100mg per day for his chronic back pain, and has not received this in at least
4 days.
As the patient is unable to take orals, what would be the appropriate converted dosage for
replacement of his methadone at this time?
A. Oxycodone 5-10mg po q6hrs as needed
B. Morphine 10mg iv q6 hours and 2-4mg iv q4 hours prn for breakthrough
C. Morphine SR 15mg tid and 2-4mg iv q4hrs for breakthough
D. Morphine PCA basal rate 2mg with 1mg q 15 minutes and lockout at 10mg in 4 hours.
E. Fentanyl 75mcg patch
3. 59 yo male with prostate cancer, which has metastasized to his bones is in the hospital for a
significant exacerbation of congestive heart failure. He was continued on his chronic opioids
(morphine sr 45mg q8hr, oxycodone 10mg q6hrs prn breakthrough), however states that he pain
has been much less controlled than previously. He recently received a pamidronate infusion for
bone pain. The concern is that the patient may not be absorbing the oral medications effectively
and is therefore receiving less pain medication than is needed.
What changes would be appropriate?
A.
B.
C.
D.
E.
Increase the morphine sr by 50% and monitor for improvement.
Begin a PCA for pain control
Start patient on IV morphine prn
Begin Fentanyl patch at 75mcg/72hrs and stop morphine sr
Begin Fentanyl patch at 75mcg/72hrs and continue morphine sr for 48-72 hrs
4. 54 yo male with squamous cell carcinoma of the throat and left esophageal wall, with a gtube and a tracheostomy, is admitted to hospital for palliative care. At this time he states that his
pain is poorly controlled. He is on a Fentanyl 25 mcg/hr patch and oxycodone 10 mg po q4 hours
(average use 50mg/day). Pt is also experiencing significant anxiety. Patients’ wife further states
that her husband had a “problem with Meth” less than one yr ago. She is concerned about his
“need for drugs” and does not “want him to be high.”
Physical exam:
Vitals: Pain 8/10 Hr 112 Bp 98/58
Gen: frail, flat affect, pale man lying on his left side with hob elevated 45 degrees continuously
coughing up bloody sputum. Answers questions by placing finger over trach opening-defers
other questions to his wife to answer.
HEENT: firm lesion-left side of neck, trach in place-blood tinged sputum, facial edema-bright
mucous membranes, no exudate-poor visualization secondary to facial edema.
What would be the most appropriate change to treat the patients symptoms (assume
Fentanyl 25 mcg/hr patch = morphine 60 mg/24hr po)?
A. Stop Fentanyl patch. Begin hydromorphone 1 mg/hr hypodermoclysis, lorazepam po prn, and
morphine 20 mg po 1 hour prn for break through pain.
B. Increase Fentanyl 25 mcg/hr patch to 50 mcg/hr. Cont oxycodone 10 mg po q4 hours.
C. Stop Fentanyl patch. Increase prn oxycodone dose to 20 mg po q4 hours and begin lorazepam
po prn.
D. Stop Fentanyl patch. Begin hydromorphone 1 mg/hr with dexamethasone and lorazepam
hypodermoclysis and morphine 20 mg po q1 hour prn for breakthrough pain.
E. Increase Fentanyl 25 mcg/hr patch to 50 mcg/hr. Decrease prn oxycodone dose and
frequency because the patient is asking for it too often and his wife is concerned that he is
using it to “get high”.
Post Module Evaluation
Please place completed evaluation in an interdepartmental mail envelope and address to Dr.
Wendy Gerstein, Department of Medicine, VAMC (111).
1) Topic of module:__________________________
2) On a scale of 1-5, how effective was this module for learning this topic? _________
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment below:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________
4) Was the attending involved in the teaching of this module? Yes/no (please circle).
5) Please provide any further comments/feedback about this module, or the inpatient curriculum
in general:
6) Please circle one:
Attending
Resident (R2/R3)
Intern
Medical student