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Managing Pain (effectively!) Alec Price-Forbes Consultant Rheumatologist December 15th 2010 Mrs W • OA, Inflammatory arthritis • April 2010 unwell anaemic, APR raised • July 2010 presumed osteomyelitis right ankle • September 2010 Staph sepsis • Cervical discitis • ? SBE Mrs W • 3/12 IV antibiotics • November 2010 - septic - CCU for inotropes - drowsy • On fentanyl 175mcg/hr – What is PRN dose – What dose of diamorphine would you convert to? Aims To consider general aspects of pain relief What is pain? To consider issues around assessing and diagnosing pain To understand the principles of choosing an analgesic To understand the use of morphine and appropriate dose calculations What is pain? How would you describe and define pain? - please share thoughts with your neighbour The background What is pain? • Pain is perceived along a spectrum from peripheral pain receptors to the cerebral cortex and is modified at every step along its travel • Pain is an unpleasant, complex, sensory and emotional experience • Pain is a distressing experience for the patient • Pain is what the patient says it is Causes of failure to relieve pain Reasons • Belief that pain is inevitable Consequences • Unnecessary pain • Inaccurate diagnosis of the cause • Lack of understanding of analgesics • Inappropriate Rx • • Unrealistic objectives • Infrequent review • Insufficient attention to mood and morale • • • Use of inappropriate, insufficient or infrequent analgesics Dissatisfaction with Rx Rejection of Rx by patient Lowered pain threshold Adapted from Twycross Update 1972 Total Pain Spiritual Physical Total Pain Social Psychological Saunders 1964 Chronic pain is different… Ms. Unhappy Why can’t you fix my back and fxxk off Ms. Unhappy • 33 year old woman, accident at work • “lifted something heavy and felt a click at the back” • MRI: unremarkable Nociception Ms. Unhappy • She felt so bad that she cannot sleep, cannot eat, and became irritable Affect Ms. Unhappy • She cannot work, cannot go out, cannot do housework, cannot…. Social Ms. Unhappy • She insisted to use a walking aid, visited 4 doctors for the “right diagnosis”, alcohol to “knock me off the pain” Behavior Pain in cancer and non-cancer diseases What % approximates the correct amount of distressing pain in the following conditions? 10%, 30%, 60%, 80% • Cancer • MND/Neurological disease • End-stage cardiac disease • AIDS Acute versus chronic pain Acute (eg fracture) • Obviously in pain • Complains of pain • Understands why they have pain • Primarily affects patient Chronic (eg neuralgia) • May only seem depressed • May only complain of discomfort • May see pain as neverending/meaningless • Pain overflows to affect others Definitions • • • • • Nociception Pain threshold versus pain tolerance Allodynia Analgesia Dysasthesia CLASSIFICATION OF PAIN • Nociceptive – associated with tissue distortion or injury • Caused by tissue damage injury – information carried to the brain via normal nerves CLASSIFICATION OF PAIN • Neuropathic – associated with nerve compression or injury • The nerves carrying the information to the brain are abnormal and are associated with abnormal sensations » Nerve compression » Nerve crushing/destruction » Nerve being cut Issues in assessing pain • • • • • • • Where is it? What is it like? How long has it been present? How severe is it? Does it spread anywhere else How is it affecting functioning? What are the goals for the pain? Managing Pain • Take a good history and examine the patient • Think about the cause or type of pain – Somatic – Visceral – Neuropathic • Establish patient’s expectations, priorities • Choose appropriate medication • Set realistic goals, negotiate a plan Problems in assessing pain Think about TWO problems that could make it difficult to assess someone’s pain? Common mistakes in pain management • Forgetting there may be more than one pain • Reluctance to prescribe morphine • Failure to explore holistically • Failure to educate patient about dose, timing, side effects and deal with their fears • Reducing the interval instead of increasing the dose Problems in assessing pain • The number of different pains (50% of patients have 3 or more different pains) • Not all pains respond to morphine • Patients underplaying their pain • Patients reacting markedly to their pain (usually anxiety, anger or depression are present) • Staff or partners assessing a patient’s pain • The patient with poor or absent communication Help with assessing pain • • • • Ask the patient Ask the partner Body chart VAS highly accurate subject to bias involves patient some patients stuggle with the concept • Pain diary qualitative research • Pain questionnaire Diagnosing Pain • Bone metastases produce pain worsened with movement • Muscle pain produces pain on active movement • Chest infection causes pain worse on inspiration • Constipation causes pain at rest in the abdomen which is periodic • Neuropathic pain causes an unpleasant sensory change at rest, sometimes with pain on touching Pain behaviours/signs where communication impaired • Expressive: grimacing, clenched teeth, shut eyes, wide open eyes • Adaptive: rubbing or holding area, keeping still, reduced or absent function • Distractive: rocking, pacing, biting, clenched fists • Postural: increased muscle tension, limping • Autonomic: sympathetic, parasympathetic Analgesic Mantra By the Mouth By the Clock By the Ladder Individualised Treatment Attention to detail Types of analgesic Primary • Non-opioids eg paracetamol • Weak opioid agonists eg codeine, DF118 • Strong opioid agonists eg morphine, diamorphine, fentanyl, oxycodone • Opioid partial agonist/antagonists eg buprenorphine • NSAIDs • NMDA antagonists eg ketamine, methadone • Nitrous oxide Types of analgesic Secondary analgesics • Adrenergic pathway modifiers eg clonidine • Antibiotics • Anticonvulsants eg CMZ, gabapentin • Antidepressants eg amitriptyline • Antispasmodics eg hyoscine • Antispastics eg Baclofen • Corticosteroids • Membrane stabilising drugs eg flecanide, lidocaine • NSAIDs WHO Pain Ladder Consider nerve block WHO Analgesic staircase • Use non-opioids, weak opioids and strong opioids as the 3 steps • However, not all pain opioid responsive (eg colic, neuropathic pain) • Consider adjuvants for each patient • Different pains need different analgesics Opioids • Agonists at opioid receptors (mu, kappa, delta) in spinal cord and brain • Differences between opioids relate to differences in receptor affinity • Morphine is the strong opioid of choicecost, effectiveness, no ceiling effect Opioid choice Morphine given Orally Regularly Prevents pain Haloperidol treats nausea Injections are unnecessary No addiction is seen and Early use is best Morphine is still the gold standard opioid: • It has more evidence for its use and safety • No evidence that other opioids are better • 30 years use • Wide safety margin • Well tolerated in most people Starting Opioids • What concerns might patients have about starting morphine? Dependence and Addiction • Dependence- state in which an abstinence syndrome may occur following abrupt opioid withdrawal or administration of opioid antagonist. • Addiction - characterised by psychological dependence Morphine dose timing • For continuous pain analgesia should be continuous • Regular administration should enable good pain control and prevent it returning • Do not rely on PRN PRN = ‘PAIN RELIEF NIL’ Indications for injections • Inability to tolerate other routes (eg nausea and vomiting) But NOT because of poor pain control: • Giving injections means need less drug to have same effect • But it cannot be more effective because it’s the same drug Metabolism • Morphine is absorbed from small bowel, metabolised in liver to active metabolite (morphine 6-glucuronide, M6G) which is renally excreted • Liver impairment has little effect; kidney impairment does affect handling • Other metabolites (eg M3G) also renally excreted and can accumulate Strong Opioids • Immediate release (peak concentration after 1h, duration of action 1-4 hours) – Oramorph, Sevredol, OxyNorm • Modified release (peak concentration after 2-6 hours, duration 12-24h depending on formulation) – MST, MXL, Oxycontin Starting morphine • (5mg – 10mg) 4hrly + 30mins prn (& laxative) (2.5 mg 4hrly if previously on non-opioid) • 4hrly dose plus prn dose over 24hrs=TDD (total daily dose) • TDD/2= 12 hourly (bd) dose • TDD/6= prn dose Calculate breakthrough dose for • • • • • MST 30mg bd MST 60mg bd MST 120 mg bd MST 1500 mg bd MST 3000 mg bd Dose titration • 12 hourly dose & total prn use= new TDD • New TDD/2= new 12 hourly dose • New TDD/6= new prn dose Calculate new MST dose and breakthrough dose for • MST 10mg bd and 4 doses of oramorph 2.5 mg • MST 120 mg bd and 2 doses of oramorph 40mg • MST 600 mg and 6 doses of oramorph 200mg Changing the route of administration • po morphine > sc morphine • 1/2 • po morphine > sc diamorphine • 1/3 • po morphine > sc oxycodone • 1/4 • po oxycodone > sc oxycodone • 1/2 STRONG OPIOIDS • Morphine – global strong oral opioid of choice • Morphine – s/c if unable to take oral morphine. (When changing to Morphine (s/c) from morphine (oral) give 1/2 of the PO morphine dose) • Fentanyl – transdermal patch or sublingual Alternative Strong Opioids Opioid Equivalent potency to oral morphine Key points Oxycodone = 1/2 x oral morphine dose (10mg oral oxycodone = 20mg oral morphine) Patients experiencing toxicity with another opioid Diamorphine =1/3 oral morphine dose (10mg diamorphine sc = 30mg oral morphine More soluble than morphine, used in CSCI Buprenorphine BuTrans 7 day patch 20 micrograms/h = 10-20 mg oral morphine Transtec 3-4 day patch 35 micrograms/h = 50100mg oral morphine In practice main route used is transdermal Useful in renal disease or when oral route not possible For CONTROLLED pain Alternative Opioids Fentanyl Patches • Adhesive patch delivering a constant amount of fentanyl per unit time: e.g. 25 micrograms/hour • Less constipation, sedation and nausea • Preferable in serious renal impairment • Change every 72 hours • Takes up to 24 hours to start or stop acting • For controlled pain • Need to supply breakthrough morphine or oxycodone Equivalent doses of fentanyl Fentanyl patch dose Approximate equivalent dose of oral morphine in 24 h Breakthrough dose of morphine 12mcg/h 45mg 5-10mg 25 mcg/h 90mg 10-20mg 50mcg/h 180mg 20-35mg 75mcg/h 270mg 35-45mg STRONG OPIOIDS continued • Hydromorphone – analogue of morphine with similar pharmacokinetics • Oxycodone – similar properties to morphine. Less SE’s in some patients • Methadone – needs to be started as inpatient Starting Opioids • Dorothy, 63y diagnosed with advanced ovarian cancer • Constant low abdominal pain • Bowels regular • Taking co-codamol 30/500, 2 tablets qds • What dose of morphine would you start? • How would you advise her to take it? •Name and address of the patient •The name of the drug •The form and strength of the preparation •The total quantity of the preparation, or the number of dose units, in both words and figures •Dosing instructions Nerve Damage • Membrane stabilizing drugs – Tricyclics – Anti-epileptic drugs eg. Carbamazepine – Gabapentin Routes of administration • Oral : Tablets / Liquids • Rectal • Sublingual / Transdermal • Parenteral / Subcutaneous Other forms of treatment • • • • • • • • Physiotherapy Hot / Warm TENS stimulation Acupuncture Hypnosis Complementary therapies Relaxation therapies Treating of underlying psychological, social, spiritual distress Mrs W • Fentanyl 175 • What is equivalent morphine/diamorphine dose? Summary • Pain is a subjective “total” experience and assessment and management must take this into account • The WHO Ladder provides a framework for managing pain • There are a number of opioid medications, with morphine being the opioid of choice in most situations • Adjuvant drugs are an important part of pain management