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Pain Management
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Pain Management
TODAY’S PRESENTER:
Jennifer Hale, RN BS CHPN
Georgia Hospice and Palliative Care Organization
Rome, GA
October 21, 2010
Objectives
1. Describe the prevalence of pain in the
hospice and palliative care setting
2. Recognize the impact of pain on
patients, families and the healthcare
system
3. Identify common barriers to effective
pain management
4
Objectives
4. Define the types of pain experienced
by the hospice and palliative patient
5. State the principles of effective pain
management
6 Identify the components of a thorough
pain assessment
5
Undertreatment of Pain
• 70-90% of patients with advance disease
experience pain
• 50% hospitalized patient’s experience pain
• 80% of long term care experience pain
– Only 40-50% are given analgesics
• Pain scores (on a 0-10 scale) greater than
or equal to “5” greatly impact on quality of
life
6
Impact of Poorly Controlled Pain
• Physical
• Psychosocial
• Emotional
• Financial
• Spiritual
7
Interdisciplinary Resources
•
•
•
•
•
Pain affects multiple dimensions
No one discipline can address all issues
Strengths and talents of many disciplines
Address multiple institutional barriers
On going communication
8
Cost of Poor Pain Management
•
•
•
•
•
$100 billion per year
Chronic pain is most expensive heath problem
40 million physician visits per year for pain
25% of all work days lost are due to pain
Improving pain management costs less than
cost of inadequate relief
9
Pain Co-morbidities
•
•
•
•
Depression
Anxiety disorder
Diabetes
Chronic fatigue syndrome
10
Barriers to Effective
Pain Management
Patient / family
 Reluctance to report; fear that pain = worse disease; not being a “good
patient”; reluctance to take/administer pain meds
Healthcare Provider
 Inadequate knowledge; poor assessment skills; regulatory concerns;
concerns about addiction, side effects, tolerance
Institutional
 Low priority for pain treatment; inadequate reimbursement; regulatory
issues; availability of specific meds
11
Definition of Pain
• An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage (APS)
– Multiple components
– Pain is a COMPLEX experience (both subjective and
objective aspects)
– Pain is not ONLY related to tissue damage but is best
described in such terms (most patients have a difficult
time relating emotional or psychosocial pain in terms
other than physical)
12
Definition of Pain
• Pain is whatever the experiencing
person says it is, existing whenever
he/she says it does (McCaffery &
Pasero, 1999)
– Subjective report is still the most reliable and must be
believed
– Downside: This definition does not capture the pain
experience of non-verbal patients
13
Types of Pain
Acute




Accompanied by physiological
Responds well to analgesic treatment
Intermittent/episodic experiences and may progress to chronic
TREAT PAIN even if cause is not known
Chronic
 Usually persist for longer than 3 months
 Autonomic nervous system adapts - patient does not exhibit
objective signs of pain
 Often associated with significant changes in personality, lifestyle,
ADL function
Breakthrough Pain (BTP)
 Transient increase in pain to greater than moderate intensity
14
Classification of Pain
Nociceptive Pain
• The normal processing of stimuli that
damages normal tissues or has the
potential to do so if prolonged
• Usually responsive to non-opioids
and/or opioids
• Stimuli from somatic or visceral
structures
15
Types of Nociceptive Pain
Somatic Pain
• Bone, Joints, Muscle, Skin, Connective tissue
• Throbbing, dull
• Well localized
16
Types of Nociceptive Pain
Visceral Pain
• Visceral organs
• Squeezing, cramping, pressure, deep
• Tumor involvement of organ capsule
– Aching & well localized
• Intermittent cramping & poorly localized
• Includes referred pain (shoulder pain secondary
to esophageal or gall bladder irritation)
17
Classification of Pain
Neuropathic Pain
• Abnormal processing of sensory input
by central or peripheral nervous
system
• Mechanisms not as well understood
• Burning, shooting, tingling, numbness,
radiating, electrical
• Responds to adjuvant analgesics
18
Neuropathic Pain
Centrally generated pain
 Deafferentation pain – caused by injury to
nerve at CNS or PNS (amputation)
 Sympathetically maintained pain –
dysregulation of autonomic nervous system
Peripherally generated pain
 Painful polyneuropathies
Diabetic neuropathy, Guillain-Barre syndrome
 Painful mononeuropathies
Nerve root compression, trigeminal neuralgia
19
APS 12 Principles of
Pain Management
1. Individualize dose, route and
schedule
2. Around the clock dosing
20
APS 12 Principles of
Pain Management
3. Selection of opioids
•
•
Morphine is gold standard for strong opioid
Patients respond differently to different meds – keep trying!
4. Adequate dosing for infants/children
•
•
Clinical and pharmacokinetics of opioids in children and
infants over 6 mos. of age are approximately the same as in
adults – dosing difference based on WEIGHT
Don’t under treat pain in kids!
21
APS 12 Principles of
Pain Management
5. Follow patients closely
•
•
•
Monitor for pain relief and side effects frequently
Adjust pain regimen accordingly
Check frequently when adding new med, changing meds
or changing routes/delivery
6. Use equianalgesic dosing
22
APS 12 Principles of
Pain Management
7. Recognize and treat side effects
•
Most common side effects include:
•
•
Sedation, constipation, nausea, itching,
respiratory depression
Treat side effects:
•
•
•
Change regimen/route
Try a different opioid
Add another drug to manage side effects
(bowel regimen!)
23
APS 12 Principles of
Pain Management
8. Be aware of hazards of Demerol®
and mixed agonist-antagonists
•
•
Mixed agonist-antagonists include pentazocine,
nalbuphine, butorphanol and may reduce overall
analgesic effect due to mu-receptor binding
Meperidine produces toxic metabolite which decreases
seizure threshold (especially for sickle-cell patients) and
does not respond well to naloxone nor is it
recommended for use longer than 48 hrs
24
APS 12 Principles of
Pain Management
9. Watch for development of tolerance
10. Be aware of physical dependence
25
APS 12 Principles of
Pain Management
11. Do not label a patient addicted
12. Be aware of psychological state
26
WHO Ladder
Recommendations
• Portrays progression in the doses and types
of analgesic drugs for effective pain relief
• Changes as patients condition and
characteristics of pain change
• Orally whenever possible
• “By the clock” dosing
• Based on assessment of the individual’s pain
experience
27
WHO 3-Step Ladder for
Treating Pain
Acute Pain
Severe Pain
(pain will
get better)
Morphine, Methadone,
Oxycodone (strong Opioid)
Moderate
Pain
Tylenol w/Codeine; Lortab;
Percocet (mild Opioid) or
strong opioid at low dose
Mild Pain
Tylenol, Advil, Vioxx, Ultram
(Non-Opioid)
Chronic
Pain
(Pain will
not go away)
WHO Ladder
Step 1 (Mild pain)
Mild Pain
• 1-3 on a scale of 0-10
• Non-opioids
• Adjuvants
– As analgesics
– To reduce side effects
29
WHO Ladder
Step 2 (Moderate pain)
Moderate Pain
• 4-6 on a scale of 0-10
• Mixed opioid/non-opioid meds or opioids in
low doses (new recommendation)
– Why new recommendation?
• Non-opioids and adjuvants may be
continued
30
WHO Ladder
Step 3 (Severe pain)
Severe Pain
• 7-10 on a scale of 0-1
• Add higher doses of opioids
• Titrate to best effect
• Monitor for increase in side effects as dose
escalates
• Continue non-opioids and adjuvants
31
Pain Assessment Principles
• Accept patient’s complaint of pain
• History of pain
• Assessment for non-verbal patients
– FLACC
– PAINAD
• Patient centered goals
32
Pain Assessment Principles
• Nonverbal signs of pain
• Psychological impact of pain
• Diagnostic workup
– Not common in EOL care but necessary
to assess tumor size/location or broken
bones, etc
• Assess effectiveness and side effects of pain
medication
33
Initial Pain Assessment
Onset/duration
-When did the pain first begin?
-Is it associated with a particular activity?
-Other symptoms?
Site
-More than 75% persons with cancer have pain in 2 or more
sites
-Ask patient to point to where it hurts – do this with each
site of pain expressed
-Assess each site for pain intensity, quality, duration
34
Initial Pain Assessment
Severity/intensity
-Select pain scale appropriate to patient
Quality
-Ask patient to describe their pain – patient’s words are best,
provide adjectives if necessary
Exacerbating/relieving factors
-What makes the pain worse or what causes the pain?
-Assess the pain at rest, with movement, and in relation to daily
activity
-Ask the caregivers how patient is doing with activities
35
Initial Pain Assessment
Effects of pain on quality of life
-What does the pain mean to the patient and family?
-Does the pain keep the patient from doing activities
he/she enjoys?
Medication history
-Current – including topicals, OTCs, homeopathic
remedies, etc
-Past
-Side effects
36
Initial Pain Assessment
Physical
-Examine site(s) of pain, including referral sites
-Consider disease process, extent of progression
Cultural considerations
-AVOID cultural generalities and determine individual differences
but keep in mind that cultural implications are present and can
impact reporting, assessment
Other factors
-Age – elderly often more stoic, more fearful
-Gender – men generally more stoic, women more emotive
-Environmental – calm, quiet, temperate, soothing, dark
37
Non-opioids
• Used in acute and chronic pain
• Relief for mild/moderate pain
– Most effective with nociceptive pain
(muscle and joint pain)
• Combined with opioid analgesics for
both additive analgesic effects or opioid
dose sparing effects
38
Non-opioids
Acetaminophen
• Mechanism
– not well understood
• Dosing
– decrease for patients with hepatic impairment
– Short half-life, Q4H dosing recommended to dose
limit (4gm, 3gm in elderly)
• Routes
39
Non-opioids
Acetaminophen
• Side effects
Considerations
• Be aware of hidden doses, i.e., APAP in
combination products
40
Non-opioids
NSAIDs
• Characteristics
– analgesic effects through the inhibition of
prostaglandin production
– multipurpose analgesia
• Drug choices
– If no response after 3 days of adjustment, consider
switching to different NSAID
– Contraindicated If patient is hypersensitive or
allergic to ASA or other NSAID’s
41
Non-opioids
NSAIDs
• Dosing
– PRN basis for occasional pain
– Around-the-clock (ATC) for ongoing pain
• Routes of Administration
• Common meds include:
– Ibuprofen, ketoprofen, naproxen sodium, aspirin
42
Non-opioids
NSAIDs
• Sides Effects
– Hematologic – better option is APAP if possible
– GI - use enteric coated, take with food, H2 blocker (ranitidine)
– Renal – chronic use at high doses can lead to this
complication
– Cognitive Impairment – dizziness, drowsiness are common,
short term memory loss less common and less often reported
– Cardiovascular
43
Teaching Points
for Non-opioids
• Risk for GI bleeding with NSAIDs
• Why medication ordered
• Stopping medications
• Reporting side effects
44
Opioids
• CNS action - bind to opioid receptor site in
brain and spinal cord
• mu, kappa, and delta receptor sites
• Pain relief occurs when opioids bind to 1
or more receptors as an agonist
• Agonists and agonist - antagonists
45
Pure Agonist Opioids
• Expect physical dependence
• Withdrawal will occur when abruptly stopped or
naloxone (Narcan®) is given
• Prevent withdrawal by reducing by 25%
• Tolerance to side effects other than constipation
• Tolerance to analgesia is rare
• Nociceptive pain more responsive to pure agonist
opioids than neuropathic
• Use pure agonists for BTP
46
Choice of Opioid Drug
-One pure agonist with one route
-If one not relieving pain with titration, may
need to switch medication
 2 reasons to switch: unmanageable side effects or toxicity
secondary to metabolite accumulation
-All pure agonist have same side effects but
patient variability in experience
 Side effects may be reported as allergies –
especially itching and nausea
-Rapid onset formulation for breakthrough
47
Opioids
Morphine
• Considered ‘gold standard’ for opioid analgesic
• Standard for comparison in opioid use
• Some patients cannot tolerate because of the side
effects
– Tolerance to side effects in a few days
– No tolerance to constipation
• MS half-life = 2-4 hrs
• SL is NOT absorbed under the tongue but trickles
down to the GI tract and is processed in the gut
48
Opioids
Codeine
-Appropriate for mild pain
-Metabolized by liver
Fentanyl
-Routes include IV, epidural, Topical patch
-Limitations
Hydrocodone
-Found in combination therapy with acetaminophen
ONLY
49
Opioids
Hydromorphone
• Short half life and lack of metabolite problems
make it preferable to morphine in patients with
renal insufficiency, particularly the elderly
• Most useful in post-op pain management or in
SC infusions due to availability of high-dose
concentrations
50
Opioids
Meperidine
• Contraindicated – normeperidine
(active metabolite) acts as a CNS
stimulant
51
Opioids
Methadone
– Long half life (12-190 hrs)
– Inexpensive
– Monitor closely for arrhythmias
– Negative perception due to use in drug rehab setting
– 85% bioavailability and metabolized in LIVER
– CUMULATIVE effect so must use caution with titration –
wait at least a week! Not recommended for patients who
cannot be closely monitored or who may not be disciplined
enough to adhere to dosing schedule
– Conversion is difficult and requires physician and
pharmacist collaboration
52
Opioids
Oxycodone
• Used in acute, cancer, chronic nonmalignant pain
• Mild to severe intensity
Propoxyphene
• Considered a weak analgesic
• Prescribed for mild to moderate pain
• Not recommended for chronic pain, cancer pain, end-of-life care
• Active metabolite accumulates in kidneys causing tremors,
seizures
53
Mixed Agonist-antagonists
Indications
• Not recommended for chronic pain
• Ceiling doses
• Psychomimetic effects
– Disorientation/hallucinations
54
Mixed Agonist-antagonists
Buprenorphine (Buprenex®)
Butorphanol (Stadol®)
Nalbuphine (Nubain®)
Pentazocine (Talwin®)
55
Opioid Dosing
•
•
•
•
Multiple routes available for pure agonists
If current dose safe but ineffective, increase
by 25% to 50% until pain relief occurs or
unmanageable side effects present
No ceiling effect for pure agonists
All opioids have side effects that eventually
limit dose escalation
56
Management of
Opioid Side Effects
Constipation
- Most common side effect of opioids –
tolerance is NEVER developed to this side
effect
- Bowel regimen
 NOT fiber or increased fluids (may lead to impaction)
 Preventive action important – stool softener and stimulant most
helpful combination
 There are many meds to choose from in the different
classifications
 Opioids reduce gastric motility and peristaltic action – may
consider metaclopramide as preventive
57
Management of
Opioid Side Effects
Nausea and Vomiting
• May be due to
– stimulation of chemoreceptor trigger zone in brain
– slowing of GI motility
– effects on balance and equilibrium of inner ear
• Management:
– Based on cause of nausea – use appropriate med based on
cause
– PRN to ATC OK
– May need to switch opioid for best effect
58
Management of
Opioid Side Effects
Sedation
- Usually when opioids started or dose increased
- Tolerance will occur over period of days to weeks
Pruritus
- Can occur with any associated histamine release & commonly
with morphine
- May be generalized, usually localized to face, neck, chest
- Usually not accompanied by rash
- Management by decreasing opioid dose by 25% and adding
adjuvant analgesic or with diphenhydramine (Benadryl) but is
sedating and should be used cautiously in elderly
59
Management of
Opioid Side Effects
Mental status change
• Cause of increased anxiety and fear for
patients, families, caregivers
• Assess to ensure that opioid is cause
• Management
–
–
–
–
Eliminate non-essential CNS meds
Consider reduction of opioid by 25% and adding adjuvant analgesic
Add haloperidol in small dose
Switch opioids
60
Management of
Opioid Side Effects
Respiratory depression
-Considered clinically significant when there is a decrease in rate
and depth of respirations from baseline
-Tolerance develops over period of days to weeks
-Longer patient on opioid, less likely to develop
-Prevention by appropriate titration, monitoring of sedation levels
-Monitor sedation levels respiratory status, every 1-2 hours for
first 24 hours in opioid naïve
-Respiratory depression is not just a measure of breaths per
minute – assess responsiveness and pupilary response as well
61
Adjuvants
• Non pain medications that have
analgesic effects on certain types of
pain
• Chronic neuropathic pain
• Additional therapy to opioids
• Distinct primary therapy
62
Adjuvants
• Choice of Drug
• Depends on type of pain, patient age,
and other medical condition
• Individual response
• Sequential trials
63
Addiction
- “A pattern of compulsive drug use characterized by
a continued craving for an opioid for effects other
than pain relief” (APS, 1999)
- Individuals become overwhelmingly involved with
using or procuring the drug and may display drug
seeking behaviors such as: missed office or clinic
appointments with subsequent off-hour calls for
prescription refills, theft or forgery of prescriptions,
prescription-seeking from more than one physician,
theft of drugs from family members or other patients,
buying or selling drugs on the streets
64
Pseudoaddiction
• The patient who seeks additional
medications appropriately or
inappropriately secondary to significant
under treatment of the pain syndrome
–
–
–
–
Clock watching
Manipulation of staff
Hoarding
Doctor shopping
• Behaviors cease when pain is treated
65
Tolerance
• A form of neuro-adaptation to the effects of
chronically administered opioids which is
indicated by the need for increasing or more
frequent doses of the medication to achieve
the initial effects
• Clinicians should not fear tolerance in
patients with extended life expectancy
• Tolerance happens! Teaching is most
important.
66
Physical Dependence
A physiological state in which abrupt
cessation of the opioid results in
withdrawal syndrome
-Physical dependency on opioids is an expected
occurrence in all individuals in the presence of
continuous use of opioids for therapeutic or for
non-therapeutic purposes. It does not, in and
of itself, imply addiction
67
Non-pharmacological
Pain Management
• Use concurrently with medications
• Methods
– Cognitive-behavioral
• Relaxation
• Guided imagery
• Distraction
68
Non-pharmacological
Pain Management
Methods
• Physical interventions
– Hot and Cold
– Massage
– Positioning
– Exercise
69
Non-pharmacological
Pain Management
Complementary therapies
– Therapeutic touch
– Music therapy
– Aromatherapy
70
Non-pharmacological
Pain Management
• Methods
• Physical interventions
– Positioning
– Exercise
71
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