Download pain management in the terminally ill

Improving Quality of Life Through
Effective Pain and Symptom
Management
Dr. BC Farnham & Elizabeth Pugh, LBSW, CM
This program is made possible through a collaborative community-education partnership between The Consortium for Advancements
in Health & Human Services, Inc. and Kindred at Home. The primary goal of this effort is to increase public awareness and access to
hospice and home health through the provision of community-based education. Contact Hours are awarded to professionals who
complete this program by The Consortium for Advancements in Health & Human Services, Inc. (www.cahhs-partners.org)
The Consortium for Advancements in Health and Human Services, Inc. © 2014
Important Information

This education program for healthcare professionals was developed by The Consortium for Advancements in Health and Human
Services, Inc. (CAHHS) and is facilitated by Kindred at Home via a community education partnership agreement. CAHHS is a private
corporation and is solely responsible for the development, implementation and evaluation of its educational programs. There is no
fee associated with receiving contact hours for participating in this program titled, Improving Quality of Life Through Effective Pain
and Symptom Management. However, participants wishing to receive contact hours must offer a signature on the sign-in sheet,
attend the entire program and complete a program evaluation form.

The Consortium for Advancements in Health and Human Services, Inc. is an approved provider of continuing nursing education by the
Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on
Accreditation.



The Consortium for Advancements in Health & Human Services, Inc., is approved as a provider of c ontinuing education in Social
Work by the Alabama Board of Social Work Examiners, #0356, Expiration Date: 10/31/2016.
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Learning Objectives
 The attendee will be able to:
 Assess patient pain and differentiate between types
of pain.
 Identify appropriate medications for treatment of
pain.
 Utilize equianalgesic table for titration of opioids.
PAIN – Why Discuss It?
“Pain is a more terrible lord of mankind than even
death itself.”
- Albert Schweitzer
Pain Defined
the experiencing
person says it is, existing whenever
s/he says it does”.
 Pain is “whatever
(McCaffery, 1968)
PAIN DEFINED
Unpleasant Somato-Psychic Experience
No Fun
It originates in
the body
(most of the
time)
It affects the mind
It is what the patient says
it is
Barriers to Effective Pain
Management
 Problems related to
 Healthcare professionals
 Patients
 The health care system
Pain Myths
 Behavioral signs of pain is more reliable
than self-report.
 Pain teaches a person to be more tolerant
of pain.
 Non-cancer pain is not as severe as cancer
pain.
 Use of opioids for pain causes addiction.
 Infants have decreased pain sensation.
Opioids = Addiction?
 Tolerance
 Physical Dependence
 Addiction
 Pseudo-addiction
Opioid Facts
 Patients in pain do not get
addicted
 May develop tolerance
Pain Management
Partnership
 Professional, Patient and Family Team
 Assess pain and associated symptoms regularly and
systematically.
 Asking patient to identify most troublesome symptom.
 Believe patient and family reports of pain and what
relieves the pain.
Pain Management
Partnership
 Choose pain-control appropriate for the patient,
family and setting.
 Deliver interventions in a timely, logical,
coordinated fashion.
 Empower patients and families.
 Develop effective plan of care
PAIN CYCLE
Pain
Decreased Tolerance
of Pain
Anxiety
Sleeplessness
Increased Anxiety
Feelings of
Hopelessness
Decreased Appetite
Decreased Mobility
Hopelessness
Decreased Psychological
Functioning
Despair
Loneliness
Principles of Pain Assessment
 JCAHO: Right to appropriate assessment and
management of pain.
 Self-report of pain is the single most reliable
indicator of pain.
 Use pain scales appropriate to patient
population.
 Chronic pain patient maybe more sensitive to
pain
 Unrelieved pain has adverse physical and
psychological consequences
ASSESSMENT OF PAIN
 ACUTE PAIN – “complex, unpleasant experience
with emotional and cognitive, as well as sensory,
features that occur in response to tissue trauma.”
 Elevated pulse, blood pressure and respirations,
diaphoresis, dilated pupils, moaning, crying,
rubbing
Assessment of Pain
 CHRONIC PAIN –a persistent pain that
“disrupts sleep and normal living, ceases
to serve a protective function, and instead
degrades health and functional capability.”
 After more than 4 months, adaptive mechanisms,
no measurable indications of pain
TYPES OF PAIN
 Somatic –
 Pain in the muscles, bones, ligaments or joints
 Described as aching, gnawing, constant and
localized
 Examples: Bone metastasis, surgical pain
 Responds to opioids, but may require adjuvant
medications such as anti-inflammatories or muscle
relaxers
TYPES OF PAIN
 Visceral –
 Pain in smooth muscles and organs
 Caused by infiltration, compression, distention, or
the stretching of tissue
 Described as aching, constant, not localized, may
radiate to other areas
 Examples: Pancreatic cancer, liver metastasis
 Responds to opioids, but may require
corticosteroid or anti-spasmodic adjuvant
therapy.
TYPES OF PAIN
 Neuropathic –
 Painful nervous system discharges
 Caused by inflammation, damage or pressure
around a nerve
 Described as burning, aching, shooting, shock-like
 Examples: Peripheral neuropathy, spinal cord
compression
 Responds poorly to opioids alone, but opioids may
be used with an anti-depressant, anti-convulsant,
anti-arrhythmic or other adjuvant
Tools for Assessment of Pain
 Site – Where is your pain?
 Character – What does it feel like?
 Onset – When did it start?
 Duration – How long does it last?
 Frequency – How often does it occur
 Intensity –
 What is the worst your pain gets?
 What is the rate of your pain one hour after taking
your pain medication?
Tools for Assessment of Pain
 Exacerbation – What makes the pain worse?
 Associated symptoms – Does your pain cause you
to have nausea, fatigue, dyspnea or weakness?
 Alleviation – What helps relieve your pain?
 Effect on quality of life – Does your pain cause you
to have anxiety, fear, depression or spiritual
stress?
What does the pain keep you from doing?
Tool For Assessment of Pain
PHYSICAL EXAMINATION
 Non verbal cues
 Examine sites of pain
 Palpation
 Auscultation, percussion
 Neuro exam
REASSESS
 Changes in pain
 Assess pain relief
 Make pain visible
PATIENTS AT RISK FOR
UNDERTREATMENT
 Children and elderly
 Cognitively impaired
 Patients who deny pain
 Non English speaking
 Different cultures
 History of substance abuse
COMMUNICATING
ASSESSMENT FINDINGS
 Communication improves pain management
 Describe intensity, limitations, and response to
treatments
Principles Regarding Use of Analgesics WHO
3 Step Analgesic Ladder
STEP 3, severe pain
STEP 2, moderate pain
STEP 1, mild pain
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
+ Nonopioid analgesics
Acet or ASA +
Codeine
Hydrocodone
Oxycodone
Dihydracodeine
Tramadol (not available with ASA or Acet)
+ Adjuvants
Aspirin (ASA)
Acetaminophen (Acet)
Nonsteroidal anti-inflammatory drugs (NSAIDS)
+ Adjuvants
NON-OPIOIDS/NON-STEROIDAL
ANTI-INFLAMMATORIES
 Acetaminophen (Tylenol)





Toxicity
Maximum
Maximum
Maximum
Mild pain,
4,000mg qd short term
3,200mg qd long term
2,400mg qd in elderly or debilitated
poor anti-inflammatory capacity
ACETAMINOPHEN
 Extra Strength Tylenol500mg
8
 Vicodin ES
750mg
5
 Lortab 2.5, 5, 7.5
500mg
8
 Lorcet Plus 7.5
 Percocet 5
650 mg
6
325mg
12
NON-STEROIDAL ANTIINFLAMMATORIES
 Risk of GI Ulcer decreases 15% after 3 months
continuous care
 For long term use, protect with misosprostol
(Cytotec), omeprazole (Prilosec), lansoprosole
(Prevacid) or pantoprazole (Protonix)
OR
 Use Cox-2 inhibitor
celecoxib
(Celebrex) or rofecoxib (Vioxx) meloxicam (Mobic)
WEAK OPIOID/NON-OPIOID
COMBINATIONS
 Hydrocodone and Oxycodone combination
products
(Lortab,
Tylox, Percocet, Vicoprofen, Percodan)
 All have ceilings due to acetaminophen, aspirin or
ibuprofen content
 Considerations: skip this step and add
acetaminophen, aspirin or ibuprofen separately
STRONG OPIOIDS
Short-acting
 BEST CHOICE Morphine, oxycodone, hydromorphone (Dilaudid)
 No ceiling
 Morphine and oxycodone come in tablet, liquid,
concentrate and suppository form
Morphine:
Pharmacokinetics/Pharmacodynamics
Morphine Formulation Half-life (t ½ )
Analgesia
Typical Dosing
Immediate release (IR) 2-3.5, q4h
Onset: 0.5-1h
Peak: 1.5-2h
Duration: 3-5h
Sustained-release
(SR)
Onset: 1.5h
Peak: ~ 4h
Duration: 8-12h
2-4* q12h
*Terminal elimination half-life for morphine SR
SHORT ACTING STRONG
OPIOIDS
 Used for occasional moderate to severe pain
 Used PRN to determine long acting dose (add
amount needed in 24hrs, divide by 2, give q 12)
Initially uses 80mg Oxylr in 24hrs, Oxtcontin 40mg q 12hrs
with 10mg Oxylr q 4 hrs for breakthrough pain
Current Oxycontin dose 40mg q 12hrs, Used 40mg Oxylr in last
24hrs. New Dose- Oxycontin 60mg q 12 hrs. New
breakthrough dose- Oxylr 15-20mg q 4hrs.
 Used to control pain that breaks through long-acting dose
(dose should be 1/3 -1/4 12 hr dose)
BREAKING THE PAIN
CYCLE
SEDATION
ANALGESIA
PAIN
1
2
3
4
5
6 7 8
9
10
11
12
LONG ACTING STRONG
OPIOIDS
 ONLY TO BE USED FOR CONTINUOUS PAIN, NEVER
GIVEN PRN
 M.S. Contin, OxyContin, Oramorph SR
 12 hour relief
 Cannot be crushed or cut
 Kadian
 24 hour relief
 Time-released sprinkles
LONG ACTING STRONG
OPIOIDS
 Duragesic (fentanyl patch)
 Lasts 72 hours
 Takes up to 24 hours to peak
 Must have subcutaneous tissue to absorb
 Fevers cause rapid absorption
 Cost prohibitive
 Slow and careful titration necessary
DOSE ESCALATION
 By percentage
 After peak effect
 Morphine resistant pain versus psychological
component
ROUTES OF
ADMINISTRATION
 Oral
 Mucosal
 Rectal
 Transdermal
 Topical
 Parenteral
 Intravenous
 Subcutaneous
 Intramuscular
EQUIANALGESIA
 Determining equal doses when changing drugs or
routes of administration
 Use of morphine equivalents
EQUIANALGESIC DOSES OF
OPIOIDS
DRUG
PARENTERAL ROUTE
ENTERNAL ROUTE
Morphine
10mg
30mg
Codeine
130mg
200mg (not
recommended)
Fentanyl
*see below
OTFC available
Hydrocodone
Not available
30mg
Hydromorphone
1.5mg
7.5mg
Levorphanol
2mg acute
4mg acute
Methadone
10mg acute
2-4mg chronic
20mg acute
2-4mg chronic
Oxycodone
Not available
20-30mg
Fentanyl 100 mcg patch = 200mg oral morphine/24hrs = 4mg IV
morphine/hour. To convert from Fentanyl 100mcg/hour patch to IV
Fentanyl, begin at 100mcg/hour IV and titrate as needed
OPIOID SIDE EFFECTS
 Sedation, light-headaches, nausea, vomiting,
itching, dry mouth, urinary retention, constipation
and respiratory depression
 Most side effects diminish 3 days after opioid
started or increased
 Minimal side effects noted if dose is correct
 Bowel protocol should be initiated at the
beginning of opioid therapy
BOWEL PROTOCOL
 Mild vegetable laxative and softener routinely
(Senekot S)
 Stronger laxative if no BM by the end of the 2nd
day (Senekot Xtra)
 Increase as needed to achieve soft, form BM q 2-3
days
OPIOID ADVERSE EFFECTS
 Nausea and Vomiting
 Use an anti-emetic prophylactically in patient who:
 Currently has nausea and vomiting
 Has nausea and vomiting from a weak opioid
 Experienced nausea and vomiting in past with strong
opioid
 Always rule out obstruction
 Haldol, Reglan, vestibular
SEDATION
 Catch up on sleep
 Other medications
 Other medical problems
DELIRIUM
 If opioid is at steady state, then think of other
causes:
 Dehydration
 Infections
 CNS event
 Other medications
REPIRATORY DEPRESSION
 A change in rate or depth
 Sedation precedes respiratory depression
 Level 3 – drifts off to sleep during conversation
PRURITIS
 Immediate hypersensitivity
OPIOID ADVERSE EFFECTS
 In general, all strong opioids have similar side
effects
 Strategies:




Different route
Different opioid
Decrease dose, increase frequency
Add a second drug
ADJUVANT DRUGS
Adjuvant medication are not analgesics, but have
properties that either assist in blocking pain
impulses or potentiates the effects of analgesics.
TRICYCLIC
ANTIDEPRESSANTS
Prevent re-uptake of serontonin and
norepinephrine – block neuropathic pain
 Amitryptyline (Elavil)S, doxepin (Sinequan)S,
desipramine (Norpramin)
 Start with small dose, titrate to ½ therapeutic dose
for depression
 SSRI’s have less effect on neuropathic pain but
may be somewhat effective. (Effexor)
ANTICONVULSANTS
Block nerve impulses by limiting sodium ions
 Carbamapezine (Tegretol) 200-1600 mg qd
 Phenytoin (Dilantin) 300-600 mg qd
 Gabapentin (Neurontin) up to 3200 mg qd
OTHER ADJUVANTS
 Clonidine (Catapres) 0.1 mg qd-tid
 Decadron 4mg qd-tid or 100mg IM x 1
 Donnatal 1-2 tabs bid-tid (GI spasms)
 Baclofen (Lioresal) up to 80mg qd
 Lorazepam (Ativan) 4-6mg qd
 Hydroxyzine (Vistaril) 25-50 mg tid
 Promethazine (Phenergan) 25-50mg q4 prn
 Dextromethorphan up to 1000 mg qd
 Ketamine 2% ointment tid
ADJUVANT PRINCIPLES
 Choose the adjuvant that will benefit the patient’s
other symptoms as well as the pain
 For severe pain use, use an adjuvant out of
several different categories
 Remember that often using adjuvant therapy
provides improved pain relief with smaller doses
of opioids and fewer side effects
ADDICTION
 Addiction – Psychological craving for the
drug’s psychic effect
 Dependence – Natural physical response to
continue use of an opioid
 Tolerance – The body’s legitimate need for
larger doses of an opioid to produce the same
effect during an extended period of use
 Pseudo-addiction – drug seeking behavior
caused by poor pain management
 Pain relief is contingent on adequate assessment
and use of both drug and non-drug therapies
 Pain extends beyond physical causes to either
causes of suffering and existential distress
 Interdisciplinary care
EFFECTS OF PAIN ON
QUALITY OF LIFE
 Physical –




Decreased functional capability
Diminished endurance and strength
Nausea, poor appetite
Poor or interrupted sleep
EFFECTS OF PAIN ON
QUALITY OF LIFE
 Psychological –






Diminished leisure, enjoyment
Increased anxiety, fear
Depression, personal distress
Difficulty concentrating
Somatic preoccupation
Loss of control
EFFECTS OF PAIN ON
QUALITY OF LIFE
 Social –




Diminished leisure, enjoyment
Decreased sexual function and intimacy
Altered appearance
Increased caregiver burden
EFFECTS OF PAIN ON
QUALITY OF LIFE
 Spiritual –
 Increase suffering
 Altered meaning
 Re-evaluation of religious beliefs
INTERVENTIONS FOR PAIN
MANAGEMENT
 Physical – Movement, Thermal, Touch, Relaxation,
Environment, Aromatherapy, Acupuncture
 Psychological – Distraction, Meditation,
Visualization, Staying Attitude, Hope, Spiritual
Support
 Palliative Treatments – Radiation Therapy,
Chemotherapy, Nerve Blocks, Surgery
 Pharmacological – Analgesic and Adjuvant
Medications
Guidelines For Follow Up to Pain
Management
All patients admitted to hospice will receive the
best level of pain control that can be safely
provided.
Guidelines For Follow Up to Pain
Management
 Assessment –
 At time of admission, a comprehensive pain
assessment will be conducted, including use of
numeric pain rating scale
 When pain is identified as a problem,
individualized pain management goals will be
established (some patients find a level of 4
acceptable in order to remain awake and alert while
others wish to be pain free is possible).
 Pain assessments will be conducted on each
nursing visit with reassessments occurring until
pain goal is achieved.
Guidelines For Follow Up to Pain
Management
 Interventions –
 If pain is scored at greater than 3 or if pain level
is unacceptable to patient, there will be an
intervention to reduce the pain.
 Follow up to determine the success of the
intervention MUST be done within 24 hrs of the
intervention. In many cases, follow up will be
necessary in a much shorter time frame
depending on the severity of the pain and the
interventions required. Nursing judgment is
crucial in determining the time frame. Follow
up may be done via telephone call or by visit at
the discretion of the nurse. Documentation
must be evident on the medical record. Follow
up via telephone should generate a progress
note, while a visit should generate a nursing
note.
Guidelines For Follow Up to Pain
Management
 Interventions cont’d –
 If pain is not improved, additional interventions
should be taken and documented.
 Follow up within the determined time frame will
be conducted until pain goal is achieved. NOTE:
Follow up MUST be done within 24hrs.
Documentation of this must be evident in the
medical record.
 Alternative pain relief measures may be
implemented as well as pharmacological
interventions. (Massage, relaxation techniques,
guided imagery, etc.)
Guidelines For Follow Up to Pain
Management
 Interventions cont’d –
 Unless pain is occurring occasionally, scheduled
analgesics are indicated with additional
medication available on demand for
breakthrough pain.
 Oral meds are the preferred routes
 Opioids are considered the analgesic of choice
for moderate to sever pain.
 Adjuvant therapies must be considered.
Guidelines For Follow Up to
Pain Management
 Documentation –
 The initial pain assessment must be completed
at time of admission. Pain sites are to be
numbered with a designation of the probable
cause of the pain at each site.
 Subsequent assessments/reassessments must
be clearly documented
 Progress notes should clearly delineate the plan
and the rationale for treatment
Guidelines for On-Call Follow
Up
All patients and their families admitted to Hospice will
receive the best level of individualized care and
personalized service that may be safely provided,
regardless of the time of day. Hospice staff is
available 24 hours a day, 7 days a week, 365 days
per year.
All calls made to Hospice will be promptly answered.
Those received after hours or on-call, will be
responded to within thirty (30) minutes.
Guidelines for On-Call Follow
Up
 Assessment –
 Once staff is notified by the service that a call has been made, a
response to the call MUST be initiated within 30 minutes.
 If the call is of routine nature and at the staff’s discretion can be
handled safely and effectively over the phone, it may be appropriate
to do so.
 If a second call comes in regarding the same patient or family, even
if the subject of the call is different, a visit must be made.
 If the on-call staff receive notification that the patient is going to or
is in the emergency room, the staff member MUST either
accompany the patient to or meet them at the emergency room.
There should be no exceptions to this.
 All deaths will be attended without regard to location.
Guidelines for On-Call Follow
Up
 Interventions –
 All calls will be documented on the on-call log
and it should be notated if a visit was made or
of the situation was resolved via telephone
consultation
 If it was determined that the situation could
appropriately be handled via telephone call, a
Progress Note (if a non-clinical problem) or an
On Call Note should thoroughly explain the
reason for the call, the action or intervention
taken in response to the call (keep a supply of
Progress Notes and On Call Notes with you).
Guidelines for On-Call Follow
Up
 Interventions cont’d –
 Follow up to determine the outcome of the
intervention MUST be done within 24 hrs of the
intervention (requires passing off to next on-call
nurse). Follow up may be done via telephone call or
by visit at the discretion of the nurse.
Documentation must be evident on the medical
record.
 If it was determined that a visit be made, an On Call
Note should thoroughly explain the nature of the
call and all pertinent information regarding the call
should be documented. All interventions should be
documented, the rationale for such interventions
and a report of the nursing
assessment/observations that prompted the
intervention.
Guidelines for On-Call Follow
Up
 Documentation –
 Follow up to ALL calls for a clinical nature
received during the on-call hours require
follow up within 24 hrs.
 Documentation of this must be evident in
the medical record.
“If we know that pain and suffering can be alleviated,
and we do nothing about it, then we ourselves
become the tormentors”
– Primo Levi
References
Meuser T, Pietruck C, Radbruch L, et al.: Symptoms during
cancer pain treatment following WHO-guidelines: a
longitudinal follow-up study of symptom prevalence,
severity and etiology. Pain 93 (3): 247-57, 2001.
Patrick DL, Ferketich SL, Frame PS, et al.: National Institutes of
Health State-of-the-Science Conference Statement:
Symptom Management in Cancer: Pain, Depression, and
Fatigue, July 15-17, 2002. J Natl Cancer Inst 95 (15): 11107, 2003.
Bruera E, Willey JS, Ewert-Flannagan PA, et al.: Pain intensity
assessment by bedside nurses and palliative care
consultants: a retrospective study. Support Care Cancer 13
(4): 228-31, 2005.
References
Miaskowski C, Dodd MJ, West C, et al.: Lack of adherence with
the analgesic regimen: a significant barrier to effective
cancer pain management. J Clin Oncol 19 (23): 4275-9,
2001.
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