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END-OF-LIFE CARE: Module 2 Pain Management http://www.growthhouse.org/stanford Module #2 Case of Mrs. Dolores Long Mrs. Dolores Long is a 70-year old widowed African American female who was recently diagnosed with lung carcinoma and metastasis to bone. She is being admitted to the hospital for a round of chemotherapy. A medical resident performs the admission H&P. Mrs. Long denies any symptoms. Physical examination is unremarkable. Mental status exam is significant for flat affect and poor eye contact. The resident finishes the exam and leaves the room. Mrs. Long’s daughter steps outside with the resident and explains that her mother has complained of severe pain and has become sedentary and withdrawn. She has refused the acetaminophen with codeine that was prescribed because she doesn’t want to “get hooked,” and the pills don’t help anyway. The resident is surprised, as Mrs. Long did not appear to be in pain. He explains that “nothing more can be done” for the pain, as strong narcotics like morphine might cause her to stop breathing and NSAIDs like ibuprofen could cause GI bleeding. However, psychiatry will be consulted to evaluate her depression. http://www.growthhouse.org/stanford Module #2 Learning Objectives Recognize and address barriers to effective EOL pain care Develop a better understanding of attitudes and beliefs about pain management Improve your knowledge and skills in assessing and treating pain Incorporate this content into your clinical teaching http://www.growthhouse.org/stanford Module #2 Outline of Module Background Barriers to treating pain Pain Assessment Non-pharmacologic treatment approaches Break Pharmacologic strategies Pain medications Application exercise Summary and goals http://www.growthhouse.org/stanford Module #2 Pain in the Hospitalized Seriously Ill 50% of conscious patients were in moderate to severe pain at least half the time in the three days prior to death SUPPORT Study (1995), N = 9105 patients http://www.growthhouse.org/stanford Module #2 Pain in Nursing Home Patients • 30% reported daily pain • 26% of these patients received no analgesia • Only 26% of them received strong opioids What predicted inadequate pain management? • Advanced age: >85 years old • Poor cognitive function • Minority status Bernabei (1998), N = 13,625 cancer patients http://www.growthhouse.org/stanford Module #2 Pain in Outpatients • 67% outpatients with metastatic CA were in pain • 42% of those not given adequate analgesic therapy What predicted inadequate pain management? • Discrepancy between patient and MD assessment of pain • Advanced age: >70 years old • Female • Better performance status • Minorities Cleeland (1994), N = 1308 http://www.growthhouse.org/stanford Module #2 Pain in 103 Children who Died of Cancer or its Complications • 89% died while suffering pain or other symptoms • Of those whose pain was treated, treatment was successful in only 27% Wolfe, 2000 http://www.growthhouse.org/stanford Module #2 Brainstorm What makes pain so difficult to treat? http://www.growthhouse.org/stanford Module #2 Six Major Barriers to Adequate Pain Care • Myth: That addiction is a common result of treating pain with opioids • Regulatory and legal concerns • System barriers • Deficits in knowledge and education • Fear of side effects • Assessment challenges http://www.growthhouse.org/stanford Module #2 Definitions • Addiction: Psychological dependence on a drug. Drugseeking behavior despite adverse consequences • Physical Dependence: Development of physical withdrawal reaction upon discontinuation or antagonism of a drug • Tolerance: Need to increase amount of drug to obtain the same effect • Pseudoaddiction: Behavior suggestive of addiction occurring as a result of undertreated pain http://www.growthhouse.org/stanford Module #2 Barrier #1: The Myth of Addiction • Addiction differs from chemical dependence, tolerance, and pseudoaddiction • Increased use of opioid analgesics for pain does not appear to contribute to increases in opioid abuse (Joranson, 2000) • Fears are exaggerated due to referral bias • Pseudoaddiction complicates the picture • Increased opioid requirement is usually related to progression of disease, not tolerance http://www.growthhouse.org/stanford Module #2 Barrier #2: Regulatory and Legal Concerns • Physicians are wary of prescribing controlled substances for fear of criminal and/or licensing sanctions – Risk is very low if indication and response are properly documented • Regulatory policies that control opioids get in the way – Triplicates – Renewal policies http://www.growthhouse.org/stanford Module #2 #3 System Barriers • Lack of systemic use of practice guidelines • Pain management historically has not been incorporated into quality management structure • Many institutions still lack pain and/or palliative care services http://www.growthhouse.org/stanford Module #2 Barrier #4: Deficits in Knowledge and Education • In patients, families, physicians, and other health care professionals • Pain management is still rarely addressed in medical school curricula • It is rarely included in textbooks – < 2% medical textbook content (Rabow, 2000) – < 5% nursing textbook pages (Ferrell, 1999) • Physicians lack awareness of their own knowledge deficits in pain management http://www.growthhouse.org/stanford Module #2 Barrier #5: Bad Side Effects of Opioids - Key Points • Pain is a partial antagonist to respiratory depression and CNS sedation • Respiratory depression, sedation, and N&V relate more to changing blood serum levels of opioids than the steady state dose • Pain management and constipation relate to steady state dosing, not the rising blood opioid level – Treat prophylactically and continually http://www.growthhouse.org/stanford Module #2 Barrier #6: Assessment Challenges • Health care professionals are more comfortable measuring objective data • We lack a scanner that is more accurate than patient report http://www.growthhouse.org/stanford Module #2 Assessment of Pain: Key Dimensions Mechanism • Neuropathic pain Abnormal state of central or peripheral nervous system gives rise to pain • Nociceptive pain Nerves responding appropriately to a painful stimulus Timeline • Acute • Chronic http://www.growthhouse.org/stanford Module #2 We are All ‘Color-blind’ to Chronic Pain Patients’ assessments correlated with those of: Nurse 0-2 Little or no pain 3-6 7-10 Moderate pain Severe pain 82% 51% 7% House Officer 66% 26% 21% Onc Fellow 70% 29% 27% Caregiver 79% 37% 13% http://www.growthhouse.org/stanford Module #2 A Tool to Help Assess Pain N - Number of pains? O - Origin/causes? P - Palliates, potentiates? Q - Quality? R - Radiation? S - Severity, suffering? T - Timing, trend? http://www.growthhouse.org/stanford Module #2 Neuropathic Pain • Origin: – Nerve damage • Palliates/potentiates: – Set off by unusual stimuli, light touch, wind on skin, shaving (trigeminal neuralgia) • Quality: – Electric, burning, tingling, pins & needles, shooting (system isn’t working right) • Radiation: – Nerve-related pattern http://www.growthhouse.org/stanford Module #2 Nociceptive Pain • Origin: – Tissue damage • Palliates/potentiates: – Worse with stress, pressure – Responds better to opioids, NSAIDs • Quality: – Sharp, dull, stabbing, pressure, ache, throbbing • Radiation: – Occasionally radiates (less well-defined), but not along an obvious nerve distribution http://www.growthhouse.org/stanford Module #2 Visual Analog Scale 1-3 Tolerable 4-6 Change therapy soon 7-10 Emergency SOS - change therapy now http://www.growthhouse.org/stanford Module #2 Suffering “A state of severe distress associated with events that threaten the intactness of the person” Cassell,1982 • Subjective: No way to measure it • Significantly diminishes quality of life http://www.growthhouse.org/stanford Module #2 Back to the Mnemonic • Timing: – When the pain occurs or with certain activities • Trend: – Whether a pain is getting better or worse over time http://www.growthhouse.org/stanford Module #2 Total Pain P - Physical pain A - Affective distress I - Interpersonal distress N - Non-acceptance, or spiritual distress http://www.growthhouse.org/stanford Module #2 Discussion Strategies for alleviating pain: Non-pharmacologic options http://www.growthhouse.org/stanford Module #2 Non-pharmacologic Approaches to Pain Behavioral therapy Spiritual counseling Physical therapy Psychotherapy Splinting Surgical correction Cold packs Meditation Support groups Radiation therapy Acupuncture Hypnosis Cultural healing rituals Heat packs Prayer Community resources And others… http://www.growthhouse.org/stanford Module #2 General Principles for Alleviating Pain • • • • Assess with NOPQRST Identify types(s) and location(s) of pain Correct underlying cause, if possible Consider special circumstances – – – – Avoid specific toxicities Look for ‘two-fers’ Medication routes Self-administered or by others http://www.growthhouse.org/stanford Module #2 Severity Pattern Matching Time http://www.growthhouse.org/stanford Module #2 Severity How Would You Treat the Acute Pain Pattern? Time http://www.growthhouse.org/stanford Module #2 Severity What Would a Chronic Pain Pattern Look Like? Time http://www.growthhouse.org/stanford Module #2 Treating Chronic Pain Basal pain medicine plus a different therapy for spikes: – Predictable spikes - Short-acting agent prior to event – Unpredictable spikes - Short-acting agent readily available http://www.growthhouse.org/stanford Module #2 Case Discussion Chronic pain escalating at night - Why? http://www.growthhouse.org/stanford Module #2 Brainstorm How might we treat Mrs. Long’s pain? http://www.growthhouse.org/stanford Module #2 Neuropathic Pain Medications • Opioids, NSAIDs somewhat less effective • Classes of agents: – Tricyclic for dysesthetic pain – Anticonvulsants for shooting pain – Steroids to decrease peri-tumor edema • ‘Two-fers’ important in choice of agent(s) • Generally harder to treat than nociceptive pain – More likely to need specialist expertise http://www.growthhouse.org/stanford Module #2 NSAIDs • May be more effective than opioids with certain forms of pain • Not necessarily less toxic than opioids • Toxicity can be minimized • For basal pain relief, consider longer-acting agent for ease of dosing http://www.growthhouse.org/stanford Module #2 Combination Drugs • Advantages: – Aspirin or acetaminophen may act as co-analgesic – Lower level regulatory control • Disadvantages: – Available in short-acting formulations only – ‘Combo wall’ http://www.growthhouse.org/stanford Module #2 Acetaminophen With Codeine • Advantages: – Low regulatory control – Inexpensive – Widely available • Disadvantages: – 10% cannot convert codeine to morphine – Many drugs interfere with conversion http://www.growthhouse.org/stanford Module #2 Acetaminophen with Oxycodone, Hydrocodone • Oxycodone combination contains 325 mg acetaminophen • Hydrocodone combination contains 500 mg acetaminophen • No clear advantage between the two • Dose equivalence is poorly established for hydrocodone http://www.growthhouse.org/stanford Module #2 Case Discussion • Why didn’t Mrs. Long respond to acetaminophen with codeine? http://www.growthhouse.org/stanford Module #2 Opioids • • • • Morphine Oxycodone Hydromorphone Transdermal fentanyl http://www.growthhouse.org/stanford Module #2 Principles of Opioid Use • • • • No ceiling effect Dose to pain relief without side effects Give orally when possible Sub-cutaneous administration is basically equivalent to intravenous (and preferable) • Treat constipation prophylactically http://www.growthhouse.org/stanford Module #2 Morphine • Advantages: – Inexpensive – Routes: PO, PR, IV, SC, lingual • Disadvantages: – Histamine release – Side effects, toxicity in high dose/renal failure – ‘Psychological allergy’ • Formulation:Long-acting ‘wax matrix,’ shortacting liquid, tab http://www.growthhouse.org/stanford Module #2 Standard Starting Dose • For opioid-naïve, 5-10 mg PO q4 PRN • After getting an idea of the 24-hour dose, go to long-acting • Or start with 15 mg q12 long-acting • There is no ceiling effect http://www.growthhouse.org/stanford Module #2 Oxycodone • Advantages: – – – – Good alternative to morphine Available PO: long-acting (q8-12) or short-acting ? Less CNS alteration than with morphine ? Less histamine release • Disadvantages: – More expensive than morphine – No parenteral form available in the U.S.A. http://www.growthhouse.org/stanford Module #2 Hydromorphone • Advantages: – – – – Available PO, IV, SC Good alternative to morphine for parenteral use No known toxic metabolites Long-acting oral form now available http://www.growthhouse.org/stanford Module #2 Transdermal Fentanyl • Advantages – Non-enteral administration – Change q72h – Steady blood levels • Disadvantages – – – – – Local skin problems Delayed onset and offset Cumbersome to titrate (only q72h) 20% of people need it changed q48h Expensive http://www.growthhouse.org/stanford Module #2 Question What were the general principles of opioid use we mentioned earlier? http://www.growthhouse.org/stanford Module #2 Case Discussion What do you suggest to help alleviate Mrs. Long’s pain? What more do we need to know? http://www.growthhouse.org/stanford Module #2 Case Discussion, Continued Mrs. Long has bony pain in the hip that seems to be nociceptive • What might this pain pattern look like? • What should we treat her with, and why? http://www.growthhouse.org/stanford Module #2 Opioid Conversion • This is a crucial skill in ELC • Traditionally, it was viewed as a task • It would be more correct to think of it as a process http://www.growthhouse.org/stanford Module #2 Using Opioid Conversion Tables • • • • • • Calculate 24h equivalent of old drug Convert to 24h equivalent of new drug or route Calculate new dosing interval Divide 24h dose by new dosing interval Round off this value Account for residual drug http://www.growthhouse.org/stanford Module #2 Application • Mrs. Long is admitted to the hospital and can no longer take pills • She has been taking sustained action oral morphine 60mg q12 • Her family just managed to get her to take her last dose 2 hours ago • Her pain is well controlled • You want to start her on a SC infusion of morphine http://www.growthhouse.org/stanford Module #2 Warnings • Most narcotic conversion charts are based on peak drug levels • Increase on percentage basis not dosage: 2550% per each 24 hours • Dose to comfort or side effects (monitor) http://www.growthhouse.org/stanford Module #2 Opioids May Differ Opioids may differ from each other significantly in: • Mechanism of action • Degree of cross-tolerance http://www.growthhouse.org/stanford Module #2 Two Principles In the conversion process: • For the new drug, use basal doses initially • Be relatively liberal in your use of breakthrough/short-acting doses http://www.growthhouse.org/stanford Module #2 Conclusion Practice! http://www.growthhouse.org/stanford Module #2 Learning Objectives Recognize and address barriers to effective . pain care Develop a better understanding of attitudes and beliefs about pain management Improve your knowledge and skills in assessing and treating pain Incorporate this content into your clinical teaching http://www.growthhouse.org/stanford Module #2