Coyne Pain Management

7/30/2019 Coyne Pain Management

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Pain Management: Thethings you should know


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Questions RegardingPain Control

What about the 20% who do not get relief fromthe WHO ladder or the 46% of those whosefamilies stated we failed?*

Have the opioids been titrated aggressively?

Is the pain neuropathic?

Has a true pain assessment been accomplished?

Have invasive techniques been employed?

Have you examined the patient? Is the patient receiving their medication?

Is the medication schedule and route appropriate?

*Tolle 2001


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Physiological effects of Pain

Increased catabolic demands: poor wound

healing, weakness, muscle breakdown

Decreased limb movement: increased risk ofDVT/PE

Respiratory effects: shallow breathing,tachypnea, cough suppression increasing risk ofpneumonia and atelectasis

Increased sodium and water retention (renal)

Decreased gastrointestinal mobility

Tachycardia and elevated blood pressure


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Psychological effects of Pain

Negative emotions: anxiety, depression

Sleep deprivation

Existential suffering: may lead to patientsseeking active end of life.


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Immunological effects of Pain

Decrease natural killer cell counts

Effects on other lymphocytes not yetdefined.


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Procedure Related Pain

Common in all patients

Frequent source of pain and distress


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Therapeutic Procedures

Surgery

Only 50% of post-operative pain isadequately managed

Post-operative pain syndromes

Traumatic neuroma

Similar to other chronic pain syndromes

Psychological factors important

Treat symptoms

Maintain functional status


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Principles of Assessment

Assess and reassess

Use methods appropriate to cognitive status and context

Assess intensity, relief, mood, and side effects

Use verbal report whenever possible

Document in a visible place

Expect accountability

Include the family


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Patient Pain History Site(s) of pain?

Severity of pain?

Date of onset?

Duration?

What aggravates or relieves pain?

Impact on sleep, mood, activity?

Effectiveness of previous medication?


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What Does Pain Mean to

Patients?

Poor prognosis or impending death

Particularly when pain worsens

Decreased autonomy

Impaired physical and social function

Decreased enjoyment and quality of life

Challenges to dignity

Threat of increased physical suffering


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Neuropathic Pain

Neuropathic pain is pain transmitted over damagednerves.

Patient Description of Neuropathic Pain:

Burning, electric, searing, tingling, and migratingor traveling.

Causes of Neuropathic Pain:

Amputation, shingles (herpes zoster), AIDS

(peripheral neuropathy), diabetic neuropathy,

fibromyalgia, and cancers that affect the spinal

cord, among others.Westbrook 2005


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Opioids

Codeine

FentanylHydrocodone

Hydormorphone

Methadone

MorphineOxycodone

Oxymorphone


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Cost of Opioids(AWP 2003 Redbook )(Equianalgesic Dose (morphine 180-200mg / day ATC)

Brand Generic Dose Cost/30 days Cost/day

Roxanol morphine 30 mg q4h $186.84 ($58.75) $6.23 ($2.00)

Morphine IR morphine 30 mg q4h $147.62 $4.92*

Oramorph SR morphine 100 mg q12h $307.20 $10.24

MS Contin morphine 100 mg q12h $328.20 $10.94

Morphine SR morphine 100 mg q12h $293.75 $9.79*

Avinza Morphine 200mg q24h $433.80 $14.46

Kadian morphine 200 mg q24h $365.00 $12.18

Duragesic fentanyl 100 mcg q72h $482.72 $16.06

Oxydose oxycodone 30 mg q4h 309.78($259.97) $10.32*

Oxycontin oxycodone 80 mg q12h $514.85 $17.16

Dilaudid hydromorphone 8 mg q4h $219.60 $7.32

Dolophine methadone 20 mg q8h $ 30.26 $1.01($0.51-4.54)


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Principles of Opioid Analgesic

Use in Acute and Cancer Pain Individualize route, dosage, and schedule

Administer analgesics regularly (not PRN) if

pain is present most of day

Become familiar with dose / time course ofseveral strong opioids

Give infants / children adequate opioid dose

Follow patients closely, particularly when

beginning or changing analgesic regimens


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Principles of Opioid AnalgesicUse in Acute and Cancer Pain

(cont) When changing to a new opioid or different route Use equianalgesic dosing table to estimate new dose

Modify estimate based on clinical situation

Recognize and treat side effects

Be aware of potential hazards of meperidine / mixedagonist-antagonists - particularly pentazocine

Do not use placebos to assess nature of pain


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Principles of Opioid AnalgesicUse in Acute and Cancer Pain

(cont) Watch for development of:

Tolerance - treat appropriately

Physical dependence prevent withdrawal

Do not label a patient psychologically dependent,addicted, if you mean physically dependent on /

tolerant to opioids

Be alert to psychological side of patient (APS,2005)


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Equianalgesia

Determining equal doses when

changing drugs or routes of

administration

Use of morphine equivalents


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Practical Prescribing:

Equianalgesic Dosing


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Some Equianalgesic Doses

Common drugs with oral doses equianalgesic to650mg oral aspirin or acetaminophen

Pentaxocine (Talwin) 30mg

Codeine 32mg

Meperidine (Demerol) po 50mg

Propoxphene (Darvon) 65mg


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Calculation:

Baseline Pain = Extended

release morphine 200 mg/24hrs

Breakthrough - 10-20% =

20-40 mg


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Principles: Use of OpioidRotation

Use when one opioid ineffective or

for adverse effects


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Methadone Acute pain: methadone morphine (1:1)

Chronic pain: ratio depends upon previous opioiddose (methadone:morphine)

< 90 mg (1:5) 91-299 mg (1:10)

>300 mg (1:12 or 20)

Torsade de Pointes in high parenteral dosesBruera &Sweeney, 2002;

Kranz et al., 2002


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Properties of Methadone

Well absorbed from all routes of administration oral

rectal

subcutaneous

IV

Sublingual

Rapid onset of analgesia effect ( 30 60 min.)

No significant cognitive impairment.

No euphoria.

Safe in renal and liver failure.


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Over 50% of patients requiredmore than one route of drug

administration during the last fourweeks of life.

N. Coyle 12/90


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Co Analgesics

Definition

Agents which enhance analgesic efficacy, have

independent analgesic activity for specific types ofpain, and / or relieve concurrent symptoms whichexacerbate pain


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Co Analgesics Commonly Used

For Pain NSAIDS

Acetaminophen

Antidepressants

Anticonvulsants

Corticosteroids

Neuroleptics

Antihistamines

Analeptics

Benzodiazepines

Antispasmodics

Muscle relaxants

Systemic localanesthetics


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Systemic Local Anesthetics

Indications

Neuropathic pain

Toxicities

Dizziness, nausea, tremor, nervousness,incoordination, headaches, paresthesias

Drugs

Lidocaine, mexiletine


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Local Anesthetics

Lidocaine Infusion

More effective in neuropathic pain but can be usedfor all pain syndromes. Starting dose 0.5mg-2 mg/kgper hr IV or SC. Some studies demonstrate long-

lasting pain relief even after drug has been stopped.Need to decrease opioids when starting. (Ferrini,Paice, 2004)

Lidocaine Patch (Lidoderm)

On 12hrs off 12 hours (but can leave on 24)

Expensive (great indigent program however)


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Miscellaneous Adjuvant

Analgesics Pamidronate (Aredia)

Zoledronic acid (Zometa)

Strontium-89(Metastron)

Calcitonin (Calcimar) Not in cancer ? arthritis

Capsaicin (Zostrix) scheduled in neuropathic pain

Clonidine (Catapres) all forms

Cannabinoid (Marinol)


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Analgesics for Neuropathic

Pain Tricyclic antidepressants nortriptaline (1st choice)

Anticonvulsants

Gabapentin, Carbamazepine, Pregaba

Local anesthetics

Parenteral, oral, topical

Topical capsaicin

Opioids for selected patients


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Ketamine

N-methyl-D-aspartate receptor antagonist(NMDA)

Used as an anesthetic for years

Case reports show effectiveness when traditionaland invasive techniques fail

Starting IV dose 150mg qd (0.1-0.2mg/kg) withreduction of opioid achieved or 10-15 mg q6increasing by 10 mg dose each day

Appears to have a synergistic effect with opioids


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Making PCA Work for your Patient

PCA History; dosing,bolus; basalrates

Always remember SC PCA


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Pain

Step 1NonopioidAdjuvant

Pain persisting or increasing

Step 2Opioid for mild to moderate pain

Nonopioid Adjuvant



Step 3

Opioid for moderate to severe painNonopioid Adjuvant

Invasive treatments

Opioid Delivery

Quality of Life

Modified WHO Analgesic Ladder

Proposed 4th Step

The WHO

Ladder

Deer, et al., 1999


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Role of Invasive (Anesthetic)

Procedures Intractable pain*

Intractable side effects*

*Symptoms that persists despite carefullyindividualized patient management


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Role of Invasive Procedures

Optimal pharmacologic managementcan achieve adequate pain control in80-85% of patients

The need for more invasive modalitiesshould be infrequent

When indicated, results may be gratifying


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Other techniques ...

Lidocaine

Ketamine Methadone

Sedation

Spinal cordstimulator

Chemotherapy,radiation

Surgery

Biphosphates

Others


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