PAIN MANAGEMENT FUNDAMENTALS

Support for this program is provided by a

grant from the Reynolds Foundation

Learning Objectives

Systematically assess pain as a symptom

Select appropriate medication for individual patient

Describe the basic principles of opioid

pharmacotherapy

Perform simple opioid dose conversions

Recognize common opioid side effects

Pain in the elderly

Sources of pain in the elderly

• Degenerative joint disease

• Spinal stenosis

• Fractures

• Pressure ulcers

• Neuropathic pain

• Urinary retention

• Post-stroke syndrome

• Improper positioning

• Fibromyalgia

• Cancer pain

• Contractures

• Post herpetic neuralgia

• Oral/dental

• Constipation

3 TYPES OF PAIN SYNDROMES

• Nociceptive—pain due to activation of nociceptive

sensory receptors; often adequately treated with

common analgesics

Somatic—well localized in skin, soft tissue, bone

Visceral—due to cardiac, GI, or lung injury

• Neuropathic—from irritation of components of the CNS

or peripheral nervous system; may respond well to

nonopioid therapies; responds unpredictably to opioids

• Mixed or unspecified—has characteristics of both

nociceptive and neuropathic pain; common in older

adults

NOCICEPTIVE PAIN

Table 15.1 Examples

Source of

pain Typical description

Effective drug

classes and

nonpharmacologic

treatments

Nociceptive: somatic

Arthritis,

bone

metastases

Tissue injury

( bones, soft

tissue, joints,

muscles)

Well localized,

constant; aching,

stabbing, gnawing,

throbbing

Acetaminophen,

opioids Physical and

cognitive-behavioral

therapies

Nociceptive: visceral

Renal colic,

constipation

Viscera Diffuse, intermittent,

paroxysmal; dull, deep,

cramping; may have

nausea, vomiting

Treat underlying cause.

Physical & cognitive-

behavioral therapies

NEUROPATHIC PAIN

Table 15.1 Examples

Source of

pain Typical description

Effective drug

classes and

nonpharmacologic

treatments

Spinal

radiculopathy,

post-herpetic or

trigeminal

neuralgia,

diabetic

neuropathy, post-

stroke syndrome,

herniated

intervertebral

disc

Peripheral

or central

nervous

system

Prolonged, usually

constant, but can be

paroxysmal sharp,

burning, pricking, tingling,

squeezing; associated with

other sensory disturbances

(eg, paresthesias and

dysesthesias); allodynia,

hyperalgesia, impaired

motor function, atrophy, or

abnormal deep tendon

reflexes

Tricyclic antidepressants,

anticonvulsants, serotonin-

norepinephrine reuptake

inhibitor antidepressants,

opioids, topical

anesthetics

Physical and cognitive-

behavioral therapies

UNDETERMINED PAIN

Table 15.1

Examples

Source of

pain Typical description

Effective drug classes

and

nonpharmacologic

treatments

Myofascial

pain

syndrome,

somatoform

pain disorders

Poorly

understood

No identifiable

pathologic processes

or symptoms out of

proportion to

identifiable organic

pathology;

widespread

musculoskeletal pain,

stiffness, and

weakness

Antidepressants,

antianxiety agents

Physical, cognitive-

behavioral and

psychological therapies

Consequences of Untreated Pain

Acute pain:

increase metabolic rate and blood clotting,

impair immune function

induce negative emotions

Without intervention, pain receptors become

sensitive and may have long lasting changes in the

neurons

Consequences of Untreated Pain

Chronic pain may lead to:

fatigue,

anxiety,

depression,

confusion,

increased falls,

impaired sleep, and

decreased physical functioning/deconditioning

Why is pain control often not optimal?

• Clinician unfamiliarity with assessment and treatment

• Opiate misconceptions

• patients, families, and clinicians

• Fear of side effects

• Concern about addiction, regulatory reprimands, and

lawsuits

“I believe in traditional Western

medicine. Here, bite this bullet.”

Pain Management and the Law

Clinicians’ fear of regulatory scrutiny is a major

contributor to the problem of under treatment of pain.

An 85-year-old California man with metastatic lung

carcinoma spent the final week of his life in severe pain.

3 years later his children sued his doctor alleging that he

had failed to prescribe drugs powerful enough to relieve

their father's suffering.

This was one of the first U.S. cases in which a doctor has

gone on trial for allegedly under-treating a patient's

pain.

The Verdict

The plaintiffs’ lawyers convinced the jury that

under-treatment of pain was ‘reckless

negligence.’ By a 9 to 3 vote the jury decided

that the physician’s lack of attention to pain

constituted elder abuse, awarding the family

$1.5 million (the amount was reduced to

$250,000).

Hip Fracture Pain Management in the

ED Hwang U et al, J Amer Geriatr Soc, 2006

• 158 patients, aged 50 and

older (mean 83yo),

presenting to the ED with hip

fracture

• 81.0% had moderate to

severe pain

• Mean time to first pain

assessment = 40 minutes

(range 0–600)

• Mean time to first pain

treatment =141 minutes

(range 10–525)

• 36% of those with pain

received no analgesia

Case 1

You are rounding on an 83 y.o. NH patient admitted with pneumonia and a stage III sacral ulcer

She has advanced dementia, is bed- bound, and has limited verbalization

PMHx: DM, HTN,

Patient stopped eating and is combative with care

Bedside Assessment

ASK the patient about present pain

Identify preferred pain terminology

-hurting, aching, stabbing, discomfort, soreness

Use a pain scale that works for the individual

-Insure understanding of its use

-Modify sensory deficits

One-dimensional Scales

Acute Pain Management Guideline Panel. Acute Pain Management in Adults:

Operative Procedures. Quick Reference Guide for Clinicians. Rockville, MD: US

Department of Health and Human Services, Public Health Service, Agency for Health

Care Policy and Research. February 1992. AHCPR Pub. No. 92-0019.

Faces Pain Scale

Assessing pain: Nonverbal, Moderate to Severe

Impairment

Formal assessment tools available but not

necessarily useful in routine clinical settings

PAINAD

FLACC

• Unique Pain Signature

• Nonverbal Pain Indicators

Nonverbal Pain Indicators

Facial expressions (grimacing)

-Less obvious: slight frown, rapid blinking, sad/frightened, any distortion

Vocalizations (crying, moaning, groaning)

-Less obvious: grunting, chanting, calling out, noisy breathing, asking for help

Body movements (guarding)

-Less obvious: rigid, tense posture, fidgeting, pacing, rocking, limping, resistance to moving

Nonverbal Pain Indicators

Changes in interpersonal interactions

-combative, disruptive, resisting care, decreased social interactions, withdrawn

Changes in mental status

-confusion, irritability, agitation, crying

Changes in usual activity

-refusing food/appetite change, increased wandering, change in sleep habits

Unique Pain Signature

How does the patient usually act?

What changes are seen when they are in pain?

family members

nursing staff

Communication across caregiver settings is key!

Assessing pain: Nonverbal, Moderate to Severe

Impairment (AGS Panel 2002)

1) Presence of non-verbal pain behaviors?

-assess at rest and with movement

2) Timely, thorough physical exam

3) Insure basic comfort needs are being met

(e.g. hunger, toileting, loneliness, fear)

4) Rule out other causative pathologies

(e.g. urinary retention, constipation, infection)

5) Consider empiric analgesic trial

Pain Assessment is NOT….

Relying on changes in vital signs

Deciding a patient does not “look in pain”

Knowing how much a procedure or disease “should

hurt”

Assuming a sleeping patient does not have pain

Assuming a patient will tell you they are in pain

Case 1

You are rounding on an 83 y.o. NH patient admitted with pneumonia and stage III sacral ulcer

She has advanced dementia, bed- bound, limited verbalization

PMHx: DM, HTN

Patient stopped eating and is combative with care

Recommended treatment- trial of empiric analgesic, such as acetaminophen 1000 mg or oxycodone 2.5-5mg 3 x day. Monitor for effect.

Case 2

You are rounding on a 75 y.o. male s/p fall

History of lumbar stenosis with new onset severe sharp pain down left leg

Xrays negative

Overnight patient was started on prn NSAIDs

Patient in severe pain at rounds

Question: How do we choose medication and dose in older adults?

Medication Selection

Good pain history

Target to the type of pain

-e.g. neuropathic, nociceptive

Consider non-pharmacologic or non-systemic

therapies alone or as adjuvants

Use the WHO 3-Step ladder

WHO 3-Step ladder

Acetaminophen

NSAIDS

Cox-2

Non-systemic therapies

+/- other adjuvants

Codeine (e.g. T #3®)

Hydrocodone (e.g. Vicodin®)

Oxycodone (e.g. Percocet®)

Tramadol (Ultram®)

+/- Adjuvants

Morphine

Oxycodone

Hydromorphone (Dilaudid®)

Fentanyl

Oxymorphone

Methadone

+/- Adjuvants

Mild

Moderate

Severe

Adjuvants

Topicals (lidocaine patch, capsaicin)

Acetaminophen

NSAIDS, celecoxib, steroids

Anticonvulsants

Antidepressants

Non-pharmacologic (TENS, PT/OT)

Multimodal Approach to Pain

Management

Physical Therapy Pharmacotherapy

Interventional

Approaches

Complementary Alternative

Psychological Support

Case 2

You are rounding on a 75 y.o. male s/p fall

History of lumbar stenosis with new onset severe sharp pain down left leg

Xrays negative

Overnight patient was started on prn NSAIDs

Patient in severe pain at rounds

Drugs to Avoid

Meperidine (Demerol®)

Mixed agonist-antagonist

-e.g. Pentazocine (Talwin®)

Codeine

Opioid Use in Renal Failure

Not rec’d: meperidine, codeine,

Use with caution: oxycodone, hydromorphone, morphine

Safest: fentanyl, methadone

Opioid dosing

CrCl

>50 mL/min normal

10 - 50 mL/min 75% of normal

<10 mL/min 50% of normal

Clearance Concerns: Dehydration, renal

failure, severe hepatic failure dosing interval (increase time between doses)

or

dosage

if oliguria or anuria: consider d/c around the clock

dosing

Opioids for Continuous Pain

Dose find, opioid naive:

-begin with short-acting opioid ATC

-allow breakthrough based on Cmax and patients metabolism

Cmax (peak) after

-po, pr 1 h

-SC, IM 30 min

-IV 6 – 15 min

Dose-finding

To achieve quick pain relief:

(LOAD)

1. Start low dose, short-acting

2. Dose q peak

3. PCA is not “prn” (Patient

controls it)

4. Re-evaluate in 4 hours to

calculate what dose is needed

Starting doses and half-life

For thin, frail elderly suggest 2-5 mg po MSO4 or an

equivalent (e.g. 1/2-1 percocet q 4h)

Half-life at steady state

po / po / SC / IM / IV 3-4 h

4-5 half-lives to reach steady state

Opioid Dose Escalation

• Should be done on percentage increase irrespective of starting dose

• mild / moderate pain 25%–50%

• severe / uncontrolled pain 50%–100%

• How frequently? Depends on t1/2

• Short-acting single-agent every 2 hrs

• Long-acting every 24 hours

• Fentanyl transdermal 72 hours

• Methadone 4-7 days

Breakthrough dosing

Use immediate-release opioids

10% of 24-h dose or 1/3 of one ER dose

offer after Cmax reached

po / pr q 1 h

SC, IM q 30 min

IV q 10–15 min

Do NOT use extended-release opioids for

breakthrough

Transdermal Fentanyl

Duration 24-72 hours

12-24 hours to reach full analgesic effect

Has caused fatal respiratory depression in opiate naïve patients (at least 1 week use of 60mg/day of oral morphine required before starting)

Lipophilic

Simple Conversion rule:

-1 mg po morphine = ½ mcg fentanyl

-(60 mg morphine roughly 25 mcg patch)

Case 3

You are rounding on a 70 y.o. male admitted with pleuritic

chest pain

New pulm mass found on chest CT

Severe pleuritic pain well-controlled on hydromorphone 4

mg IV q 3 hours

You want to convert him to something he can take at home

Question: How do convert from one opiate to another route

or drug?

Equianalgesic Dosing Ratios

Opioid Oral/Rectal IV/SC

Hydromorphone

Morphine

Oxycodone

Hydrocodone Codeine

7.5

30

20

15 100

1.5

10

NA

NA 50

Note: Equianalgesic equivalencies are merely

estimates and are based on single-dose studies.

Converting from one opioid to another

X mg TDD new opioid Equigesic factor new opioid

mg TDD current opioid Equigesic factor current

Let’s practice on this patient…

(X) mg po morphine 15 mg po morphine

(32 mg)IV dilaudid 0.75 IV dilaudid

Remember he is receiving hydromorphone 4 mg IV

q 3 hours.

Incomplete cross tolerance

When changing from 1 opiate to another ALWAYS

decrease the dose of the new opiate by 50% of the

equianalgesic dose.

So our patient would need 320mg/day of sustained

release oral morphine

Don’t forget to give immediate release

medication for breakthrough (5-15% of

TDD)

Opiate adverse effects

Constipation

Dry mouth

Nausea / vomiting

Sedation

Sweats

Delirium

Bad dreams / hallucinations

Dysphoria / delirium

Myoclonus / seizures

Pruritus / urticaria

Respiratory depression

Urinary retention

Hypogonadism

SIADH

Common Uncommon

Managing GI Side Effects

• NEVER resolves!

• Prevent with

scheduled softeners

PLUS stimulants

• Avoid bulking agents

(e.g. Metamucil®)

Frequent, small meals

Antiemetic agents

Promotility agents

(metoclopramide)

serotonergic blocking agents (odansetron)

dopaminergic blocking agents (haloperidol, metoclopramide, prochlorperazine)

Constipation

Nausea/Vomiting

The Evidence: Pain, Opioids, and Delirium

Two studies* have reported a significant association between opioid use and delirium

Neither study controlled for pain

All patients received meperidine

*Marcontonio et al, JAMA 1994, Schor et al, JAMA 1992

†Egbert et al, Arch Intern Med 1990 ,

Duggleby & Lander, JPSM 1994,

Lynch et al, Anesth Analg 1998;

Morrison et al, J of Gerontology: Medical Sciences, 2004

Five studies† have reported a significant association between uncontrolled pain and delirium

No relationship found between opioid use/dose and delirium in 4 studies

Opioids found to reduce the risk of delirium in 2 studies

Respiratory Depression

Does not occur in patients on chronic opioids

Can occur in opioid-naïve patients whose opioid dose is rapidly escalated

Is always preceded by slowly progressive somnolence

If you must treat:

-Dilute naloxone (10:1) in saline and infuse 1 mL until breathing pattern returns to normal

Case 4

You are rounding on a 90 year old female with severe osteoporosis admitted for sudden severe back pain

New vertebral compression fracture

Pain controlled on morphine 4 mg IV q 4 hours

Patient very sedated, family concerned

Sedation and Delirium

Consider trying one of the following:

1. If pain control is adequate, decrease dose by 25%

2. Rotate to a different opioid preparation

3. Use small doses of psychostimulants (2.5 to 5 mg methylphenidate or dextroamphetamine) for excessive somnolence

Use nonsedating antipsychotics (haloperidol, risperidone) for delirium

Case 5

Ms. GG is a 67 year-old female with history of

osteoarthritis, coronary artery disease, chronic

kidney disease, and new diagnosis of metastatic

breast cancer, who presents to clinic for follow after

RT to her hip.

She says, “I am taking 10 pills of morphine (600mg

q 12 hours) twice a day; I want to stop it. The

radiation therapy worked and the pain is gone. What

should I do?”

Case 5 continued

Keep in mind the physical dependence properties of

opioids.

Decreased by 50% every 4-5 half lives.

If the dose is lowered too quickly and abstinence signs

appear, you can: increase the opioid transiently, treat

symptoms with clonidine or small amounts of lorazepam.

On average, XRT can take anywhere from 1-4 weeks to

begin having pain relief effects. XRT can cause initially

cause increase in pain due to inflammatory effects and

release of cytokines.

Case 6

AA is a 65-year-old woman with breast cancer

taking long acting morphine who developed a

pathologic fracture of the femur and was started on

Morphine 40mg IV Q4h and the new rescue dose of

24mg IV every 1 hour prn.

The next morning, you come in to see Ms. Amidiaz

but she seems very lethargic. Her respiratory rate is

6 and she is only responsive to painful stimuli.

What should you do?

Opioid Overdose

Provide ventilatory assistance with bag-valve mask

Naloxone should only be used for life threatening opioid induced respiratory depression.

To avoid withdrawal:

Dilute 0.4mg (1 ml) with NS 9ml for a total volume of 10ml and administer 1-2 ml IV q2-3 min until response

Half life: 30-81minutes (mean 64 min)

Naloxone’s half-life is less than most opioid agents so respiratory depression may recur

Common pitfalls to avoid

Changing meds/route on discharge

Writing the prescription

Medication cost

Educating patient/family

Appropriate follow-up

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References

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