Pain Management
Content
Introduction
End of Life Pain
50% of elders report “significant problems with
pain” in the last 12 months of life.
One-third of nursing home patients complain
daily pain.
Predictable, explainable pain is under treated.
Elders list pain control as one of their
top 5 quality of life concerns
Patients “have a legal right” to proper
pain assessment and treatment.
Common
Misconceptions
• “I should expect to have pain”
• “I’ll hold off so the medicine will
work when I really need it”
• “Pain is for wimps”
• “I don’t want to get hooked”
Barriers
We assess pain poorly and erratically
We haven’t been well trained in pain
management
We’re afraid of addiction issues
We’re afraid of mistreating the patient
Basic Approach to Pain
Management
• Ask the patient about pain and
believe them.
• Use a pain scale.
• Document what you know about the
pain
• Reassess the pain
Diagnosing and
Documenting Pain
Examples of Pain
Scales
Documenting Pain
Onset
• What relieves?
Location
• What worsens?
Intensity
• Effects on Daily Activities
Quality
• Treatment History
Neurological
Classification
Nociceptive Pain
Neuropathic Pain
Nociceptive Pain
Damage is to other tissue and nerve fibers are
stimulated.
Travels along usual pain and temperature
nerves
Responds well to common analgesics and
opioids
Sharp, throbbing, aching
Neuropathic Pain
The nervous system itself damaged
Direct damage to nerves, plexes, spinal
cord (shingles, diabetic neuropathy)
Burning, tingling, shooting
May not respond as well to usual analgesics
including opioids
Physical Examination
motor, sensory, reflexes
headaches: intracranial mass
zoster, pressure sores
non-verbal communication
Treating Pain
Treatment of Pain
Treat Causes if possible
Remember Non-Drug Treatments
Analgesics: Narcotic, Non-narcotic
Adjuvants: Anti-convulsants, Antidepressants
Standard Approach
Treat Quickly (Pain leads to more pain)
Mild Pain: acetaminophen, ASA, NSAIDS
Moderate: mixtures, weak opioid, maybe
adjuvants
Severe: strong opioid and non-opioid,
maybe adjuvant
Non-Narcotic
Analgesics
Acetaminophen (< 4 g / 24 hrs.)
NSAIDS (bone pain or
inflammation)
– Lots of side effects
– Newer are expensive
Basics of Analgesic Use
1. By Mouth When Possible
2. Timed Doses
3. Whatever dose it takes
4. Watch for Expected Side Effects
5. Consider Adjuvants
Narcotic Analgesics:
Morphine
IV: if >50 Kg. Give 10 mg. IV Q3-4 h
If child or <50 kg. Give 0.1mg/kg. IV
If Opioid Naïve, consider lower dose
Oral: Start 5-10 mg. Titrate Up
Morphine
Max Effect: IV -15 minutes
SC- 30 minutes
PO: -I hr.
Using Concentrates
Dying Patient; Can’t swallow
MSIR 20 mg/ml : .25 to .50 ml. Q
1 hr. sl. PRN
Oxycodone conc. 20 mg/ml : .25
to .50 ml. Q 1 hr. sl. PRN
DOSING
Titrate Up Slowly Until pain controlled
or side effects occur
Anticipate Next Dose: tend to give a
little early
Use Breakthrough Doses When
Needed
Extended Release
Better Compliance
More Expensive
Dose q 8,12, or 24
Extended Release
Don’t Crush or Chew
May flush through feeding tubes
Don’t Start with Extended Dose
Breakthrough Pain
Is it new incident (new cause? or
end-of-dose?)
Use 10% of total daily dose
(rounded up) up to q 1-2 h
Continuing Use
Can continue to increase (no real
upper limit)
Gradually increase – Limited by Side
effects
Note that the effective rescue dose
increases as total dose does
Other Options: Fentanyl
Patch
25, 50, 75, 100 mcg/hr.
Apply every 3 Days
Divide Morphine Daily Dose in Half
Rescue with Opioids
Other Options: Fentanyl
Patch
Initial Dose May Take 12- 24 hrs.
May continue previous meds for
8 - 12 h
If switching, remove and use
rescue for 24 hrs.
Fentanyl is well absorbed across
mucous membranes
“Lolly-pop”
approved only for breakthrough
in already receiving opioids
not to be chewed 200ug units
not proven to be more effective
than morphine concentrates
Other Options:
Methadone
Starts working in about 1 hr.
Inexpensive
Neuropathic Pain
A patient with advanced lung cancer has severe
pain from a localized bony metastasis. He
begins to consistent feel pain about four hours
after his last dose of opioid medication.
A.
B.
C.
D.
1. According to the program which
of the following would be most
helpful?
Increase medication dose
Change medication
Begin to give the medication at intervals of
less than four hours
Add adjuvant medication.
Answer C.
A.
Begin to give the
medication at intervals of
less than four hours
2. The most likely classification
of this pain is:
A.
B.
C.
D.
Referred Pain
Nociceptive Pain
Neuropathic Pain
Visceral Pain
Answer B.
Nociceptive Pain
3. The oral morphine preparation
given to this patient will begin to
take full effect in about:
A. 15 minutes
B. 30 minutes
C. 1 hour
D. 2 hours
Answer C.
1 hour
Problems with Pain
Management
Problems with Opiates:
Addiction
Define: compulsive use, lack of control,
harmful use
Iatrogenic: may be as low as 1% if no
previous history
Avoid making this tricky diagnosis
“Have you used this drug five times in your
life?”
Warning signals
Dominating Concerns over Availability
Non-Provider Sanctioned Increases
Ignoring Major Side Effects
Warning signals
Altering, losing Prescriptions
Multiple Sources
Unaccounted Medication
Problems with Opiates:
Dependence
Defined by the occurrence of a
withdrawal syndrome after reduction
or cessation.
May occur after only 2- 3 days of
strong opioids
Usually well controlled by tapering
Problems with Opiates:
Tolerance
Need for higher doses for same effect
Can occur with effects other than analgesia
Often develops faster for sedation,
respiration, nausea than analgesia
Slow tolerance to obstipation
Problems with Opiates:
Obstipation
Fluids, Bran
Pericolace or Senicot-S
No BM in 48 hrs: MOM or Lactulose
No BM in 72 hrs: Rectal Exam; Mag
Citrate, Fleets, Oil
Problems with Opiates:
Nausea/Vomiting
Usually occurs initially
Improves with Time
May be Able to Prevent with
other meds, no movement
Problems with Opiates:
Respiratory Depression
Remember, fairly rapid tolerance develops
Almost always associated with sedation
Follow Respiratory Rate
Withhold Next 2 Doses
Naloxone
Dilute 1 Vial (0.4mg) in 10 cc.
Normal Saline
Give 1 cc. per minute until
respiratory rate OK
End of Life Pain
50% of elders report “significant problems with
pain” in the last 12 months of life.
One-third of nursing home patients complain
daily pain.
Predictable, explainable pain is under treated.
Elders list pain control as one of their
top 5 quality of life concerns
Patients “have a legal right” to proper
pain assessment and treatment.
Common
Misconceptions
• “I should expect to have pain”
• “I’ll hold off so the medicine will
work when I really need it”
• “Pain is for wimps”
• “I don’t want to get hooked”
Barriers
We assess pain poorly and erratically
We haven’t been well trained in pain
management
We’re afraid of addiction issues
We’re afraid of mistreating the patient
Basic Approach to Pain
Management
• Ask the patient about pain and
believe them.
• Use a pain scale.
• Document what you know about the
pain
• Reassess the pain
Diagnosing and
Documenting Pain
Examples of Pain
Scales
Documenting Pain
Onset
• What relieves?
Location
• What worsens?
Intensity
• Effects on Daily Activities
Quality
• Treatment History
Neurological
Classification
Nociceptive Pain
Neuropathic Pain
Nociceptive Pain
Damage is to other tissue and nerve fibers are
stimulated.
Travels along usual pain and temperature
nerves
Responds well to common analgesics and
opioids
Sharp, throbbing, aching
Neuropathic Pain
The nervous system itself damaged
Direct damage to nerves, plexes, spinal
cord (shingles, diabetic neuropathy)
Burning, tingling, shooting
May not respond as well to usual analgesics
including opioids
Physical Examination
motor, sensory, reflexes
headaches: intracranial mass
zoster, pressure sores
non-verbal communication
Treating Pain
Treatment of Pain
Treat Causes if possible
Remember Non-Drug Treatments
Analgesics: Narcotic, Non-narcotic
Adjuvants: Anti-convulsants, Antidepressants
Standard Approach
Treat Quickly (Pain leads to more pain)
Mild Pain: acetaminophen, ASA, NSAIDS
Moderate: mixtures, weak opioid, maybe
adjuvants
Severe: strong opioid and non-opioid,
maybe adjuvant
Non-Narcotic
Analgesics
Acetaminophen (< 4 g / 24 hrs.)
NSAIDS (bone pain or
inflammation)
– Lots of side effects
– Newer are expensive
Basics of Analgesic Use
1. By Mouth When Possible
2. Timed Doses
3. Whatever dose it takes
4. Watch for Expected Side Effects
5. Consider Adjuvants
Narcotic Analgesics:
Morphine
IV: if >50 Kg. Give 10 mg. IV Q3-4 h
If child or <50 kg. Give 0.1mg/kg. IV
If Opioid Naïve, consider lower dose
Oral: Start 5-10 mg. Titrate Up
Morphine
Max Effect: IV -15 minutes
SC- 30 minutes
PO: -I hr.
Using Concentrates
Dying Patient; Can’t swallow
MSIR 20 mg/ml : .25 to .50 ml. Q
1 hr. sl. PRN
Oxycodone conc. 20 mg/ml : .25
to .50 ml. Q 1 hr. sl. PRN
DOSING
Titrate Up Slowly Until pain controlled
or side effects occur
Anticipate Next Dose: tend to give a
little early
Use Breakthrough Doses When
Needed
Extended Release
Better Compliance
More Expensive
Dose q 8,12, or 24
Extended Release
Don’t Crush or Chew
May flush through feeding tubes
Don’t Start with Extended Dose
Breakthrough Pain
Is it new incident (new cause? or
end-of-dose?)
Use 10% of total daily dose
(rounded up) up to q 1-2 h
Continuing Use
Can continue to increase (no real
upper limit)
Gradually increase – Limited by Side
effects
Note that the effective rescue dose
increases as total dose does
Other Options: Fentanyl
Patch
25, 50, 75, 100 mcg/hr.
Apply every 3 Days
Divide Morphine Daily Dose in Half
Rescue with Opioids
Other Options: Fentanyl
Patch
Initial Dose May Take 12- 24 hrs.
May continue previous meds for
8 - 12 h
If switching, remove and use
rescue for 24 hrs.
Fentanyl is well absorbed across
mucous membranes
“Lolly-pop”
approved only for breakthrough
in already receiving opioids
not to be chewed 200ug units
not proven to be more effective
than morphine concentrates
Other Options:
Methadone
Starts working in about 1 hr.
Inexpensive
Neuropathic Pain
A patient with advanced lung cancer has severe
pain from a localized bony metastasis. He
begins to consistent feel pain about four hours
after his last dose of opioid medication.
A.
B.
C.
D.
1. According to the program which
of the following would be most
helpful?
Increase medication dose
Change medication
Begin to give the medication at intervals of
less than four hours
Add adjuvant medication.
Answer C.
A.
Begin to give the
medication at intervals of
less than four hours
2. The most likely classification
of this pain is:
A.
B.
C.
D.
Referred Pain
Nociceptive Pain
Neuropathic Pain
Visceral Pain
Answer B.
Nociceptive Pain
3. The oral morphine preparation
given to this patient will begin to
take full effect in about:
A. 15 minutes
B. 30 minutes
C. 1 hour
D. 2 hours
Answer C.
1 hour
Problems with Pain
Management
Problems with Opiates:
Addiction
Define: compulsive use, lack of control,
harmful use
Iatrogenic: may be as low as 1% if no
previous history
Avoid making this tricky diagnosis
“Have you used this drug five times in your
life?”
Warning signals
Dominating Concerns over Availability
Non-Provider Sanctioned Increases
Ignoring Major Side Effects
Warning signals
Altering, losing Prescriptions
Multiple Sources
Unaccounted Medication
Problems with Opiates:
Dependence
Defined by the occurrence of a
withdrawal syndrome after reduction
or cessation.
May occur after only 2- 3 days of
strong opioids
Usually well controlled by tapering
Problems with Opiates:
Tolerance
Need for higher doses for same effect
Can occur with effects other than analgesia
Often develops faster for sedation,
respiration, nausea than analgesia
Slow tolerance to obstipation
Problems with Opiates:
Obstipation
Fluids, Bran
Pericolace or Senicot-S
No BM in 48 hrs: MOM or Lactulose
No BM in 72 hrs: Rectal Exam; Mag
Citrate, Fleets, Oil
Problems with Opiates:
Nausea/Vomiting
Usually occurs initially
Improves with Time
May be Able to Prevent with
other meds, no movement
Problems with Opiates:
Respiratory Depression
Remember, fairly rapid tolerance develops
Almost always associated with sedation
Follow Respiratory Rate
Withhold Next 2 Doses
Naloxone
Dilute 1 Vial (0.4mg) in 10 cc.
Normal Saline
Give 1 cc. per minute until
respiratory rate OK
