Why Do We Wait

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Why Do We Wait?
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Goals

• Recognize barriers to good pain control
• Adequately assess pain
• Provide a basic approach to pain therapy
• Review some commonly used analgesics

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Barriers

• Fear of addiction
• Fear of tolerance
• Fear of resp depression
• Fear of side effects
• Magical thinking
• Misconceptions

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Misconceptions

• People in pain should look like they hurt.
• If it wouldnt hurt me, it shouldnt hurt him.
• If a placebo works, shes a liar.
• If hes exaggerating his Sx demanding a drug as
  soon as allowed, hes addicted.

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Definitions

• Addiction ongoing compulsive use despite harm
• Physical dependence physiological adaptation to
  presence of drug such that withdrawal syndrome
  may occur w/ abrupt D/C or use of antagonist
• Pseudoaddiction drug-seeking behavior d/t
  inadequate analgesia

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Taking a Pain Hx

• P ppting/palliative factors
• Q quality
• R radiation
• S severity (Use a pain scale!)
• T timing
• U effect on yoU

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3 Types of Pain

• Musculoskeletal
• Visceral
• Neuropathic

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Musculoskeletal Pain

• Localized
• Constant dull ache
• Worse w/ mvt or wt-bearing
• Often worse at night

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Visceral Pain

• Hard to localize or describe
• Deep, aching, cramping,twisting, tearing,
  squeezing, pressure
• May be referred elsewhere
• May be assoc w/ ANS Sx (eg, n/v)

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Neuropathic Pain

• Poorly localized or dermatomal
• Shooting, stabbing, burning, tingling, electric
  shock
• May have assoc neurol Sx
• Allodynia, hyperalgesia

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Taking a Pain Hx

• P ppting/palliative factors
• Q quality
• R radiation
• S severity (Use a pain scale!)
• T timing
• U effect on yoU

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Basic Approach

• By mouth
• By the clock
• By the ladder
• Titrate to the individual
• Prevent side effects

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WHO 3-Step Ladder
8-10
Severe (morphine, Dilaudid, oxycodone, fentanyl)
4-7
Moderate (hydrocodone, oxycodone)
Mild (ASA, APAP, NSAID)
1-3
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Remember
Step 1 analgesics all have ceiling doses.
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Step 1 Analgesic Ceiling Doses

• APAP 4000mg
• Celebrex 400mg
• Ibuprofen 3200mg
• Tramadol 400mg
• NB Avoid NSAIDs in CHF, cirrhosis, CKD,
  asthma.
• Limit APAP to 2000mg/d in severe liver
  disease.

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Opioids
NB Most SR meds must be taken whole. All
exhibit incomplete cross-tolerance.
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Hydrocodone

• Monitor APAP!
• Abused (eg, teens)
• As potent as IR oxycodone

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Tramadol

• Weak opioid activity (50mg MS 5mg)
• SNRI
• dose in CKD elderly
• Potentiates warfarin
• Can sz threshold

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Morphine

• GOLD STANDARD!
• Renal excretion
• Granular SR products can be given per PEG

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Hydromorphone

• No SR form
• Safer in mild-mod CKD than MS

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Fentanyl

• Safe in CKD
• IV peaks 5min dur 30-60min
• SL onset 5-10min dur 2hrs
• Transdermal pros cons

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Re Duragesic

• Do not place on hairy, scarred, or oily skin.
• Place over area w/ SC tissue.
• Avoid electric blankets, hot baths/showers,
  heating pad, cooling blankets, etc.
• If it wrinkles, its not doing its job.
• If pt. is febrile unresponsive, remove patch!

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Oxycodone

• dose in renal/liver disease
• Hillbilly Heroin
• SR expensive

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Drugs to Avoid

• Meperidine (Demerol)
• Propoxyphene (Darvocet)
• Pentazocine (Talwin)
• Butorphanol (Stadol)

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Acute Pain Treatment

• Is pt opioid naïve?
• Choose IR analgesic
• Choose timing
• Consider co-analgesics

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Chronic Pain

• Choose SR analgesic
• Provide IR analgesic for breakthru pain
• Use coanalgesics whenever possible
• Prevent SEs
• Educate pt family

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Opioid Side Effects

• Constipation 99-100
• Sedation 29
• Confusion 18
• Nausea/vomiting 15
• Hallucinations 3
• Dry mouth 2
• Myoclonus 1
• Pruritis rare

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Treating Side Effects

• Constipation Start bowel regimen.
• Nausea/vomiting Treat reassure.
• Sedation Wait 2-3d. If continues, call MD.
• Other CNS problems Call MD.
• For all of above check med list for other
  potential culprits.

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Treating an OD

• Is pt unresponsive w/ RR under 8 pinpoint
  pupils?
• D/C all routine opioids sedatives.
• Dilute Narcan 1 amp in 10ml NS. Give 0.5ml slow
  IVP repeat after 1 min. if needed. Cont. same
  until RR over 9 pt takes deep breaths when told
  to.
• Monitor be ready to give more.
• When pt arouses easily w/ RR over 9, resume
  routine opioid _at_ ½ prior dose.

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Coanalgesicsfor Musculoskeletal Pain

• NSAIDs
• Topical agents
• Corticosteroids
• Muscle relaxants

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Coanalgesics for Visceral Pain

• If GI/GU spasm anticholinergic
• If esoph spasm or angina NTG
• If obstructed tube consider Decadron.
• If SBO consider octreotide.

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Coanalgesics for Neuropathic Pain

• Anticonvulsants (eg, gabapentin)
• Antidepressants (eg, TCA, SNRI)
• Corticosteroid
• Clonidine
• Baclofen
• Clonazepam
• EMLA cream, Lidoderm

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Some Basic Principles
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Start Low Go Slow!!!
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Breakthrough Dosing
PO 10 of 24hr dose q1hr prn IV 1hr dose q15min
prn SC 1hr dose q30min prn
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Titrate up 30-50 if pain uncontrolled.
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Practice
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Mrs. Irene Hurte
72yo w/ NSCLC to bones. Reports bone pain
5/10 on Tylenol. Where would you start?
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D.36
Her pain is now inadequately controlled on MS
Contin 30mg q12h. What do you suggest?
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D.100
Her pain is currently controlled on MS Contin
100mg q12h. What should be her breakthrough med
its dose?
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D.120
Mrs. Hurte is taking MS elixir 20mg _at_ least 5X/d
in addition to her MS Contin. With that regimen
her pain is controlled. What do you suggest?
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D.200

• Now Mrs. I. Hurte has dysphagia from radiation
  esophagitis. She has lost 100. She was on MS
  Contin 180mg BID. She cannot get down PO meds.
  What do you suggest?

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Other Routes

• Rectal
• SL/buccal (esp for lipophilic meds)
• Intra-stomal
• NOT vaginal!
• IV (esp if she has central line.)
• SC

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Re rectal meds

• Any PO opioid can be given rectally.
• Be sure to put it just above the anal sphincter
  have the pt lie on 1 side for 15 mins.

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What if she cant swallow, has no rectum, is
febrile?
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Other Routes

• SL/buccal opioids work in 15-60mins. Give only
  1cc SL _at_ a time.
• Intra-stomal meds work like PR meds.
• Vaginal absorption is too unpredictable.
• IV meds are an option, esp if central line
  available.

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What if she cant swallow, is having diarrhea
through her stoma, is febrile, has no veins?
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Subcutaneous Opioids

• Morphine Dilaudid
• Same potency as IV
• Permit mobility if hooked to a syringe driver

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Mr. Macho Man

• You have just admitted Mr. Macho Man w/ newly
  diagnosed cancer. He is crying w/ pain afraid
  to move a muscle. He rates his pain a 10/10.
• When you call his doctor for orders, what do you
  request?

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D.5

• He is now on a morphine drip. His pain is still a
  10/10. You are helping him w/ his bath when he
  tells you he is sure he is going to Hell because
  of some misdeeds in his youth.
• Is this contributing to his physical pain?

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His wife wants to know how she can help. What do
you suggest?
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Non-Drug Measures

• Nature
• Music
• Social contacts
• Arts crafts
• Laughter
• Pets

• Heating pad
• Massage
• A good nights sleep
• A warm bath
• A back rub
• Prayer

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D.30

• Mr. Macho Man has undergone palliative XRT
  counseling by a chaplain. His cancer has shrunk
  dramatically. His pain is gone. He wants to come
  off the morphine he has been on for 1 month.
• What do you tell him?

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D.33

• Mrs Macho Man brings her husband to the ER w/ a 1
  day h/o n/v/d, abdominal pain, muscle cramps,
  agitation.
• On exam, you note HR 120, T 101, dilated pupils,
  diaphoresis, rhinorrhea, a tremor, goose bumps.
• What is wrong?

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Pain is a more terrible lord of mankind than
even death itself.Albert Schweitzer, MD
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If we know that pain and suffering can be
alleviated and we do nothing about it, we
ourselves are tormentors.Primo Levy
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Our Mantra
Start Low Go Slow But Achieve Comfort