CLINICAL REVIEW FOR THE GENERALIST     HOSPICE & PALLIATIVE NURSEWEEK 2   Pain Management
Objectives1.    Describe the prevalence of pain in the hospice and P.C.      setting2.    Recognize the impact of pain on ...
Definition of Pain:   An unpleasant sensory and emotional    experience associated with actual or potential    tissue dam...
Pain is SUBJECTIVE―Pain is whatever the person says it is, experienced whenever they say they are experiencing it.‖ (McCaf...
Self-Report is the most valid measure of pain.
Under-treatment of Pain   70-90% of pts. w/ advanced    disease have pain   50% of hospitalized pts.    experience pain...
It’s Estimated That—   98-99% of all pain    could be controlled,    using current tools    and knowledge.   The other 1...
Ethical Considerations   Patient rights—to good pain    management   Joint Commission/ANA value    pain relief   Double...
Palliative SedationIs given with the intent to relieve refractory suffering(physical, psychological, or spiritual). It is ...
Uncontrolled Pain Impacts                   Physical                   Psychosocial                   Emotional        ...
Costs of Poor Pain Management   40 million Dr. visits/yr. for    pain   25% of all lost work days    are due to pain   ...
Pain Co-Morbidities   Depression   Anxiety   Diabetes   Chronic Fatigue    Syndrome
Pain is Multi-Dimensional   Each member of the    IDT can address it                            Nurse                   ...
Patients’ attitudes are sometimesbarriers to good pain management   Fear of addiction   Good patients don’t    complain...
Another Barrier: Clinicians Attitudes                   Doubt patients’ reports of                    pain               ...
Institutional Barriers•   Low Priority•   Poor reimbursement•   Restrictive regulations•   Availability/Access to treatment
Types of Pain   Acute—short-term, observable, signs    (MI, appendicitis, surgery, toothache, labor    pains), accompanie...
Types of Pain (continued)   Nociceptive—arises from stim. of nerves in skin,    soft tissue, or viscera.     Somatic—mus...
Types of Pain   Mixed Nociceptive/Neuropathic—common in    life-threatening illnesses (chronic low back    pain, cancer p...
How does it Feel?                                “aching/thro                                    bbing”  Which type of pai...
How to treat each type   Somatic—Non-opioids,    opioids   Visceral—non-opioids,    opioids   Neuropathic—adjuvants    ...
NMDA Receptor Antagonists                     Work well for                      nerve pain                     Also use...
APS—12 Principles of Pain Mgmt.1.   Individualize dose, route, + schedule2.   ATC dosing3.   Selection of opioids4.   Adeq...
APS—12 Principles of Pain Management7.    Recognize and treat side effects (constip.!!)8.    Be aware of hazards of mixed ...
W.H.O. PAIN LADDER
W.H.O. Recommendations   START LOW—GO SLOW with dosing   Preference for routes is:       #1 PO       #2 Transdermal   ...
W.H.O. RECOMMENDS     Immediate-release meds. for Breakthrough   Continuous pain is always there—steady       Treat it w...
W.H.O. RECOMMENDS USING BOTH LONG    AND SHORT-ACTING PAIN MEDICATIONS   Start with short-acting or IR pain meds.     Ex...
WORLD HEALTH ORGANIZATION              RECOMMENDATIONSTreat Cancer Pain  By   the   MOUTH  By    CLOCK,        the   not...
Pain Assessment**Accept pt’s c/o pain   History of pain   Non-Verbal signs   Patient-Centered Goals   Psychological im...
Pain Assessment         Onset/Activity         Other symptoms         Site(s) (point to it)         Intensity (use app...
Medication History   Current regimen?     Effective?     Side   Effects?   Past regimen?
The Checklist of Non-Verbal Pain Indicators    Measures:•Vocal Complaints (moaning, crying)•Facial Grimaces and Winces•Bra...
Physical Exam                   Examine site                   Consider disease                    process/progression  ...
COMMUNICATION TOOLS    (w/physician, family, team, LTC staff)       BackgroundB                            SituationA   ...
Factors influencing pain perception   Physical   Psycho-social   Emotional   Spiritual   Financial   Cultural (Caref...
ADDICTION is characterized by:                  Using a drug for                   psychic benefits                  Com...
Tolerance   Dose loses effectiveness over time   End-of-Dose failure occurs first   Then pain relief becomes inadequate...
DEPENDENCEA state of neuro-adaptation that develops with repeated opioid use.   If drug is stopped or    decreased abrupt...
Pseudo-Addiction   Iatrogenic   Due to inadequate treatment of pain   Patient behaves as though addicted—    problems d...
Pain Syndromes   Cancer Pain (poss. associated with tumor, tx,.    or unrelated)   HIV pain (poss. associated with virus...
Side Effects   Aspirin /NSAIDS      GI                          distress/bleeding/ulcers                         Renal ...
Acetaminophen (Tylenol)   Hepato-toxic at large doses   Dose limited to 4g/day (lower for    alcoholics, AIDS pts., thos...
Opioids (morphine, dilaudid, oxycodone, codeine)   Side effects (tolerance 3 day)     Sedation     Nausea (due 2 ctz,  ...
With Opioids, expect physical dependence         To avoid withdrawal symptoms, taper dose         Taper by about 25% eve...
Adverse Effects--Morphine                 Active metabolites may                  cause myoclonus +                  hype...
Respiratory Depression   Mechanism—Opioids render CO2 receptors    gradually less sensitive to CO2 levels   Very rare, e...
Drugs to Avoid   Demerol (meperidine)—should NOT be used    for cancer pain, due to poor oral bio-availability    and lon...
ADJUVANT PAIN MEDICINESAnti-Convulsants—Used to treat nerve pain (lancinating,  paroxysmal)  carbamazepine (Tegretol)  gab...
ADJUVANT PAIN MEDICINESLocal Anesthetics — for    neuropathic pain (post-herpetic    neuralgia)    Can give topically (Lid...
ADJUVANT PAIN MEDICINES --CORTICOSTEROIDS dexamethasone (Decadron)   Anti-inflammatory effect   Given for pain caused b...
Delivery Route                Oral/SL is preferred                Rectal useful w/N/V                SQ or IV infusion,...
More Delivery Routes   Trans-mucosal (fentanyl    pops)   Trans-dermal (not the    same as topical)(delayed    onset 12-...
Equi-Analgesic Conversions1.   Charts are considered estimates —good way     to determine starting dose2.   Titration is b...
Sample Equianalgesic Chart      Drug      Dose (mg.)   Dose(mg.)   Duration                Parenteral     Oral      (hours...
Titrating Opioids            Make dose increases at peak             effect. (see if current dose in             effectiv...
TITRATION   Based on     Pt.Goals (wants to be awake/aware, or to sleep)     Pain intensity (would rather deal with mil...
Method of Titrating1.   Add total 24 hour dose (LA     + Break thru)2.   Increase by 50% if initial     dose not effective...
LONG-ACTING + BREAKTHROUGH   Long-acting medicine covers baseline pain   P.R.N. dose covers breakthrough pain   May giv...
Calculating a Long Acting DoseExample:  Mrs. Bernardo takes Percocet 5/325 mg. 2 tabs q 6  hrs.             =8 tabs in 24 ...
Breakthrough Dose   A breakthrough dose is ALWAYS ordered with    long-acting opioids.   It’s best to match the long-act...
Calculating Breakthrough Dosing         (aka ―rescue dosing‖, ―supplemental dosing‖)   Breakthrough dose + 1/10 to 1/6 of...
Example   A patient is taking 120    mg. of MS Contin q12h.   That’s 240 mg/24h   1/10 of 240 = 24 mg.   1/6 of 240 = ...
If Reducing Opioid Dose        Do a gradual taper to avoid         ―abstinence syndrome‖ or         withdrawal symptoms  ...
For patients with intractable (refractory)pain and suffering at the end             Palliative sedation is an option     ...
ADJUVANT PAIN MEDICINES—non-painmeds. w/analgesic effects on certain types of painTricyclic Anti-depressants     Used   t...
Other Adjuvants   SSRI’s—Fluoxetine,    Venlafaxine, Paraxetine, etc.   Anti-Convulsants—    Gabapentin (Neurontin),    ...
Other Adjuvants   Local Anesthetics     Lidocaine, Mexiletine (Mexitil)     Local action w/minimal systemic side effect...
Other Adjuvants   Corticosteroids     Dexamethasone   #1     Prednisone, Methylprednislone   Analgesic mechanism unkno...
Special Populations   Geriatric ( metabolism, renal funct., GIB Risk)   Pediatric (develop. level, believe report, calc....
Non-Pharmacological Techniques                   Repositioning/Bracing                   Relaxation/Distraction         ...
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Sg chpn review week 2.pain

  1. 1. CLINICAL REVIEW FOR THE GENERALIST HOSPICE & PALLIATIVE NURSEWEEK 2 Pain Management
  2. 2. Objectives1. Describe the prevalence of pain in the hospice and P.C. setting2. Recognize the impact of pain on pts./families/and the healthcare system3. Identify common barriers to effective pain management.4. Define types of pain experienced by pts.5. State principles of effective pain mgmt.6. I.D. the components of a thorough pain assessment7. Demonstrate the ability to do equi-analgesic conversions
  3. 3. Definition of Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (APS)
  4. 4. Pain is SUBJECTIVE―Pain is whatever the person says it is, experienced whenever they say they are experiencing it.‖ (McCaffery &Passero, 1999).
  5. 5. Self-Report is the most valid measure of pain.
  6. 6. Under-treatment of Pain 70-90% of pts. w/ advanced disease have pain 50% of hospitalized pts. experience pain 80% of pts. In LTC experience pain  Only 40-50% of them are given analgesics Pain scores > or = 5 (on a 1- 10 scale) greatly impact QOL
  7. 7. It’s Estimated That— 98-99% of all pain could be controlled, using current tools and knowledge. The other 1-2% could be offered palliative sedation with good results.
  8. 8. Ethical Considerations Patient rights—to good pain management Joint Commission/ANA value pain relief Double Effect—ethical if dose is needed to treat pain, and that effect is the intended one. Nurses have a duty to relieve pain & suffering
  9. 9. Palliative SedationIs given with the intent to relieve refractory suffering(physical, psychological, or spiritual). It is NOT―euthanasia‖ or ―assisted suicide‖.
  10. 10. Uncontrolled Pain Impacts  Physical  Psychosocial  Emotional  Financial  Spiritual Elements of a person
  11. 11. Costs of Poor Pain Management 40 million Dr. visits/yr. for pain 25% of all lost work days are due to pain Costs $100 Billion/yr. Chronic pain is our most expensive health problem
  12. 12. Pain Co-Morbidities Depression Anxiety Diabetes Chronic Fatigue Syndrome
  13. 13. Pain is Multi-Dimensional Each member of the IDT can address it  Nurse  Aide  Physician  Chaplain  SW  Volunteer
  14. 14. Patients’ attitudes are sometimesbarriers to good pain management Fear of addiction Good patients don’t complain Fear of side effects Afraid to use strong pain medicines too soon
  15. 15. Another Barrier: Clinicians Attitudes  Doubt patients’ reports of pain  Fear of causing resp. depression  Confusion: addiction /dependence/ tolerance  Belief opioids shorten life
  16. 16. Institutional Barriers• Low Priority• Poor reimbursement• Restrictive regulations• Availability/Access to treatment
  17. 17. Types of Pain Acute—short-term, observable, signs (MI, appendicitis, surgery, toothache, labor pains), accompanied by physiological signs Chronic—long-lasting, no purpose, often no observable signs (arthritis, chronic back pain, diabetic neuropathy)
  18. 18. Types of Pain (continued) Nociceptive—arises from stim. of nerves in skin, soft tissue, or viscera.  Somatic—musculo-skeletal (ex. sprain, bone mets) (well-localized)  Visceral—involving internal organs+ structures (ex. SBO, liver capsule pain, menstrual cramps) (NOT well-localized-radiates or refers) Neuropathic—results from actual injury to nerves (―sharp, shooting, burning‖—ex. Phantom limb pain, sciatica, shingles)
  19. 19. Types of Pain Mixed Nociceptive/Neuropathic—common in life-threatening illnesses (chronic low back pain, cancer pain) Referred pain—usually visceral pain referred to skin, bone, muscle (ex. Gall bladder or liver pain referred to R. shoulder, pancreas or stomach pain referred to back)
  20. 20. How does it Feel? “aching/thro bbing” Which type of pain is it? “dull/sore” “It hurts right here” “Burning” “Cramps” “Numbness/Tingling” “Pressure” “Shooting/Stabbing” “Deep, squeezing” “Pins and Needles” “Around this area-it“Radiating/Electrical” radiates”
  21. 21. How to treat each type Somatic—Non-opioids, opioids Visceral—non-opioids, opioids Neuropathic—adjuvants (anti-dep., anti-convulsants, steroids, NMDA antag. etc.)
  22. 22. NMDA Receptor Antagonists  Work well for nerve pain  Also used in veterinary medicine
  23. 23. APS—12 Principles of Pain Mgmt.1. Individualize dose, route, + schedule2. ATC dosing3. Selection of opioids4. Adequate dosing for infants/children5. Follow pts. closely (do not stereotype)6. Use equi-analgesic dosing
  24. 24. APS—12 Principles of Pain Management7. Recognize and treat side effects (constip.!!)8. Be aware of hazards of mixed agonist- antagonists and Demerol9. Watch for development of tolerance (use combo., switch to ½ equi-analgesic dose)10. Be aware of physical dependence11. Do not label a patient addicted (if tol./dep.)12. Be aware of psychological state (anxiety, dep. may co-exist. Treat pain 1st)
  25. 25. W.H.O. PAIN LADDER
  26. 26. W.H.O. Recommendations START LOW—GO SLOW with dosing Preference for routes is:  #1 PO  #2 Transdermal  #3 IV or SQ•Prevent and treat side effects—constipation and nausea
  27. 27. W.H.O. RECOMMENDS Immediate-release meds. for Breakthrough Continuous pain is always there—steady  Treat it with long-acting meds. Breakthrough pain is one of 3 types  End-of Dose Failure (pain prior to next dose)  Incident-Related (dressing changes, coughing)  Idiopathic (unknown cause) Treat it with immediate-release meds.
  28. 28. W.H.O. RECOMMENDS USING BOTH LONG AND SHORT-ACTING PAIN MEDICATIONS Start with short-acting or IR pain meds.  Example: Percocet, codeine, morphine IR, oxycodone IR. These are dosed every 3-4 hours.  Once pain relief is achieved for 24-48 hours with stable dose of short-acting pain meds., calculate the total mg. taken in 24 hours, and convert to a long- acting formulation. (LABELLED SA, SR, LA, CR, Contin)
  29. 29. WORLD HEALTH ORGANIZATION RECOMMENDATIONSTreat Cancer Pain  By the MOUTH  By CLOCK, the not prn  By the LADDER
  30. 30. Pain Assessment**Accept pt’s c/o pain History of pain Non-Verbal signs Patient-Centered Goals Psychological impact Diagnostic workup Effectiveness + side effects of medication
  31. 31. Pain Assessment  Onset/Activity  Other symptoms  Site(s) (point to it)  Intensity (use appropriate scale)  Quality (sharp, shooting, etc.)  Duration  Exacerbating/Relieving factors  At rest/With movement  Effects on QOL (―What can’t you do?‖)
  32. 32. Medication History Current regimen?  Effective?  Side Effects? Past regimen?
  33. 33. The Checklist of Non-Verbal Pain Indicators Measures:•Vocal Complaints (moaning, crying)•Facial Grimaces and Winces•Bracing During Movement•Restlessness•Rubbing•Verbal Complaints (―Ouch‖ ―That hurts‖) *** Observations are made at rest AND with movement.
  34. 34. Physical Exam  Examine site  Consider disease process/progression  Consider referral sites  Consider  Culture  Age  Gender  Environment
  35. 35. COMMUNICATION TOOLS (w/physician, family, team, LTC staff)  BackgroundB SituationA  Assessment Symptoms/Situation BackgroundS I  Interpretation AssessmentC  Communication RecommendationS  Successful outcome
  36. 36. Factors influencing pain perception Physical Psycho-social Emotional Spiritual Financial Cultural (Careful not to stereotype)
  37. 37. ADDICTION is characterized by:  Using a drug for psychic benefits  Compulsive behavior to acquire the drug  Continued use despite harm
  38. 38. Tolerance Dose loses effectiveness over time End-of-Dose failure occurs first Then pain relief becomes inadequate Titrate dose up to effectiveness or rotate opioid (incomplete cross-tolerance)
  39. 39. DEPENDENCEA state of neuro-adaptation that develops with repeated opioid use. If drug is stopped or decreased abruptly, pt. will have withdrawal symptoms. Taper drug to avoid this.
  40. 40. Pseudo-Addiction Iatrogenic Due to inadequate treatment of pain Patient behaves as though addicted— problems disappear when dose is increased
  41. 41. Pain Syndromes Cancer Pain (poss. associated with tumor, tx,. or unrelated) HIV pain (poss. associated with virus, tx., or unrelated) Sickle cell disease pain (due to vascular- occlusive episodes) MS pain (neuralgia-follows nerve path, dysthesias-abnormal sense of touch,‖pain‖) Post-CVA pain (often delayed for several years after stroke—hyperalgesia, allodynia)
  42. 42. Side Effects Aspirin /NSAIDS  GI distress/bleeding/ulcers  Renal insufficiency  Bleeding/anti-platelet  Hypersensitivity rxns.  CNS effects (dizziness, tinnitus)  Dose limit (―analgesic ceiling‖)
  43. 43. Acetaminophen (Tylenol) Hepato-toxic at large doses Dose limited to 4g/day (lower for alcoholics, AIDS pts., those w/liver disease Look out for ―hidden doses‖. Why? Combos. have limited use. Why?
  44. 44. Opioids (morphine, dilaudid, oxycodone, codeine) Side effects (tolerance 3 day)  Sedation  Nausea (due 2 ctz, GI motil., effect on inner ear)  Dizziness, dysphoria  Pruritis (often on face/neck/chest only), urticaria  Respiratory depression (only after sedation)  Side effects may be reported as ―allergies‖ The hand that orders an opioid and does NOT order a laxative, is the  **Constipation (treat proactively! hand that does the dis-impaction! NO Tolerance)
  45. 45. With Opioids, expect physical dependence  To avoid withdrawal symptoms, taper dose  Taper by about 25% every 2 -3 days  Ex.: A patient is ready to start tapering off her Vicodin tabs after surgery. She now takes 2 tabs q 6 hours (8 tablets per day). Option A: Rapid taper (duration 10 days) Option B: Slow taper 1 tab every 6 hrs x 1 day (4/day), then… (duration 3 weeks) 1 tab every 8 hrs x 3 days (3/day), then… •Reduce by 1 tablet/ day q 3 1 tab every 12 hrs x 3 days (2/day), then… days until off 1 tab every daily x 3 days (1/day), then… Discontinue
  46. 46. Adverse Effects--Morphine  Active metabolites may cause myoclonus + hyperexcitability, esp. in the elderly and w/low renal function  Dilaudid, hydromorphone may be safer choices
  47. 47. Respiratory Depression Mechanism—Opioids render CO2 receptors gradually less sensitive to CO2 levels Very rare, especially when doses are titrated up in appropriate steps— START LOW—GO SLOW Pt. at risk—opioid-naïve and taking other sedating drugs at the same time True respiratory depression can be treated w/dilute naloxone/narcan—also reverses analgesia!
  48. 48. Drugs to Avoid Demerol (meperidine)—should NOT be used for cancer pain, due to poor oral bio-availability and long-lived excitatory metabolite Propoxyphene—(Darvon, Darvocet)—Not recommended for long-term use or use in the elderly, due to long-lived toxic metabolites, ineffective analgesic action, and large amt. of acetaminophen.
  49. 49. ADJUVANT PAIN MEDICINESAnti-Convulsants—Used to treat nerve pain (lancinating, paroxysmal) carbamazepine (Tegretol) gabapentin (Neurontin) phenytoin (Dilantin) valproic Acid (Depakote)
  50. 50. ADJUVANT PAIN MEDICINESLocal Anesthetics — for neuropathic pain (post-herpetic neuralgia) Can give topically (Lidoderm Patch, EMLA cream) or by spinal route—epidural or intrathecal (lidocaine, marcaine) Muscle relaxer  Baclofen
  51. 51. ADJUVANT PAIN MEDICINES --CORTICOSTEROIDS dexamethasone (Decadron)  Anti-inflammatory effect  Given for pain caused by swelling or bone pain  Side Effects  Increased appetite  Improved mood  Increased energy (or insomnia)* Recommended for bone pain, liver capsule pain)
  52. 52. Delivery Route  Oral/SL is preferred  Rectal useful w/N/V  SQ or IV infusion, useful for rapid titration  IM injections not recommended— pain, unreliable absorption
  53. 53. More Delivery Routes Trans-mucosal (fentanyl pops) Trans-dermal (not the same as topical)(delayed onset 12-24 h, not good for all pts.—why not?) Spinal (intrathecal or epidural) expensive—use for carefully selected pts.
  54. 54. Equi-Analgesic Conversions1. Charts are considered estimates —good way to determine starting dose2. Titration is best way to dose (based on pt. goals, breakthru, pain intensity, side-effects, function, QOL)3. Start with 100% dose listed for ―severe pain‖ ( 20-50% in the elderly). 50% for moderate. 25% for mild.
  55. 55. Sample Equianalgesic Chart Drug Dose (mg.) Dose(mg.) Duration Parenteral Oral (hours)Morphine (IR) 5 15 3-4Hydromorphone 1.5 4 3-4(Dilaudid)Oxycodone ____ 10 8-12(Long-Acting)
  56. 56. Titrating Opioids  Make dose increases at peak effect. (see if current dose in effective)  Give the smallest dose that gives the greatest relief with the fewest side-effects.  Titrate in increments of 25% to 100%
  57. 57. TITRATION Based on  Pt.Goals (wants to be awake/aware, or to sleep)  Pain intensity (would rather deal with mild pain)  Severity of side effects (constipation or nausea)  Functional status (driving? working?)  Sleep  QOL—as reported by pt. and family
  58. 58. Method of Titrating1. Add total 24 hour dose (LA + Break thru)2. Increase by 50% if initial dose not effective.3. Divide by dose interval (if q 12 hrs., divide 24 hour dose by 2)4. Provide appropriate breakthru dosing
  59. 59. LONG-ACTING + BREAKTHROUGH Long-acting medicine covers baseline pain P.R.N. dose covers breakthrough pain May give together, if needed. [just like insulin]
  60. 60. Calculating a Long Acting DoseExample: Mrs. Bernardo takes Percocet 5/325 mg. 2 tabs q 6 hrs. =8 tabs in 24 hours =40 mg. Oxycodone in 24 hours =20 mg. Oxycontin BID = or 40 mg. Kadian or Avinza q 24 hoursAdvantage: Steady pain relief, and pt. Is able to sleep for 8 hours and not wake up in pain.
  61. 61. Breakthrough Dose A breakthrough dose is ALWAYS ordered with long-acting opioids. It’s best to match the long-acting with the short-acting (e.g. MS contin w/MSIR). Only ONE breakthrough med should be ordered. If >3 breakthrough doses are used in 24h (or pt. wakes up + needs a nighttime dose), increase the baseline long-acting dose.
  62. 62. Calculating Breakthrough Dosing (aka ―rescue dosing‖, ―supplemental dosing‖) Breakthrough dose + 1/10 to 1/6 of the 24h dose (so divide 24 hr. dose by 10 or 6) Give breakthrough dose q1-2h prn May give ATC + breakthru dose together If pt. on opioid inf., BT dose is 25-50% of hourly dose q 30 mins. Remember to increase BT dose when ATC dose increases
  63. 63. Example A patient is taking 120 mg. of MS Contin q12h. That’s 240 mg/24h 1/10 of 240 = 24 mg. 1/6 of 240 = 40 mg. Appropriate dose would be 30 mg. q1-2h prn
  64. 64. If Reducing Opioid Dose  Do a gradual taper to avoid ―abstinence syndrome‖ or withdrawal symptoms  If switching from IV to PO or vice versa, keep in mind the “first pass effect”– Gut filters out 2/3 of opioids given by mouth. So multiply IV dose by 3 to get PO. Divide PO dose by 3 to get IV.
  65. 65. For patients with intractable (refractory)pain and suffering at the end  Palliative sedation is an option  Opioids  Barbiturates  Neuroleptics(Haldol, Thorazine, etc.)  Benzodiazepines  IV Ketamine
  66. 66. ADJUVANT PAIN MEDICINES—non-painmeds. w/analgesic effects on certain types of painTricyclic Anti-depressants  Used to treat nerve pain (up to 1 wk.’ til effect)  Inhibits neurotransmitters  Ex. amitriptyline (Elavil) nortriptyline (Pamelor) SIDE EFFECTS  These can be sedating—give at HS  Orthostatic Hypotension  Anti-cholinergic—dry mouth, constipation
  67. 67. Other Adjuvants SSRI’s—Fluoxetine, Venlafaxine, Paraxetine, etc. Anti-Convulsants— Gabapentin (Neurontin), Carbamazepine (Tegretol)  1st line drugs for chronic, lancinating, neuropathic pain  Works by lessening conduction of pain signals along nerve fibers (same mechanism as anti-seizure action.)
  68. 68. Other Adjuvants Local Anesthetics  Lidocaine, Mexiletine (Mexitil)  Local action w/minimal systemic side effects  Avoid use in pts. w/cardiac dyrhythmias Psychostimulants  Caffeine (P.O.), Dextramphetamine, Methylphenidate  Side effects: insomnia, anorexia, anxiety, agitation
  69. 69. Other Adjuvants Corticosteroids  Dexamethasone #1  Prednisone, Methylprednislone Analgesic mechanism unknown Multi-purpose  appetite  mood/energy Long-term side effects: blood sugar, bone loss, cushing’s, HTN, edema, immuno- supression
  70. 70. Special Populations Geriatric ( metabolism, renal funct., GIB Risk) Pediatric (develop. level, believe report, calc. dose by wt., learn child’s words for pain) Dying (pain is a priority, pall. sedation if needed) Cognitively Impaired (hi-risk 4 under treatment of pain, 0-5 scale, learn pain behaviors) Veterans (stoicism, pain=weakness, use interdiscipl. approach)
  71. 71. Non-Pharmacological Techniques  Repositioning/Bracing  Relaxation/Distraction  Exercise  Guided Imagery  Massage  Heat/Cold

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