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 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
Definition of Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (APS)
Pain is SUBJECTIVE―Pain is whatever the person says it is, experienced whenever they say they are experiencing it.‖ (McCaffery &Passero, 1999).
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 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
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.
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
Palliative SedationIs given with the intent to relieve refractory suffering(physical, psychological, or spiritual). It is NOT―euthanasia‖ or ―assisted suicide‖.
Uncontrolled Pain Impacts Physical Psychosocial Emotional Financial Spiritual Elements of a person
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
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)
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)
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)
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”
How to treat each type Somatic—Non-opioids, opioids Visceral—non-opioids, opioids Neuropathic—adjuvants (anti-dep., anti-convulsants, steroids, NMDA antag. etc.)
NMDA Receptor Antagonists Work well for nerve pain Also used in veterinary medicine
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
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)
W.H.O. PAIN LADDER
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
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.
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)
WORLD HEALTH ORGANIZATION RECOMMENDATIONSTreat Cancer Pain By the MOUTH By CLOCK, the not prn By the LADDER
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
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?‖)
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•Bracing During Movement•Restlessness•Rubbing•Verbal Complaints (―Ouch‖ ―That hurts‖) *** Observations are made at rest AND with movement.
Factors influencing pain perception Physical Psycho-social Emotional Spiritual Financial Cultural (Careful not to stereotype)
ADDICTION is characterized by: Using a drug for psychic benefits Compulsive behavior to acquire the drug Continued use despite harm
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)
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.
Pseudo-Addiction Iatrogenic Due to inadequate treatment of pain Patient behaves as though addicted— problems disappear when dose is increased
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)
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?
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)
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
Adverse Effects--Morphine Active metabolites may cause myoclonus + hyperexcitability, esp. in the elderly and w/low renal function Dilaudid, hydromorphone may be safer choices
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!
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.
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
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)
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
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.
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.
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%
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
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
LONG-ACTING + BREAKTHROUGH Long-acting medicine covers baseline pain P.R.N. dose covers breakthrough pain May give together, if needed. [just like insulin]
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.
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.
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
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
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.
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
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
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.)
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
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
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)