Supported by evidence-based data, this webinar helped physicians and healthcare professionals gain greater understanding of the multifaceted applications of pain management in the context of palliative hospice care.

1. Understanding Pain Management and
Daily Practice Management
Agron Ismaili MD | Regional Medical Director
VITAS®
Healthcare | agron.ismaili@vitas.com

2. CME Provider Information
Satisfactory Completion
Learners must complete an evaluation form to receive a certificate of completion. You must participate
in the entire activity as partial credit is not available. If you are seeking continuing education credit for
a specialty not listed below, it is your responsibility to contact your licensing/certification board to
determine course eligibility for your licensing/certification requirement.
Physicians
In support of improving patient care, this activity has been planned and implemented by Amedco LLC and
VITAS®
Healthcare. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical
Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses
Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit Designation
Statement – Amedco LLC designates this live activity for a maximum of 1 AMA PRA Category 1 CreditTM.
Physicians should claim only the credit commensurate with the extent of their participation in the activity.

3. CE Provider Information
VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through:
VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved By: Florida Board of Nursing/Florida Board
of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling.
VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists through:
VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number: 139000207/RT
CE Provider Number: 195000028/Approved By the Illinois Division of Profession Regulation for: Licensed Nursing Home Administrators
and Illinois Respiratory Care Practitioner.
VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB)
Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and
provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing
education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2021 – 06/06/2024.
Social workers completing this course receive 1.0 ethics continuing education credits.
VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board
of Registered Nursing, Provider Number 10517, expiring 01/31/2023.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH:
No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois.

4. Objective
• Describe, define, and differentiate
aspects of pain:
– Acute vs. chronic, nociceptive,
nociplastic, neuropathic
• Discuss the importance of identifying pain:
– Receptor sensing
– Mechanism of transmission
– Complex interaction of the elements
of the peripheral and central
nervous systems
• Enhance assessment and management
of both medication and non-medication
measures used to treat total pain
After this presentation, learners should be able to:

5. Goal
• To achieve an appropriate understanding of pain
management’s multifaceted applications in the
context of palliative and hospice care

6. Pain Definition
• An unpleasant sensory and emotional experience
associated with actual or potential tissue damage
Merskey, H. et al. (1979). Pain terms: a list with definitions and notes on usage.
Recommended by the IASP Subcommittee on Taxonomy. Pain, 6, 249-252.

7. Acute vs. Chronic Pain (Practice, Reality)
• Acute pain is the most common reason
for ED visits
• Chronic pain comprises around 20%
of physician office visits
• $60 billion/year in lost productivity
Zelaya, et al. (2020). Chronic Pain and High-impact Chronic Pain Among U.S. Adults, 2019. NCHS Data Brief No. 390. Available at:
https://www.cdc.gov/nchs/products/databriefs/db390.htm
Stewart, et al. (2003). Lost Productive Time and Cost Due to Common Pain Conditions in the US workforce. JAMA, 290(18), 2443-54.
Van den Beuken-van Everdingen, et al. (2007). Prevalence of Pain in Patients With Cancer: A Systematic Review of the Past 40 Years. Annals of Oncology, 18(9), 1437-1449.

8. The Importance of Goals of Care
• Patients’ values are honored
• Symptoms are attended to
quickly and effectively
• Patient and family maintain
control of treatment plan
• Poorly defined goals can lead to:
– Unwanted treatments
– Inappropriate use of resources
– Undue suffering
– Miscommunication
• Emergency clinicians establish
GOC with patients daily
• Any team member can
assess GOC

9. Pain in response to
an injury or stimuli;
typically acute
Nocioplastic Pain that arises from
nocioceptive function,
typically chronic
Neuropathic Pain that develops
when nervous symptom
is damaged
Fibromyalgia, irritable bowl
syndrome, non-specific
low back pain
Post-operative pain, sports
injuries, arthritis, sickle cell
disease, mechanical low
back pain
Post-herpetic neuralgia,
trigeneuralgia, distal
polyneuropathy, CRPS,
neuropathic low back pain
Nociceptive Pain
Types of Pain

10. Acute and Chronic Pain
• Acute pain:
– Usually hours to weeks, most likely responsive
to multimodal therapies
– Noted physiological changes and notable
pain behaviors
• Chronic pain:
– > 3 months (persistent with long-term conditions,
can be expressed as anxiety, depression, irritability;
may not respond easily to drug therapies; essentially
correlates with function)
Source for Acute/chronic pain statistics (FSMB USA Model guidelines for the use of controlled
substances for the treatment of pain, Euless, TX 1998 source 1/2/3.

11. Nociceptive, Nocioplastic, and Neuropathic Pain
• Nociceptive:
– Bone (aching, gnawing, localized)
– Visceral (cramping, regionally
localized or referred)
– Somatic (easy to localize and describe)
• Nocioplastic:
– Central SENSITIZATION
– Increased response to stimulation
mediated by amplification of
CNS (e.g., fibromyalgia, chronic
back pain, etc.)
• Neuropathic:
– Damage or injury to the nerves
that transfer information between
the brain and spinal cord from
the skin, muscles, and other parts
of the body
– Burning sensation, and affected
areas are often sensitive to
the touch
Federation of State Medical Boards of the United States, Inc. (2005). Model Policy for the Use of Controlled
Substances for the Treatment of Pain. Journal of Pain & Palliative Care Pharmacotherapy, 19(2), 73-8.

12. Prevalence in Older Adults, Barriers
• Pain is in patients with and without cancer
• Present in 75% institutionalized and
50% community elderly
• About 25% of elderly do not receive
adequate analgesiaBarriers
• Patient
• Prescribers
• Pharmacy
• System
• Legal
• Common: racial, elderly, lack of
educational skills, fear of addiction, etc.
J. Med. 2007,120(4) 306-315 JAMA 1998; 279; (23)1877-1882 J.Am. Ger. Soc.,1999 47 (8) 936-942 Source 1, 2, 3

13. Integrated Pain Model
Dame Cicely Saunders devised
a new paradigm of the concept
of pain beyond the confines of
the physical body responses.
Resources 1/2/3
Total pain is
characterized as the
multidimensional nature
of the pain experience
and includes these
domains of pain:
Physical
Social
Psychological
Spiritual

14. Comprehensive Symptom Evaluation
• Symptom ascertainment (PQRST tool, etc.)
• Past medical and treatment history
(pharmacologic/non-pharmacologic,
comorbid, hx of opioid use-PDMP,
the effectiveness of treatment)
• Social, psychological, and family
history (mental health, personal and
family hx of polysubstance abuse,
cultural background, social network,
other behavioral patterns)
• Opioid Risk Assessment (identifies
persons at higher risk for SUD,
possibly necessitates additional
monitoring; ># high risk, mitigation,
misuse, abuse, diversion, periodic UDS)
• Physical exam and assessment
(integrates hx with observation
for corroboration of symptoms)
• Pharmacologic and non-pharmacologic
management plan
Resources 1/2/3

15. Pain Physiology Half-Life
• An important aspect in the management
of pain issues to determine dosage
times by knowing how long the drug
will continue to do its job
• What is it?
– How much time it takes for blood
levels of a drug to decrease to half
of what they were when the drug
was at peak performance in the body
Resources 1/2/3

16. Pain Management Goals
• Optimize patient comfort
• Enhance FUNCTION, physical
well-being, psychological well-being,
spiritual well-being
• Minimize side effects
• Enhance quality of life
Resource: 1/2/3

17. Role and Importance of Hospice IDT in Pain Management
• Paint the picture, narrative subjective process, REASSESSMENT is very important
• VITAS for many years has been the leader in effective pain management for patients
with terminal diseases
• Teamwork is vital for effective pain management
• We as members of IDT have a responsibility to manage pain:
Resource: 1/2/3
Team
manager
Nurse Hospice
aide
Chaplain Team
physician
Volunteer

18. Pain Assessment
Tolerance Physiologic phenomenon
resulting from regular use of a drug
in which increased use is needed
to produce same effect
• Common concern but
uncommon phenomenon
• E.g., N/V/fatigue (with opioids),
developing tolerance leading
to diminished side effects
• ATTENTION: Tolerance does not
develop for opioid constipation
• Managing opioid tolerance
• Rotation (uncontrolled pain, neurotoxicity)
Physiologic Dependence
• Adaption manifested by drug class specific
WITHDRAWAL syndrome –after abrupt
cessation, rapid dose reduction, decreased
blood levels, administration of antagonist;
common after 1-2 weeks of continuous
weeks of use. Treatment: reintroduction
of opioid, clonidine, BZD, Imodium
Resources 1/2/3

19. Pain Assessment (cont.)
• Addiction: Impaired control, compulsive use, continued
use despite harm, cravings
• Pseudo-addiction: Inadequate pain management,
disease progression, can creates mistrust with patient?
inadequate prescriptions
• Pain is a subjective process, narrative story; validate
the experience
Resources 1/2/3

20. Opioid Therapy: Pharmacology Morphine
• Most frequent indications in the
daily practice:
– Pain/dyspnea/cough/
anesthesia, diarrhea
• Few important steps in the
mechanism of action:
– Bind to opioid receptors, activate
descending inhibitory pathway,
prevent neurotransmitter release,
reduce formation of action potentials
• Receptors:
– Mu: brain stem, medical
thalamus, peripheral
– Mu1-analgesia
– Mu2-analgesia GI tract,
respiratory depression, pruritus
– Kappa:
• Limbic system, brain stem, spinal cord,
spinal analgesia, sedation, dysphoria
• Delta: brain, periphery spinal analgesia,
decreased GI motility, respiratory depression
Resources 1/2/3

21. Morphine
• Opioid-like receptor (ORL-1):
Affects stress, feeding, learning,
memory, opioid tolerance
• Sigma: It is not considered true
opioid receptor, potential for psych
mimetic effects, dysphoria
• DEA class II
• Strong MU and weak kappa and
delta; metabolized in the liver,
excreted by kidneys
• Morphine-3-glucuronide and
morphine-6-glucuronide toxicity
concerns; generally not used
in patients with end-stage
renal disease
• Management of side effects
• Forms: Injectable, oral, rectal
Resources 1/2/3

22. Pharmacology of Specific Drugs
• Oxycodone: agonist MU/Kappa,
metabolized with conjugation
in the liver by CYP 450 to active/
inactive metabolites
• ATTENTION: Prolonged elimination
in renal impairment/failure
• It is combined with
acetaminophen/aspirin
• Hydromorphone
• Main mechanisms
• Mu agonist
• Hepatic metabolism via
glucouronidation to
Hydromorphone 3G;
excreted by kidneys
Resources 1/2/3

23. Pharmacology of Specific Drugs (cont.)
• Fentanyl
– MU agonist
• Has lipophilic effect
• Hepatic metabolism to inactive
metabolites-not dialyzed
• ATTENTION: reduce dose in
severe renal impairment
• Oxymorphone preparation IR/ER
• ATTENTION: can take 2 hours
before or after as taking with
meals can increase serum levels
Resources 1/2/3

24. Pharmacology of Specific Drugs (cont.)
Hydrocodone
• Derived from codeine
• Can be combined with acetaminophen; DEA II
Buprenorphine
• MU partial agonist (high affinity, low potency),
Kappa antagonist, lipophilic, first-pass metabolism,
CYP 450, may cause QT prolongation; MAT
(medication-assisted treatment-use in opioid use
disorder; low ceiling effect; high doses lead to the
same level of analgesia with more side effects)
• Option for patient use with serious illness and opioids
use disorder (used with or without naloxone)
Resources 1/2/3

25. Pharmacology
Tramadol Weak opiate agonist;
SNRI effect like; CAUTION with SSRI
use (can cause serotonin syndrome)
MU agonist inhibits 5-HT/NE reuptake
(similar to SNRI); NMDA antagonist;
can use in treatment of neuropathic
pain-central pain, opioid induced
hyperalgesia
METHADONE Synthetic DEA II;
for pain any provider; for MAT needs
special license/certification
Resources 1/2/3
Methadone Pharmacology: Primary
hepatic with some renal clearance;
no active metabolites (IT IS
CONSIDERED safe in renal impairment)
• Takes time to build stores; Analgesic
half life 9-59h
• Special CAUTION in elderly, rapid
dose titration; HIGHLY VARIABLE
RESPONSE RATES; CYP450
inhibitor, drug-drug interactions,
PROLONG QT, not a good choice
for rapid titration

26. Dosing and Management
• Choosing an opioid:
– ATTENTION: Review specific
patient/diseases characteristics-
ASSESSMENT
• Short- vs long-acting
– Short-acting: Intermittent/
breakthrough/incident
dose frequency per time
to peak effect
– Long-acting: Continuous pain
• Converting short-acting
to long-acting
– Assess and and determine
total daily dose of opioid
– Convert to oral morphine
equivalents (MME) adjust and
individualize new dosing;
follow up in no more than
1 week
Resources 1/2/3

27. Management / Side Effects Specifics
• Opioid rotation:
– Dose-limiting side effects change in route
CAUTIOUS OPIOID NAÏVE start low dose
and individualize
• APPRORIATE DOSING
– reduces side effects; balances between
side effects, rotations, multiple barriers etc.

28. Management / Side Effects Specifics
Adverse effects:
Sedation (often tolerance,
modulate dose, non-opioid
options, rotations, psychostimulants)
Respiratory Depression brain
system MU receptors activation,
sedation occurs first pruritus
(dose limiting, NOT TRUE
hypersensitivity-tx MU antagonist,
naloxone antihistamine,
rotations, naloxone)
Concomitant use of benzodiazepines
anticholinergics, Neurontin, alcohol,
sleeping medicines, and muscle relaxants
is dangerous for respiratory depression
Nausea/vomiting (GI slowing
CTZ, vestibular; tolerance
in 3-7 days; antiemetics, rotations)
Tolerance anticipate constipation,
schedule methylnaltrexone,
laxative, etc.

29. Opioid Management
• Opioid selection variables:
medication, patient, EBM
• Initiation considerations:
Opioid Naïve, half-life
• IR forms: Mild/moderate pain
increase 25-50%
– Severe/uncontrolled increase
by 50-100%, dose frequency
per time to peak effect
• Re-ASSESSMENT FREQUENT and
important (side effects, function,
dose adjustments, temporal pattern
• ER forms: Total of IR /daily dose
(adjust for severity)
– E.g., Oxycodone
5 mg po x 4 doses/d=20 mg;
50-75% of above and convert
to long-acting oxycodone
CR 5 mg po bid
Resources 1/2/3

30. • Fentanyl transdermal; not effective
for acute pain; lasts 48-72hrs, depending
on patient metabolism; direct heat can
increase drug absorption, still distributed
after patch removed; 70% bound to
albumin, so hypoalbuminemia decreases
plasma levels (EOL frequently low albumin).
Must be opioid tolerant to initiate this therapy.
VITAS pharmacy can help manage these
medications for patients on VITAS service.
• Extended-release forms: improve
adherence, CANNOT CRUSH or chew
• Fentanyl transdermal every 48h-72h
• Methadone 4-7 days
Resources 1/2/3
Opioid Management (cont.)

31. Opioid Management Challenges
• Challenges: with increasing
dose escalations-increasing
side effects
– Incomplete cross-tolerance
– Drug-receptor interactions
• Safe to reduce
equianalgesic dose
by 25-50% to compensate
Resources 1/2/3
• Exception:
– Rotating to methadone,
reduce more than
5%-90%
– In EOL care
• VERY IMPORTANT use
of VITAS Pharmacy
counselling to help
physicians/other caregivers
that prescribe pain meds,
in managing complexities
of pain. VITAS pharmacist
significant assist in patient-
centric and safe care.

32. Opioid Management (cont.)
• Sedation precedes respiratory depression
– Loading dose (initial dose administered
by RN); Bolus (demand), Lockout
10-15 min based on peak effect),
basal rate (hourly rate-not in
opioid naïve)
– Some control (alleviates anxiety,
individualized)
– Loading dose (initial dose administered
by RN); Bolus (demand), Lockout
(10-15 min based on peak effect),
basal rate (hourly rate-not in
“opioid naïve”)
• Please be aware a national shortage
of parenteral opioids exists and is
not available outside of the hospital
Resources 1/2/3
Opioid Controlled Analgesia (PCA) challenges:

33. Continue Non-Opioid Pain Management
• NSAIDS: anti-inflammatory, periphery-
acting, bind to plasma albumin, do not
cross blood brain barrier, metabolized
by the liver, low renal clearance (<10%)
• Used in bone pain, soft tissue, visceral pain
• Multiple negative side effects (GI, renal etc.)
• Steroids:
– Dexamethasone decreases
inflammation; tumor shrinkage,
anti-tumor effects, enhances
appetite weight gain, improved
sense of well being
– Side effects:
• Immunosuppression
• Psychosis
• Proximal muscle wasting
Resource: 1/2/3

34. Non-Opioid Analgesia
• Poor Drugs with additional
analgesic properties
• Some indications:
– Response to opioid, marked
predisposition to opioids,
opioids side effects to
increasing opioids dose
• Different pain syndromes
• Neuropathic pain
Resources 1/2/3
• Bone pain
• Myofascial pain
• Safe use:
– One adjuvant at a time
– Increase dose until limiting
side effects or analgesia
– Can add another analgesic
if partial analgesia and
maximal dose

35. Non-Opioid Pain Management
• Neuropathic pain
• Few meds that can be used:
– TCAs (AVOID IN GERIATRIC
populations mostly due to
ANTICHOLINERGIC effects)
– SNRI can be used: painful, neuropathy,
post mastectomy, fibromyalgia
– SSRI paroxetine painful neuropathy,
Fluoxetine (if comorbid depression),
avoid in geriatric population
Resources 1/2/3

36. Non-Opioid Pain Management
• Gabapentin can be used in neuropathic
pain, pregabalin (faster titration)
• Ketamine NMDA antagonist can
be used as neuropathic pain
• OPIOID RESISTANT EMPASIZE
role of VITAS Pharmacy
education/assistance
• OPIOID SPARRING effect (important
with worsening shortage of opioids
especially IV forms)
• Post-op pain: much lower dose
analgesic effect than anesthetic
Resources 1/2/3

37. Non-Pharmacologic Pain Management
Resources 1/2/3
• CBT (improving mental health, thoughts,
beliefs and behaviors, QOL; anxiety,
bereavement, insomnia)
• Acupuncture
• Music therapy
• Hypnotherapy
• Massage
• PT/OT
• Heat therapy:
– Increases circulation to affected tissues
– Relieves joint stiffness and muscle spasm
– Decreases sensitivity to pain
– Chronic swelling may be reduced
– Simple, easy to do, inexpensive and
possibly effective in the short-term
– Caution: prolonged use which
may lead to irritation and actual burn
of the over lying skin.

38. Liver Failure
• Liver responsible for metabolism
of most drugs through CYP450
• Opioids in the liver failure
• Oxycodone: oxymorphone by
liver, increased half life,
unpredictable levels
• Morphine: first pass metabolism
(no CYP450), less hepatic
flow-increased bioavailability
• Methadone (CYP 450),
clearance not altered
• Hydromorphone (first pass metabolism,
good choice for liver dysfunction)
• Patients frequently experience fatigue,
mental and mood disorders
• Patients, family and care providers
may experience guilt, anger, sadness,
fear, anxiety, and depressed mood
• Additionally, there are effects on
the health of care providers, family
social interactions, and finances

39. Renal Failure
• Renal Failure
• Responsible for clearance
of many pain meds;
• Accumulation (in renal failure)
can cause:
• Neurotoxicity, Hepatotoxicity
• Codeine and its metabolites
(morphine, hydrocodone) are
excreted by kidney
• M3G neurotoxic, MSG
analgesic effects
• Oxycodone can accumulate
in renal failure
• Hydromorphone/fentanyl
considered Safe
• Acetaminophen <3g/d; no
significant changes observed
in renal failure

40. Summary Ideas/Thoughts
• It is important to note that increased
social and spiritual interactions may
well have a positive influence upon
pain perception and are too often
under-used as therapy.
• Selected therapies based upon
a thorough evaluation of the
patient’s pain and ability to
tolerate additional treatments
is required of the practitioner.
• Reevaluation to assess responses
to these added therapies needs
to occur as often as reassessment
of analgesic therapy does.
• It is far too easy to simply have
tunnel vison and provide analgesia
for pain and not consider the total
pain concept, which is part of the
benefit to a team approach to
care management

41. Questions?

42. References
Hospice and Palliative Medicine Board Review-American Physician institute
Medical Knowledge
VITAS Resource Library
Merskey, H., et al. (1979). Pain terms: a list with definitions and notes on usage. Recommended by the IASP Subcommittee on
Taxonomy. Pain, 6, 249-252.
JAMA 2003, 290(18)2443-24454
National Academy Press US 1997
Annal Oncology 2007;18(9) 1437-1449
Stewart, et al. (2003). Lost Productive Time and Cost Due to Common Pain Conditions in the US workforce. JAMA, 290(18), 2443-54.
Zelaya, et al. (2020). Chronic Pain and High-impact Chronic Pain Among U.S. Adults, 2019. NCHS Data Brief No. 390. Available at:
https://www.cdc.gov/nchs/products/databriefs/db390.htm
Van den Beuken-van Everdingen, et al. (2007). Prevalence of Pain in Patients With Cancer: A Systematic Review of the Past 40 Years.
Annals of Oncology, 18(9), 1437-1449.