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Chpn hpna ppt #2 pain management

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Pain management info for Palliative Nurses

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Chpn hpna ppt #2 pain management

  1. 1. Clinical Review for the Hospice and Palliative Nurse Pain Management
  2. 2. Objectives <ul><li>1. Describe the prevalence of pain in the hospice and palliative care setting </li></ul><ul><li>2. Recognize the impact of pain on patients, families and the healthcare system </li></ul><ul><li>3. Identify common barriers to effective pain management </li></ul>
  3. 3. Objectives <ul><li>4. Define the types of pain experienced by the hospice and palliative patient </li></ul><ul><li>5. State the principles of effective pain management </li></ul><ul><li>6 Identify the components of a thorough pain assessment </li></ul><ul><li>7. Demonstrate the ability to do equianalgesic conversions </li></ul>
  4. 4. Undertreatment of Pain <ul><li>70-90% of patients with advance disease experience pain </li></ul><ul><li>50% hospitalized patient’s experience pain </li></ul><ul><li>80% of long term care experience pain </li></ul><ul><ul><li>Only 40-50% are given analgesics </li></ul></ul><ul><li>Pain scores (on a 0-10 scale) greater than or equal to “5” greatly impact on quality of life </li></ul>
  5. 5. Impact of Poorly Controlled Pain <ul><li>Physical </li></ul><ul><li>Psychosocial </li></ul><ul><li>Emotional </li></ul><ul><li>Financial </li></ul><ul><li>Spiritual </li></ul>
  6. 6. Interdisciplinary Resources <ul><li>Pain affects multiple dimensions </li></ul><ul><li>No one discipline can address all issues </li></ul><ul><li>Strengths and talents of many disciplines </li></ul><ul><li>Address multiple institutional barriers </li></ul><ul><li>On going communication </li></ul>
  7. 7. Cost of Poor Pain Management <ul><li>$100 billion per year </li></ul><ul><li>Chronic pain is most expensive heath problem </li></ul><ul><li>40 million physician visits per year for pain </li></ul><ul><li>25% of all work days lost are due to pain </li></ul><ul><li>Improving pain management costs less than cost of inadequate relief </li></ul>
  8. 8. Pain Co-morbidities <ul><li>Depression </li></ul><ul><li>Anxiety disorder </li></ul><ul><li>Diabetes </li></ul><ul><li>Chronic fatigue syndrome </li></ul>
  9. 9. Barriers to Effective Pain Management <ul><li>Patient / family </li></ul><ul><li>Healthcare Provider </li></ul><ul><li>Institutional </li></ul>
  10. 10. Definition of Pain <ul><li>An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (APS) </li></ul>
  11. 11. Definition of Pain <ul><li>Pain is whatever the experiencing person says it is, existing whenever he/she says it does (McCaffery & Pasero, 1999) </li></ul>
  12. 12. Types of Pain <ul><li>Acute </li></ul><ul><ul><li>Accompanied by physiological </li></ul></ul><ul><li>Chronic </li></ul><ul><ul><li>Usually persist for longer than 3 months </li></ul></ul><ul><ul><li>Autonomic nervous system adapts - patient does not exhibit objective signs of pain </li></ul></ul>
  13. 13. Classification of Pain Nociceptive Pain <ul><li>The normal processing of stimuli that damages normal tissues or has the potential to do so if prolonged </li></ul><ul><li>Usually responsive to non-opioids and/or opioids </li></ul><ul><li>Stimuli from somatic or visceral structures </li></ul>
  14. 14. Types of Nociceptive Pain <ul><li>Somatic Pain </li></ul><ul><li>Bone, Joints, Muscle, Skin, Connective tissue </li></ul><ul><li>Throbbing, dull </li></ul><ul><li>Well localized </li></ul>
  15. 15. Types of Nociceptive Pain <ul><li>Visceral Pain </li></ul><ul><li>Visceral organs </li></ul><ul><li>Squeezing, cramping, pressure, deep </li></ul><ul><li>Tumor involvement of organ capsule </li></ul><ul><ul><li>Aching & well localized </li></ul></ul><ul><li>Intermittent cramping & poorly localized </li></ul>
  16. 16. Neuropathic Pain <ul><li>Abnormal processing of sensory input by central or peripheral nervous system </li></ul><ul><li>Mechanisms not as well understood </li></ul><ul><li>Burning, shooting, tingling, numbness, radiating, electrical </li></ul><ul><li>Responds to adjuvant analgesics </li></ul>
  17. 17. Neuropathic Pain <ul><li>Centrally generated pain </li></ul><ul><ul><li>Deafferentation pain </li></ul></ul><ul><ul><li>Sympathetically maintained pain </li></ul></ul><ul><li>Peripherally generated pain </li></ul><ul><ul><li>Painful polyneuropathies </li></ul></ul><ul><ul><li>Painful mononeuropathies </li></ul></ul>
  18. 18. APS 12 Principles of Pain Management <ul><li>1. Individualize dose, route and schedule </li></ul><ul><li>2. Around the clock dosing </li></ul>
  19. 19. APS 12 Principles of Pain Management <ul><li>3. Selection of opioids </li></ul><ul><li>4. Adequate dosing for infants/children </li></ul>
  20. 20. APS 12 Principles of Pain Management <ul><li>5. Follow patients closely </li></ul><ul><li>6. Use equianalgesic dosing </li></ul>
  21. 21. APS 12 Principles of Pain Management <ul><li>7. Recognize and treat side effects </li></ul>
  22. 22. APS 12 Principles of Pain Management <ul><li>8. Be aware of hazards of Demerol ® and mixed agonist-antagonists </li></ul>
  23. 23. APS 12 Principles of Pain Management <ul><li>9. Watch for development of tolerance </li></ul><ul><li>10. Be aware of physical dependence </li></ul>
  24. 24. APS 12 Principles of Pain Management <ul><li>11. Do not label a patient addicted </li></ul><ul><li>12. Be aware of psychological state </li></ul>
  25. 25. WHO Ladder Recommendations <ul><li>Portrays progression in the doses and types of analgesic drugs for effective pain relief </li></ul><ul><li>Changes as patients condition and characteristics of pain change </li></ul><ul><li>Orally whenever possible </li></ul><ul><li>“ By the clock” dosing </li></ul><ul><li>Based on assessment of the individual’s pain experience </li></ul>
  26. 26. WHO Ladder Step 1 (Mild pain) <ul><li>Mild Pain </li></ul><ul><li>1-3 on a scale of 0-10 </li></ul><ul><li>Non-opioids </li></ul><ul><li>Adjuvants </li></ul><ul><ul><li>As analgesics </li></ul></ul><ul><ul><li>To reduce side effects </li></ul></ul>
  27. 27. WHO Ladder Step 2 (Moderate pain) <ul><li>Moderate Pain </li></ul><ul><li>4-6 on a scale of 0-10 </li></ul><ul><li>Opioids in low doses </li></ul><ul><li>Non-opioids and adjuvants may be continued </li></ul>
  28. 28. WHO Ladder Step 3 (Severe pain) <ul><li>Severe Pain </li></ul><ul><li>7-10 on a scale of 0-10 </li></ul><ul><li>Add higher doses of opioids </li></ul><ul><li>Continue non-opioids and adjuvants </li></ul>
  29. 29. Pain Assessment Principles <ul><li>Accept patient’s complaint of pain </li></ul><ul><li>History of pain </li></ul><ul><li>Assessment for non-verbal patients </li></ul><ul><li>Patient centered goals </li></ul>
  30. 30. Pain Assessment Principles <ul><li>Nonverbal signs of pain </li></ul><ul><li>Psychological impact of pain </li></ul><ul><li>Diagnostic workup </li></ul><ul><li>Assess effectiveness and side effects of pain medication </li></ul>
  31. 31. Initial Pain Assessment <ul><li>Onset/duration </li></ul><ul><li>When did the pain first begin? </li></ul><ul><li>Is it associated with a particular activity </li></ul><ul><li>Other symptoms </li></ul><ul><li>Site </li></ul><ul><li>More than 75% persons with cancer have pain in 2 or more sites </li></ul><ul><li>Ask patient , “To point to the pain </li></ul><ul><li>Assess each site for pain intensity, quality, duration </li></ul>
  32. 32. Initial Pain Assessment <ul><li>Severity/intensity </li></ul><ul><li>Select pain scale appropriate to patient </li></ul><ul><li>Quality </li></ul><ul><li>Ask patient to describe their pain </li></ul><ul><li>Exacerbating/relieving factors </li></ul><ul><li>What makes the pain worse or what causes the pain? </li></ul><ul><li>Assess the pain at rest, with movement, and in relation to daily activity </li></ul><ul><li>Ask the caregivers how patient is doing with activities </li></ul>
  33. 33. Initial Pain Assessment <ul><li>Effects of pain on quality of life </li></ul><ul><li>What does the pain mean to the patient and family? </li></ul><ul><li>Does the pain keep the patient from doing activities he/she enjoys? </li></ul><ul><li>Medication history </li></ul><ul><li>Current </li></ul><ul><li>Past </li></ul><ul><li>Side effects </li></ul>
  34. 34. Initial Pain Assessment <ul><li>Physical </li></ul><ul><li>Examine site(s) of pain, including referral sites </li></ul><ul><li>Consider disease process, extent of progression </li></ul><ul><li>Cultural considerations </li></ul><ul><li>Cultural generalities and determine individual differences </li></ul><ul><li>Other factors </li></ul><ul><li>Age </li></ul><ul><li>Gender </li></ul><ul><li>Environmental </li></ul>
  35. 35. Communication <ul><li>Physician/Nurse </li></ul><ul><li>critical in providing excellent patient care </li></ul><ul><li>BASICS </li></ul><ul><ul><li>Background, Assessment, Symptoms/Situation, Interpretation, Communication, Successful outcome </li></ul></ul><ul><li>SBAR </li></ul><ul><ul><li>Situation, Background, Assessment, Recommendation </li></ul></ul>
  36. 36. Communication <ul><li>Interdisciplinary Team </li></ul><ul><li>Establish common goals </li></ul><ul><li>Use common language </li></ul><ul><li>Common knowledge base </li></ul><ul><li>Regular communication </li></ul>
  37. 37. Non-opioids <ul><li>Used in acute and chronic pain </li></ul><ul><li>Relief for mild/moderate pain </li></ul><ul><ul><li>Most effective with nociceptive pain (muscle and joint pain) </li></ul></ul><ul><li>Combined with opioid analgesics for both additive analgesic effects or opioid dose sparing effects </li></ul>
  38. 38. Non-opioids <ul><li>Acetaminophen </li></ul><ul><li>Mechanism </li></ul><ul><ul><li>not well understood </li></ul></ul><ul><li>Dosing </li></ul><ul><ul><li>decrease for patients with hepatic impairment </li></ul></ul><ul><li>Routes </li></ul>
  39. 39. Non-opioids <ul><li>Acetaminophen </li></ul><ul><li>Side effects </li></ul><ul><li>Considerations </li></ul><ul><li>Be aware of hidden doses, i.e., APAP in combination products </li></ul>
  40. 40. Non-opioids <ul><li>NSAIDs </li></ul><ul><li>Characteristics </li></ul><ul><ul><li>analgesic effects through the inhibition of prostaglandin production </li></ul></ul><ul><ul><li>multipurpose analgesia </li></ul></ul><ul><li>Drug choices </li></ul><ul><ul><li>If no response after 3 days of adjustment, consider switching to different NSAID </li></ul></ul><ul><ul><li>Contraindicated If patient is hypersensitive or allergic to ASA or other NSAID’s </li></ul></ul>
  41. 41. Non-opioids <ul><li>NSAIDs </li></ul><ul><li>Dosing </li></ul><ul><ul><li>PRN basis for occasional pain </li></ul></ul><ul><ul><li>Around-the-clock (ATC) for ongoing pain </li></ul></ul><ul><li>Routes of Administration </li></ul>
  42. 42. Non-opioids <ul><li>NSAIDs </li></ul><ul><li>Sides Effects </li></ul><ul><ul><li>Hematologic </li></ul></ul><ul><ul><li>GI </li></ul></ul><ul><ul><li>Renal </li></ul></ul><ul><ul><li>Cognitive Impairment </li></ul></ul><ul><ul><li>Cardiovascular </li></ul></ul>
  43. 43. Teaching Points for Non-opioids <ul><li>Risk for GI bleeding with NSAIDs </li></ul><ul><li>Why medication ordered </li></ul><ul><li>Stopping medications </li></ul><ul><li>Reporting side effects </li></ul>
  44. 44. Opioids <ul><li>CNS action - bind to opioid receptor site in brain and spinal cord </li></ul><ul><li>mu, kappa, and delta receptor sites </li></ul><ul><li>Pain relief occurs when opioids bind to 1 or more receptors as an agonist </li></ul><ul><li>Agonists and agonist - antagonists </li></ul>
  45. 45. Pure Agonist Opioids <ul><li>Expect physical dependence </li></ul><ul><li>Withdrawal will occur when abruptly stopped or naloxone (Narcan ® ) is given </li></ul><ul><li>Prevent withdrawal by reducing by 25% </li></ul><ul><li>Tolerance to side effects other than constipation </li></ul><ul><li>Tolerance to analgesia is rare </li></ul>
  46. 46. Choice of Opioid Drug <ul><li>One pure agonist with one route </li></ul><ul><li>If one not relieving pain with titration, may need to switch medication </li></ul><ul><li>All pure agonist have same side effects </li></ul><ul><ul><li>Side effects may be reported as allergies </li></ul></ul><ul><li>Rapid onset formulation for breakthrough </li></ul>
  47. 47. Opioids <ul><li>Morphine </li></ul><ul><li>Considered ‘gold standard’ for opioid analgesic </li></ul><ul><li>Standard for comparison in opioid use </li></ul><ul><li>Some patients cannot tolerate because of the side effects </li></ul><ul><ul><li>Tolerance to side effects in a few days </li></ul></ul><ul><ul><li>No tolerance to constipation </li></ul></ul>
  48. 48. Opioids <ul><li>Codeine </li></ul><ul><li>Appropriate for mild pain </li></ul><ul><li>Metabolized by liver </li></ul><ul><li>Fentanyl </li></ul><ul><li>Routes include IV, epidural, Topical patch </li></ul><ul><li>Hydrocodone </li></ul><ul><li>Found in combination therapy with acetaminophen </li></ul>
  49. 49. Opioids <ul><li>Hydromorphone </li></ul><ul><li>Short half life and lack of metabolite problems make it preferable to morphine in patients with renal insufficiency, particularly the elderly </li></ul>
  50. 50. Opioids <ul><li>Meperidine </li></ul><ul><li>Contraindicated – normeperidine (active metabolite) acts as a CNS stimulant </li></ul>
  51. 51. Opioids <ul><li>Methadone </li></ul><ul><ul><li>Long half life </li></ul></ul><ul><ul><li>Inexpensive </li></ul></ul><ul><ul><li>Monitor closely for arrhythmias </li></ul></ul>
  52. 52. Opioids <ul><li>Oxycodone </li></ul><ul><li>Used in acute, cancer, chronic nonmalignant pain </li></ul><ul><li>Mild to severe intensity </li></ul><ul><li>Propoxyphene </li></ul><ul><li>Considered a weak analgesic </li></ul><ul><li>Prescribed for mild to moderate pain </li></ul><ul><li>Not recommended for chronic pain, cancer pain, end-of-life care </li></ul>
  53. 53. Mixed Agonist-antagonists <ul><li>Indications </li></ul><ul><li>Not recommended for chronic pain </li></ul><ul><li>Ceiling doses </li></ul><ul><li>Psychotomimetic effects </li></ul><ul><ul><li>Disorientation/hallucinations </li></ul></ul>
  54. 54. Mixed Agonist-antagonists <ul><li>Buprenorphine (Buprenex ® ) </li></ul><ul><li>Butorphanol (Stadol ® ) </li></ul>
  55. 55. Mixed Agonist-antagonists <ul><li>Nalbuphine (Nubain ® ) </li></ul><ul><li>Pentazocine (Talwin ® ) </li></ul>
  56. 56. Opioid Dosing <ul><li>Multiple routes available for pure agonists </li></ul><ul><li>If current dose safe but ineffective, increase by 25% to 50% until pain relief occurs or unmanageable side effects present </li></ul><ul><li>No ceiling effect for pure agonists </li></ul><ul><li>All opioids have side effects that eventually limit dose escalation </li></ul>
  57. 57. Opioid Routes <ul><li>Oral/Sublingual </li></ul><ul><ul><li>Usually preferred route </li></ul></ul><ul><ul><li>Consider liquid if difficulty swallowing </li></ul></ul><ul><li>Intramuscular </li></ul><ul><ul><li>Not recommended - painful </li></ul></ul><ul><li>Subcutaneous </li></ul><ul><ul><li>Not used in acute pain situations </li></ul></ul><ul><ul><li>Limited volume of infusion </li></ul></ul>
  58. 58. Opioid Routes <ul><li>Intravenous </li></ul><ul><li>Bolus provides most rapid onset of effect </li></ul><ul><li>Peak times vary among opioids </li></ul><ul><li>Starting doses may be one-half the oral route </li></ul><ul><li>Transdermal </li></ul>
  59. 59. Opioid Routes <ul><li>Transdermal </li></ul><ul><li>Medication is delivered continuously through skin </li></ul><ul><li>Caution patients that increased heat to patch or skin area may increase release of medication </li></ul><ul><li>Best results when applied to skin without hair and adequate subcutaneous tissue </li></ul>
  60. 60. Opioid Routes <ul><li>Rectal </li></ul><ul><li>Alternative to patients who cannot swallow </li></ul><ul><li>Onset of action may be within 10 minutes </li></ul><ul><li>Stomal </li></ul><ul><li>Not equivalent to rectal administration </li></ul><ul><li>Starting dose should be considered same as oral or rectal route </li></ul>
  61. 61. Opioid Routes <ul><li>Intraspinal </li></ul><ul><li>Used for postoperative pain, cancer pain </li></ul><ul><li>Opioid binds to receptors of spinal cord at level of injection </li></ul><ul><li>Dose related side effects: nausea, itching, urinary retention </li></ul><ul><li>Patient Controlled Analgesia </li></ul>
  62. 62. Opioid Routes <ul><li>Patient Controlled Analgesia </li></ul><ul><li>Predetermined dose of opioid delivered based on time intervals </li></ul><ul><li>Primarily used in acute pain situations </li></ul><ul><li>Allows greater control over pain experience </li></ul>
  63. 63. Management of Opioid Side Effects <ul><li>Constipation </li></ul><ul><li>Most common side effect of opioids </li></ul><ul><li>Bowel regimen </li></ul>
  64. 64. Management of Opioid Side Effects <ul><li>Nausea and Vomiting </li></ul><ul><li>May be due to </li></ul><ul><ul><li>stimulation of chemoreceptor trigger zone in brain </li></ul></ul><ul><ul><li>slowing of GI motility </li></ul></ul><ul><ul><li>effects on balance and equilibrium of inner ear </li></ul></ul>
  65. 65. Management of Opioid Side Effects <ul><li>Sedation </li></ul><ul><li>Usually when opioids started or dose increased </li></ul><ul><li>Tolerance will occur over period of days to weeks </li></ul><ul><li>Pruritus </li></ul><ul><li>Can occur with any associated histamine release & commonly with morphine </li></ul><ul><li>May be generalized, usually localized to face, neck, chest </li></ul><ul><li>Usually not accompanied by rash </li></ul>
  66. 66. Management of Opioid Side Effects <ul><li>Mental status change </li></ul><ul><li>Cause of increased anxiety and fear for patients, families, caregivers </li></ul><ul><li>Assess to ensure that opioid is cause </li></ul>
  67. 67. Management of Opioid Side Effects <ul><li>Respiratory depression </li></ul><ul><li>Considered clinically significant when there is a decrease in rate and depth of respirations from baseline </li></ul><ul><li>Tolerance develops over period of days to weeks </li></ul><ul><li>Longer patient on opioid, less likely to develop </li></ul><ul><li>Prevention by appropriate titration, monitoring of sedation levels </li></ul><ul><li>Monitor sedation levels respiratory status, every 1-2 hours for first 24 hours in opioid naïve </li></ul>
  68. 68. Opioid Teaching Points <ul><li>Discuss effects of unrelieved pain </li></ul><ul><li>Review how to administration </li></ul><ul><li>Side effects </li></ul><ul><li>Fear of addiction </li></ul><ul><li>Written information </li></ul>
  69. 69. Equianalgesia <ul><li>Doses of various opioids analgesics that provide approximately the same pain relief </li></ul><ul><li>Charts </li></ul><ul><li>Consistent </li></ul><ul><li>Most use morphine 10 mg and every 4 hour dosing as basis </li></ul>
  70. 70. Sample Equianalgesic Chart 8-12 20 ---- Oxycodone (long acting) 3-4 7.5 1.5 Hydromorphone 3-4 30 10 Morphine (IR) Duration (hours) Dose (mg) Oral Dose (mg) Parenteral Drug
  71. 71. Titration of opioids <ul><li>Adjusting the amount of dose of an opioid </li></ul><ul><li>Make increases at the onset or peak effect </li></ul><ul><li>Provide smallest dose that provides greatest relief with fewest side effects </li></ul><ul><li>Titrate in increments of 25% to 100% </li></ul>
  72. 72. Methods of Titration <ul><li>Add total of scheduled doses and immediate-release over 24 hr period </li></ul><ul><li>Increase by 50% if initial dose not effective </li></ul><ul><li>Provide breakthrough dosing </li></ul>
  73. 73. Breakthrough Dosing <ul><li>Referred to as rescue dosing or supplemental dosing </li></ul><ul><li>Occurs in 2/3 of patients receiving opioids for chronic malignant pain </li></ul><ul><li>Assessing for breakthrough – no tool – rely on patient’s report of pain </li></ul><ul><li>Types </li></ul><ul><ul><li>Incident - elicited by specific activities </li></ul></ul><ul><ul><li>Spontaneous </li></ul></ul><ul><ul><li>End-of-dose failure </li></ul></ul>
  74. 74. Rescue Dosing <ul><li>1/10 to 1/6 of total daily dose </li></ul><ul><li>Adjust when ATC dose increases </li></ul><ul><li>Provide every 1-2 hrs </li></ul><ul><li>May be taken with ATC dose </li></ul><ul><li>Increase ATC dose if received more than 3 rescue doses in a 24 period </li></ul>
  75. 75. Calculating Rescue Dose <ul><li>ATC dose in 24 hrs </li></ul><ul><li>Divided by 10 (1/10) or 6 (1/6) </li></ul><ul><li>Equals IR rescue dose to be given every 3 hrs PRN </li></ul><ul><li>180mg in 24 hrs </li></ul><ul><li>180 ÷ 10 = 18 or </li></ul><ul><li>180 ÷ 6 = 30 </li></ul><ul><li>18mg to 30mg PO every 3 hr PRN </li></ul>
  76. 76. Calculating Rescue Dose <ul><li>Example </li></ul><ul><li>Oral Transmucosal Fentanyl Citrate </li></ul><ul><li>Must convert opioid to morphine using equianalgesic chart or manufacturer recommendation </li></ul><ul><li>200  g transdermal fentanyl = 400 mg morphine (total fentanyl  gs x 2 for morphine equivalent) </li></ul><ul><li>400  10 (1/10 or 10%) = 40 mg </li></ul><ul><li>400  6 (1/6 or 15%) = 70 mg </li></ul><ul><li>Immediate release rescue dose = 40-70 mg PO every 1-2 hour PRN </li></ul>
  77. 77. Calculating Rescue Dose <ul><li>Parenteral opioid infusions </li></ul><ul><li>Recommended rescue dose for patients receiving continuous parenteral or epidural opioid infusion is 25-50% of hourly opioid dose </li></ul><ul><li>Should be offered every 30 minutes if not using Patient Controlled Analgesia (PCA) </li></ul>
  78. 78. Adjuvants <ul><li>Non pain medications that have analgesic effects on certain types of pain </li></ul><ul><li>Chronic neuropathic pain </li></ul><ul><li>Additional therapy to opioids </li></ul><ul><li>Distinct primary therapy </li></ul>
  79. 79. Adjuvants <ul><li>Choice of Drug </li></ul><ul><li>Depends on type of pain, patient age, and other medical condition </li></ul><ul><li>Individual response </li></ul><ul><li>Sequential trials </li></ul>
  80. 80. Tricyclic Antidepressants <ul><li>In co-administration with opioids, interaction may result in higher opioid concentrations </li></ul><ul><li>Analgesia usually occurs within 1 week </li></ul><ul><li>May be effective for both lancinating and continuous neuropathic pain </li></ul><ul><li>Not indicated for acute pain </li></ul><ul><li>In palliative care, strongest indication in neuropathic pain not responding to opioids </li></ul><ul><li>In terminal care, benefits from non-analgesic effects </li></ul>
  81. 81. Tricyclic Antidepressants <ul><li>Choice of Drug </li></ul><ul><li>Amitriptyline (Elavil ® ) </li></ul><ul><li>Imipramine (Tofranil ® ) </li></ul><ul><li>Doxepin (Sinequan ® ) </li></ul><ul><li>Clomipramine (Anafranil ® ) </li></ul><ul><li>Desipramine (Norpramine ® ) </li></ul><ul><li>Nortriptyline (Aventyl ® , Pamelor ® ) </li></ul>
  82. 82. Tricyclic Antidepressants <ul><li>Dosing </li></ul><ul><li>Start low: elderly 10 mg; younger 25 mg </li></ul><ul><li>Increase by same amount as starting dose </li></ul><ul><li>Evaluate and increase every 3 to 5 days </li></ul><ul><li>Side Effects </li></ul><ul><li>Orthostatic hypotension </li></ul><ul><li>Sedation / mental clouding </li></ul><ul><li>Antocholergic effects </li></ul>
  83. 83. SSRIs <ul><li>Duloxetine (Cymbalta ® ) </li></ul><ul><li>Venlafaxine (Effexor ® ) </li></ul><ul><li>Paraxetine (Paxil ® ) </li></ul><ul><li>Fluoxetine (Prozac ® ) </li></ul>
  84. 84. Anticonvulsants <ul><li>First line drugs for chronic lancinating neuropathic pain </li></ul><ul><li>Variability among drugs is great </li></ul><ul><li>Analgesia similar mechanism that inhibit seizure activity </li></ul><ul><li>Lessens conduction of pain signals along damaged peripheral nerves </li></ul>
  85. 85. Anticonvulsants <ul><li>Gabapentin (Neurontin  ) </li></ul><ul><li>Considered first line drug of choice for all types of neuropathic pain due to effectiveness of analgesic action and low side effect profile </li></ul><ul><li>Carbamazepine (Tegretol  ) </li></ul><ul><li>Effective in lancinating neuropathic pain </li></ul>
  86. 86. Anticonvulsants <ul><li>Phenytoin (Dilantin  ) </li></ul><ul><li>Clonazepam (Klonopin  ) </li></ul><ul><li>Valproic acid (Depakene  ) </li></ul><ul><li>Baclofen (Lioresal  ) </li></ul>
  87. 87. Other Adjuvants <ul><li>Corticosteroids </li></ul><ul><li>Considered multipurpose adjuvant analgesic </li></ul><ul><li>Mechanism of action as analgesia is unknown </li></ul><ul><li>Drug of choice </li></ul><ul><li>dexamethasone (Decadron  ) </li></ul><ul><li>Prednisone and methylprednisolone </li></ul><ul><li>Adverse Effects </li></ul><ul><li>Short Term Therapy </li></ul><ul><li>Long Term Therapy </li></ul>
  88. 88. Other Adjuvants <ul><li>Local anesthetic agents </li></ul><ul><li>Local action with minimal systemic side effects </li></ul><ul><li>Limited information on long term safety and effectiveness </li></ul><ul><li>Medications </li></ul><ul><li>Mexiletine (Mexitil  ) </li></ul><ul><li>Tocainide (Tonocard  ) </li></ul><ul><li>Lidocaine  </li></ul>
  89. 89. Other Adjuvants <ul><li>Adverse Effects </li></ul><ul><li>Central nervous system effects </li></ul><ul><li>Caution or avoid use with patients with preexisting heart disease such as cardiac dysrhythmias, those receiving antiarrhythmic drugs, cardiac insufficiency </li></ul><ul><li>If topical route used, side effects include redness, edema, and abnormal sensation at the site of application </li></ul>
  90. 90. Other Adjuvants <ul><li>Psychostimulants </li></ul><ul><ul><li>Multipurpose for acute or chronic pain </li></ul></ul><ul><ul><li>Useful in nociceptive or neuropathic pain </li></ul></ul><ul><li>Caffeine (PO) </li></ul><ul><ul><li>Used in combination products for relief of headache </li></ul></ul><ul><ul><ul><li>Dextroamphetamine: (Dexedrine  ) (PO) </li></ul></ul></ul><ul><ul><ul><li>Methylphenidate: (Ritalin  ) (PO) </li></ul></ul></ul><ul><li>Side Effects </li></ul><ul><li>Insomnia, anorexia, tremulousness, anxiety, agitation, cognitive changes </li></ul>
  91. 91. Other Adjuvants <ul><li>Teaching Points </li></ul><ul><li>May take days to weeks for pain relief </li></ul><ul><li>Reassessment and titration may be necessary </li></ul><ul><li>Review adverse effects </li></ul><ul><li>Provide educational materials </li></ul>
  92. 92. Addiction <ul><li>“ A pattern of compulsive drug use characterized by a continued craving for an opioid for effects other than pain relief” (APS, 1999) </li></ul>
  93. 93. Pseudoaddiction <ul><li>The patient who seeks additional medications appropriately or inappropriately secondary to significant undertreatment of the pain syndrome </li></ul><ul><li>Behaviors cease when pain is treated </li></ul>
  94. 94. Tolerance <ul><li>A form of neuroadaptation to the effects of chronically administered opioids which is indicated by the need for increasing or more frequent doses of the medication to achieve the initial effects </li></ul><ul><li>Clinicians should not fear tolerance in patients with extended life expectancy </li></ul>
  95. 95. Physical Dependence <ul><li>A physiological state in which abrupt cessation of the opioid results in withdrawal syndrome </li></ul>
  96. 96. Physical Dependence <ul><li>Pain management for </li></ul><ul><li>Substance abuse history </li></ul><ul><ul><li>Accept patient’s report of pain </li></ul></ul><ul><ul><li>Clinicians most likely to under medicate </li></ul></ul>
  97. 97. Physical Dependence <ul><li>Pain management for </li></ul><ul><li>Active addict – general guidelines </li></ul><ul><ul><li>Reassure patient of staff commitment to pain management of all patients </li></ul></ul><ul><li>Inpatient </li></ul><ul><li>Consider IV PCA: gives patient control, avoids confrontation with staff, safely regulates dosing </li></ul><ul><li>Outpatient </li></ul><ul><li>less frequent dosing increases compliance to treatment plan </li></ul>
  98. 98. Physical Dependence <ul><li>Pain management for </li></ul><ul><li>Patient recovering from addiction </li></ul><ul><ul><li>Acknowledge patient’s addiction history </li></ul></ul><ul><ul><li>Offer non-pharmacologic and non-opioid pain management options </li></ul></ul><ul><ul><li>Differentiate between addiction and physical dependence </li></ul></ul><ul><ul><li>If relapse occurs, intensify recovery effort - do not terminate pain care </li></ul></ul>
  99. 99. Special Populations <ul><li>Geriatric </li></ul><ul><li>Dying </li></ul><ul><li>Pediatric </li></ul><ul><li>Cognitive Impaired </li></ul><ul><li>Veteran </li></ul>
  100. 100. Special Populations Geriatric <ul><li>Age classifications </li></ul><ul><ul><li>Younger old: age 65 to 75 years </li></ul></ul><ul><ul><li>Older old: age 75 to 85 years </li></ul></ul><ul><ul><li>Oldest old: over 85 years </li></ul></ul><ul><li>Most under treated population for pain </li></ul><ul><li>Rule of thumb: start low and go slow </li></ul>
  101. 101. Special Populations Geriatric <ul><li>Common types of pain </li></ul><ul><li>Acute pain </li></ul><ul><li>Cancer pain </li></ul><ul><li>Chronic nonmalignant pain </li></ul>
  102. 102. Special Populations Geriatric <ul><li>Analgesic Therapy issues </li></ul><ul><li>Physiologic changes </li></ul><ul><li>Absorption </li></ul><ul><li>Distribution </li></ul>
  103. 103. Special Populations Geriatric <ul><li>Analgesic Therapy issues </li></ul><ul><li>Metabolism </li></ul><ul><li>Elimination </li></ul>
  104. 104. Special Populations Geriatric <ul><li>Analgesic Therapy </li></ul><ul><li>Acetaminophen </li></ul><ul><ul><li>Generally well-tolerated by elderly </li></ul></ul><ul><li>NSAIDs </li></ul><ul><ul><li>Increased risk of GI problems, renal insufficiency, platelet dysfunction </li></ul></ul><ul><ul><li>Always take NSAIDs with food and water </li></ul></ul>
  105. 105. Special Populations Geriatric <ul><li>Analgesic Therapy </li></ul><ul><li>Opioids </li></ul><ul><ul><li>Recommend reducing initial opioid dosing by 25-50% in elderly patient </li></ul></ul>
  106. 106. Special Populations Geriatric <ul><li>Analgesic Therapy </li></ul><ul><li>Drug selection </li></ul><ul><li>Adjuvants </li></ul><ul><ul><li>Tricyclic Antidepressants </li></ul></ul><ul><ul><li>Anticonvulsants </li></ul></ul><ul><ul><li>Local Anesthetics </li></ul></ul>
  107. 107. Special Populations Cognitively Impaired <ul><li>Cognitively Impaired </li></ul><ul><li>High risk for under treatment </li></ul><ul><li>Assessment ability to report pain </li></ul><ul><li>0-5 scale </li></ul><ul><li>Collaborate with family or caregiver to determine behaviors that indicate pain </li></ul>
  108. 108. Special Populations Dying <ul><li>Dying </li></ul><ul><li>Pain assessment continues to be a priority at end-of-life </li></ul><ul><li>Palliative Sedation or Therapeutic Sedation </li></ul>
  109. 109. Special Populations Pediatrics <ul><li>Pediatric </li></ul><ul><li>Consider age, developmental level, verbal capabilities, past experiences, cultural factors, types of pain </li></ul><ul><li>Child self report of pain considered most reliable and valid indicator </li></ul><ul><li>Medication dose determined by body weight (kilogram) </li></ul><ul><li>Learn the child's word for pain </li></ul>
  110. 110. Special Populations Veterans <ul><li>Pain may be seen as a weakness </li></ul><ul><li>Military taught to ‘grin and bear it’ </li></ul><ul><li>Many suffer in silence, do not report pain </li></ul><ul><li>Assess for pain in consistent manner </li></ul><ul><li>Provide interdisciplinary, multimodal approach to pain management </li></ul>
  111. 111. Non-pharmacological Pain Management <ul><li>Use concurrently with medications </li></ul><ul><li>Methods </li></ul><ul><ul><li>Cognitive-behavioral </li></ul></ul><ul><ul><ul><li>Relaxation </li></ul></ul></ul><ul><ul><ul><li>Guided imagery </li></ul></ul></ul><ul><ul><ul><li>Distraction </li></ul></ul></ul>
  112. 112. Non-pharmacological Pain Management <ul><li>Methods </li></ul><ul><li>Physical interventions </li></ul><ul><ul><li>Hot and Cold </li></ul></ul><ul><ul><li>Massage </li></ul></ul><ul><ul><li>Positioning </li></ul></ul><ul><ul><li>Exercise </li></ul></ul>
  113. 113. Non-pharmacological Pain Management <ul><li>Methods </li></ul><ul><li>Physical interventions </li></ul><ul><ul><li>Positioning </li></ul></ul><ul><ul><li>Exercise </li></ul></ul>
  114. 114. Non-pharmacological Pain Management <ul><li>Complementary therapies </li></ul><ul><ul><li>Therapeutic touch </li></ul></ul><ul><ul><li>Music therapy </li></ul></ul><ul><ul><li>Aromatherapy </li></ul></ul>
  115. 115. Ethical Considerations <ul><li>Related to Pain Management </li></ul><ul><li>Patient rights </li></ul><ul><li>Relief from pain </li></ul><ul><ul><li>The Joint Commission </li></ul></ul><ul><ul><li>American Nurses Association </li></ul></ul><ul><li>Double Effect </li></ul><ul><ul><li>distinguishing between harming and benefiting patient </li></ul></ul>
  116. 116. Ethical Considerations <ul><li>Related to Pain Management </li></ul><ul><li>Principle of Double Effect </li></ul><ul><ul><li>Found in situations when distinguishing between harm and benefit </li></ul></ul>
  117. 117. Ethical Considerations <ul><li>Related to Pain Management </li></ul><ul><li>Advocacy </li></ul><ul><li>Nurses have duty to relieve pain and suffering </li></ul><ul><li>Patient and family view nurse as advocate which increases trusting relationship </li></ul>
  118. 118. References <ul><li>1. Berry PH, ed. Core Curriculum for the Generalist Hospice and Palliative Nurse . 2nd ed. Dubuque, IA: Kendal/Hunt; 2005. </li></ul><ul><li>2. SUPPORT SPI. A controlled trial to improve care for seriously ill hospitalized patients: a study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). Journal of the American Medical Association . 1995;274:1591-1598. </li></ul><ul><li>3. McMillan S. Pain and pain relief experienced by hospice patients with cancer. Cancer Nursing . 1996;19:298-307. </li></ul><ul><li>4. Warfield C, Kahn C. Acute pain management: programs in U.S. hospitals and experiences and attitudes among U.S. adults. Anesthesiology . 1995;83:1090-1094. </li></ul><ul><li>5. Ferrell BR, Dean G. The meaning of cancer pain. Seminars in Oncology Nursing . 1995:11(1):17-22. </li></ul>
  119. 119. References <ul><li>6. Gloth F. Concerns with chronic analgesic therapy in elderly patients. American Journal of Medicine . 1996;101(suppl 1A):19S-24S. </li></ul><ul><li>7. McCaffery M, Passero C. Pain: Clinical Manual. St. Louis, MO: Mosby; 1999. </li></ul><ul><li>8. Arnst C. Conquering Pain. Business Week . 1999:3681102-109. </li></ul><ul><li>9. Paice JA, Fine PG. Pain at the end of life. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing . 2nd ed. New York, NY: Oxford University Press; 2006:131-153. </li></ul><ul><li>10. American Pain Society. Principles of analgesic use in the treatment of acute pain and cancer pain. 3rd ed. Skokie, IL: American Pain Society; 1999. </li></ul>
  120. 120. References <ul><li>11. McCaffery M. Nursing Practice Theories Related To Cognition, Bodily Pain, And Man-Environment Interactions . Los Angeles, CA: UCLA; 1968. </li></ul><ul><li>12. (AHCPR). A.f.H.C.P.a.R. Acute Pain Management: Operative or Medical Procedures and Trauma. Clinical Practice Guideline. Rockville, MD: Public Health Service, U.S. Department of Health and Human Services; 1992. </li></ul><ul><li>13. Fink R, Gates R. Pain assessment. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing . 2nd ed. New York, NY: Oxford University Press; 2006:97-129. </li></ul><ul><li>14. Foley KM. Pain assessment and cancer pain syndromes. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. New York, NY: Oxford University Press: 2005: 298-316. </li></ul><ul><li>15. (AHCPR). A.f.H.C.P.a.R. Cancer Pain Management. Clinical Practice Guideline. Rockville, MD: Public Health Service, U.S. Department of Health and Human Services; 1994. </li></ul><ul><li>16. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC ) . Washington, DC: Association of Colleges of Nursing; 2009. </li></ul>
  121. 121. References <ul><li>17. Coyle N, Layman-Goldstein M. Pain assessment and pharmacological interventions. In: Matzo, ML, Sherman DW, eds. Palliative Care Nursing: Quality Care to the End of Life . 2nd New York, NY: Springer; 2006: 345-405 . </li></ul><ul><li>18. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association; 2003. </li></ul><ul><li>19. Mariano C. Holistic integrative therapies in palliative care. In: Matzo ML, Sherman DW, eds. Palliative Care Nursing: Quality Care to the End of Life . New York, NY: Springer; 2006: 51-86. </li></ul><ul><li>20. Stanley KJ, Zoloth-Dorman L. Ethical considerations. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing . 2nd ed. New York, NY: Oxford University Press; 2006: 1031-1053. 21. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association; 2003. </li></ul>
  122. 122. References <ul><li>21. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association; 2003. </li></ul><ul><li>22. Mariano C. Holistic integrative therapies in palliative care. In: Matzo, ML, Sherman DW, eds. Palliative Care Nursing: Quality Care to the End of Life . New York, NY: Springer; 2006: 51-86. </li></ul><ul><li>23. Stanley KJ, Zoloth-Dorman L. Ethical considerations. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing . 2nd ed. New York, NY: Oxford University Press; 2006: 1031-1053. </li></ul><ul><li>24. Gorman L, Beach P, Ersek M, Montana B, Bartel J. Pain Position Statement . Pittsburgh, PA: Hospice and Palliative Nurses Association; 2003. </li></ul>

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