The document provides an overview of pain management for nurses. It discusses [1] the prevalence and impact of pain, common barriers to treatment, and types of pain experienced by patients. It also [2] outlines principles of effective pain management including thorough assessment, appropriate medication selection and dosing, and multidisciplinary treatment. [3] Barriers to treatment include patients' and clinicians' attitudes as well as institutional factors, and uncontrolled pain negatively impacts multiple aspects of patients' lives.

1. CLINICAL REVIEW FOR THE GENERALIST
HOSPICE & PALLIATIVE NURSE
WEEK 2 Pain Management

2. Objectives
1. Describe the prevalence of pain in the hospice and P.C.
setting
2. Recognize the impact of pain on pts./families/and the
healthcare system
3. 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 assessment
7. Demonstrate the ability to do equi-analgesic conversions

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. Pain is SUBJECTIVE
―Pain is whatever the person says it
is, experienced whenever they say
they are experiencing it.‖ (McCaffery &
Passero, 1999).

5. Self-Report is the most valid measure of pain.

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. 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. 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. Palliative Sedation
Is given with the intent to relieve refractory suffering
(physical, psychological, or spiritual). It is NOT
―euthanasia‖ or ―assisted suicide‖.

10. Uncontrolled Pain Impacts
 Physical
 Psychosocial
 Emotional
 Financial
 Spiritual
Elements of a person

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. Pain Co-Morbidities
 Depression
 Anxiety
 Diabetes
 Chronic Fatigue
Syndrome

13. Pain is Multi-Dimensional
 Each member of the
IDT can address it
 Nurse
 Aide
 Physician
 Chaplain
 SW
 Volunteer

14. Patients’ attitudes are sometimes
barriers 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. Another Barrier: Clinicians Attitudes
 Doubt patients’ reports of
pain
 Fear of causing resp.
depression
 Confusion: addiction
/dependence/ tolerance
 Belief opioids shorten life

16. Institutional Barriers
• Low Priority
• Poor reimbursement
• Restrictive regulations
• Availability/Access to treatment

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. 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. 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. 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. How to treat each type
 Somatic—Non-opioids,
opioids
 Visceral—non-opioids,
opioids
 Neuropathic—adjuvants
(anti-dep., anti-convulsants,
steroids, NMDA antag. etc.)

22. NMDA Receptor Antagonists
 Work well for
nerve pain
 Also used in
veterinary
medicine

23. APS—12 Principles of Pain Mgmt.
1. Individualize dose, route, + schedule
2. ATC dosing
3. Selection of opioids
4. Adequate dosing for infants/children
5. Follow pts. closely (do not stereotype)
6. Use equi-analgesic dosing

24. APS—12 Principles of Pain Management
7. Recognize and treat side effects (constip.!!)
8. Be aware of hazards of mixed agonist-
antagonists and Demerol
9. Watch for development of tolerance (use
combo., switch to ½ equi-analgesic dose)
10. Be aware of physical dependence
11. Do not label a patient addicted (if tol./dep.)
12. Be aware of psychological state (anxiety, dep.
may co-exist. Treat pain 1st)

25. W.H.O. PAIN LADDER

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. 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. 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. WORLD HEALTH ORGANIZATION
RECOMMENDATIONS
Treat Cancer Pain
 By the MOUTH
 By CLOCK,
the
not prn
 By the LADDER

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. 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. Medication History
 Current regimen?
 Effective?
 Side Effects?
 Past regimen?

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. Physical Exam
 Examine site
 Consider disease
process/progression
 Consider referral sites
 Consider
 Culture
 Age
 Gender
 Environment

35. COMMUNICATION TOOLS
(w/physician, family, team, LTC staff)
 Background
B Situation
A  Assessment
Symptoms/Situation
Background
S 
I  Interpretation Assessment
C  Communication Recommendation
S  Successful outcome

36. Factors influencing pain perception
 Physical
 Psycho-social
 Emotional
 Spiritual
 Financial
 Cultural (Careful
not to stereotype)

37. ADDICTION is characterized by:
 Using a drug for
psychic benefits
 Compulsive behavior
to acquire the drug
 Continued use
despite harm

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. DEPENDENCE
A 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. Pseudo-Addiction
 Iatrogenic
 Due to inadequate treatment of pain
 Patient behaves as though addicted—
problems disappear when dose is increased

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. Side Effects
 Aspirin /NSAIDS  GI
distress/bleeding/ulcers
 Renal insufficiency
 Bleeding/anti-platelet
 Hypersensitivity rxns.
 CNS effects (dizziness,
tinnitus)
 Dose limit (―analgesic
ceiling‖)

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. 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. 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. 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. 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. 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. ADJUVANT PAIN MEDICINES
Anti-Convulsants—Used to treat nerve pain (lancinating,
paroxysmal)
carbamazepine (Tegretol)
gabapentin (Neurontin)
phenytoin (Dilantin)
valproic Acid (Depakote)

50. ADJUVANT PAIN MEDICINES
Local 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. 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. 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. 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. Equi-Analgesic Conversions
1. Charts are considered estimates —good way
to determine starting dose
2. 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. Sample Equianalgesic Chart
Drug Dose (mg.) Dose(mg.) Duration
Parenteral Oral (hours)
Morphine (IR) 5 15 3-4
Hydromorphone 1.5 4 3-4
(Dilaudid)
Oxycodone ____ 10 8-12
(Long-Acting)

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. 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. Method of Titrating
1. 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. 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. Calculating a Long Acting Dose
Example:
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 hours
Advantage: Steady pain relief, and pt. Is able to sleep
for 8 hours and not wake up in pain.

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. 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. 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. 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. 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. ADJUVANT PAIN MEDICINES—non-pain
meds. w/analgesic effects on certain types of pain
Tricyclic 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. 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. 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. 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. 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. Non-Pharmacological Techniques
 Repositioning/Bracing
 Relaxation/Distraction
 Exercise
 Guided Imagery
 Massage
 Heat/Cold