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).
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
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
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.)
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)
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.
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)
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.
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.
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