Chpn hpna ppt #2 pain management

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Clinical Review for the Hospice and Palliative Nurse

Pain Management

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Objectives

1. Describe the prevalence of pain in the hospice and palliative care setting

2. Recognize the impact of pain on patients, families and the healthcare system

3. Identify common barriers to effective pain management

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Objectives

4. Define the types of pain experienced by the hospice and palliative patient

5. State the principles of effective pain management

6 Identify the components of a thorough pain assessment

7. Demonstrate the ability to do equianalgesic conversions

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Undertreatment of Pain

70-90% of patients with advance disease experience pain 50% hospitalized patient’s experience pain 80% of long term care experience pain

Only 40-50% are given analgesics Pain scores (on a 0-10 scale) greater than or equal to “5”

greatly impact on quality of life

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Impact of Poorly Controlled Pain

Physical

Psychosocial

Emotional

Financial

Spiritual

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Interdisciplinary Resources

Pain affects multiple dimensions No one discipline can address all issues Strengths and talents of many disciplines Address multiple institutional barriers On going communication

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Cost of Poor Pain Management

$100 billion per year Chronic pain is most expensive heath problem 40 million physician visits per year for pain 25% of all work days lost are due to pain Improving pain management costs less than cost of

inadequate relief

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Pain Co-morbidities

Depression Anxiety disorder Diabetes Chronic fatigue syndrome

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Barriers to Effective Pain Management

Patient / family

Healthcare Provider

Institutional

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Definition of Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (APS)

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Definition of Pain

Pain is whatever the experiencing person says it is, existing whenever he/she says it does (McCaffery & Pasero, 1999)

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Types of Pain

Acute

Accompanied by physiological

Chronic

Usually persist for longer than 3 months Autonomic nervous system adapts - patient

does not exhibit objective signs of pain

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Classification of Pain Nociceptive Pain

The normal processing of stimuli that damages normal tissues or has the potential to do so if prolonged

Usually responsive to non-opioids and/or opioids Stimuli from somatic or visceral structures

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Types of Nociceptive Pain

Somatic Pain

Bone, Joints, Muscle, Skin, Connective tissue

Throbbing, dull

Well localized

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Types of Nociceptive Pain

Visceral Pain Visceral organs Squeezing, cramping, pressure, deep Tumor involvement of organ capsule

Aching & well localized Intermittent cramping & poorly localized

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Neuropathic Pain

Abnormal processing of sensory input by central or peripheral nervous system

Mechanisms not as well understood

Burning, shooting, tingling, numbness, radiating, electrical

Responds to adjuvant analgesics

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Neuropathic Pain

Centrally generated pain Deafferentation pain Sympathetically maintained pain

Peripherally generated pain Painful polyneuropathies Painful mononeuropathies

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APS 12 Principles of Pain Management

1. Individualize dose, route and schedule

2. Around the clock dosing

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APS 12 Principles of Pain Management

3. Selection of opioids

4. Adequate dosing for infants/children

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APS 12 Principles of Pain Management

5. Follow patients closely

6. Use equianalgesic dosing

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APS 12 Principles of Pain Management

7. Recognize and treat side effects

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APS 12 Principles of Pain Management

8. Be aware of hazards of Demerol® and mixed agonist-antagonists

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APS 12 Principles of Pain Management

9. Watch for development of tolerance

10. Be aware of physical dependence

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APS 12 Principles of Pain Management

11. Do not label a patient addicted

12. Be aware of psychological state

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WHO Ladder Recommendations

Portrays progression in the doses and types of analgesic drugs for effective pain relief

Changes as patients condition and characteristics of pain change

Orally whenever possible “By the clock” dosing Based on assessment of the individual’s pain experience

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WHO LadderStep 1 (Mild pain)

Mild Pain 1-3 on a scale of 0-10

Non-opioids Adjuvants

As analgesics To reduce side effects

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WHO LadderStep 2 (Moderate pain)

Moderate Pain 4-6 on a scale of 0-10

Opioids in low doses Non-opioids and adjuvants may be continued

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WHO LadderStep 3 (Severe pain)

Severe Pain 7-10 on a scale of 0-10

Add higher doses of opioids Continue non-opioids and adjuvants

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Pain Assessment Principles

Accept patient’s complaint of pain

History of pain

Assessment for non-verbal patients

Patient centered goals

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Pain Assessment Principles

Nonverbal signs of pain

Psychological impact of pain

Diagnostic workup

Assess effectiveness and side effects of pain medication

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Initial Pain Assessment

Onset/duration When did the pain first begin? Is it associated with a particular activity Other symptoms

Site More than 75% persons with cancer have pain in 2 or

more sites Ask patient , “To point to the pain Assess each site for pain intensity, quality, duration

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Initial Pain Assessment

Severity/intensity Select pain scale appropriate to patient

Quality Ask patient to describe their pain

Exacerbating/relieving factors What makes the pain worse or what causes the pain? Assess the pain at rest, with movement, and in relation to

daily activity Ask the caregivers how patient is doing with activities

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Initial Pain Assessment

Effects of pain on quality of life What does the pain mean to the patient and family? Does the pain keep the patient from doing activities

he/she enjoys?

Medication history Current Past Side effects

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Initial Pain Assessment

Physical Examine site(s) of pain, including referral sitesConsider disease process, extent of progression

Cultural considerations Cultural generalities and determine individual differences

Other factors Age Gender Environmental

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Communication

Physician/Nurse critical in providing excellent patient care BASICS

Background, Assessment, Symptoms/Situation, Interpretation, Communication, Successful outcome

SBAR

Situation, Background, Assessment, Recommendation

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Communication

Interdisciplinary Team Establish common goals Use common language Common knowledge base Regular communication

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Non-opioids

Used in acute and chronic pain Relief for mild/moderate pain

Most effective with nociceptive pain (muscle and joint pain)

Combined with opioid analgesics for both additive analgesic effects or opioid dose sparing effects

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Non-opioids

Acetaminophen Mechanism

not well understood

Dosing decrease for patients with hepatic impairment

Routes

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Non-opioids

Acetaminophen Side effects

Considerations Be aware of hidden doses, i.e., APAP in combination

products

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Non-opioids

NSAIDs Characteristics

analgesic effects through the inhibition of prostaglandin production

multipurpose analgesia Drug choices

If no response after 3 days of adjustment, consider switching to different NSAID

Contraindicated If patient is hypersensitive or allergic to ASA or other NSAID’s

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Non-opioids

NSAIDs Dosing

PRN basis for occasional pain Around-the-clock (ATC) for ongoing pain

Routes of Administration

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Non-opioids

NSAIDs Sides Effects

Hematologic GI Renal Cognitive Impairment Cardiovascular

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Teaching Points for Non-opioids

Risk for GI bleeding with NSAIDs

Why medication ordered

Stopping medications

Reporting side effects

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Opioids

CNS action - bind to opioid receptor site in brain and spinal cord

mu, kappa, and delta receptor sites Pain relief occurs when opioids bind to 1 or

more receptors as an agonist Agonists and agonist - antagonists

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Pure Agonist Opioids

Expect physical dependence Withdrawal will occur when abruptly stopped or naloxone

(Narcan®) is given Prevent withdrawal by reducing by 25% Tolerance to side effects other than constipation Tolerance to analgesia is rare

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Choice of Opioid Drug

One pure agonist with one route

If one not relieving pain with titration, may need to switch medication

All pure agonist have same side effects Side effects may be reported as allergies

Rapid onset formulation for breakthrough

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Opioids

Morphine Considered ‘gold standard’ for opioid analgesic Standard for comparison in opioid use Some patients cannot tolerate because of the side effects

Tolerance to side effects in a few days No tolerance to constipation

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Opioids

Codeine Appropriate for mild pain Metabolized by liver

Fentanyl Routes include IV, epidural, Topical patch

Hydrocodone Found in combination therapy with acetaminophen

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Opioids

Hydromorphone Short half life and lack of metabolite problems make it

preferable to morphine in patients with renal insufficiency, particularly the elderly

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Opioids

Meperidine Contraindicated – normeperidine (active

metabolite) acts as a CNS stimulant

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Opioids

Methadone Long half life Inexpensive Monitor closely for arrhythmias

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Opioids

Oxycodone Used in acute, cancer, chronic nonmalignant pain Mild to severe intensity

Propoxyphene Considered a weak analgesic Prescribed for mild to moderate pain Not recommended for chronic pain, cancer pain, end-of-

life care

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Mixed Agonist-antagonists

Indications Not recommended for chronic pain Ceiling doses Psychotomimetic effects

Disorientation/hallucinations

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Mixed Agonist-antagonists

Buprenorphine (Buprenex®)

Butorphanol (Stadol®)

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Mixed Agonist-antagonists

Nalbuphine (Nubain®)

Pentazocine (Talwin®)

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Opioid Dosing

Multiple routes available for pure agonists If current dose safe but ineffective, increase by 25% to

50% until pain relief occurs or unmanageable side effects present

No ceiling effect for pure agonists All opioids have side effects that eventually limit dose

escalation

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Opioid Routes

Oral/Sublingual

Usually preferred route Consider liquid if difficulty swallowing

Intramuscular

Not recommended - painfulSubcutaneous

Not used in acute pain situations Limited volume of infusion

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Opioid Routes

Intravenous Bolus provides most rapid onset of effect Peak times vary among opioids Starting doses may be one-half the oral route

Transdermal

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Opioid Routes

Transdermal Medication is delivered continuously through skin Caution patients that increased heat to patch or skin area

may increase release of medication Best results when applied to skin without hair and

adequate subcutaneous tissue

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Opioid Routes

Rectal Alternative to patients who cannot swallow Onset of action may be within 10 minutes

Stomal Not equivalent to rectal administration Starting dose should be considered same as oral or rectal

route

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Opioid Routes

Intraspinal Used for postoperative pain, cancer pain Opioid binds to receptors of spinal cord at level of

injection Dose related side effects: nausea, itching, urinary

retention

Patient Controlled Analgesia

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Opioid Routes

Patient Controlled Analgesia Predetermined dose of opioid delivered based on time

intervals Primarily used in acute pain situations Allows greater control over pain experience

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Management ofOpioid Side Effects

Constipation Most common side effect of opioids Bowel regimen

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Management ofOpioid Side Effects

Nausea and Vomiting May be due to

stimulation of chemoreceptor trigger zone in brain slowing of GI motility effects on balance and equilibrium of inner ear

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Management of Opioid Side Effects

Sedation Usually when opioids started or dose increased Tolerance will occur over period of days to weeks

Pruritus Can occur with any associated histamine release &

commonly with morphine May be generalized, usually localized to face, neck, chest Usually not accompanied by rash

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Management ofOpioid Side Effects

Mental status change Cause of increased anxiety and fear for patients, families,

caregivers Assess to ensure that opioid is cause

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Management of Opioid Side Effects

Respiratory depression Considered clinically significant when there is a decrease

in rate and depth of respirations from baseline Tolerance develops over period of days to weeks Longer patient on opioid, less likely to develop Prevention by appropriate titration, monitoring of sedation

levels Monitor sedation levels respiratory status, every 1-2 hours

for first 24 hours in opioid naïve

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Opioid Teaching Points

Discuss effects of unrelieved pain Review how to administration Side effects Fear of addiction Written information

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Equianalgesia

Doses of various opioids analgesics that provide approximately the same pain relief

Charts Consistent

Most use morphine 10 mg and every 4 hour dosing as basis

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Sample Equianalgesic Chart

Drug Dose (mg)

Parenteral

Dose (mg)

Oral

Duration (hours)

Morphine (IR) 10 30 3-4

Hydromorphone 1.5 7.5 3-4

Oxycodone (long acting)

---- 20 8-12

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Titration of opioids

Adjusting the amount of dose of an opioid

Make increases at the onset or peak effect

Provide smallest dose that provides greatest relief with fewest side effects

Titrate in increments of 25% to 100%

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Methods of Titration

Add total of scheduled doses and immediate-release over 24 hr period

Increase by 50% if initial dose not effective

Provide breakthrough dosing

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Breakthrough Dosing

Referred to as rescue dosing or supplemental dosing Occurs in 2/3 of patients receiving opioids for chronic

malignant pain Assessing for breakthrough – no tool – rely on patient’s

report of pain

Types

Incident - elicited by specific activities Spontaneous End-of-dose failure

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Rescue Dosing

1/10 to 1/6 of total daily dose Adjust when ATC dose increases Provide every 1-2 hrs May be taken with ATC dose Increase ATC dose if received more than 3 rescue doses

in a 24 period

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Calculating Rescue Dose

ATC dose in 24 hrs

Divided by 10 (1/10) or 6 (1/6)

Equals IR rescue dose to be given every 3 hrs PRN

180mg in 24 hrs

180 ÷ 10 = 18 or 180 ÷ 6 = 30

18mg to 30mg PO every 3 hr PRN

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Calculating Rescue Dose

Example

Oral Transmucosal Fentanyl Citrate Must convert opioid to morphine using equianalgesic chart or

manufacturer recommendation 200 g transdermal fentanyl = 400 mg morphine (total

fentanyl gs x 2 for morphine equivalent) 400 10 (1/10 or 10%) = 40 mg 400 6 (1/6 or 15%) = 70 mg Immediate release rescue dose = 40-70 mg PO every 1-2 hour

PRN

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Calculating Rescue Dose

Parenteral opioid infusions Recommended rescue dose for patients receiving

continuous parenteral or epidural opioid infusion is 25-50% of hourly opioid dose

Should be offered every 30 minutes if not using Patient Controlled Analgesia (PCA)

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Adjuvants

Non pain medications that have analgesic effects on certain types of pain

Chronic neuropathic pain Additional therapy to opioids Distinct primary therapy

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Adjuvants

Choice of Drug Depends on type of pain, patient age, and other medical

condition Individual response Sequential trials

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Tricyclic Antidepressants

In co-administration with opioids, interaction may result in higher opioid concentrations

Analgesia usually occurs within 1 week May be effective for both lancinating and continuous

neuropathic pain Not indicated for acute pain In palliative care, strongest indication in neuropathic pain

not responding to opioids In terminal care, benefits from non-analgesic effects

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Tricyclic Antidepressants

Choice of Drug Amitriptyline (Elavil®) Imipramine (Tofranil®) Doxepin (Sinequan®) Clomipramine (Anafranil®) Desipramine (Norpramine®) Nortriptyline (Aventyl®, Pamelor®)

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Tricyclic Antidepressants

Dosing Start low: elderly 10 mg; younger 25 mg Increase by same amount as starting dose Evaluate and increase every 3 to 5 days

Side Effects Orthostatic hypotension Sedation / mental clouding Antocholergic effects

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SSRIs

Duloxetine (Cymbalta®) Venlafaxine (Effexor®) Paraxetine (Paxil®) Fluoxetine (Prozac®)

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Anticonvulsants

First line drugs for chronic lancinating neuropathic pain Variability among drugs is great Analgesia similar mechanism that inhibit seizure activity Lessens conduction of pain signals along damaged

peripheral nerves

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Anticonvulsants

Gabapentin (Neurontin) Considered first line drug of choice for all types of

neuropathic pain due to effectiveness of analgesic action and low side effect profile

Carbamazepine (Tegretol) Effective in lancinating neuropathic pain

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Anticonvulsants

Phenytoin (Dilantin) Clonazepam (Klonopin) Valproic acid (Depakene) Baclofen (Lioresal)

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Other Adjuvants

Corticosteroids Considered multipurpose adjuvant analgesic Mechanism of action as analgesia is unknown

Drug of choice dexamethasone (Decadron) Prednisone and methylprednisolone

Adverse Effects Short Term Therapy Long Term Therapy

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Other Adjuvants

Local anesthetic agents Local action with minimal systemic side effects Limited information on long term safety and effectiveness

Medications Mexiletine (Mexitil) Tocainide (Tonocard) Lidocaine

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Other Adjuvants

Adverse Effects Central nervous system effects Caution or avoid use with patients with preexisting heart

disease such as cardiac dysrhythmias, those receiving antiarrhythmic drugs, cardiac insufficiency

If topical route used, side effects include redness, edema, and abnormal sensation at the site of application

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Other Adjuvants

Psychostimulants

Multipurpose for acute or chronic pain Useful in nociceptive or neuropathic pain

Caffeine (PO) Used in combination products for relief of headache

Dextroamphetamine: (Dexedrine) (PO) Methylphenidate: (Ritalin) (PO)

Side Effects Insomnia, anorexia, tremulousness, anxiety, agitation,

cognitive changes

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Other Adjuvants

Teaching Points May take days to weeks for pain relief Reassessment and titration may be necessary Review adverse effects Provide educational materials

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Addiction

“A pattern of compulsive drug use characterized by a continued craving for an opioid for effects other than pain relief” (APS, 1999)

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Pseudoaddiction

The patient who seeks additional medications appropriately or inappropriately secondary to significant undertreatment of the pain syndrome

Behaviors cease when pain is treated

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Tolerance

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

Clinicians should not fear tolerance in patients with extended life expectancy

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Physical Dependence

A physiological state in which abrupt cessation of the opioid results in withdrawal syndrome

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Physical Dependence

Pain management for Substance abuse history

Accept patient’s report of pain Clinicians most likely to under medicate

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Physical Dependence

Pain management for Active addict – general guidelines

Reassure patient of staff commitment to pain management of all patients

Inpatient Consider IV PCA: gives patient control, avoids

confrontation with staff, safely regulates dosingOutpatient less frequent dosing increases compliance to treatment plan

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Physical Dependence

Pain management for Patient recovering from addiction

Acknowledge patient’s addiction history Offer non-pharmacologic and non-opioid pain

management options Differentiate between addiction and physical

dependence If relapse occurs, intensify recovery effort - do

not terminate pain care

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Special Populations

Geriatric Dying Pediatric Cognitive Impaired Veteran

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Special PopulationsGeriatric

Age classifications

Younger old: age 65 to 75 years Older old: age 75 to 85 years Oldest old: over 85 years

Most under treated population for pain Rule of thumb: start low and go slow

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Special PopulationsGeriatric

Common types of pain Acute pain Cancer pain

Chronic nonmalignant pain

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Special PopulationsGeriatric

Analgesic Therapy issues Physiologic changes Absorption Distribution

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Special PopulationsGeriatric

Analgesic Therapy issues Metabolism Elimination

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Special PopulationsGeriatric

Analgesic Therapy Acetaminophen

Generally well-tolerated by elderly NSAIDs

Increased risk of GI problems, renal insufficiency, platelet dysfunction

Always take NSAIDs with food and water

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Special PopulationsGeriatric

Analgesic Therapy Opioids

Recommend reducing initial opioid dosing by 25-50% in elderly patient

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Special PopulationsGeriatric

Analgesic Therapy Drug selection Adjuvants

Tricyclic Antidepressants Anticonvulsants Local Anesthetics

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Special Populations Cognitively Impaired

Cognitively Impaired High risk for under treatment Assessment ability to report pain 0-5 scale Collaborate with family or caregiver to determine

behaviors that indicate pain

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Special PopulationsDying

Dying Pain assessment continues to be a priority at end-of-life Palliative Sedation or Therapeutic Sedation

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Special PopulationsPediatrics

Pediatric Consider age, developmental level, verbal capabilities, past

experiences, cultural factors, types of pain Child self report of pain considered most reliable and valid

indicator Medication dose determined by body weight (kilogram) Learn the child's word for pain

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Special PopulationsVeterans

Pain may be seen as a weakness Military taught to ‘grin and bear it’ Many suffer in silence, do not report pain Assess for pain in consistent manner Provide interdisciplinary, multimodal approach to pain

management

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Non-pharmacological Pain Management

Use concurrently with medications Methods

Cognitive-behavioral Relaxation Guided imagery Distraction

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Non-pharmacological Pain Management

Methods Physical interventions

Hot and Cold Massage Positioning Exercise

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Non-pharmacological Pain Management

Methods Physical interventions

Positioning Exercise

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Non-pharmacological Pain Management

Complementary therapies

Therapeutic touch Music therapy Aromatherapy

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Ethical Considerations

Related to Pain Management Patient rights Relief from pain

The Joint Commission American Nurses Association

Double Effect distinguishing between harming and benefiting patient

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Ethical Considerations

Related to Pain Management Principle of Double Effect

Found in situations when distinguishing between harm and benefit

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Ethical Considerations

Related to Pain Management Advocacy Nurses have duty to relieve pain and suffering Patient and family view nurse as advocate which increases

trusting relationship

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References

1. Berry PH, ed. Core Curriculum for the Generalist Hospice and Palliative Nurse. 2nd ed. Dubuque, IA: Kendal/Hunt; 2005.

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.

3. McMillan S. Pain and pain relief experienced by hospice patients with cancer. Cancer Nursing. 1996;19:298-307.

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.

5. Ferrell BR, Dean G. The meaning of cancer pain. Seminars in Oncology Nursing. 1995:11(1):17-22.

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References

6. Gloth F. Concerns with chronic analgesic therapy in elderly patients. American Journal of Medicine. 1996;101(suppl 1A):19S-24S.

7. McCaffery M, Passero C. Pain: Clinical Manual. St. Louis, MO: Mosby; 1999.

8. Arnst C. Conquering Pain. Business Week. 1999:3681102-109.

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.

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.

120

References

11. McCaffery M. Nursing Practice Theories Related To Cognition, Bodily Pain, And Man-Environment Interactions. Los Angeles, CA: UCLA; 1968.

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.

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.

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.

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.

16. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC ). Washington, DC: Association of Colleges of Nursing; 2009.

121

References

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 .

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.

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.

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.

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References

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.

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.

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.

24. Gorman L, Beach P, Ersek M, Montana B, Bartel J. Pain Position Statement. Pittsburgh, PA: Hospice and Palliative Nurses Association; 2003.