Http:// Module #2 END-OF-LIFE CARE: Module 2 Pain Management

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END-OF-LIFE CARE:Module 2

Pain Management

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Case of Mrs. Dolores Long

Mrs. Dolores Long is a 70-year old widowed African American female who was recently diagnosed with lung carcinoma and metastasis to bone. She is being admitted to the hospital for a round of chemotherapy.A medical resident performs the admission H&P. Mrs. Long denies any symptoms. Physical examination is unremarkable. Mental status exam is significant for flat affect and poor eye contact. The resident finishes the exam and leaves the room. Mrs. Long’s daughter steps outside with the resident and explains that her mother has complained of severe pain and has become sedentary and withdrawn. She has refused the acetaminophen with codeine that was prescribed because she doesn’t want to “get hooked,” and the pills don’t help anyway.The resident is surprised, as Mrs. Long did not appear to be in pain. He explains that “nothing more can be done” for the pain, as strong narcotics like morphine might cause her to stop breathing and NSAIDs like ibuprofen could cause GI bleeding. However, psychiatry will be consulted to evaluate her depression.



Learning Objectives

Recognize and address barriers to effective EOL pain care

Develop a better understanding of attitudes and beliefs about pain management

Improve your knowledge and skills in assessing and treating pain

Incorporate this content into your clinical teaching



Outline of Module

Background

Barriers to treating pain

Pain Assessment

Non-pharmacologic treatment approaches

Break

Pharmacologic strategies

Pain medications

Application exercise

Summary and goals



Pain in the Hospitalized Seriously Ill

50% of conscious patients were in moderate to severe pain at least half the time in the three days prior to death

SUPPORT Study (1995), N = 9105 patients



Pain in Nursing Home Patients

• 30% reported daily pain• 26% of these patients received no analgesia• Only 26% of them received strong opioids

What predicted inadequate pain management?• Advanced age: >85 years old• Poor cognitive function• Minority status

Bernabei (1998), N = 13,625 cancer patients



Pain in Outpatients

• 67% outpatients with metastatic CA were in pain• 42% of those not given adequate analgesic therapy

What predicted inadequate pain management?• Discrepancy between patient and MD assessment of

pain• Advanced age: >70 years old• Female• Better performance status• Minorities

Cleeland (1994), N = 1308



Pain in 103 Children who Died of Cancer or its Complications

• 89% died while suffering pain or other symptoms

• Of those whose pain was treated, treatment was successful in only 27%

Wolfe, 2000



Brainstorm

What makes pain so difficult to treat?



Six Major Barriers to Adequate Pain Care

• Myth: That addiction is a common result of treating pain with opioids

• Regulatory and legal concerns• System barriers• Deficits in knowledge and education• Fear of side effects• Assessment challenges



Definitions

• Addiction: Psychological dependence on a drug. Drug-seeking behavior despite adverse consequences

• Physical Dependence: Development of physical withdrawal reaction upon discontinuation or antagonism of a drug

• Tolerance: Need to increase amount of drug to obtain the same effect

• Pseudoaddiction: Behavior suggestive of addiction occurring as a result of undertreated pain



Barrier #1: The Myth of Addiction

• Addiction differs from chemical dependence, tolerance, and pseudoaddiction

• Increased use of opioid analgesics for pain does not appear to contribute to increases in opioid abuse (Joranson, 2000)

• Fears are exaggerated due to referral bias• Pseudoaddiction complicates the picture• Increased opioid requirement is usually related

to progression of disease, not tolerance



Barrier #2: Regulatory and Legal Concerns

• Physicians are wary of prescribing controlled substances for fear of criminal and/or licensing sanctions– Risk is very low if indication and response are

properly documented

• Regulatory policies that control opioids get in the way– Triplicates– Renewal policies



#3 System Barriers

• Lack of systemic use of practice guidelines• Pain management historically has not been

incorporated into quality management structure• Many institutions still lack pain and/or palliative

care services



Barrier #4: Deficits in Knowledge and Education

• In patients, families, physicians, and other health care professionals

• Pain management is still rarely addressed in medical school curricula

• It is rarely included in textbooks– < 2% medical textbook content (Rabow, 2000)– < 5% nursing textbook pages (Ferrell, 1999)

• Physicians lack awareness of their own knowledge deficits in pain management



Barrier #5: Bad Side Effects of Opioids - Key Points

• Pain is a partial antagonist to respiratory depression and CNS sedation

• Respiratory depression, sedation, and N&V relate more to changing blood serum levels of opioids than the steady state dose

• Pain management and constipation relate to steady state dosing, not the rising blood opioid level– Treat prophylactically and continually



Barrier #6: Assessment Challenges

• Health care professionals are more comfortable measuring objective data

• We lack a scanner that is more accurate than patient report



Assessment of Pain:Key Dimensions

Mechanism• Neuropathic pain

Abnormal state of central or peripheral nervous system gives rise to pain

• Nociceptive pain

Nerves responding appropriately to a painful stimulus

Timeline• Acute• Chronic



We are All ‘Color-blind’ to Chronic Pain

Patients’ assessments

correlated with those of:

0-2

Little or no pain

3-6

Moderate pain

7-10

Severe pain

Nurse 82% 51% 7%

House Officer 66% 26% 21%

Onc Fellow 70% 29% 27%

Caregiver 79% 37% 13%



A Tool to Help Assess Pain

N - Number of pains?

O - Origin/causes?

P - Palliates, potentiates?

Q - Quality?

R - Radiation?

S - Severity, suffering?

T - Timing, trend?



Neuropathic Pain

• Origin: – Nerve damage

• Palliates/potentiates: – Set off by unusual stimuli, light touch, wind on skin,

shaving (trigeminal neuralgia)

• Quality: – Electric, burning, tingling, pins & needles, shooting

(system isn’t working right)

• Radiation: – Nerve-related pattern



Nociceptive Pain

• Origin:– Tissue damage

• Palliates/potentiates:– Worse with stress, pressure– Responds better to opioids, NSAIDs

• Quality:– Sharp, dull, stabbing, pressure, ache, throbbing

• Radiation:– Occasionally radiates (less well-defined), but not

along an obvious nerve distribution



Visual Analog Scale

1-3 Tolerable

4-6 Change therapy soon

7-10 Emergency SOS - change therapy now



Suffering

“A state of severe distress associated with events that threaten the intactness of the person”

Cassell,1982

• Subjective: No way to measure it• Significantly diminishes quality of life



Back to the Mnemonic

• Timing:– When the pain occurs or with certain activities

• Trend:– Whether a pain is getting better or worse over time



Total Pain

P - Physical pain

A - Affective distress

I - Interpersonal distress

N - Non-acceptance, or spiritual distress



Discussion

Strategies for alleviating pain:

Non-pharmacologic options



Non-pharmacologic Approaches to Pain

Behavioral therapy

Spiritual counseling

Physical therapy

Psychotherapy

Splinting

Surgical correction

Cold packs

Meditation

Support groups

Radiation therapy

Acupuncture

Hypnosis

Cultural healing rituals

Heat packs

Prayer

Community resources

And others…



General Principles for Alleviating Pain

• Assess with NOPQRST• Identify types(s) and location(s) of pain• Correct underlying cause, if possible• Consider special circumstances

– Avoid specific toxicities– Look for ‘two-fers’– Medication routes– Self-administered or by others



Pattern MatchingS

ever

ity

Time



How Would You Treat the Acute Pain Pattern?

Sev

erity

Time



What Would a Chronic Pain Pattern Look Like?

Sev

erity

Time



Treating Chronic Pain

Basal pain medicine plus a different therapy for spikes:

– Predictable spikes - Short-acting agent prior to event– Unpredictable spikes - Short-acting agent readily

available



Case Discussion

Chronic pain escalating at night - Why?



Brainstorm

How might we treat Mrs. Long’s pain?



Neuropathic Pain Medications

• Opioids, NSAIDs somewhat less effective• Classes of agents:

– Tricyclic for dysesthetic pain– Anticonvulsants for shooting pain– Steroids to decrease peri-tumor edema

• ‘Two-fers’ important in choice of agent(s)• Generally harder to treat than nociceptive pain

– More likely to need specialist expertise



NSAIDs

• May be more effective than opioids with certain

forms of pain• Not necessarily less toxic than opioids• Toxicity can be minimized• For basal pain relief, consider longer-acting

agent for ease of dosing



Combination Drugs

• Advantages:– Aspirin or acetaminophen may act as co-analgesic– Lower level regulatory control

• Disadvantages:– Available in short-acting formulations only– ‘Combo wall’



Acetaminophen With Codeine

• Advantages:– Low regulatory control– Inexpensive– Widely available

• Disadvantages:– 10% cannot convert codeine to morphine– Many drugs interfere with conversion



Acetaminophen with Oxycodone, Hydrocodone

• Oxycodone combination contains 325 mg acetaminophen

• Hydrocodone combination contains 500 mg acetaminophen

• No clear advantage between the two• Dose equivalence is poorly established for

hydrocodone



Case Discussion

• Why didn’t Mrs. Long respond to acetaminophen with codeine?



Opioids

• Morphine• Oxycodone• Hydromorphone• Transdermal fentanyl



Principles of Opioid Use

• No ceiling effect• Dose to pain relief without side effects• Give orally when possible• Sub-cutaneous administration is basically

equivalent to intravenous (and preferable)• Treat constipation prophylactically



Morphine

• Advantages:– Inexpensive– Routes: PO, PR, IV, SC, lingual

• Disadvantages:– Histamine release– Side effects, toxicity in high dose/renal failure– ‘Psychological allergy’

• Formulation:Long-acting ‘wax matrix,’ short-acting liquid, tab



Standard Starting Dose

• For opioid-naïve, 5-10 mg PO q4 PRN• After getting an idea of the 24-hour dose, go

to long-acting• Or start with 15 mg q12 long-acting• There is no ceiling effect



Oxycodone

• Advantages:– Good alternative to morphine– Available PO: long-acting (q8-12) or short-acting– ? Less CNS alteration than with morphine– ? Less histamine release

• Disadvantages:– More expensive than morphine– No parenteral form available in the U.S.A.



Hydromorphone

• Advantages:– Available PO, IV, SC– Good alternative to morphine for parenteral use– No known toxic metabolites– Long-acting oral form now available



Transdermal Fentanyl

• Advantages– Non-enteral administration– Change q72h– Steady blood levels

• Disadvantages– Local skin problems– Delayed onset and offset– Cumbersome to titrate (only q72h)– 20% of people need it changed q48h– Expensive



Question

What were the general principles of opioid use we mentioned earlier?



Case Discussion

What do you suggest to help alleviate Mrs. Long’s pain?

What more do we need to know?



Case Discussion, Continued

Mrs. Long has bony pain in the hip that seems to be nociceptive

• What might this pain pattern look like?• What should we treat her with, and why?



Opioid Conversion

• This is a crucial skill in ELC• Traditionally, it was viewed as a task• It would be more correct to think of it as a

process



Using Opioid Conversion Tables

• Calculate 24h equivalent of old drug• Convert to 24h equivalent of new drug or route• Calculate new dosing interval• Divide 24h dose by new dosing interval• Round off this value• Account for residual drug



Application

• Mrs. Long is admitted to the hospital and can no longer take pills

• She has been taking sustained action oral morphine 60mg q12

• Her family just managed to get her to take her last dose 2 hours ago

• Her pain is well controlled• You want to start her on a SC infusion of

morphine



Warnings

• Most narcotic conversion charts are based on peak drug levels

• Increase on percentage basis not dosage: 25-50% per each 24 hours

• Dose to comfort or side effects (monitor)



Opioids May Differ

Opioids may differ from each other significantly in:

• Mechanism of action• Degree of cross-tolerance



Two Principles

In the conversion process:

• For the new drug, use basal doses initially• Be relatively liberal in your use of

breakthrough/short-acting doses



Conclusion

Practice!



Learning Objectives

Recognize and address barriers to effective pain care

Develop a better understanding of attitudes and beliefs about pain management

Improve your knowledge and skills in assessing and treating pain

Incorporate this content into your clinical teaching

.


Documents

Http:// Module #2 END-OF-LIFE CARE: Module 2 Pain Management