Basic and Advanced Pain Management for Clinicians - Margaret Jacobson and Shaun Sullivan

Palliative Care Summer Institute

Basic and AdvancedPain Management for

CliniciansMargaret A. Jacobson, MD

Shaun Sullivan, MDMedical Directors, Whatcom Hospice


Effective pain management is a moral imperative, a professional responsibility, and the duty of people in the healing professions

Relieving Pain in America: Institute of Medicine (2011)


2010 Washington State Rules regarding chronic pain management DO NOT APPLY to

Chronic cancer pain Acute pain caused by an injury or a surgical

procedure Palliative, hospice, and other end-of-life care

Pain Management for whom?


1986 WHO Pain Ladder


2015 WHO Pain Ladder


Ongoing Individualized Documented

“Tell me about your pain….”

Pain Assessment: The cornerstone of optimal pain management


OPQRST “Tell me about your pain”

Onset Provoking, Palliating Quality Region/ Radiation Severity Treatment Understanding


Universal Pain Intensity Assessment Tool


Analgesics should be given “by mouth, by the clock, by the ladder, and for the

individual”(World Health Organization)

Principles of Analgesia


It is not necessary to traverse each step of the ladder sequentially

For mild pain (1-3) start at step 1 For moderate pain (4-6) start at step 2 For severe pain (7-10) start at step 3

…By the WHO ladder


Safe Reliable Effective for all types of pain Have multiple routes of administration Are easily titrated

Opioids: Mainstay of treatment of moderate-severe pain in advanced illness


Opioids follow first-order kinetics and pharmacologically behave similarly Peak plasma concentration (C max)

60-90 minutes after oral administration 5-10 minutes after IV administration

Opioids are eliminated from the body in a direct and predictable way, irrespective of the dose The liver conjugates them The kidney excretes 90-95% of the metabolites Their metabolic pathways do not become saturated

Each opioid metabolite has a half life that depends on its rate of renal clearance When renal clearance is normal, codeine, hydrocodone, hydromorphone,

morphine, and their metabolites all have effective half lives of approximately 3-4 hours

When dosed repeatedly, their plasma concentrations approach a steady state after about 4-5 half lives (1 day)

Opioid Pharmacology


Routine dosing: Dosing interval is 1 half life

4 hours Bolus/breakthrough dosing: dosing interval

is time to peak effect

1 hour orally, 10 minutes IV Steady state: achieved after 4-5 half lives

1 day

Opioid pharmacology simplified


Constant pain needs constant control Start an opioid naïve patient with a short acting opioid, and

dose every 4 hours, NOT prn The best possible pain control for the dose will be achieved

within a day (once steady-state is reached) Provide the patient access to prn doses of the SAME medication

that can be used should breakthrough pain occur Every hour for oral opioids Every 10 minutes for IV opioids Do not use extended release opioids for rescue dosing Longer intervals between breakthrough dosing only

prolong a patients pain unnecessarily

Opioid basics


Renal considerations Opioids and their metabolites are primarily excreted renally Morphine has 2 principal metabolites: 3 and 6 glucuronide Morphine 6 glucuronide is active and has a longer half life

than the parent drug With impaired renal clearance, excessive accumulation of

the drug must be avoided by either Increasing the dosing interval Decreasing the dose

With oliguria or anuria, stop routine dosing and administer only as needed

Renal Failure considerations


Opioid metabolism is not as sensitive to hepatic compromise

With severe hepatic impairment Increase the dosing interval Decrease the dose

Liver failure considerations


DRUG IV PO

Morphine 10mg 30mg

Codeine 200 mg

Hydrocodone 30 mg

Oxycodone 20 mg

Hydromorphone 1.5 mg 7.5 mg

Fentanyl 0.1 mg

Equianalgesic conversions

Important insights: 1. Oral morphine and oral hydrocodone are equally potent2. Oral oxycodone is more potent than oral morphine3. Hydromorphone is 4-7 X more potent than morphine


Opioid side effects


Clinician barriers

Barriers to effective use of opioids


Patient barriers

Barriers to effective use of opioid

Healthcare

Basic and Advanced Pain Management for Clinicians - Margaret Jacobson and Shaun Sullivan