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TRANSCRIPT
Pain Management
Christine Nevins-Herbert, MD
Disclosures
Nothing to disclose
Objectives
Understand the basic physiology of pain Review different types of pain and how to
assess pain Focus on appropriate pain management
with opioids
*Not a lecture on opioid addiction/ misuse, long term outpatient opioid prescribing, or determining who is appropriate for opioids
What is Pain?
An unpleasant sensory and emotional experience associated with actual or potential tissue damage
- International Association for the Study of Pain (IASP)
Concept of Total Pain
Physical Emotional Social/interpersonal Spiritual/existential
Pathophysiology of Pain
Detected by peripheral nociceptors – Nociceptors – primary sensory neurons that
respond to painful stimuli – In skin, muscle, joints, viscera – A delta fibers – immediate, sharp pain – C fibers – delayed, longer lasting dull pain
Nociceptors send afferent signals through dorsal horn of spinal cord to brain
Spinothalamic Pathway
Multiple ascending pathways involved Signals sent via spinothalamic tract –
synapses in thalamus Neurons in thalamus project to primary
somatosensory cortex
Acute vs. Chronic Pain
Acute Pain – Serves a purpose, time limited – Cause often known – Diminishes as healing takes place – May have observable signs
Chronic Pain – Purposeless, cyclical, irreversible – Vegetative, depressive signs – Autonomic adaptation
Why Treat Pain?
Promote healing Patient experience/satisfaction Improve quality of life Alleviate suffering Avoid evolution to chronic pain
Consequences of Undertreatment in Elderly Depression Anxiety Social isolation Cognitive impairment Immobility Sleep disturbances Delirium
Types of Pain
Nociceptive – Somatic – Visceral
Neuropathic Mixed Psychogenic
Nociceptive Pain
From actual or potential tissue damage Somatic
– Nociceptor activation in body surface or musculoskeletal tissue
– Easy to localize – “sharp, stabbing, aching, throbbing”
– Examples: arthritis, wounds, bone mets
Nociceptive Pain
Visceral – Nociceptor activation due to compression,
obstruction, infiltration, ischemia, stretching, or inflammation of viscera
– Difficult to localize – “cramping, gnawing, pressure”
– Examples: SBO, angina, liver mets, urinary retention, constipation
Neuropathic Pain
Direct injury or dysfunction of peripheral or central nervous system
“Burning, shooting, tingling” Examples: diabetic neuropathy,
postherpetic neuralgia, radiculopathy, phantom pain, post-mastectomy or post-thoracotomy pain syndromes
Assessing Pain
O – Onset – When did it begin? How long does it last?
How often does it occur?
P – Provoking/palliating – What makes it worse? What makes it
better?
Q – Quality – What does it feel like? Can you describe it?
Assessing Pain
R – Region/Radiation – Where is it? Does it go anywhere else?
S – Severity – How intense is the pain (0-10 scale)? Right now?
At its worst? At its best?
Assessing Pain
T – Treatment – What medications are being used? How effective
are they? Any side effects? What have you tried in the past?
U – Understanding/Impact – What do you think is causing the pain? How is the
pain affecting you? Functional impairment? Impaired quality of life?
V – Values – What is your goal? What level of pain would be
acceptable for you?
Barriers in the Elderly
Under-reporting by patients Atypical manifestations of pain in the
elderly – Changes in function or gait – Withdrawn, agitated, confused
Misconceptions about tolerance and addiction to opioids
Reluctance to use opioids
Opiates
Receptors involved – Mu, kappa, delta
Mechanism of action – Bind to receptors – Modulate pain by inhibiting calcium
channels – Prevent or induce release of
neurotransmitters
Opiates – Adverse Effects
GI – constipation, nausea, vomiting Autonomic – dry mouth, urinary
retention, postural hypotension Cutaneous – itching, sweating CNS – sedation, confusion, dizziness,
hallucinations, delirium Pulmonary – respiratory depression True allergy is rare
Definitions
Tolerance – physiologic state; effectiveness of drug has decreased due to chronic use; need higher dose to achieve same effect
Physical dependence – how body experiences physiologic adaptation; withdrawal if stopped abruptly
Definitions
Addiction – behavior; compulsive use of drugs often for inappropriate reasons; continued use despite harmful consequences
Pseudoaddiction – behavior that mirrors addiction; often due to inadequately controlled pain
Opioid Calculation and Conversion
Getting Started
Consider scheduled tylenol “Start low, go slow” especially in elderly Tempting to use tramadol and lidocaine
patches in elderly – Tramadol: dizziness, lowers seizure threshold,
med interactions – Lidocaine patches: cost, works topically, does
not penetrate bone or joint space
Getting Started
Start with short acting opiates in opiate naïve patient
Long acting opiates should only start after 24hr need is assessed
Breakthrough dose should be 10-15% of total daily dose
Breakthrough Dose?
Patient is on MSContin 150mg q12hrs
What should breakthrough/short acting dose be?
Breakthrough Dose
Total daily dose is 300mg of PO morphine
Breakthrough dose should be MSIR 30-45mg q3-4hrs prn pain
Adjusting Long Acting Dose
Generally, if 3 or more breakthrough doses are used in 24hrs – Increase long acting opiate by 50-100%
of total amount of breakthrough med used in 24hrs
Long Acting Dose?
Patient is on MSContin 100mg q12hrs Has used 6 breakthrough doses of
MSIR 30mg in the past 24hrs
What should the new MSContin dose be?
Long Acting Dose
Patient used 180mg of breakthrough morphine
MSContin should be increased by 90-180mg = 145mg q12hrs - 190mg q12hrs
Based on patient’s pain intensity, side effects, and goals of care
Opioid Rotation
Intolerable side effects Poor analgesic effect despite aggressive
dose titration Drug-drug interactions Change in route Drug availability
Opioid Rotation
Dose of new opioid should be reduced by 25-50%
Accounts for incomplete cross-tolerance – Due to differing structures of individual
opioids and action at various receptors
Potency
IV opioids are more potent than oral opioids – Morphine 3:1 – Dilaudid 5:1
Dilaudid is far more potent than morphine – PO dilaudid 4x more potent than PO
morphine – IV dilaudid nearly 7x more potent than IV
morphine
Potency
Fentanyl patches – 50mcg fentanyl patch = 40mg IV morphine
= 120mg PO morphine
Caution
Long acting opioids (MSContin/ Oxycontin) should not be given any more frequently than q8hrs
Long acting opioids cannot be crushed Long acting opioids should never be
used for breakthrough pain
Breakthrough Pain
If separating PRN meds based on mild, moderate, severe pain – Make sure it makes sense equianalgesically – Make sure full range is covered
Fear of Respiratory Depression Principle of double effect Sedation will always precede respiratory
depression Consider use of holding parameters
– Hold for RR <10
Conversion Questions
MSContin to TD Fentanyl
1. 85 y/o M with lung cancer on MSContin 100mg q12hrs which has been effectively controlling pain for the past few months. He is now having trouble swallowing. What would be an appropriate dose of a fentanyl patch?
Decrease dose by 40% for incomplete cross tolerance.
MSContin to TD Fentanyl
Total daily dose of morphine = 200mg Decrease by 40% (80mg) = 120mg 120mg oral morphine = 50mcg fentanyl
patch
IV Morphine to PO MSContin
2. 78 y/o F with metastatic breast cancer on morphine drip at 4mg/hr in the hospital. She is getting ready to be discharged home and wants to switch to oral meds. What dose of MSContin would you recommend? (Comes in 15mg, 30mg, 60mg, and 100mg)
What would be an appropriate breakthrough dose?
IV Morphine to PO MSContin
4mg/hr x 24hrs = 96mg IV morphine/day IV:PO = 1:3 96mg x3 = 288mg PO morphine/day 288/2 = 144mg PO morphine q12hrs 145mg MSContin q12hrs Breakthrough dose 10-15% of total daily
dose ≈ 30mg MSIR q3-4hrs prn
Morphine drip to Hydromorphone drip 3. 71 y/o M with colon cancer has been
well controlled on morphine drip at 30mg/hr, but has developed uncomfortable itching. What would be an appropriate hourly rate of hydromorphone?
Decrease dose by 33% for incomplete cross tolerance.
Morphine drip to Hydromorphone Drip 30mg/hr IV morphine - 33% (10mg) =
20mg/hr IV morphine IV morphine:IV hydromorphone =
10:1.5 = 6.67 20/6.67 = 3mg/hr IV hydromorphone
TD Fentanyl to IV Morphine
4. 78 y/o F with ovarian cancer has been well controlled on 200mcg fentanyl patch, but has developed fevers. She also has difficulty swallowing and plan is to start morphine via pump. What would be an appropriate hourly rate of morphine?
Decrease by 40% for incomplete cross tolerance
TD Fentanyl to IV Morphine
200mcg fentanyl = 160mg IV morphine 160mg - 40% (64mg) = 96mg IV
morphine/day 96mg/24hrs = 4mg/hr IV morphine
Percocet to Oxycontin
5. 67 y/o M with renal cancer has been taking Percocet 5/325mg (oxycodone/ acetaminophen) 2 tabs every 4 hours, but does not wake up overnight to take a dose, and often wakes up in the morning in a lot of pain. Plan is to start Oxycontin q12hrs. What would be an appropriate starting dose of Oxycontin?
Percocet to Oxycontin
10mg oxycodone x6 = 60mg oxycodone/ day
60/2 = 30mg Oxycontin q12hrs
Reasonable to continue percocet 2 tabs PO q4hrs prn breakthrough pain
Questions??