Pain Management

Part I: PAIN MANAGEMENT IN HOSPICE

*** PAIN: subjective unpleasant physical & emotional experience
***pain what patient says “hurts”; believe the patient
**pain is not : due to old age, a last ditch, wrath of God,
**good pain control will not shorten life,
**Morphine do not hastens death

1. General pointers:

**Pain is often under treated,

**> 90% of pain in hospice can be controlled
**only 1-2 % may need palliative sedation
**the palliative sedation is excellent supportive care is not to be confused with euthanasia
**In Hospice: 70-90% experience pain; 50% moderate; 30 % severe pain
**pain equal to or > 5/10 will affect the quality of life
**almost all patients can have good control of pain
** treatment: start low, go slow but keep going up till you achieve patients goals
** do not wait for testing, investigations and records to be collected
**50 million people in US have chronic pain,
**Pain : 70-78% in cancer and MS; 30-79% in AIDS;
**Cost 100 billion / year
***Pain is fifth vital sign
**unrelieved pain is a major source of fear
***4/10 do not get adequate relieve of pain
***Unrelieved pain causes : anxiety, depression, memory loss, sleep disturbances; affects physical, emotional, social life; work related activities, affects practically every aspect of the person’s life
***Barriers to good pain control: both patients / physicians/nurses/family/ friends have fear of addiction, dependency; different myths & believes, cost of meds, misuse, regulatory over sight, will use pain medications later
***Pain description: where, when, how, type, continuous, intermittent, location, radiation, intensity, triggers, relieving factors, aggravating factors, associated s/s, quality of life, medications used,
**frequently evaluate & re-evaluate the pain

2. Pathophysiology:
***Acute pain : identifiable event, days to week, usually Nociceptive
***Chronic pain: difficult to identify an event or time period, multifactorial,
***Nociceptive pain: can be somatic / visceral, due to direct involvement of thermal, mechanical or chemical receptors, Rx opioids, =/- co-analgesics,
**visceral pain: involves the viscera, due to autonomic nervous system, difficult to described / localize at times; cramp, pressure, due to lung cancer, gallbladder, bowel obstruction
**somatic pain: due to soma, skin, muscle, soft tissue, or bone; localized, trauma, tissue damage, burn, metastasis; *throbbing, aching, gnawing,
***Neuropathic pain: due to nerve / CNS involvement, due injur to nerve, compression, infiltration, ischemia *neuropathic pain : BENTSS = burning, electrical, numbness, shooting, tingling, stabbing; plusating, sharp, lancinating *requires TCA’s; anticonvulsants, but opioids may be needed
** pain is caused by disease process but increases due to fear, fatigue, frustration, untreated depression; unresolved spiritual, mental, physical and social issues

3. Assessment :
***Pain assessment : process of pain management starts with good History / physical exam (80% help), onset, quality, type or nature, location, intensity, duration, onset, relieving / aggravating factors, response to prior treatments, current medications, patients goals. we need to know nature, cause, social, emotional, spiritual factors. collect information about pathophysiology of pain.
***does the pain interfere with ADL (activities of daily living), sleep, relaxation, work, Family time, good time!
**use all of your team members
**Pain reported by patient or care giver, believe them
**Scale: 0-10; 0= no pain; 10 is maximum; target to bring pain down to < 4
**examine the site, review the medications with each visit
**Asses the total patient
**asses for functional limitations due to pain
**successful plans are tailored to the individual patient
**ask for help

4. Guideline for consideration plus other pointers:
*** Pain decreased by: Adequate sleep, Discussing worries and fears, Resolving emotional problems, controlling other symptoms, maintaining contact with family and friends, relaxation, Aroma therapy, Various activities: Yoga, Tai Chi, biofeedback, resolving conflicts, TENS unit,
**pain can / should be controlled
**escalating / acutely increasing pain is an emergency
**addiction is not an issue at this stage (hospice)
**Physician’s / nurses barriers to control pain: addiction; dependency; diversion; Regulatory issues;
**patient’s related barriers: addiction; dependency; cost; saving pain meds for future use; worsening of disease process
**the goal: adequate pain control, happy & alert patient depending upon the stage of the disease process

***pain could be due to: disease +/- physical, mental, emotional & spiritual problems
**Nurses: before calling doctor: have all the facts ready; good history, conceptualize the pathology & causes, med list, failed meds, your plan of care & your suggestions, be concise
**no placebos
**if practical treat source of the pain (radiation for cancer)

**Long acting opioids as baseline around the clock, Q 8 or 12 hrs mostly (think of 2-3 good meals a day)

**PRN: immediate release opioids ; used it as needed, 10-20% of total dose; oral q 1-2 hrs; SQ / IV PRN is q 30-60 minutes (think of snacks)

**adjust baseline meds daily up in the amount equivalent to daily PRN, except Methadone
**oral route better than SQ better than IV
**Renal failure, liver problems, elderly start with 1/2 the dose, keep it low,

***Opioids are renally excreted except Methadone

***treatment: start low, go slow, keep going up till goals are met
**prefer PO,
**routine meds for constant pain,
**PRN meds for breakthrough meds,

***ANALGESIC LADDER: 1986

By mouth, by the clock, for the patient, attention to details
I. Mild pain: (1-3) Non-Opiod ± Adjuvant
II. Moderate pain: (4-7) Opioid ± Non-Opioid ± Adjuvant
III. Severe pain: (8-10) morphine ± Non-Opioid + Adjuvant

***Control “total pain” which require physical, psychological, spiritual & social therapies

**First line=NSAIDS, Tylenol
**Mild Opioids: Vicodin, Codeine,
**MILD TO MODERATE PAIN: NSAIDS ± Vicodin or Percocet
**Moderate pain: Percocet, Oxycontin
**Strong Opioids: for strong pain: Morphine, Methadone
**First line=NSAIDS, Tylenol, Mild Opioids: Vicodin, Codeine,
**MILD TO MODERATE PAIN: NSAIDS ± vicodin or Percocet
**Severe pain: Morphine, Methadone, Dilauded, Duragesic

***ADJUVANT ANALGESICS: Adjuvant analgesics are co-analgesics. They have analgesic properties but developed for something else. They help to alleviate pain either alone or in combination with pain medications. Elavil, Trazodone, Paxil, Prozac , Cymbalta,Tegretol, Neurontin, Lyrica, Calcitonin, Capsaicin , Baclofen, Clonidine, Dextro-methorphan, Neuroleptics, Bisphos-phonates (Fosamax), Miacalcin, Scopolamine, Nonsteroidal Anti-inflammatory (NSAIDS),Local applications (lidoderm patches or 4% local lidocaine),Cox-2: Celebrex,
***ADEQUATE TREATMENT OF PAIN: Chronic pain in hospice: intractable, irreversible, requires special attention & skills
** Cancer pain: Opioid therapy is the first-line approach for moderate to severe pain
** > 95% of pain can be controlled
**Severe pain is a medical emergency which should be treated promptly & adequately
**Addiction is very rare when opiates are used for pain relief in hospice
**Don’t use Agonist / Antagonists with morphine: Stadol ( Butorphenol), Nubain (Nalbuphine), & Talwin (Pentazocine)

**No Demerol: breakdown products are epileptogenic
** Adequate analgesia
** Control insomnia
** Radiation therapy: reduces a tumor’s mass, pathological fracture, painful localized bony metastases, Epidural met, Spinal Cord compression
** Debulking a soft tissue tumor may not relieve pain
** Immobilize fracture or joint
**Estrogens or Lupron (gonadotropin inhibitor) in metastatic prostrate cancer
**Co-analgesics : NSAIDS, Adjuvant analgesics, Anti-depressants , Muscle relaxants, Hypnotic, Anxiolytic , Neuroleptics, Corticosteroids,
**Explanation, Education, Counseling, Relaxation therapy, Imagery, family support

**Physical Dependence: Withdrawal symptoms on abrupt dose reduction
**withdrawal S/S : for short acting meds starts in 6-12 hrs; peak in 48-72 hours; remember DT’s : irritability, severe anxiety, rhinoorhea, nausea, vomiting, diarrhea, lacrimation, HTN, tachycardia, hypervigilence, insomnia,

Pseudo addiction: 1989, due to poorly treated pain, Improves with adequate Rx, aggressive dose escalation, establish trust & confidence

**Tolerance: Diminish drug effects
**Substance abuse: Use of a drug illegally
**Addiction : craving, primary chronic neuro-psych & behavioral disorder, *continuous compulsive use of drug despite harm, SO “compulsive use of drug with loss of control despite harm”
** Psychological dependency : lies and play tricks to get more medications, clock watching, excessive complaints, use of meds despite harm, family/ friends have substance abuse, avoid referral and non drug treatments, drug seeking (reports his are stolen), loss of control over drug use, frequently takes extra doses, overwhelming involvement with acquisition of drugs, compulsive drug use,
**Tolerance: increasing dosage to achieve the same effect, uncommon, not diagnostic of addiction
**Physical dependence: withdrawal when drug is suddenly stopped, most pain patient could have this,

*** Tylenol : Acetaminophen: step 1 analgesic, coanalgesic, > 4 g / day, ceiling effect, increased risk with alcohol abuse / hepatic disease
***NSAIDs: step 1, coanalgesic, ceiling effect, used: bony pain, bony mets, inflammation,

***vicodin 5/500 = morphine 5 mg

***NON-OPIOID-ANALGESICS: NSAIDS, Prostaglandin-synthesis inhibitor, no central effect **Side effects: bleeding under the skin, GI blood loss, renal dysfunction, liver (rare) **all have ceiling effect **GI side effects seem to be quite low with Tylenol, Arthrotec, Relafen, Lodine, Trillisate, Dolobid, Disalcid, Celebrex, Mobic
**1st line: Ibuprofen or Naprosyn or Indocin with or without Cytotec (misoprostol) protect GI side effects **Avoid Tylenol in liver failure
**uses of non- Opioids: bony mets, pancreatic ca, head & neck tumor, tissue damage, joint inflammation, arthralgia

***OPIOID ANALGESICS:
For severe chronic intractable pain drug of choice is Morphine sulfate,
**morphine has Mu1 Mu2 receptors
** Opioids are Safe & Effective
**Pain should be anticipated, and treated with regular dosing not PRN
**good dose: alert but has less pain
**no ceiling dose of effectiveness
**Anticipate constipation & Rx
**Rx Nausea: Reglan, Haldol, Scopolamine

**tolerance & addiction is rare
**Morphine does not shorten life
**Dilaudid (hydromorphone): use in morphine intolerance, potency X 4 morphine
**Methadone (dolophine): use in Morphine allergy, drug accumulation, sedation, constipation
** 1% of patients are intolerant to morphine (severe, persistent nausea, vomiting) then use Dilauded, if fails use Methadone (different chemically)
** Demerol, short acting, breakdown product that causes seizures (not used in hospice)
** Duragesic (fentanyl) patch or lollipop
** use same type opioids for long and short acting (MS Contin & MS IR)

***Morphine Sulphate (MS)
Morphine sulphate: can be used in tab/Elixir/SQ/IM/IV/Rectal forms
** long acting morphine was introduced in 1985
**most commonly used in hospice
**Poor pain control: increased MS by 50% & add TCA or adjuvant meds (may enhance MS effect)
**Still in pain: Re-evaluate, consider: Neuropathic pain, neuralgia, infection, muscle spasm, bony pain, vascular disorders, Stress, depression ; Still no help: Radiation, hormonal therapy, counseling / psychotherapy, Co-analgesics, non drug measures, Antidepressants, Chemotherapy
**SE: drowsiness, confusion, nausea, vomiting, constipation, bowel obstruction, urinary retention
** Drowsiness for > 2-3 days, then decrease narcotics 10-25% &/or decrease sedatives; switch meds, use long acting Opioids *Consider: Ritalin, Dexamphetamine **Nausea: Antiemetics: Compazine, Haldol
**Constipation: Docusate; Senokot; Pericolace, Enema
**Narcotic excess: miosis, sedation, hypo-ventilation, prolong confusion: lower the dose by 50% or more **Morphine-intolerance change to Dilaudid
**Allergic to Morphine: use Methadone (chemically different) or Fentanyl
**used in appropriate patients, Morphine does not cause addiction, or tolerance
**when patient is on higher dosage the increments should be larger
**Prior to death, do not stop; use 25-50% of the usual morphine dose to avoid withdrawal symptoms (restlessness, sweating, and tremulousness)
**If pain lessened lower Opioids
** > 40% receive poor pain control (fear of addiction, lack of experience & knowledge) **No addiction to Morphine in chronic pain in hospice
**Dosing Schedule: Fixed Schedule Dosing has replace PRN dosing in hospice
**PRN= rescue dose in Hospice= 10% to 20% of the total daily dose
**Otherwise PRN means pain relieve not enough
**Do not wait for days to control the pain
**Methadone: long-half life, pain relieve lasts for few hours, 5-6 hrs
**The myths of tolerance, addiction, and respiratory depression led to the poor management of cancer pain
**Start with a low dose and adjust according to the response & goals
** Tolerance: does not occur & Respiratory depression does not occur when morphine is correctly to control pain
**Try to achieve full pain control
**TCA & Adjuvant or Co-analgesics may potentate morphine

****Methadone:
*increasingly used in the last 6 years due to the price and found to be effective even in Neuropathic pain, **methadone accumulate with chronic dosing,
**Inhibits reuptake of nor epinephrine & seratonin, binds to NMDA receptors (NMDA receptor antagonist) : prevention of opioid tolerance, potentiation of opioid effects, and efficacy for neuropathic pain syndromes,
**increase deaths due to: accidental overdose, improper prescribing, recreational use, improper use, increasing the dose without being recommended;
**QT interval prolongation
**a potent opioid agonist, useful when continuous opioid analgesia is needed
**special license is required to prescribe methadone for the treatment of addiction.

**highly lipophilic with rapid GI absorption and onset of action.
It has a large initial volume of distribution with slow tissue release.
Unlike morphine there are no active metabolites, can be use in renal failure
Metabolized in the liver with significant fecal excretion; renal excretion can be enhanced by urine acidification (pH <6.0). Available in tablet, liquid and injectable forms; oral preparations can be used rectally.

**half life 190 hrs, but pain relief lasts for 6-12 hrs once steady state is reached
**rapid dose adjustment could be dangerous

Morphine to Methadone conversion
* methadone is at least 10 times more potent than morphine

<100 mg – 3:1 (i.e., 3 mg morphine:1 mg methadone)
101-300 mg – 5:1
301-600 mg – 10:1
601-800 mg – 12:1
801-1000 mg – 15:1
>1001 mg – 20:1
Due to incomplete cross-tolerance, it is recommended that the initial dose is 50-75% of the equianalgesic dose.

Methadone is not indicated in poorly controlled pain where rapid dose adjustments are needed; do not increase oral methadone more frequently than every 4 days.
Dose conversion to:from other opioids and methadone is complex; consultation with pain management specialists familiar with methadone use is recommended.
Patient and family education is essential as they may misinterpret prescription of methadone to mean that their physician believes that they already are an addict.

***Fentanyl :
It may increases sedation / respiratory depression in opioid naive, elderly, renal, liver impairment. All equianalgesic ratios are approximations. use lower end whenever converting. start low, go slow. use more frequent PRN doses to avoid opioid withdrawals. The max therapeutic levels reach in 13-24 hrs. The medication over the skin continue to supply medication for 24 hrs after removing the patch. You can change patches every 72 hrs (except in some will be 48 hrs). The titration should be no less than 72 hrs, no direct heat over the patch, apply patches to hairless areas.

** NEUROPATHIC PAIN: Sharp, shooting, burning, due to nerve involvement **Rx: *TCA *SNRIs: Effexor Cymbalta *Tegretol * Neurontin *Depakote * Dilantin

***BONY PAIN: = Severe, constant, worse pain with movement, poorly correlate with site **80% by breast, lungs, and prostate, others 20% **w/u: X-rays, Bone Scan (2mm lesion); CT; MRI; Bone Biopsy
***Metastases (most common axial mainly lumbar or lower extremities), compression or pathological fractures ** NSAID’s **corticosteroids **Bisphos-phonates **Calcitonin **radiation **Tamoxifen **Opioids **chemotherapy **RADIATION: treatment of choice in uncontrolled bony pain,hemoptysis,Tumor (pleura or chest wall), bleeding, Pleural effusion, bony mets = Pre-med: Steroids Hydrocortisone 100 mg & Antiemetics Reglan 10-20 mg IV= 4 800 RADS single dose 4 3000 RADS in ten divided doses as 300 RADS X 104 800 RADS upper body & 1-2 months later lower body
**Radiopharmaceuticals: Strontium 89 (89 SR); Samarium 153 ( 153 Sm) and Phosphorus (32 P) : high affinity binding to Hydroxyapatite in rapid bone turnover near the osteoblastic metastases, * given in single IV without any special preparation, *eligibility: prostate, breast mets, if life expectancy is > 3 months, transient increase in pain around the first week (good response)*no one agent is superior *do not use: cord compression, pathological fracture, WBC < 3, platelets < 60-100 K

****Pointers
***Naloxone: in dire emergency: dilute 0.4 mg with 9 ml NS, give -2 ml q 15 minutes until effective; repeat 30-60 min
**Morphine gel nor mouthwash works well (avoid)
**Pain in impaired patients: try history taking, interview caregivers & family & friends, watch facial expressions, vocalizations, posture, irritability, interaction, appetite,
**Pain in Assisted living or nursing home: discuss with nurses & supervisors, educate them, ask nurses to do complete pain assessment frequently, use non- pharmacologic therapies, schedule pain meds, PRN pain meds, bowel regimen, prn pain med before activities or therapies,
***Monitoring patient with pain: detail pain history, evaluation, impression and formulate a treatment plan, then reassess frequently, adjust the dosing and control the symptoms, most of the Opioids agonist do not have ceiling effect,
** do not forget non- pharmacologic therapies
**educating : patient, family, caregiver and on- call or cross covering personnel
**ongoing assessment of treatment outcome
**in hospice involve all team members to help the patient
**be flexible
**ask for help when your plans are not fruitful
***acute pain: lasts days to weeks, easily identifiable condition or injury, or event
***chronic pain: cause is not easily identifiable, nociceptic or neuropathic, unknown duration,
***unmanaged pain may lead to changes in the nervous system that could reduce its responsiveness to treatment (unmanaged pain causes nervous system changes, in turn causes permanent damage which amply the pain)
***unmanaged / poor pain control can have a devastating psycho- social and mental and physical effect on patient and family
***C max for oral opioids is 60 minutes, subcutaneous / IM is 30 minutes, IV is 6 minutes
***90-95% is excreted through kidneys
*** plasma concentration reach steady state in 4-5 half lives
***Methadone: even though the half life is long but analgesia lasts for 4-8 hours, adjust the dose every 4-7 days
*** Corticosteroids: frequently helpful & commonly used, Dexamethasone, with its long half-life (>36 hours) & less mineralocorticoid effect,is the adjuvant steroid of choice. It can be administered once a day.
***chronic pain never ends in hospice
,
*** breakthrough meds: used : end of dose failure of long acting opioids, incidental pain, spontaneous pain
***Duragesic: Fentanyl: 72 hours half life, requires slow titration, incomplete cross tolerance, skin acts as reservoir so patch is removed may not stop the absorption,
***Adjuvant Analgesics: Antidepressants, anticonvulsants, muscle relaxants, steroids, antiarrythmics
***Anticipate, Prevent, & Manage effects & side effects
***Incomplete cross tolerance is most likely due to subtle differences in each opioids, start with 50-75% of published equianalgesic dosing, may need to reduce the dose as much if pain is poorly control

0pioids in hospice

See picture attached to this document. It is black & white so you can Print it.

My formula to calculate the Opioid dose is:

                N
X = —————–X (OD 24 hrs. dose)
               O
N=equivalent dose of new drug from chart above
O=equivalent of old drug from the chart above
OD 24 hrs dose=24hrs dose of old drug.
X=24 hrs dose of new drug po

After the calculation : 25% reduction for incomplete tolerance

Further reading : http://endlink.lurie.northwestern.edu
http://endoflife.stanford.edu
http://eperc.mcw.edu/EPERC/FastFactsandConcepts
Dr. Kazmi,
3-25-13