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PAIN CONTROL

PAIN CONTROL. Edward Warren, MD, CAQG Chair Geriatrics VCOM, Carolinas Campus. Learning Objectives:. By the end of the session, participants will be able to: Discuss the generation and perception of pain and use this understanding clinically. Assess patients effectively for pain.

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PAIN CONTROL

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  1. PAIN CONTROL Edward Warren, MD, CAQG Chair Geriatrics VCOM, Carolinas Campus

  2. Learning Objectives: By the end of the session, participants will be able to: • Discuss the generation and perception of pain and use this understanding clinically. • Assess patients effectively for pain. • Overcome barriers to pain control in patients and staff. • Use non-pharmacologic strategies to treat pain. • Use opioid pain medications safely and effectively. • Use adjuvant medications to treat pain. • Avoid and manage side effects. • Manage opioid addiction, tolerance, dependence, and abuse.

  3. Prevalence of Pain

  4. What is Pain? Pain is “ whatever the experiencing person says it is and (it) exists whenever he says it does.” -- M. McCaffery

  5. TOTAL PAIN A concept introduced by Dame Cicely Saunders, founder of hospice • Physical • Psychological • Emotional • Social • Spiritual

  6. Pain Terms • Allodynia – pain from stimuli that are not usually painful • Hyperalgesia – increased sensitivity to normally painful stimuli

  7. Pain Results in: • Decreased mobility • Sleep disturbance • Agitation • Behavioral problems • Depression

  8. Pain as the Fifth Vital Sign • Temperature • Pulse • Respirations • Blood Pressure • Ask about pain !

  9. Nociceptive Pain Initiation

  10. Nociceptive Pain Experience

  11. Neuropathic PainVSSC = voltage sensitive sodium channels

  12. Neuropathic pain • Pain may exceed observable injury • Described as burning, tingling, shooting, stabbing, electrical • Management • opioids • adjuvant / coanalgesics often required

  13. Neurotransmitters Impacting Pain 5HT = serotonin NE = norepinephrine NO = nitrous oxide

  14. Opiate, NE, & 5HT Influence on Pain

  15. NSAID Acts on Pain at the Sensor

  16. Opioid Action on Pain at the μReceptor of the Nucleus Acumbens

  17. SNRI Action on Pain at the Locus Coerulius via NE • SNRI’s are serotonin and NE reuptake inhibitors. • The Locus Coerulius is on the ventral brainstem and is the origin of most NE neurons.

  18. SNRI Action on Pain at the Median Raphe via Serotonin • SNRI’s are serotonin/NE reuptake inhibitors. • The Median Raphe, on the ventral brainstem,is the origin of serotonin neurons.

  19. a2d Ligands: pregabalin & gabapentin a2d Ligands bind to voltage sensitive calcium channels at the dorsal horn (and centrally) to decrease excitatory transmission.

  20. Assessment of Pain P - Palliative and Pejorative Factors Q - Quality of Pain (more than one type?) R - Region and Radiation S - Severity of the Pain (scale & effect on activities) T - Timing and Type of Onset (continuous, throbbing, lancinating, intermittent, crescendo, decrescendo, etc.)

  21. Pain Rating Scales • Generally on a scale of 1 to 10 • 1 is none • 10 is the worst pain imaginable • May be done verbally or visually • Commonly with a series of faces with increasingly severe grimaces.

  22. Pain Rating Scale

  23. PAIN-AD SCOREto rate pain in demented patients

  24. Patient Barriers(beliefs that prevent good pain control) • Pain is unavoidable • Pain is punishment • Asking for pain medication is too demanding (not being a good patient) • Asking for pain medication is a sign of weakness • Fear of addiction

  25. Patient Barriers(beliefs that prevent good pain control) • Fear of side effects • Pain isn’t harmful • Complaining will lead to more tests • Fear of cost of medication • Fear of distracting physician from other concerns • Fear of Tolerance

  26. Patient Barriers(beliefs that prevent good pain control) • “Too many mg’s” • “Too many pills”

  27. Physician Barriers to Effective Pain Rx • Elderly have less sensation of pain. • Cognitively impaired don’t feel pain. • A sleeping patient isn’t experiencing pain. • Complaining more is a natural part of aging. • Those that ask for meds are drug seekers. • They “can tell” if a patient “really” has pain. • Fear of regulations • Fear of side effects

  28. Physician Barriers to Effective Pain Rx • Fear that opioids will hasten death • Fear of contributing to addiction • Fear of causing more tolerance • Fear of being “the one” to cause death • Lack of assessment • Influence of the patient’s family • Inadequate knowledge base

  29. Non Pharmacologic RxPhysical Measures • OMT • Occupational therapy • Heat and cold • Massage • Transcutaneous Electrical Nerve Stimulation (TENS) • Therapeutic Touch • Acupressure/Acupuncture • Music: Singing, humming, tapping • Dance

  30. Non Pharmacologic RxPhysical Measures • Art • Exercise • Tai-Chi • Movement • Gliders, rockers • Aromatherapy • Whirlpool • Environmental alteration • Repositioning/bracing

  31. Non Pharmacologic RxCognitive/ Psychosocial/ Behavioral • Distraction • Talking/Listening • Reading • Pet Therapy • Meditation/Prayer • Humor • Peer Support Groups • Pastoral counseling

  32. Non Pharmacologic RxCognitive/ Psychosocial/ Behavioral • Cueing • Relaxation therapy • Guided imagery • Deep breathing • Hypnosis • Biofeedback • Herr (2008), Altilio(2008) • Palliative Care Dementia Consortium (2008)

  33. Medical Pain Management • Don’t delay for investigations or disease treatment • Unmanaged pain  nervous system changes • permanent damage with amplified pain • Treat underlying cause (eg, radiation for a neoplasm)

  34. Pain Medication Principles • By the patient • By the mouth • By the clock • With attention to bowels • Cecily Saunders also said, "Constant pain requires constant pain control."

  35. WHO Analgesic Ladder

  36. Acetaminophen • Step 1 analgesic • APAP = acetyl-para-amino-phenol • Inhibitor of cyclo-oxygenase, COX-2 • low anti-inflammatory effect due to sensitivity to peripheral peroxidases • Prevents formation of prostaglandins and resultant pain • Blocks reuptake of endogenous cannabinoids • Dose routinely: i.e. 650 mg po qid

  37. NSAIDS • Step 1 analgesic, coanalgesic • Inhibit cyclo-oxygenase (COX) • vary in COX-2 selectivity • All have analgesic ceiling effects • Effective for bone, inflammatory pain • High incidence of adverse effects

  38. NSAIDS • GI inflammation • gastric cytoprotection possible (misoprostol) • COX-2 selective inhibitors less irritating • Proton Pump Inhibitors and H2 Blockers fail to help • Renal insufficiency • maintain adequate hydration • COX-2 selection inhibitors just as bad • never combine with ACE inhibitors ( renal failure) • Inhibition of platelet aggregation • assess for coagulopathy

  39. OPIOIDS • Step 2 when combined with APAP in varying doses and ratios • Hydrocodone with APAP • Oxycodone with APAP • Codeine with APAP • Keep total daily dose of APAP below 4000 mg, (3000 mg chronically)

  40. OPIOIDS Step 3 as a single entity product NO CEILING DOSE • Morphine • Oxycodone • Hydromorphone • Methadone • Fentanyl

  41. Opioid pharmacology • Conjugated in liver • Excreted via kidney (90%–95%) • First-order kinetics • Dehydration, renal failure, severe hepatic failure • ádosing interval, â dosage size • if oliguric or anuric • reassess routine dosing • consider prn

  42. Opioid pharmacology • Cmax after • po  1 h • SC, IM  30 min • IV  6 min • half-life at steady state • po / pr / SC / IM / IV  3-4 h • Steady state after 7 half lives (1 day) • Duration of immediate release  4 hours

  43. Physicians who care do not order PRN analgesics alone. PRN stands for: • pro re nata == when necessary • Patient Receives Nothing • Please Restrict Narcotics • Pain Relief Nil • Physician’s Routine Nonsense • Pretend Relief is Nearby • Patient Required to Nag • Patient Restless all Night • Pathetic Rx of Narcotics

  44. Routine Oral Dosing(immediate-release) Codeine, hydrocodone, morphine, hydromorphone, oxycodone • dose q 4 h • adjust dose daily • mild / mod pain 25%–50% • severe pain 50%–100% • adjust more quickly for severe uncontrolled pain

  45. Routine Oral Dosing (timed release) • Improved compliance, adherence • Total daily dose divided • Dose q 8, 12, or 24 h (product specific) • don’t crush or chew tablets • may flush time-release granules through feeding tubes (Avinza) • Adjust dose q 2 - 4 days (once steady state reached)

  46. Irrational Medications • Mixed agonist-antagonists: pentazocine, butorphanol, nalbuphine, dezocine, buprenorphine • compete with agonists  withdrawal • analgesic ceiling effect • antagonist effect may outlast agonist • Weak opioids for breakthrough: • MSContin 40 mg po bid with hydrocodone/APAP 5/325 i po q4h prn breakthrough pain. • “If this strong opioid fails to work, then try a little of this weak one to cover the deficiency.” – absurd!

  47. Breakthrough dosing (prn) • Use immediate-release opioids • 5% - 15% of daily dose given q4h prn • May offer after Cmax reached • po / pr  q 1 h • SC, IM  q 30 min • IV  q 10–15 min • Do NOT use extended-release opioids for breakthrough pain

  48. METHADONE • Dose interval for methadone is variable (q6h or q8h usually adequate) • Adjust methadone dose q 4 - 7 days • Start 2.5 q12h • Watch for sedation • Mu agonist like other opioids

  49. METHADONE • NMDA antagonist: reverses opioid tolerance • Allows opioid action to treat neuropathy • Blocks reuptake of norepinephrine & serotonin • Decreases sensitivity of dorsal horn to pain input

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