the ins and outs of pain
DESCRIPTION
Geared towards advanced pain nurses for the hospital-based and evidence-based management of pain. Overview of physiology, pathophysiology, assessment and management.TRANSCRIPT
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THE INS AND OUTS OF PAIN
Kyle P. Edmonds, MDFellow, Scripps Health & The Institute for Palliative Medicine at San Diego
Hospice
Adapted from the Palliative Care International Curriculum Series
Editor, Frank R. Ferris, MD
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OBJECTIVES
• Review the definitions, pathophysiology & classifications of pain.
• Perform a standardized assessment of pain and state why it is important for team communication.
• State how Cmax and half-life relate to opioid dosing.
• Describe the hallmark of addiction and the low likelihood of occurrence in pain management.
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International Association for the Study of Pain ( IASP ):
“An unpleasant sensory and emotional experience
associated withactual or potential tissue damage.”
PAIN
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Margo McCaffery:
“Pain is whatever the person says it is…”
PAIN
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TOTAL PAINCICELY SAUNDERS 1964
Patient
with Pain
Physical
Emotional
Existential
Social
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MECHANISM OF PAIN- DESCARTES
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NOCICEPTOR
• Nerve cell
• Activation• Thermal • Chemical• Mechanical
• Transmits signal
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NOCICEPTION
• Activation of receptors
• Transmitting
• Processing
• Leads to pain perception
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BASIC STEPS: PAIN PROCESSING
• Transduction
• Transmission
• Perception
• Modulation
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Mechanical Thermal
Chemical
Judith A. Paice, AAHPM, 2008
Aδ or C fibers
PAIN TRANSDUCTION
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TRANSMISSION
• Stimulus to cord
• Cord to brain stem
• Brain stem to higher cortex
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Thalamus
Somatosensory Cortex
Associative Cortex
Judith A. Paice, AAHPM, 2008
TRANSMISSION
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PERCEPTION
• Experience• Conscious
• Multidimensional
• Interaction of transmission/transduction
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MODULATION
• Changing
• Inhibiting
• Spinal cord level
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PAIN PROCESSING
• Transduction
• Transmission
• Modulation
• Perception
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CLASSIFICATION OF PAIN
• Physiologic• Nociceptive
• Neuropathic
• Mixed
• Temporal• Acute
• Chronic
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NOCICEPTIVE PAIN
• Somatic
• Visceral
• “Sharp” “Aching” “Throbbing”
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NEUROPATHIC PAIN
• Damaged or dysfunctional nerves
• Central
• Peripheral
• “Burning” “Tingling” “Numbness” “Electric”
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MIXED PAIN
• Experiencing • nociceptive
and
• neuropathic
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CLASSIFICATION OF PAIN
• Physiologic• Nociceptive
• Neuropathic
• Mixed
• Temporal• Acute
• Chronic
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TEMPORAL CLASSIFICATION: ACUTE
• Sudden or recent onset
• Identifiable cause
• Short duration
• Sympathetic response
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TEMPORAL CLASSIFICATION: CHRONIC
• Persistent
• May have no obvious cause
• Prolonged functional impairment
• No sympathetic response
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INTERVAL SUMMARY
Understanding the pathophysiologyleads to improved assessment and
targeted management that will improve outcomes
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PAIN ASSESSMENT
1. Location2. Description (type)3. Change over time4. Severity (0 – 10)5. Effect of
treatments• Benefit (+)• Unwanted effects (-)
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1. LOCATION
• Where is it ? • Does it move ?
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2. DESCRIPTION
• What does the pain feel like ?
• Does it ever feel burning or shooting ?
• How does the pain impact your life ?
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• Constant
• Breakthrough
• Intermittentacute
3. CHANGE OVER TIME
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4. PAIN SEVERITY = 5TH VITAL SIGN
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5. EFFECT OF TREATMENTS
• Therapies tried• What worked ?• What didn’t work ? • Any affects you
didn’t like ?
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EXAMINATION
• General exam• Changes in behavior• Focused exam• Psychological exam
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INTERDISCIPLINARY TEAM
• Physician•Assess•Diagnose•Prescribe•Monitor•Communicate
• Nurse•Assess•Deliver•Monitor•Teach•Communicate
• Pharmacist•Assess•Provide•Monitor•Teach•Communicate
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INTERVAL SUMMARY
Assessment of pain requires a thoughtful history and physical. Standardizing the
process helps prevent miscommunication.
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PAIN MANAGEMENT: DEFINITIONS
• Opioid: anything that binds the opioid receptor
• Opiate: derived from the opium poppy (Papaver somniferum)
• Narcotic: archaic term, associated with illicit use
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PAIN MANAGEMENT PRINCIPLES
• Don’t delay control
• Unmanaged pain nervous system changes
• Treat underlying cause
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WHO LADDER
1, Pain 1 – 3
2, Pain 4 – 6
3, Pain 7 – 10
Morphine
Hydromorphone
Fentanyl
Oxycodone
Methadone
Levorphanol
± Adjuvants
Codeine
Tramadol
A / Codeine
A / Hydrocodone
A / Oxycodone
A / Dihydrocodeine
± Adjuvants
ASA
Paracetamol / Acetaminophen
NSAID’s
± Adjuvants WHO. Geneva, 1996.
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Pla
sma
Co
nce
ntr
atio
n
0 Time
AbsorptionExcretion
First Order KineticsWhen biological effect
follows plasma concentration
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Pla
sma
Co
nce
ntr
atio
n
0
Maximum Concentration ( Cmax )
20
10
= maximum concentration during the dosage interval
Cmax
Time ( hours )4
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Pla
sma
Co
nce
ntr
atio
n
0 Time ( hours )
Time to MaximumConcentration ( t Cmax )
20
10
1 4
= time it takes to get to maximum concentration
Cmax MorphinePO / PR
Cmax = 1 hour
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Pla
sma
Con
cen
trat
ion
0 Half-life (t1/2) Time
IV
PO / PR
SC / IM
Cmax
Time to MaximumConcentration ( t Cmax )
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Pla
sma
Co
nce
ntr
atio
n
0
Half-Life ( t ½ )
Morphineall routes
t ½ = 4 hours
20
10
= time it takes for the body to excrete half the dose
Time ( hours )4
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CLEARANCE CONCERNSMORPHINE
Liver
•Morphine M3G . . .
M6G . . .
Analgesia CNS
+ +++
++++
Collins SL, et al. J Pain Symptom Manage. 1998.Mercadante S, Arcuri E. J Pain. 2004.
Urine90 – 95 %
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PRINCIPLEFOR CONTINUOUS PAIN
For constant pain
• To achieve steady-state, dose routinely every
half-life ( t ½ )
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CONTINUOUS PAIN PRINCIPLE
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Pla
sma
Co
nce
ntr
atio
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0
Dosing every half-life ( t ½ )Oral morphine = 4 hours
164 8 12Time ( hours )20 24
50%75%
87.5%93.75%
97%100%
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Pla
sma
Co
nce
ntr
atio
n
0 Time
Steady state after 5 half-livesMorphine ≈ 20 hours
Peak
TroughConcentration
needed to control pain
Concentration where side-effects
start to occur
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PRINCIPLEFOR BREAKTHROUGH PAIN
• Dose once every Time to Cmax
• PO 1 h
• Dose =10% of total 24 hr routine dose
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Pla
sma
Con
cen
trat
ion
0 Time
Cmax
Breakthrough Pain
PO / PR≈ 1 hr
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OPIOID ADVERSE EFFECTS
Uncommon
• Bad dreams / hallucinations
• Delirium
• Myoclonus / seizure
• Pruritis / urticarial
• Respiratory depression
• Urinary retention
Common
• Constipation
• Dry mouth
• Nausea
• Sedation
• Sweats
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EQUIANALGESIC DOSES
Oral/Rectal Analgesic IV/SC/IM
150 Codeine --
15 Hydrocodone --
15 Morphine 5
10 Oxycodone --
3 Hydromorphone 1
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MORPHINE PO OXYCODONE POMorphine 15 mg PO = Oxycodone 10 mg PO
• Patient is on Morphine ER 90mg BID PO
• Oral Morphine Equivalent?
• (90 mg x 2 = )180mg
• This equals how much Oxycodone?
• ( 180 mg x 15 / 10 =) 120mg
• How much Oxycodone ER?
• 60mg PO BID
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MORPHINE PO HYDROMORPHONE IV
Morphine 15 mg PO = Morphine 5 mg IV = Hydromorphone 1 mg IV
• Patient is on Morphine IR 20mg q2hrs PO PRN
• Now can’t take PO, how much HM?
• ( 20mg / 3 then 6.67 mg / 5 =) 1.3mg IV
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MORPHINE PO HYDROMORPHONE IV
Morphine 15 mg PO = Morphine 5 mg IV = Hydromorphone 1 mg IV
• Patient is on Morphine ER 90mg BID (OME 180mg)
• How much IV Hydromorphone in a day?
• ( 180mg / 3 then 60 mg / 5 =) 12mg IV / 24hrs
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MORPHINE PO HYDROMORPHONE IV
Morphine 15 mg PO = Morphine 5 mg IV = Hydromorphone 1 mg IV
• Patient is getting 8mg IV Morphine hourly PRN without relief
• What is this equal to in Hydromorphone IV?
• ( 8 mg / 5 =) 1.6 mg
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INTERVAL SUMMARY
Understanding the way these medications enter and leave the body can help you safely and effective treat pain. Always
have someone independently check your work when changing medications.
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SARAH, 43 YO
• Metastatic colorectal CA
• Sacral plexus destruction
• Multiple opioid trials• Pain 6 / 10
• Drowsiness
• Confusion
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58
“TOTAL PAIN”
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ADJUVANT THERAPIES
• Pharmacological• Interventional Anesthesia
• Non-pharmacological• Acupuncture
• Biofeedback
• TENS
• Counseling
• Integrative therapies
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ADJUVANT EVIDENCE
• Therapies extrapolated from non-cancer pain
• Few RCTs
• Very few comparative trials
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GUIDING THERAPY
• Diagnosis
• Assessment
• Efficacy
• Safety / tolerability
• Ease of use
• Cost
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OPIOIDS
• Nociceptive pain > neuropathic pain
• First-line for mod to severe neuropathic pain
• Titrate to effect or side-effect
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METHADONE
• Long half-life
• NOT first order kinetics
• Experienced palliative care / pain experts
• Coanalgesic: 2.5 – 5+ mg
• Cost PO << parenteral
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GABAPENTINOIDS
• Sodium channel antagonist
• Positive RCT’s
• NNT less favorable than TCAs
• First-line 2º safety
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• Trial gabapentin
•Start 100-300 mg qhs
•Daily, increase 100 mg q8h
•Effective 900 - 1800 mg / 24 hr
•Max 3600 - 5400 mg / 24 hr
• If ineffective, pregabalin
•Start 25-75 mg q12h
•Increase 25 mg q12h
•Effective 100-150 mg / 24 hr
•Max 300 - 600 mg / 24 hr
GABAPENTINOIDS…
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ANTIDEPRESSANTS
• 3º amine TCAs (amitriptyline)
• 2º amine TCAs (desipramine, nortriptyline)
• Mixed SNRIs (duloxetine, venlafaxine)
• SSRIs (citalopram, paroxetine)
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OTHER ANTICONVULSANTS
• excitation
• Limited data, trial-and-error
• Newer drugs have better safety profiles
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CORTICOSTEROIDS
• Limited data, widely used in • Bone pain
• Neuropathic pain
• Lymphedema
• Other conditions
• Dexamethasone• Start high dose 8+ mg daily
• Taper to lowest effective dose
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OTHER OPTIONS
• Lidocaine (IV or SC)
• Sodium channel blockade
• Good evidence
• Ketamine (PO, IV, SC)
• NMDA blocker
• Dose-limiting psychological effects
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SARAH, 43 YO, CA COLON
• Touch
• Simplify meds ( ! )
• Address total suffering
• Feb 14…Pain 6 / 10
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INTERVAL SUMMARY
Sometimes the best long-acting medicine for a patient may not be an opioid. Poor
opiate-responsiveness is a sign that multimodal therapies may be necessary
to achieve pain relief.
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CLARIFYINGADDICTION
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TOLERANCE
• Reduced effectiveness over time
• Not clinically significant with chronic dosing
• Suspect disease progression
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PHYSICAL DEPENDENCE
• Process of neuro-adaptation
• Abrupt cessation withdrawal
• Titrate down if stopping
• Avoid antagonists
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DRUG DIVERSION
• Regulation
• Record keeping
• Accountability
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PSEUDO-ADDICTION
• Most common cause of apparent drug ‘ failure ’ is under-dosing
• Behavior LOOKS like drug seeking
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ADDICTION: CHARACTERISTICS
• Psychological dependence
• Compulsive use
• Loss of control over drugs
• Loss of interest in pleasurable activities
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ADDICTION: HALLMARK
• Continued use of drugs in spite of harm
• Rare outcome of pain management
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SUBSTANCE USERS
• Can have pain too
• Treat with compassion
• Consultation with pain or addiction specialists
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INTERVAL SUMMARY
True addiction is rare in the management of pain and pain can occur in those with a
history of substance use.
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SUMMARY
81
• Pain may be nociceptive, neuropathic or both and the history tells you which.
• A standardized approach to the assessment of pain helps prevent miscommunication.
• For constant pain, dose on the half-life (q4hrs). For breakthrough pain, dose on the Cmax (route-dependent).
• True addiction is uncommon in pain management.
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THE INS AND OUTS OF PAIN
Kyle P. Edmonds, MDFaculty, UCSD Division of Palliative Medicine
928.853.1483
Kylepedmonds.com