Pain Management

Strategies
Mark Kantrow MD

OR, Everything a
nurse (and doctor!)
should know
about pain management

Objectives
Know basic steps of analgesic
management
Know basic conversions between
common opioids
Know adverse effects of analgesics, their
management
understand pain management at the end
of life

Pain
Neuropathic
Visceral
Somatic
direct

tissue
damage
direct

nerve
damage

Acute Pain
Short duration usually from trauma,
surgery or other injury
Variations in intensity
Pain behaviorsmoaning, rubbing
Anxiety
Sympathetic hyperactivitysweating,
tachycardia, hypertension

Chronic Pain
Variable onset with variable duration
Variable intensity
Behavior may not give away pain
Patient may be depressed or irritable or
stiff--unpleasant
Often the physical findings one sees in
acute pain are absent

Pain equation
Tissue damage
+
emotional + spiritual + social =
THE PAIN EXPERIENCE

WHO (World Health

Organization) Recs for
Pain Treatment
By the mouth
By the clock
By the ladder
For the individual
With attention to detail

WHO 3-step
3 severe
Ladder
Morphine

2 moderate
1

mild
ASA

Acetaminophen
NSAIDs
Adjuvants

Hydromorphone
Methadone

A/Codeine

Levorphanol

A/Hydrocodone

Fentanyl

A/Oxycodone

Oxycodone

A/Dihydrocodeine

Adjuvants

Tramadol
Adjuvants

Adjuvant Analgesics
Medications that supplement primary
analgesics
--Often have another primary use:
anticonvulsants, steroids,
antidepressants
May themselves be the primary
analgesics
May use at any step of the WHO ladder

Dyspnea

Treatment is similar to pain.

Pay attention to patients experience as

much as the numbers

Dyspnea is a subjective experience

Be careful about IVF if patients dyspnea

is worsening or if patient is dying

Opioid pharmacology .
..
Cmax after
po

1h

SC, IM 30 min
IV

6 min

Plasma Concentration

IV

SC / IM
Cmax

po / pr

Half-life (t1/2)

Time

Routine Oral Dosing

Hydrocodone, Oxycodone, Morphine,
Hydromorphone
Dose q 4
Adjust dose daily
Mild to moderate pain increase by
25-50%
Severe/ uncontrollable pain increase
by 50-100%

Bolus Effect
Swings in plasma concentration
Drowsiness - 1 hour after ingestion
Pain before next dose due
Should move to extended release
preparation or continuous SC, IV
infusion with PCA

Extended Release
Improves compliance and pain reliefreduces bolus effect
provides background pain relief
Orally can dose q8, 12 or 24 (product
specific)
dont crush or chew tablets
May flush time-release granules down
feeding tubes (Kadian, Avinza)
Adjust q 2-4 days as steady state is
reached

Transdermal patch
Fentanyl
Peak effect after application in 12-24
hours
Patch lasts 48-72 hours
NOT for the opioid nave
Ensure adherence to skin
Must have subcutaneous fat to allow
absorptionnot for the cachectic
patient
Fever makes absorption unpredictable

Breakthrough dosing
Use immediate release opioids
Approximately 10% of the 24-h dose
May offer again after Cmax is reached
for previous dose
PO/PR q 1 hr
SC, IM q 30 minutes
IV q 15 minutes

Alternative Routes of
Administration
Enteral Feeding Tubes/ Oral
Transmucosal
Rectal
Transdermal
Parenteral (IV, SubQ, IM)
Intraspinal

Equianalgesic Chart
Drug

Dose(mg)
Parenteral

Dose (mg)
Oral

Duration
Hours

Morphine (IR)

10

30

3-4

Hydromorphone

1.5

7.5

3-4

Oxycodone

____

20

3-4

Equianalgesic Survival
Skills
IV morphine is THREE times as strong as
oral morphine

10 mg IV morphine equals 30 mg p.o.

morphine

Equianalgesic Survival
Skills
IV Dilaudid is 5 times as strong as oral
1 mg Dilaudid IV equals 5 mg Dilaudid
p.o.
Little known fact:
1 mg Dilaudid IV = 7.5 mg Morphine
IV

Equianalgesic Survival
Skills
Morphine 5mg IVP = Percocet 10
(oxycodone)
Morphine 3mg IVP = Lortab 10
(hydrocodone)

Equinanalgesic
Survival Skills
Case 1
Your patient has been receiving
Morphine 5mg IVP q 4 hours prn and
now has lost her IV. The physician you
call orders a dose of oral Morphine
liquid 5mg q 4 hours.
DO THE MATH!
What do you say when you hear this?

Case #2
Mrs. Bourgeois is a 37y/o housewife who
has suffered from chronic back pain for
10 years following an MVA. She had a
laminectomy 2 years ago with only
minimal improvement in pain.
She takes MS Contin 60 BID as
prescribed by her pain management
physician as an outpatient and has
tolerable chronic pain.
She is admitted to your unit with a
retropharyngeal abscess and cannot
swallow.

Case #2 contd
The admitting physician writes for
Morphine 5 mg IV q 4 PRN pain.
DO THE MATH!
How do you expect this will manage her
pain?
How do you think this patient will be
regarded by the nursing and physician
staff?
Be careful of story we tell ourselves

PSEUDO-ADDICTION
*DRUG SEEKING
BEHAVIOR

Case 3
Mr. Sampson is a 45 y/o WM with bone
pain related to newly discovered
metastatic prostate CA. He is admitted
for poorly controlled pain. He is
tachycardic, diaphoretic and grimacing,
describing his pain as 10/10

There are several PRN medication

choices
Oxycodone 10mg, ii po q 4 prn
Morphine 5 mg IVP q 3 prn
Dilaudid 1 mg IVP q 3 prn
STRONGEST
LONGEST ACTING
FASTEST ACTING

Opioid adverse effects

Uncommon
Common
-hallucinations
-Constipation
-delirium
-Dry Mouth
-Myoclonus/seizures
-Nausea/Vomiting
-urticaria
-Sedation
-Respiratory Depression
-Pruritis
-urinary retention

Opioid allergy
Anaphylactic reactions are very rare with
opioids
Bronchospasm
Urticaria
Nausea / vomiting, constipation,
drowsiness, confusion
adverse effects, not allergic
reactions

PRURITIS
Mast cell destabilization with all opioids
causing itching
Treat with routine long-acting, nonsedating
antihistamines
Fexofenadine (Allegra), 60 mg po bid, or
Loratadine (Claritin)
Sedating antihistamines or doxepin if
sleep desired

Constipation . . .
Common to all opioids
One does not develop tolerance to this!
Opioid effects on CNS, spinal cord,
myenteric plexus of gut
Easier to prevent than treat

. . . Constipation
Diet usually insufficient to relieve
Bulk forming agents not recommended
(no metamucil!)
Stool Softener: senna, bisacodyl,
glycerine, casanthranol, etc
Stimulant laxative: Docusate sodium
senna + docusate sodium is best
combo

Constipation . . .
Prokinetic agent
metoclopramide
Osmotic laxative
MOM, lactulose, sorbitol
Other measures

Nausea / vomiting . . .
Onset with start of opioids- opioid naive
usually improves within days
Prevent or treat with dopamine-blocking
antiemetics or prokinetics
prochlorperazine, (Compazine) 10 mg q
6h
haloperidol, 1 mg q 6 h
metoclopramide,(Reglan) 10 mg q 6 h

Sedation . . .
*Onset with start of opioids
*distinguish from exhaustion
due to pain
* usually improves within
days

. . . Sedation
If persistent and undesired, rotate to
another opioid or change route of
administration
Psychostimulants may be useful
methylphenidate, 5 mg q am and q
noon, titrate

Respiratory
depression . . .
Opioid effects differ for patients treated
for extreme pain and at the end of life
pain is a potent stimulus to breathe
Depressed level of consciousness
precedes respiratory depression!!

pharmacologic tolerance develops

rapidly to respiratory effects of opioids

take care if combining with benzos

. . . Respiratory
depression

Management

identify, treat contributing causes

reduce opioid dose

observe

if stable vital signs but unarousable

use Narcan gently: naloxone, 0.1-0.2
mg IV q 1-2 min

Pain Assessment at
end of life
May be difficult in patient with dementia

or terminal delirium;
Vital signs not reliable indicator;
Moaning & groaning;
Objective signs:
Facial grimacing, frowning, furrowed brow
Increased agitation
Clenched jaw
Guarding

dying
patient
receiving
suboptimal
treatment

Death

dying patient receiving adequate

symptom control

death

Rule of Double Effect

Any

action which has foreseen harmful

effects which are inseparable from the
good effect is considered justifiable if the
following conditions are satisfied:
Intent is good effect no intent to harm
Act is good, morally acceptable
Good outweighs bad

Summary:

WHO ladder of pain management

Equianalgesic Dosing

Common Side Effects of Opioids

Pain treatment at the end of life

Quiz:

Dilaudid 1mg IV equals how much

Morphine IV?

Percocet 10 (oxycodone) equals how

much IV morphine?

What always preceeds respiratory

depression from opioids?

What important side effect of opioids

does one not develop a tolerance to?

Thank You