Pain Management

Robert B. Walker, M.D., M.S.

DABFP, CAQ (Geriatrics)
Robert C. Byrd Center
for Rural Health
Marshall University

Introduction

End of Life Pain

50% of elders report significant problems with

pain in the last 12 months of life.

One-third of nursing home patients complain

daily pain.

Predictable, explainable pain is under treated.

Elders list pain control as one of their

top 5 quality of life concerns

Patients have a legal right to proper

pain assessment and treatment.

Common
Misconceptions
I should expect to have pain
Ill hold off so the medicine will
work when I really need it
Pain is for wimps
I dont want to get hooked

Barriers

We assess pain poorly and erratically

We havent been well trained in pain

management

Were afraid of addiction issues

Were afraid of mistreating the patient

Basic Approach to Pain

Management
Ask the patient about pain and
believe them.
Use a pain scale.
Document what you know about the
pain
Reassess the pain

Diagnosing and
Documenting Pain

Examples of Pain
Scales

Documenting Pain

Onset
What relieves?

Location
What worsens?

Intensity
Effects on Daily Activities

Quality
Treatment History

Neurological
Classification

Nociceptive Pain

Neuropathic Pain

Nociceptive Pain

Damage is to other tissue and nerve fibers are

stimulated.

Travels along usual pain and temperature

nerves

Responds well to common analgesics and

opioids

Sharp, throbbing, aching

Neuropathic Pain

The nervous system itself damaged

Direct damage to nerves, plexes, spinal

cord (shingles, diabetic neuropathy)

Burning, tingling, shooting

May not respond as well to usual analgesics

including opioids

Physical Examination

motor, sensory, reflexes

headaches: intracranial mass

zoster, pressure sores

non-verbal communication

Treating Pain

Treatment of Pain

Treat Causes if possible

Remember Non-Drug Treatments

Analgesics: Narcotic, Non-narcotic

Adjuvants: Anti-convulsants, Antidepressants

Standard Approach

Treat Quickly (Pain leads to more pain)

Mild Pain: acetaminophen, ASA, NSAIDS

Moderate: mixtures, weak opioid, maybe

adjuvants

Severe: strong opioid and non-opioid,

maybe adjuvant

Non-Narcotic
Analgesics

Acetaminophen (< 4 g / 24 hrs.)

NSAIDS (bone pain or

inflammation)
Lots of side effects
Newer are expensive

Basics of Analgesic Use

1. By Mouth When Possible

2. Timed Doses

3. Whatever dose it takes

4. Watch for Expected Side Effects

5. Consider Adjuvants

Narcotic Analgesics:
Morphine

IV: if >50 Kg. Give 10 mg. IV Q3-4 h

If child or <50 kg. Give 0.1mg/kg. IV

If Opioid Nave, consider lower dose

Oral: Start 5-10 mg. Titrate Up

Morphine

Max Effect: IV -15 minutes

SC- 30 minutes

PO: -I hr.

Using Concentrates

Dying Patient; Cant swallow

MSIR 20 mg/ml : .25 to .50 ml. Q

1 hr. sl. PRN

Oxycodone conc. 20 mg/ml : .25

to .50 ml. Q 1 hr. sl. PRN

DOSING

Titrate Up Slowly Until pain controlled

or side effects occur

Anticipate Next Dose: tend to give a

little early

Use Breakthrough Doses When

Needed

Extended Release

Better Compliance

More Expensive

Dose q 8,12, or 24

Extended Release

Dont Crush or Chew

May flush through feeding tubes

Dont Start with Extended Dose

Breakthrough Pain

Is it new incident (new cause? or

end-of-dose?)

Use 10% of total daily dose

(rounded up) up to q 1-2 h

Continuing Use

Can continue to increase (no real

upper limit)

Gradually increase Limited by Side

effects

Note that the effective rescue dose

increases as total dose does

Other Options: Fentanyl

Patch

25, 50, 75, 100 mcg/hr.

Apply every 3 Days

Divide Morphine Daily Dose in Half

Rescue with Opioids

Other Options: Fentanyl

Patch

Initial Dose May Take 12- 24 hrs.

May continue previous meds for

8 - 12 h

If switching, remove and use

rescue for 24 hrs.

Fentanyl is well absorbed across

mucous membranes
Lolly-pop
approved only for breakthrough
in already receiving opioids
not to be chewed 200ug units
not proven to be more effective
than morphine concentrates

Other Options:
Methadone

Starts working in about 1 hr.

Inexpensive

Neuropathic Pain

A patient with advanced lung cancer has severe

pain from a localized bony metastasis. He
begins to consistent feel pain about four hours
after his last dose of opioid medication.

A.
B.
C.
D.

1. According to the program which

of the following would be most
helpful?
Increase medication dose
Change medication
Begin to give the medication at intervals of
less than four hours
Add adjuvant medication.

Answer C.
A.

Begin to give the

medication at intervals of
less than four hours

2. The most likely classification

of this pain is:
A.
B.
C.
D.

Referred Pain
Nociceptive Pain
Neuropathic Pain
Visceral Pain

Answer B.

Nociceptive Pain

3. The oral morphine preparation

given to this patient will begin to
take full effect in about:
A. 15 minutes
B. 30 minutes
C. 1 hour
D. 2 hours

Answer C.
1 hour

Problems with Pain

Management

Problems with Opiates:

Addiction

Define: compulsive use, lack of control,

harmful use

Iatrogenic: may be as low as 1% if no

previous history

Avoid making this tricky diagnosis

Have you used this drug five times in your

life?

Warning signals
Dominating Concerns over Availability
Non-Provider Sanctioned Increases
Ignoring Major Side Effects

Warning signals

Altering, losing Prescriptions

Multiple Sources

Unaccounted Medication

Problems with Opiates:

Dependence

Defined by the occurrence of a

withdrawal syndrome after reduction
or cessation.

May occur after only 2- 3 days of

strong opioids

Usually well controlled by tapering

Problems with Opiates:

Tolerance

Need for higher doses for same effect

Can occur with effects other than analgesia

Often develops faster for sedation,

respiration, nausea than analgesia

Slow tolerance to obstipation

Problems with Opiates:

Obstipation

Fluids, Bran

Pericolace or Senicot-S

No BM in 48 hrs: MOM or Lactulose

No BM in 72 hrs: Rectal Exam; Mag

Citrate, Fleets, Oil

Problems with Opiates:

Nausea/Vomiting

Usually occurs initially

Improves with Time

May be Able to Prevent with

other meds, no movement

Problems with Opiates:

Respiratory Depression

Remember, fairly rapid tolerance develops

Almost always associated with sedation

Follow Respiratory Rate

Withhold Next 2 Doses

Naloxone

Dilute 1 Vial (0.4mg) in 10 cc.

Normal Saline

Give 1 cc. per minute until

respiratory rate OK

Problems with Opiates:

Sedation

Look at Other Meds

Look for Other Reasons

Try Decrease Dose 25%

Try another Analgesic,

Psychotropic

A patient with widespread cancer is being

treated with a mixed narcotic analgesic.
Addition of non-narcotic pain medication
for breakthrough is being considered.

Which of the following is the most

significant pharmacologic concern?
A. Acetaminophen hepatic toxicity
B. Addiction
C. Tolerance
D. Respiratory depression

Answer A.
Acetaminophen hepatic toxicity

If a decision is made to change to a

strong opioid alone, which starting dose
of oral morphine would be reasonable?
A.
B.
C.
D.

1 mg.
5 mg.
10 mg.
50 mg.

Answer C.
10 mg.

To which of the following morphine

effects will tolerance probably develop
most slowly?
A.
B.
C.
D.

Sedation
Nausea
Pain relief
Obstipation/constipation

Answer D.
Obstipation/constipation

Adjuvant Use

Anticonvulsants (Shooting Pain)

Gabapentin (expensive, 100 mg TID)
Carbamazine 100 mg. PO TID
Valproic Acid 250 mg. QHS
Clonazepam 0.5 mg PO BID (sedating)

Adjuvant Use

Tricyclic Antidepressants (Burning, Tingling)

Low Doses (10 - 25 mg.)
Amitriptyline
Anticholenergic (sedating, drying, cardiac effects)

Gabapentin

Special Situations

Terminal Events

Cant Swallow: Go to
Concentrate

If No Urine Output: Titrate to

Pain (no routine dosing)

Converting from IV to Oral

Morphine, Oxycodone, Meperidine: 3

X dose

Hydromorphone (Dilaudid): up to 5 X
dose

Then Reduce by 25% (cross

tolerance)

West Virginia Schedule II.

Regulations

In Emergency May Telephone or Mail (60

doses)

One Drug Per Prescription with MD/DO

Name Printed on Blank

May Fax to Long Term Care or Hospice

Should Write Out Concentrations

Non-Drug Treatments

Blocks & Infusions

Surgery: rhizotomy
and nerve
decompression
Radiation: localized
Tumor Treatment
Heat & Cold
TENS
Relaxation

Complementary
Medicine:
acupuncture,
chiropractic,
massage
Spiritual Therapy
Diversions: Pets,
Music, Art, Humor

SUMMARY
Optimizing well-being of the
patient and loved ones
Improving control over ones life
Can reduce uncontrolled pain to
less than 1 in 20.
We primary care physicians can,
and must, get better at this.

A patient with advanced, widespread

cancer is at end-stage of her disease. She
begins to experience breakthrough pain
every 1 or 2 hours between doses of
OxyContin.
What dose should be given for rescue or
breakthrough pain?
A. Regular interval dose
B. 10% of total daily dose
C. 20% of total daily dose
D. 30% of total daily dose

Answer B.
10% of total daily dose

This patient lives many miles from the

office and the Hospice nurse wished to
increase the regular interval dose of
medication. Which of the following is a
legal option?
A.
Give doses of another patients medicine
B.
Fax a prescription for the regular
medication to the local pharmacist.
C.
Give a medication on-hand not previously
prescribed
D.
Wait until a written script can be obtained.

Answer B.
Fax a prescription for the regular
medication to the local
pharmacist.

The patient begins to take no fluids

and has instructed no IV be started.
Urine output ceases. How should
dosing
be determined?
A.
Titrate
to pain, using rescue dose only
B.
C.
D.

Half the usual interval dose

Give 10% of the usual interval dose
Double the usual interval dose.

Answer A.
Titrate to pain, using rescue
doses only