Transcript Pain Management and Palliative Care

Clinical Review for the
Hospice and Palliative Nurse
Pain Management
1
Objectives
1. Describe the prevalence of pain in the
hospice and palliative care setting
2. Recognize the impact of pain on patients,
families and the healthcare system
3. Identify common barriers to effective pain
management
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Objectives
4. Define the types of pain experienced by
the hospice and palliative patient
5. State the principles of effective pain
management
6 Identify the components of a thorough
pain assessment
7. Demonstrate the ability to do
equianalgesic conversions
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Undertreatment of Pain
 70-90% of patients with advanced disease experience pain
 50% hospitalized patient’s experience pain
 80% of long term care experience pain
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Only 40-50% are given analgesics
 Pain scores (on a 0-10 scale) greater than or equal to “4”
greatly impact on quality of life
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Impact of Poorly Controlled
Pain
 Physical
 Psychosocial
 Emotional
 Financial
 Spiritual
 Cultural
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Interdisciplinary Resources
 Pain affects multiple dimensions
 No one discipline can address all issues
 Strengths and talents of many disciplines
 Address multiple institutional barriers
 On going communication
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Cost of Poor Pain Management
 $100 billion per year
 Chronic pain is most expensive heath problem
 40 million physician visits per year for pain
 25% of all work days lost are due to pain
 Improving pain management costs less than cost of
inadequate relief
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Pain Co-morbidities
 Depression
 Anxiety disorder
 Diabetes
 Chronic fatigue syndrome
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Barriers to Effective
Pain Management
 Patient / family
 Healthcare Provider
 Institutional
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Definition of Pain
 An unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage (APS)
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Definition of Pain
 Pain is whatever the experiencing person says it is,
existing whenever he/she says it does (McCaffery &
Pasero, 1999)
The patient’s report must be accepted!
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Types of Pain
 Acute
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Accompanied by physiological
Perceived as reversible
 Chronic
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Often not a clear cause
Usually persist for longer than 3 months
Autonomic nervous system adapts – patient does not
exhibit objective signs of pain
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Classification of Pain
Nociceptive Pain
 The normal processing of stimuli that damages normal
tissues or has the potential to do so if prolonged
 Usually responsive to non-opioids and/or opioids
 Stimuli from somatic or visceral structures
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Types of Nociceptive Pain
Somatic Pain
 Bone, joints, muscle, skin, connective tissue
 Throbbing, dull
 Well localized
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Types of Nociceptive Pain
Visceral Pain
 Visceral organs
 Often referred to distant dermatomal sites
 Squeezing, cramping, pressure, deep ache
 Poorly localized
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Neuropathic Pain
 Results from actual injury to nerves rather than
stimulation of nerve endings
 Burning, shooting, tingling, numbness, radiating,
electrical
 Responds to adjuvant analgesics
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Neuropathic Pain
Centrally generated pain
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Deafferentation pain
Sympathetically maintained pain
Peripherally generated pain
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Painful polyneuropathies
Painful mononeuropathies
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Mixed nociceptive and
neuropathic pain syndrome
 Common in life-threatening illnesses
 Thorough assessment is indicated
 Occur concomitantly so patients may require agents from
more than one category of analgesics
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APS 12 Principles of
Pain Management
1. Individualize dose, route and schedule
2. Around the clock dosing
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APS 12 Principles of
Pain Management
3. Selection of opioids
4. Adequate dosing for infants/children
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APS 12 Principles of
Pain Management
5. Follow patients closely
6. Use equianalgesic dosing
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APS 12 Principles of
Pain Management
Recognize and treat side effects
Most common side effects of opioids:
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Sedation
Constipation
Nausea
Vomiting
Itching
Respiratory depression
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APS 12 Principles of
Pain Management
8. Be aware of hazards of Demerol® and mixed agonistantagonists
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APS 12 Principles of
Pain Management
9. Watch for development of tolerance
10. Be aware of physical dependence
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APS 12 Principles of
Pain Management
11. Do not label a patient addicted
12. Be aware of psychological state
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WHO Ladder
Recommendations
 Portrays progression in the doses and types of analgesic
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drugs for effective pain relief
Changes as patients condition and characteristics of pain
change
Orally whenever possible
“By the clock” dosing
Based on assessment of the individual’s pain experience
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WHO Ladder
Step 1 (Mild pain)
Mild Pain
 1-3 on a scale of 0-10
 Non-opioids
 Adjuvants
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As analgesics
To reduce side effects
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WHO Ladder
Step 2 (Moderate pain)
Moderate Pain
 4-6 on a scale of 0-10
 Opioids in low doses
 Non-opioids and adjuvants may be continued
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WHO Ladder
Step 3 (Severe pain)
Severe Pain
 7-10 on a scale of 0-10
 Add higher doses of opioids
 Continue non-opioids and adjuvants
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Pain Assessment Principles
 Accept patient’s complaint of pain
 History of pain
 Assessment for non-verbal patients
 Patient centered goals
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Pain Assessment Principles
 Nonverbal signs of pain
 Psychological impact of pain
 Diagnostic workup
 Assess effectiveness and side effects of pain medication
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Initial Pain Assessment
Onset/duration
 When did the pain first begin?
 Is it associated with a particular activity
 Other symptoms
Site
 More than 75% persons with cancer have pain in 2 or
more sites
 Ask patient to point to the pain
 Assess each site for pain intensity, quality, duration
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Initial Pain Assessment
Severity/intensity
 Select pain scale appropriate to patient
Quality
 Ask patient to describe their pain
Exacerbating/relieving factors
 What makes the pain worse or what causes the pain?
 Assess the pain at rest, with movement, and in relation to
daily activity
 Ask the caregivers how patient is doing with activities
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Initial Pain Assessment
Effects of pain on quality of life
 What does the pain mean to the patient and family?
 Does the pain keep the patient from doing activities
he/she enjoys?
Medication history
 Current
 Past
 Side effects
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Initial Pain Assessment
Physical
 Examine site(s) of pain, including referral sites
Consider disease process, extent of progression
Cultural considerations
 Cultural generalities and determine individual differences
Other factors
 Age
 Gender
 Environmental
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Initial Pain Assessment
Pain Assessment in the Non-verbal patient
 Self-report
 Search for potential causes of pain
 Observe patient behaviors
 Surrogate reporting
 Attempt an analgesic trial
Hierarchy of Pain Assessment Techniques
(McCaffery & Pasero, 1999)
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Initial Pain Assessment
Persons with Advanced Dementia
 Self report
 Search for potential causes of pain/discomfort
 Observation of patient behaviors
Behavioral pain assessment tools
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Communication
Physician/Nurse
 Critical in providing excellent patient care
 SBAR
 Situation
 Background
 Assessment
 Recommendation
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Communication
Interdisciplinary Team
 Establish common goals
 Use common language
 Common knowledge base
 Regular communication
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Non-opioids
 Used in acute and chronic pain
 Relief for mild/moderate pain
Most effective with nociceptive pain (muscle
and joint pain)
 Combined with opioid analgesics for both additive
analgesic effects or opioid dose sparing effects
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Non-opioids
Acetaminophen
 Mechanism
Not well understood
 Dosing
 Decrease for patients with hepatic impairment
 Routes
 Oral
 Rectal
 IV
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Non-opioids
Acetaminophen
 Side effects
Considerations
 Be aware of hidden doses, i.e., APAP in combination
products
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Non-opioids
NSAIDs
 Characteristics
Analgesic effects through the inhibition of prostaglandin
production
 Multipurpose analgesia
 Drug choices
 If no response after 3 days of adjustment, consider
switching to different NSAID
 Contraindicated If patient is hypersensitive or allergic to
ASA or other NSAIDs
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Non-opioids
NSAIDs
 Dosing
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PRN basis for occasional pain
Around-the-clock (ATC) for ongoing pain
 Routes of Administration
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Non-opioids
NSAIDs
 Sides Effects
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Hematologic
GI
Renal
Cognitive Impairment
Cardiovascular
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Teaching Points
for Non-opioids
 Risk for GI bleeding with NSAIDs
 Why medication ordered
 Stopping medications
 Reporting side effects
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Opioids
 CNS action – bind to opioid receptor site in brain and
spinal cord
 mu, kappa, and delta receptor sites
 Pain relief occurs when opioids bind to 1 or more
receptors as an agonist
 Agonists and agonist – antagonists
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Pure Agonist Opioids
 Expect physical dependence
 Withdrawal will occur when abruptly stopped or naloxone
(Narcan®) is given
 Prevent withdrawal by reducing by 25%
 Tolerance to side effects other than constipation
 Tolerance to analgesia is rare
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Choice of Opioid Drug
 One pure agonist with one route
 If one not relieving pain with titration, may need to
switch medication
 All pure agonist have same side effects
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Side effects may be reported as allergies
 Rapid onset formulation for breakthrough
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Opioids
Morphine
 Considered ‘gold standard’ for opioid analgesic
 Standard for comparison in opioid use
 Some patients cannot tolerate because of the side effects
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Tolerance to side effects in a few days
No tolerance to constipation
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Opioids
Codeine
 Appropriate for mild pain
 Metabolized by liver
Fentanyl
 Routes include IV, epidural, topical patch
Hydrocodone
 Found in combination therapy with acetaminophen
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Opioids
Hydromorphone
 Short half life and lack of metabolite problems make it
preferable to morphine in patients with renal insufficiency,
particularly the elderly
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Opioids
Meperidine
 Contraindicated – normeperidine (active metabolite) acts as
a CNS stimulant
Evidence to support that should NOT be used as a first line
analgesic for any type of pain
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Opioids
Methadone
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Long half life
Inexpensive
Monitor closely for arrhythmias
Caution in equianalgesic conversion – methadone may be up
to 10 times more potent than indicated on most equianalgesic
charts
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Opioids
Oxycodone
 Used in acute, cancer, chronic nonmalignant pain
 Mild to severe intensity
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Opioids
 Tepentadol (Nucynta)
management of moderate to severe chronic pain
 Mu-opioid agonist
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 NUCYNTA® ER
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extended-release formulation
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Mixed Agonist-antagonists
Indications
 Not recommended for chronic pain
 Ceiling doses
 Psychotomimetic effects
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Disorientation/hallucinations
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Abuse Resistant Opioids
Oxecta
 The first immediate-release oxycodone medicine
that applies technology designed to discourage
common methods of tampering associated with
opioid abuse and misuse
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Mixed Agonist-antagonists
Buprenorphine (Buprenex®)
Butorphanol (Stadol®)
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Mixed Agonist-antagonists
Nalbuphine (Nubain®)
Pentazocine (Talwin®)
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Opioid Dosing
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Multiple routes available for pure agonists
If current dose safe but ineffective, increase by 25% to
50% until pain relief occurs or unmanageable side effects
present
No ceiling effect for pure agonists
All opioids have side effects that eventually limit dose
escalation
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Opioid Routes
Oral/Sublingual
 Usually preferred route
 Consider liquid if difficulty swallowing
Intramuscular
 Not recommended – painful
Subcutaneous
 Not used in acute pain situations
 Limited volume of infusion
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Opioid Routes
Intravenous
 Bolus provides most rapid onset of effect
 Peak times vary among opioids
 Starting doses may be one-half the oral route
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Opioid Routes
Transdermal
 Medication is delivered continuously through skin
 Caution patients that increased heat to patch or skin area
may increase release of medication
 Best results when applied to skin without hair and
adequate subcutaneous tissue
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Opioid Routes
Rectal
 Alternative to patients who cannot swallow
 Onset of action may be within 10 minutes
Stomal
 Not equivalent to rectal administration
 Starting dose should be considered same as oral or rectal
route
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Opioid Routes
Intraspinal
 Used for postoperative pain, cancer pain
 Opioid binds to receptors of spinal cord at level of
injection
 Dose related side effects: nausea, itching, urinary
retention
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Opioid Routes
Patient Controlled Analgesia
 Predetermined dose of opioid delivered based on time
intervals
 Primarily used in acute pain situations
 Allows greater control over pain experience
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Management of
Opioid Side Effects
Constipation
 Most common side effect of opioids
 Bowel regimen
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Management of
Opioid Side Effects
Nausea and Vomiting
 May be due to:
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Stimulation of chemoreceptor trigger zone in brain
Slowing of GI motility
Effects on balance and equilibrium of inner ear
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Management of
Opioid Side Effects
Sedation
 Usually when opioids started or dose increased
 Tolerance will occur over period of days to weeks
Pruritus
 Can occur with any associated histamine release &
commonly with morphine
 May be generalized, usually localized to face, neck, chest
 Usually not accompanied by rash
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Management of
Opioid Side Effects
Mental status change
 Cause of increased anxiety and fear for patients, families,
caregivers
 Assess to ensure that opioid is cause
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Management of
Opioid Side Effects
Respiratory depression
 Considered clinically significant when there is a decrease
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in rate and depth of respirations from baseline
Tolerance develops over period of days to weeks
Longer patient on opioid, less likely to develop
Prevention by appropriate titration, monitoring of sedation
levels
Monitor sedation levels respiratory status, every 1-2 hours
for first 24 hours in opioid naïve
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Opioid-induced neurotoxicity
 Caused by prolonged opioid use
 Frequently missed in assessments
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Unusual and unpredictable painful sensations
Pain out of proportion to disease condition
Involuntary muscle tremors (myoclonus)
Sudden decreased LOC, or confusion/hallucinations
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Opioid Teaching Points
 Discuss effects of unrelieved pain
 Review how to administration
 Side effects
 Fear of addiction
 Written information
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Equianalgesia
Doses of various opioids analgesics that provide
approximately the same pain relief
Charts
 Consistent
Most use morphine 10 mg and every 4 hour dosing as basis
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Sample 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 (long
acting)
----
20
8-12
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Titration of opioids
Adjusting the amount of dose of an opioid
Make increases at the onset or peak effect
Provide smallest dose that provides greatest relief with
fewest side effects
Titrate in increments of 25% to 100%
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Methods of Titration
Add total of scheduled doses and immediate-release over
24 hr period
Increase by 50% if initial dose not effective
Provide breakthrough dosing
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Breakthrough Dosing
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Referred to as rescue dosing or supplemental dosing
Occurs in 2/3 of patients receiving opioids for chronic
malignant pain
Assessing for breakthrough – no tool – rely on patient’s
report of pain
Types
 Incident – elicited by specific activities
 Spontaneous
 End-of-dose failure
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Rescue Dosing
 Always ordered with long-acting opioids
APS
 10-15% of the 24-hour oral dose, given every 2 hours as
needed
 Adjust with ATC dosing increases
 Increase ATC dose if received more than 3 rescue doses
in a 24 period
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Calculating Rescue Dose
 ATC dose in 24 hrs
 180mg in 24 hrs
 Divided by 10 (1/10 or
 180 ÷ 10 = 18 or
10%) or 6 (1/6 or 15%)
 Equals IR rescue dose to be
given every 3 hrs PRN
 180 ÷ 6 = 30
 18mg to 30mg PO every 3
hr PRN
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Calculating Rescue Dose
Example
Oral Transmucosal Fentanyl Citrate
 Must convert opioid to morphine using equianalgesic chart or
manufacturer recommendation
 200 g transdermal fentanyl = 400 mg morphine (total
fentanyl gs x 2 for morphine equivalent)
 400 10 (1/10 or 10%) = 40 mg
 400  6 (1/6 or 15%) = 70 mg
 Immediate release rescue dose = 40-70 mg PO every 1-2 hour
PRN
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Calculating Rescue Dose
Parenteral opioid infusions
 Recommended rescue dose for patients receiving
continuous parenteral or epidural opioid infusion is
25-50% of hourly opioid dose
 Should be offered every 30 minutes if not using
Patient Controlled Analgesia (PCA)
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Adjuvants
 Non pain medications that have analgesic effects on
certain types of pain
 Chronic neuropathic pain
 Additional therapy to opioids
 Distinct primary therapy
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Adjuvants
 Choice of drug
 Depends on type of pain, patient age, and other medical
condition
 Individual response
 Sequential trials
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Tricyclic Antidepressants
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In co-administration with opioids, interaction may result in
higher opioid concentrations
Analgesia usually occurs within 1 week
May be effective for both lancinating and continuous
neuropathic pain
Not indicated for acute pain
In palliative care, strongest indication in neuropathic pain
not responding to opioids
In terminal care, benefits from non-analgesic effects
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Tricyclic Antidepressants
Choice of Drug
 Desipramine (Norpramine®)
 Nortriptyline (Aventyl®, Pamelor®)
 Imipramine (Tofranil®)
 Doxepin (Sinequan®)
 Clomipramine (Anafranil®)
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Tricyclic Antidepressants
Dosing
 Start low: elderly 10 mg; younger 25 mg
 Increase by same amount as starting dose
 Evaluate and increase every 3 to 5 days
Side Effects
 Orthostatic hypotension
 Sedation / mental clouding
 Anticholergic effects
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SSRIs
 Venlafaxine (Effexor®)
 Duloxetine (Cymbalta®)
 Paraxetine (Paxil®)
 Fluoxetine (Prozac®)
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Anticonvulsants
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First line drugs for chronic lancinating neuropathic pain
Variability among drugs is great
Analgesia similar mechanism that inhibit seizure activity
Lessens conduction of pain signals along damaged
peripheral nerves
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Anticonvulsants
Gabapentin (Neurontin)
 Considered first line drug of choice for all types of
neuropathic pain due to effectiveness of analgesic action
and low side effect profile
Carbamazepine (Tegretol)
 Effective in lancinating neuropathic pain
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Anticonvulsants
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Phenytoin (Dilantin)
Clonazepam (Klonopin)
Valproic acid (Depakene)
Baclofen (Lioresal)
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Other Adjuvants
Corticosteroids
 Considered multipurpose adjuvant analgesic
 Mechanism of action as analgesia is unknown
Drug of choice
 Dexamethasone (Decadron)
 Prednisone and methylprednisolone
Adverse Effects
 Short Term Therapy
 Long Term Therapy
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Other Adjuvants
Local anesthetic agents
 Local action with minimal systemic side effects
 Limited information on long term safety and effectiveness
Medications
 Mexiletine (Mexitil)
 Tocainide (Tonocard)
 Lidocaine
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Other Adjuvants
Adverse Effects
 Central nervous system effects
 Caution or avoid use with patients with preexisting heart
disease such as cardiac dysrhythmias, those receiving
antiarrhythmic drugs, cardiac insufficiency
 If topical route used, side effects include redness, edema,
and abnormal sensation at the site of application
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Other Adjuvants
Psychostimulants
 Multipurpose for acute or chronic pain
 Useful in nociceptive or neuropathic pain
Caffeine (PO)
 Used in combination products for relief of headache
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Dextroamphetamine: (Dexedrine) (PO)
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Methylphenidate: (Ritalin) (PO)
Side Effects
 Insomnia, anorexia, tremulousness, anxiety, agitation,
cognitive changes
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Other Adjuvants
Teaching Points
 May take days to weeks for pain relief
 Reassessment and titration may be necessary
 Review adverse effects
 Provide educational materials
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Addiction
 “A pattern of compulsive drug use characterized by a
continued craving for an opioid for effects other than pain
relief” (APS, 1999)
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Pseudoaddiction
 The patient who seeks additional medications appropriately
or inappropriately secondary to significant undertreatment
of the pain syndrome
 Behaviors cease when pain is treated
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Tolerance
 A form of neuroadaptation to the effects of chronically
administered opioids which is indicated by the need for
increasing or more frequent doses of the medication to
achieve the initial effects
 Clinicians should not fear tolerance in patients with
extended life expectancy
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Physical Dependence
A physiological state in which abrupt cessation of the opioid
results in withdrawal syndrome.
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Physical Dependence
Pain management for
 Substance abuse history
 Accept patient’s report of pain
 Clinicians most likely to under medicate
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Physical Dependence
Pain management for
 Active addict – general guidelines
 Reassure patient of staff commitment to pain
management of all patients
Inpatient
 Consider IV PCA: gives patient control, avoids
confrontation with staff, safely regulates dosing
Outpatient
 Less frequent dosing increases compliance to treatment plan
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Physical Dependence
Pain management for
 Patient recovering from addiction
 Acknowledge patient’s addiction history
 Offer non-pharmacologic and non-opioid pain
management options
 Differentiate between addiction and physical
dependence
 If relapse occurs, intensify recovery effort – do not
terminate pain care
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Special Populations
 Geriatric
 Dying
 Pediatric
 Cognitive impaired
 Veteran
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Special Populations
Geriatric
Age classifications
 Younger old: age 65 to 75 years
 Older old: age 75 to 85 years
 Oldest old: over 85 years
 Most under treated population for pain
 Rule of thumb: start low and go slow
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Special Populations
Geriatric
Common types of pain
 Acute pain
 Cancer pain
 Chronic nonmalignant pain
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Special Populations
Geriatric
Analgesic therapy issues
 Physiologic changes
 Absorption
 Distribution
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Special Populations
Geriatric
Analgesic therapy issues
 Metabolism
 Elimination
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Special Populations
Geriatric
Analgesic therapy
 Acetaminophen
Generally well-tolerated by elderly
 NSAIDs
 Increased risk of GI problems, renal insufficiency,
platelet dysfunction
 Always take NSAIDs with food and water
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Special Populations
Geriatric
Analgesic therapy
 Opioids
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Recommend reducing initial opioid dosing by
25-50% in elderly patient
111
Special Populations
Geriatric
Analgesic therapy
 Drug selection
 Adjuvants
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Tricyclic antidepressants
Anticonvulsants
Local anesthetics
112
Special Populations
Cognitively Impaired
Cognitively impaired
 High risk for under treatment
 Assessment ability to report pain
 0-5 scale
 Collaborate with family or caregiver to determine behaviors
that indicate pain
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Special Populations
Dying
Dying
 Pain assessment continues to be a priority at end-of-life
 Palliative sedation or therapeutic sedation
114
Special Populations
Pediatrics
Pediatric
 Consider age, developmental level, verbal capabilities, past
experiences, cultural factors, types of pain
 Child self report of pain considered most reliable and valid
indicator
 Medication dose determined by body weight (kilogram)
 Learn the child's word for pain
115
Special Populations
Veterans
 Pain may be seen as a weakness
 Military taught to ‘grin and bear it’
 Many suffer in silence, do not report pain
 Assess for pain in consistent manner
 Provide interdisciplinary, multimodal approach to pain
management
116
Non-pharmacological
Pain Management
 Use concurrently with medications
 Methods
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Cognitive-behavioral
 Relaxation
 Guided imagery
 Distraction
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Non-pharmacological
Pain Management
Methods
 Physical interventions
 Hot and cold
 Massage
 Positioning
 Exercise
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Non-pharmacological
Pain Management
 Methods
 Physical interventions
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Positioning
Exercise
119
Non-pharmacological
Pain Management
Complementary therapies
 Therapeutic touch
 Music therapy
 Aromatherapy
120
Ethical Considerations
Related to pain management
 Patient rights
 Relief from pain
 The Joint Commission
 American Nurses Association
 Double effect
 Distinguishing between harming and benefiting patient
121
Ethical Considerations
Related to pain management
 Principle of double effect

Found in situations when distinguishing between harm
and benefit
122
Ethical Considerations
Related to pain management
 Advocacy
 Nurses have duty to relieve pain and suffering
 Patient and family view nurse as advocate which increases
trusting relationship
123
REMS
Opioid drugs and Risk Evaluation and
Mitigation Strategies (REMS)
 REMS are FDA-mandated requirements to minimize the
risks associated with certain medications. REMS can be
mandated for any medication or class of medication, and
certain opioids have been included in this mandate.
124
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Additional References
 Mariano C. Holistic integrative therapies in palliative care. In: Matzo ML,
Sherman DW, eds. Palliative Care Nursing: Quality Care to the End of
Life. New York, NY: Springer; 2006:51-86.
 HPNA.org. Position Statements. Available at
http://www.hpna.org/DisplayPage.aspx?Title=Position Statement.
Accessed November 15, 2011.
 Panke J, Coyne P. Conversations in Palliative Care. 3rd ed. Pittsburgh,
131
PA. Hospice and Palliative Nurses Association:2011.