Pain Management

1. Pain Management • Introduction for incoming Trainees. • Includes UMHHC specific information. • “clicking” will progress you thru the slide show. • Click now June/July Orientation

2. Pain ….is a Medical Emergency !!

3. It’s more than a good idea……it’s the law. • 1992: US Department Health and Human Services Report on Acute Pain Management notes pervasive under-treatment and establishes guidelines • 1997: Congress defined pain as a medical emergency…. • 2001: Pain Standards developed by JCAHO are in effect

4. Physicians often fail to identify pain... And even when recognized, pain is often under-treated….

5. Opioid Dosing • Opioid analgesia is most effective when titrated to effect. • Effective doses are highly variable between patients. • “Standard” doses may be insufficient. • When used properly for analgesia addiction occurs in less than 1% of patients.

6. Addiction, Physical Dependence, ToleranceDefined • Addiction Psychological dependence and aberrant use of drug characterized by compulsively taking the drug despite harm • Physical dependence Differs from addiction. Dependence is a physical response to continued use of narcotics. • Tolerance Decrease in susceptibility to the effects of a drug due to its continued administration

7. Pain must be assessed in every patient at UMHS • When performing History & Physical Examination • Daily while evaluating inpatients • During outpatient visits

8. Factors to consider in pain assessment may include, but are not limited to: • Location, intensity, quality, character • Duration, fluctuation, pattern • Associated symptoms and signs • Contribution of depressed or anxious mood • Aggravating and alleviating factors • Impact on functional ability • Prior pain management interventions and their effects • Current pain management methods and their effects • Personal goals for pain relief and functionality • Side effects of therapies

9. Documentation of Pain:Requirements • Example for H&P’s: “He describes his back pain as very sharp and burning as opposed to the dull nature that it was prior to an accident. He now rates it as a 9/10. He states his average ranges from 6, most of the time, to as great as 10.” • Example for an impatient note: “The patient states that he had difficulty sleeping last night because of pain in the sternal area. He admits to having had this type of pain frequently in the past. He describes pain as “burning like fire” with variable intensity. At the worst he reports pain as a 7/10 on a scale of 0-10. His pain is currently 0/10….”

10. Factors to consider in choosing a pain scale • Age of patient • Physical condition • Level of consciousness • Mental status • Ability to communicate

11. Numeric Pain Rating Scale _________________________________ 0 1 2 3 4 5 6 7 8 9 10 Ask the patient to rate their pain intensity on a scale of 0 (no pain) to 10 (the worst pain imaginable). Some patients are unable to do this with only verbal instructions, but may be able to look at a number scale and point to the number that describes the intensity of pain.

12. Wong-Baker FACES Pain Rating Scale • Can be used with young children (sometimes as young as 3 years of age) • Works well for many older children and adults as well as for those who speak a different language • Explain that each face represents a person who may have no pain, some pain, or as much pain as imaginable. Point to the appropriate face and say the appropriate description. e.g. “This face hurts just a little bit” • Ask the patient to choose the face that best matches how she or he feels or how much they hurt.

13. Color Pain Rating Scale Ask the patient to point to the area on the scale that shows their level of pain from white (no pain) to dark red (worst possible pain). Obtain a number corresponding to the area where the patient points.

14. Meperidine (Demerol ®) Restrictions on use: • Only available at UMHS for Management of infusion-related reactions (rigors) or post-operative shivering. • At its May 2002 meeting, the Pharmacy and Therapeutics Committee voted to remove Meperidine from the Formulary for pain control. • Meperidine should not be used to treat pain in patients who have sickle cell disease, a history of seizures, or chronic pain

15. Meperidine (Demerol ®)metabolite: • Meperidine should not be used in high doses for prolonged durations. • Its active metabolite, normeperidine, accumulates after repeated high doses. • May induce tremors, myoclonus and generalized seizures.

16. Morphine:Caution • Morphine has an active metabolite excreted by the kidney, morphine-6-glucuronide (M6G). • M6G is 4 to 20 times more potent then morphine. • As creatinine clearance decreases, ratios of metabolites rise exponentially. • Analgesic and respiratory depressant effects are related to serum concentrations of both morphine and M6G. • As renal function declines, estimation of creatinine clearance is important for morphine dosing. Impaired renal function warrants use of an alternative opioid analgesic if repeat dosing is planned or expected.

17. You have just written an order for:“2 mg Hydromorphone IV Push” Do you know that: Hydromorphone is NOT Morphine Hydromorphone is also known as Dilaudid 1 mg of Dilaudid is about as potent as 7.5 mg of Morphine Did you really intend to give this patient the equivalent of : 15 mg of Morphine IV push? If not rewrite the Hydromorphone order as “0.2 mg Hydromorphone IV push”

18. Dilaudid®(Hydromorphone)Caution YOU ! must be alert to the possibility of overdose when using Dilaudid (hydromorphone) in • opiate-naive patients • the elderly • pediatric patients

19. Opioid Range Orders FYI: “Morphine 2-6 mg IV q 3-4 hours, prn” This order is not permitted per JCAHO at UMHS Correct Form: “Morphine 2-4 mg IV q 3 hours prn for pain” Better Form: “Morphine 2 mg IV q 3 hours prn for pain. If pain score >5/10 may increase Morphine dose to 4 mg IV q 3 hours.”

20. Opiod use in the Elderly:Caution • Always consider reducing the average adult dose by 25-50% • Titrate up slowly • Reassess frequently while adjusting opioid dosing to prevent over or under dosage

21. Realistic pain treatment goals must consider patient expectations P A I N

22. Next Steps • Complete the Pain Management Test. There are 8 questions. • Use the resources available to you such as the “Pain Pocket Card” which is attached to this computer. • Please DO NOT remove this card. You will receive your own card when you exit this station. • Welcome to UMHS and Best Wishes!