Pain Management

1. Pain Management Paul Rozynes, M.D. Medical Director Vitas Broward

2. Pain—Definition is based upon our own experiences with pain. • Pain is subjective and influenced by our background and emotional status.

3. Somatic Pain • Tumor pressure upon internal organs, inflammation of tissues, or traumatic injuries.

4. Neuropathic Pain • Effect nerve or nerve complexes. • Shingles, post herpetic neuralgia, diabetic peripheral neuropathy, nerve compression from tumor.

5. Pain scale:1 to 10. • 1 to 3—mild pain. • 4 to 6---moderate pain • 7 to 10—severe pain • Pain vs. pain and inflammation.

6. Choice of Analgesic Depends Upon: • Severity of Pain • Location of pain • Pain type i.e. Neuropathic vs Somatic pain vs. mixed neuropathic somatic • Individual Physician Preference • Cost and drug availability. • Mode of administration.

7. Step 1 • Over the counter analgesics: • Tylenol-analgesic effect but is not an anti-inflammatory and is not an NSAID. • Anti-inflammatory and analgesic effect---The non steroidal anti-inflammatory drugs(NSAIDS): Disalsid, motrin, aleve, naprosyn, advil. • Used usually for mild pain or arthritic pain of a mild to moderate nature.

8. All NSAIDS can cause gastritis and peptic ulcers except disalsid which is absorbed in the small intestine. • Protect the GI tract if you use NSAIDS except disalsid for any significant length of time. • Use zantac, pepsid, or prilosec. • Caution—There is a drug interaction between all NSAIDS and coumadin. This includes disalsid. Remember, Tylenol is not an NSAID and can be safely used with coumadin.

9. Step 2 • Mild to moderate pain. • Moderate strength narcotics. • Percocet, vicodin, Tylenol#3.

10. Can be used if step 1 doesn’t work. • Meds are constipating—always order a laxative. • Can also cause nausea—consider compazine prn.

11. Step 3 • Moderate to severe pain. • Stronger narcotics. • Morphine-the gold standard.

12. Long acting-Kadian—once a day or twice a day. Can open capsule and give via g- tube. Convenient, improves compliance, expensive, cannot be given rectally. • MS Contin-twice a day. • Duragesic—A patch. Applied once every 3 days(72 hours). Very expensive. Abuse potential. At certain times duragesic can be used—unable to take po, or has severe nausea or vomiting ie. can’t keep meds down.

13. Methadone • Long acting. • Convenient. • Effective. • Very cost effective. • Start low dose then work up slowly. Usually don’t have an attitude problem as you see with morphine. Probably not used as often as it should be. • Has cumulative effect. Increase dose slowly.

14. Dilaudid • Short acting. • Requires 3 to 4 hour dosing. • Abuse potential. • Can be given via subcutaneous pump as constant drip.

15. All step 3s are very constipating—always order a laxative and bowel prep.

16. The concept of “breakthrough” or rescue in pain management: • All long acting analgesics have limitations in pain control ie. the dose may be too low, or the interval chosen for dosing the drug may not be short enough to fully control the pain for the length of time desired. • A short acting narcotic is ordered on a prn basis in the event more analgesics are needed.

17. Roxanol or short acting liquid morphine: • Dosed usually every 4 hour prn breakthrough pain. • Often given every 4 hours around the clock with a breakthrough dose every 2 hours prn. • Easy to take po. • Can be given sublingual. • Can be used as a breakthrough for kadian and duragesic. • Can also be used for respiratory distress.

18. Choices for breakthrough depends upon long acting drug • ie. use methadone as breakthrough for methadone • -try not to mix different narcotics.

19. Concepts: • Dosing. • Increasing the dose. • Conversions. • Half life.

20. Special drugs for pain management: • Prednisone—excellent for arthritic and bone pain. Also can stimulate the appetite. Can cause peptic ulcers and gastritis. Protect GI tract with zantac or prilosec. Also not safe to use with coumadin. • Elavil—raises pain threshold. Good for neuropathic pain ie shingles or peripheral neuropathy in addition to narcotic. Elavil is an antidepressant but specifically effects the pain threshold. • Ativan, xanax, or paxil and prozac if anxiety and or depression is a factor.

21. Examples of Medications Discussed & Dosing: • Morphine (Roxanol) • Start with 5 mg po q 4 h ATC with 5mg po q2h prn BT (breakthrough). • If patient uses 2 or 3 BT in 24 hours, increase dosage to 10 mg po q4h ATC with 10 mg po q2h prn BT. • Keep adjusting dose until pain is controlled with minmum need for BT as the goal.

22. Kadian • Start with 30mg po qd with Roxanol 5mg po q4h prn BT. • Increase Kadian to 50mg po qd with Roxanol 10mg po q4h prn BT if patient had required frequent BT dosing.

23. Duragesic • Start with 25mcg patch q 72h with Roxanol 5mg po q4h prn BT. • If frequent dosing of BT is required after 48 to 72 hours, increase Duragesic to 50 mcg q 72h with Roxanol 10 mg po q4h prn BT

24. Dilaudid • Start with 2mg. • Can give ATC or prn and if so, give q3h. • If not effective, increase to 4mg.

25. Methadone • Start with 2.5mg po q 12h ATC with 2.5mg q6h prn BT. • If multiple BT are required, change to 5mg po q12h ATC. • The BT dose may need to stay at 2.5mg due to the cumulative nature of methadone. • Doses should be increased slowly and more cautiously.

26. Suggested Methadone Conversion Protocol • Calculate total daily dose of methadone • Stop current opioid • Start methadone, dividing total dose into 3 q 8 hr doses • Breakthrough dose is 10% of total daily dose given q 3-4 hrs prn • Adjust dose only q 3 – 5 days • Watch closely for signs of increasing drug level: sedation

27. Morphine/24hrs MS: methadone • <100 mg = 4:1 • 100-300 mg = 8:1 • 301-600 mg = 12:1 • 601-799 mg = 15:1 • >800 mg = 20:1

28. Percocet or Vicodin • 1 or 2 tablets either ATC or PRN

29. MS Contin • Start with 30mg po q 12h ATC • With MS IR (immediate release) 15mg po q4h prn BT. • IF BT used often, increase MS Contin to 60 mg po q12h ATC and MSIR to 30mg q4h prn BT.

30. The Drips

31. When do we use IV or Subcu analgesic drips? • Patient unable to take PO analgesics • Nausea • Vomiting • Intestinal obstruction • Pain medication not effective by mouth or by patch despite high dosages of medication. • Avoid use of multiple analgesics when one is not effective

32. Patient and of family request in an ethical setting. • Port of IV site readily accessible. • Patient can control amount and time of medication administration.

33. PCA=PATIENT CONTROLLED ANALGESICS • PCA is a small, lightweight, battery-operated pump attached to a syringe filled with pain medication. • The syringe is hooked to an IV tube. • A catheter is placed IV or SQ and the IV tube is conned to this. • A “basal rate” is the amount of medicine which infuses at a constant rate.

34. A button is pushed to allow a breakthrough dose of analgesic to be given at the patient’s discretion after a fixed time interval. • The patient is limited in frequency of administration at the fixed amount. • If the patient attempts more frequent doses, there will be no additional medication given because the pump is programmed to give the analgesic in a fixed time interval. This time interval is called the “lock out” period.

35. What do we commonly use? • Morphine and Dilaudid • Effective • Can convert from PO to Parenteral (other than oral or GI route) • Can use IV or Subcutaneous • Can be given via continuous drip pump with patient, family or Nurse controlled breakthrough administration (PCA).

36. Problems with the Drips: • Difficult to administer at home • Need Continous Care • Need RN familiar with pumps and patient controlled devices if the narcotic is given IV. • IV may come out and RN needs to be able to reinsert. • Can use IV certified LPN if the narcotic is given SQ.

37. Must work with infusion company to provide the narcotic, pump and establish initial settings. • Adjustments are made by a RN with Physician’s order and supervision by the infusion company pharmacist (usually by phone). • If possible use SQ route especially if port not available • Easier to keep intact • Easier to insert and re-insert • Easier to staff Continuous Care

38. Examples: • Morphine • Patient is on PO Morphine at 60 mg q4h. • The patient must be switched to subqu Morphine due to intractable vomiting. • 60 mg PO q4h = 5 mg SQ qh via continuous drip (see conversion ruler) • Choose a breakthrough • i.e. 25 to 50% of the hourly dose which is 2mg in this case and administer every 15 minutes via patient or caregiver control.

39. Dilaudid • Patient is on PO Dilaudid at 16 mg q3h. • The patient is not getting relief of his symptoms and cannot tolerate any more PO analgesics. • 16 mg PO q3h = 0.8 mg SQ qh via continuous drip (see conversion ruler) • Choose a breakthrough • 0.2mg in this case and administer every 15 minutes via patient or caregiver control prn

40. If the patient uses frequent breakthrough, increase the continuous drip dose according to the amount of breakthrough.

41. Hypodermoclysis: Objectives • Familiarize with this time-honored technique. • This can be used in the Inpatient Units and at Home with great ease! • Also to promote its use amongst our Physicians, as an alternative to tx dehydrated patients, a treatment for delirium and to administer medications when po is not practical.

42. Hypodermoclysis: Safe and Simple • Subcutaneous infusion of fluids • Under-recognized and under-used! • Safe, no serious consequences • Suitable for the elderly, Cancer patients with phlebosclerosis for the treatment of moderate or severe dehydration and as an alternative to administer medications (other than intravenous).

43. Hypodermoclysis • Fluids to be infused are isotonic: NSS, D5/NS, D5/0.5NS. • Volume: 1.5L in 24h per sitefrom 20-75 ml/hr. • Sites: most common is the abdominal wall, thigh, upper arm, chest, back.

44. Adverse Effects of clysis • Local Edema: most common. Resolved by massage. In other cases Decadron 2-4 mg and/or lidocaine 1% can be infused prn. • Local Catheter reactions: rare (6%) • Cellulitis: minimal if aseptic technique is maintained. • Pulmonary edema: very, very rare (0.6%).

45. Clysis: • Generally Safe to administer: Dilaudid, Morphine, Decadron, haloperidol, lorazepam, ranitidine and most palliative meds. • In a situation as this, it would call for multiple sites, normally two. One would be for volume and others for meds.

46. Medications that are inappropriatefor S/C route: • Compazine • Diazepam • Thorazine

47. Technique: Use 23 or 25G Winged Butterfly Needle • Sites are changed every 3 to 5 days or earlier if warranted. (average in one study: 4 days). Choose a site that patient would not tend to reach. • Aseptic technique: Swab the site with povidone-iodine in a circular motion and allow a minute of contact time. • Flush with 3 ml NSS.

48. Clysis technique: • Insert needle bevel up into subcutaneous tissue at a 30-45 degree angle. • Secure needle and tubing with occlusive dressing (for eg. Opsite®). • By definition, you are NOT going to obtain a blood return, since you’re subcutaneous. • Adjust fluid drip rate as prescribed.

49. Q & A