Pain Management

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Pain Management

• Paul Rozynes, M.D.
• Medical Director
• Vitas Broward

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

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Somatic Pain

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

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Neuropathic Pain

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

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• Pain scale1 to 10.
• 1 to 3mild pain.
• 4 to 6---moderate pain
• 7 to 10severe pain
• Pain vs. pain and inflammation.

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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.

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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.

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• 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.
• CautionThere 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.

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Step 2

• Mild to moderate pain.
• Moderate strength narcotics.
• Percocet, vicodin, Tylenol3.

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• Can be used if step 1 doesnt work.
• Meds are constipatingalways order a laxative.
• Can also cause nauseaconsider compazine prn.

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Step 3

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

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• Long acting-Kadianonce 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.
• DuragesicA patch. Applied once every 3 days(72
  hours). Very expensive. Abuse potential. At
  certain times duragesic can be usedunable to
  take po, or has severe nausea or vomiting ie.
  cant keep meds down.

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

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

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• All step 3s are very constipatingalways order a
  laxative and bowel prep.

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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.

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• 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.

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

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

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Special drugs for pain management

• Prednisoneexcellent 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.
• Elavilraises 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.

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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.

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• 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.

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• 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

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

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• 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.

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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

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• Morphine/24hrs MS methadone
• lt100 mg 41
• 100-300 mg 81
• 301-600 mg 121
• 601-799 mg 151
• gt800 mg 201

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

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• 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.

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The Drips
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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

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

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PCAPATIENT 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.

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• A button is pushed to allow a breakthrough dose
  of analgesic to be given at the patients
  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.

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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).

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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.

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• Must work with infusion company to provide the
  narcotic, pump and establish initial settings.
• Adjustments are made by a RN with Physicians
  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

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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.

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• 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

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

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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.

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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).

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Hypodermoclysis

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

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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).

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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.

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Medications that are inappropriate for S/C route

• Compazine
• Diazepam
• Thorazine

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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.

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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 youre subcutaneous.
• Adjust fluid drip rate as prescribed.

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Q A