1. THE RESIDENT’S GUIDE TO PAIN MANAGEMENT Elizabeth Kvale, MD Palliative Medicine
AGS
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
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2. PAIN PHYSIOLOGY BASICS: TYPES OF PAIN
Nociceptive — arthritis, fracture, laceration
Visceral — pancreatitis, MI, constipation
Neuropathic — herpes zoster, diabetic neuropathy
Complex regional pain syndromes (RSD)
Central pain
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3. PAIN PHYSIOLOGY BASICS: ACUTE VS. CHRONIC PAIN
Acute pain
Identified event, resolves in days–weeks
Usually nociceptive
Chronic pain
Cause often not easily identified; multifactorial
Indeterminate duration
Nociceptive and/or neuropathic
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4. PAIN ASSESSMENT BASICS: BELIEVE THE PATIENT
Pain is a subjective experience ― the patient is the best source of information about their pain
Pain history ― site(s), intensity, temporality, character, exacerbating and alleviating factors
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5. PAIN ASSESSMENT BASICS: USE AN ASSESSMENT INSTRUMENT
Allows you to know and document whether you have helped the patient
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6. Pain Management Basics:
Match the medication to the amount of the patient’s discomfort
3 Severe
2 Moderate
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
± Adjuvants
A/Codeine
A/Hydrocodone
A/Oxycodone
A/Dihydrocodeine
Tramadol
± Adjuvants
1 Mild
ASA
Acetaminophen
NSAIDs
± Adjuvants
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7. Pain Management Basics
Don’t delay for investigations or disease treatment
Unmanaged pain  nervous system changes
Permanent damage
Amplification of pain
Treat underlying cause (eg, radiation for a neoplasm)
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8. Pain Management Basics: Opioid pharmacology (1 of 2)
Conjugated in liver
Excreted via kidney (90%–95%)
First-order kinetics
Time to Cmax
PO dosing ― 1 hour
SC or IM dosing ― 30 minutes
IV dosing ― 6 minutes
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9. Pain Management Basics: Opioid pharmacology (2 of 2)
Steady state after 4–5 half-lives
Steady state after 1 day (24 hours)
Duration of effect of “immediate-release” formulations (except methadone)
3–5 hours PO or PR
Shorter with parenteral bolus
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10. Pain Management Basics Oral dosing of immediate-release preparations
Codeine, hydrocodone, morphine, hydromorphone, oxycodone
Dose q4h
Adjust dose daily
Mild or moderate pain: ↑ 25%–50%
Severe or uncontrolled pain: ↑ 50%–100%
Adjust more quickly for severe uncontrolled pain
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11. Pain Management Basics Oral dosing of extended-release preparations
Improve compliance, adherence
Dose q8h, q12h, or q24h (product-specific)
Don’t crush or chew tablets
May flush time-release granules down feeding tubes
Adjust dose q2–4 days (once steady state reached)
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12. Pain Management Basics Breakthrough pain
Use immediate-release opioids
5%–15% of 24-h dose
Offer after Cmax reached
PO or PR: ~ q1h
SC or IM: ~ q30min
IV: ~ q10–15min
Do not use extended-release opioids
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13. Pain Management Basics
Ongoing assessment
Increase analgesics until pain is relieved or adverse effects are unacceptable
Be prepared for sudden changes in pain
Driving is safe if pain is controlled, dose is stable, no adverse effects
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14. Concerns ABOUT opioid use: POOR RESPONSE
If dose escalation  adverse effects:
Use more sophisticated therapy to counteract adverse effect
Use an alternative:
Route of administration
Opioid (“opioid rotation”)
Use a co-analgesic
Use a nonpharmacologic approach
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15. Concerns ABOUT opioid use: Clearance
Conjugated in liver
90%–95% excreted in urine
If dehydration, renal failure, severe hepatic failure develops:
 dosing interval,  dosage size
If oliguria or anuria develops:
Stop routine dosing of morphine
Use only PRN
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16. Concerns ABOUT opioid use: TOLERANCE
Reduced effectiveness to a given dose over time
Not clinically significant with chronic dosing
If dose requirement is increasing, suspect disease progression
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17. Concerns ABOUT opioid use: Addiction
Psychological dependence
Compulsive use
Loss of control over drugs
Loss of interest in pleasurable activities
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18. Concerns ABOUT opioid use: Physical dependence
A process of neuroadaptation
Abrupt withdrawal may  abstinence syndrome
If dose reduction required, reduce by 50% q2–3 days
Avoid antagonists
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19. Concerns ABOUT opioid use: Substance ABUSERS
Can have pain too
Treat with compassion
Protocols, contracting
Consult with pain or addiction specialists
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20. Concerns ABOUT OPIOID USE: Things to avoid
Meperidine — accumulates toxic metabolite normeperidine
Mixed agonists/antagonists – Nubain, Talwin
Do not use naloxone (Narcan) unless true respiratory crisis (RR < 6)
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21. SUMMARY: BASIC PRINCIPLES OF PAIN MANAGEMENT
Ask the patient
Palliative medicine corollary ― believe the patient
Match the pain medicine to patient’s level of pain
Increase pain medicine (with awareness of Cmax and half-life) until patient is comfortable
Slide 21
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22. Mrs Paine Very pleasant 68-year-old admitted with COPD exacerbation
Home meds include 2 tablets of oxycodone 5 mg/APAP “whenever my back acts up” — usually 4 tablets a day
Appropriate pain medication order?
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23. Mrs Paine
Readmitted months later with stage IV non-small cell lung cancer
Taking 2 oxycodone/APAP tabs every 6 hours
Rates her pain as 7/10 “most of the time”
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24. Key Points Maximum acetaminophen dose in 24 hours is 4 grams
Tylenol #3 (codeine 30 mg/APAP 325 mg)  24-hr maximum = 12 tablets
Percocet (oxycodone 5 mg/APAP 325 mg)  24-hr maximum = 12 tablets
Tylox (oxycodone 5 mg/APAP 500 mg)  24-hr maximum = 8 tablets
Lortab 5 (hydrocodone 5 mg/APAP 500 mg)  24-hr maximum = 8 tablets
How long does it take to get a PRN dose of pain medication once it is requested?
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25. Key Points
Mrs Paine’s total daily oxycodone dose is 40 mg (8 tablets  5 mg)
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