ASPMN 22nd National Conference - Workshop 1

ASPMN 22nd National Conference Workshop 1: ASPMN Pain Management Certification Preparation Course™ Faculty: Mary Milano Carter, MSN, RN-BC, APRN-BC Carol Curtiss, MSN, RN-BC Renee C. Manworren, PhD, RN-BC, CNS Lora McGuire, MS, RN Melanie H. Simpson, PhD, RN-BC, OCN, CHPN

Workshop #1 ASPMN Certification Review Course ASPMN National Conference, Baltimore MD AGENDA

8AM -9:45AM

Foundations of Pain - Mary Carter

9:45AM – 10 AM Break 10AM - 11AM

Pain Diagnoses - Lora McGuire

11AM-11:45AM

Assessment - Carol Curtiss

11:45-12:45

Lunch

12:45-3:45PM

Pain Management Interventions- Renee Manworren Analgesics, nonpharmacological and interventional modalities – with brief stretch break in middle

3:45-4:45PM

Patient Education - Melanie Simpson

4:45PM -5PM

Questions and Answers

8/22/2012

Certification Review Course

Course Objectives     



Define pain & it’s impact on individuals and families Identify pain transmission List strategies to assess pain in a variety of populations Describe barriers to effective pain management Describe the pharmacodynamics and pharmacokinetics of pain medications Identify theories that support pain management interventions

     

Identify side effects of interventions Identify principles of patient education Describe strategies to improve collaboration and leadership Identify standards and guidelines Describe importance of research and advocacy Understand major pain diagnoses

Review Course • Follows the ASPMN Study Guide – Only test developers know the exam!

• • • •

Covers a great deal of information Reviews major areas of content Cannot go into great detail Gives participants a way to identify areas needing more study

1

8/22/2012

Test Content Outline Domains of Practice

Percent

Foundations

18%

Pain Assess & Reassess

21%

Interventions

29%

Patient/ Family Education

32%

Helpful Resources • ANCC website (www.nursecredentialing.org) • ASPMN website (www.aspmn.org) • ASPMN Core Curriculum 2010 • American Pain Society (2006). Pain: Current Understanding of Assessment, Management, and Treatments

Preparing for the Exam • Review ASPMN Core Curriculum • Review this ASPMN Study Guide • Spend shorter periods of time each day studying, avoid “cramming” • Become familiar with exam composition • Identify areas for improvement and give these areas more attention

2

8/22/2012

The Night Before the Exam • Organize everything you will need for the exam • Find the exam site • Try to get at least 8 hours of sleep

Exam Day • Eat breakfast or at least a nourishing protein snack • Avoid caffeine if possible (adds to stress) • Dress comfortably (layers) • Get to the testing site early to avoid stress • No negative self-talk, have confidence!

Exam Day (Cont’d) • Be positive

• Avoid distractions, concentrate on the exam only

3

8/22/2012

Taking the Exam • Read each question carefully, cover the answers and answer in your head first • Don’t read into the question • Don’t add or subtract words • Read all the choices before choosing your answer • Eliminate one or two answers • Remember the Nursing Process: Assess, Plan, Intervene, Evaluate – “What is the first thing you would do?”

Taking the Exam (Cont’d) • Stay away from answers that contain “always, never” • Pay attention to the last words in the question, “What is the highest priority, which best demonstrates” • A positive choice is more likely to be true than a negative one • If there is an "All of the above" option and you know that at least two of the choices are correct select the "All of the above"

Taking the Exam (Cont’d) • Usually the correct answer is the choice with the most information.

• Don’t change an answer unless you know for sure you misread the question • Skip a question you can’t answer and mark it, don’t waste time if you don’t know the answer • If you have no idea of the answer, at least make a good guess, do not leave a question blank

4

8/22/2012

ANCC web-based Test-Taking Course www.nursecredentialing.org/cert/webcourses.html

Sample Test Question Which of the following best describes the purpose of this course?

A. To keep you out of the heat for a few hours B. To teach Pain Assessment and Management 101: Everything you ever wanted to know about pain but were afraid to ask C. To be a REVIEW course

Foundations of Pain

18% of the exam

5

8/22/2012

Definitions of Pain • “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (Mersky, 1986) • NOTE: “The inability to communicate verbally does not negate the possibility that an individual is experiencing pain & is in need of appropriate painrelieving treatment” (International Association for the Study of Pain)

Definitions of Pain • “Whatever the experiencing person says it is, existing whenever the experiencing person says it does.”

McCaffery, 1968

• “Pain is always subjective” APS, 1999

Theories of Pain • Specificity theory Pain is a physical (not emotional) phenomenon traveling a specific anatomic path; to replace “pain is punishment”

• Pattern theory Articulated to account for abnormal pain; emphasizes importance of stimuli intensity and central summation

• Psychosocial theories Pain as an emotional state

• Gate control theory of pain Incorporates pieces of the all three

6

8/22/2012

Gate Control Theory Melzak & Wall, 1965

• The flow of pain impulses from the periphery and descending messages from the central nervous system can be increased or decreased by a neural “gating” mechanism in the dorsal horn (substantia gelatinosa) • Endogenous opioids “close” the gate and reduce the transmission of pain

Gate Control Theory • Small A delta & C fibers carry messages to dorsal horn of spinal cord • Dorsal horn acts like gate  &  flow • Large A beta fibers close the gate

Sample Test Question Many theories regarding pain exist. Which of the following is the most comprehensive and most widely accepted?

A. B. C. D.

Specificity Gate Control Pattern Pain is subjective

7

8/22/2012

Pain Transmission

http://www.georgiapainphysicians.com/ Under Education Tab

Nociception • Four distinct processes beginning in the periphery

• Transduction • Transmission • Perception • Modulation

Nociception

Cortex

PAIN !

Thalamus Substance P Glutamate Action Potential Release of neurotransmitters

Spinal cord

ENDOGENOUS OPIOIDS RELEASED SEROTONIN & NOREPINEPHRINE REUPTAKE INHIBITED

Na+

INJURY

TRANSDUCTION

TRANSMISSION

PERCEPTION

MODULATION

8

8/22/2012

Nociception: Transduction - Definition

INJURY

Release of neurotransmitters

Transfer of energy from one form to another, causing a neuron to respond Converts stimulus energy into electrical impulse

Nociception: Transduction - The Process • Noxious stimuli causes tissue damage resulting in release of intracellular substances that sensitize and activate nociceptors • Released substances include – – – – – –

Prostaglandin Bradykinin Serotonin Substance P Potassium Histamine

Nociception: Transduction - The Process • Released substances cause sodium to move in through the neural membrane, creating a change in the electrical charge (depolarization) called an “action potential” • Pain impulse is transmitted through the neuron

9

8/22/2012

A Delta Vs. C Fibers • A Delta

• C Fibers

– – – –

– – – –

Thinly myelinated Large in diameter Quick conduction Transmit sharp, localized pain – Sensitive to mechanical and thermal stimuli – “First pain”

Unmyelinated Thin Slower transmission Transmit dull, aching visceral pain that is diffuse in nature

Nociception: Transmission - Definition • The process of moving a painful message from nerve endings at the periphery, through the dorsal root ganglion, through the spinal cord and the ascending tract to the brain Cortex

Substance P, Glutamate Thalamus Spinal cord

Action Potential Na+

Nociception: Perception - Definition • The conscious realization that pain is present

Cortex

PAIN !

Thalamus

Spinal cord

10

8/22/2012

Nociception: Perception – The Process • Hypothalamus – Activator of emotional input – Controls emotional response

• Limbic system – Generates purposeful goal-directed behavior – Affects mood states

• Thalamus – Allows perception

• Reticular formation at the brainstem

– Triggers arousal and alertness – Add emotive response

• Cerebral cortex – Receives the message

Nociception: Modulation • Used by the brain to inhibit pain impulses • Release of endogenous opioids

Pain !

ENDOGENOUS OPIOIDS RELEASED SEROTONIN & NOREPINEPHRINERE UPTAKE INHIBITED

Nociception: Modulation Inhibitory effect in the dorsal horn when re-uptake of norepinephrine and serotonin is inhibited and can stop nociceptive impulse from being communicated to the next neuron

11

8/22/2012

Endogenous Opioids Endorphins discovered in 1976 – Produced by the body – Released when large diameter inhibitory fibers (A beta) are stimulated – “Close the gate” to decrease pain transmission

Therapies that stimulate endorphins – Heat, cold, massage, acupuncture, TENS, sucrose

Sample Test Question _____ fibers are unmyelinated, thin, slower transmitters, transmit dull, aching visceral pain that is diffuse in nature. _____ fibers are responsible for what is known as “first pain”?

Sample Test Question Which of the following is the correct sequence of events describing pain transmission?

A. B. C. D.

Modulation, Transmission, Perception, Transduction Transmission, Transduction, Modulation, Perception Transduction, Transmission, Perception, Modulation Transmission, Perception, Modulation, Transduction

12

8/22/2012

Multidimensional Model of Pain Pain Behavior Suffering Pain Nociception Adapted from Loeser JD. In: Bonica’s Management of Pain.

Philadelphia; Lippincott Williams & Wilkins: 2001.

Pain Experiences • Are: – Unique and individual for each person – Complex in nature

• Influenced by: – Physical factors – Psychological factors

• Can be altered in the periphery, cord or cerebrum

Pain: A Multimodal Issue • • • • • • •

Physical Sensory Affective Cognitive Behavioral Socio-cultural Spiritual

Individual experience

13

8/22/2012

Suffering • A state of severe anguish or distress associated with an event or perceived threat.

• A subjective secondary response while pain is a primary response to the environment.

(Cox, 2002, 32).

Pain Behavior: Cultural Differences and Minority Groups • Perception and response to pain is culturally influenced • Disparities in treating pain exist • Conflict arises when we judge

Variations in Perception and Response • Pain expression – Stoic vs. Emotive – Eye contact – Gender differences

• • • • • •

Familial support Choice of interpreters Use of pain medication Use of complimentary medicine Use of prayer Personal space requirements

14

8/22/2012

Who Gets Poor Pain Management?

Providers infer LESS pain: – Attractive – Less expressive – Females – Newborns (less anesthesia) – Elderly (fewer pain meds) – Minority (Hispanics) – Irresponsible life style

Providers infer MORE pain: – Unattractive – Expressive – Males (more extensive work up) – Nurses who have experienced pain themselves infer more pain in their patients

Activities That Enhance Pain Management • • • •

Show respect for health beliefs and practices Promote a feeling of acceptance Avoid stereotyping Understand individual’s goals and expectations • Use appropriate language (translated) and pain assessment tools

The Purpose of Pain • Serves as a warning sign • Body responds in a protective manner – Promoting healing – Minimizing blood loss – Fighting infection

• Prolonged pain serves no purpose and can cause harm

15

8/22/2012

Acute Pain • • • •

Recent onset Short duration Cause usually known Diminishes as healing occurs

• Autonomic response usually present • Focus of treatment is on the cause of pain

Persistent (chronic) Pain • Duration at least 1 month longer than usual course of pain OR • Continuous or recurring pain from a chronic condition • Cause may not be known

• Serves no purpose • Usually, no autonomic response • May have acute exacerbations • Treatment: –  pain –  coping strategies

Nociceptive vs. Neuropathic Pain 1) Nociceptive

2) Neuropathic

• Normal processing of stimuli – Noxious stimuli and intact nervous system

• Abnormal processing of sensory input by central or peripheral nervous system – Difficult to treat – Less responsive to opioids

• Post op pain • Paper cut • Arthritic pain

16

8/22/2012

Nociceptive Pain • Somatic

• Visceral

– Occurs in bone, joint, muscle, skin or connective tissues – Sharp, aching, throbbing – Well localized – ___fibers responsible for this type of pain – Responds well to opioids and NSAIDS

– Produced in an organ capsule – May be referred to distant site

– Intermittent cramping and aching – Poorly localized – __ fibers responsible for this type of pain

Referred Pain • Pain presents in an area removed or distant from it’s point of origin Examples: – – – – – – –

Liver-R shoulder & R back Heart-Upper back & L arm Pancreas-Mid back Stomach-Center abdomen, upper center back Bladder-Pubis, coccyx, lower buttock & upper thigh Kidney-flank extending down, outer & inner thigh Gallbladder- scapula

Pathophysiology of Neuropathic Pain Occurs with abnormal processing in central and/or peripheral nervous system – Centrally generated • Post-stroke Syndrome • Spinal Cord Injury

– Peripherally generated • CRPS 1 and 2 • Peripheral Neuropathy • Radiculitis

Described as burning, stabbing, shooting, electricshock like, tingling, lancinating

17

8/22/2012

Nociceptive vs. Neuropathic Pain From: National Initiative for Pain Education, 2005 www.painedu.org

Nociceptive Pain

Mixed Type

Neuropathic Pain

CRPS* Postherpetic Arthritis neuralgia

Postoperative pain Mechanical low back pain

Sickle cell crisis

Trigeminal neuralgia

Neuropathic low back pain

Central poststroke pain Distal polyneuropathy (eg, diabetic, HIV)

Sports/exercise injuries *Complex regional pain syndrome.

Sample Test Question ________ pain is an ABNORMAL processing in central and/or peripheral nervous system producing pain that serves no purpose and is difficult to treat

Wind Up

• Activation of N-methyl-D-asparate (NMDA) receptors from repeated stimulation by C fibers • May cause changes in the CNS resulting in persistent pain

18

8/22/2012

Wind Up (cont’d) • Progressive increase in the discharge of dorsal horn neurons: a hyper-excitability state • Develops with repeated episodes of pain • Intensity, length & distribution of pain become greater than anticipated for given stimuli • Lowers activation threshold • Increases the response to stimuli • Causes damage to pain inhibitory system with widespread and intense pain

Wind Up (cont’d) May reshape the structure & function of the spinal segment of nervous system •Neuroplasticity •Damage to pain inhibition systems •Protein synthesis stimulating pain fiber growth

Consequences of Unrelieved Pain

19

8/22/2012

Consequences of Unrelieved Pain • Physiological – Triggers stress response – Activates sympathetic nervous system

• Psychological • Socioeconomic effects • Liability issues

Consequences: Physiological • Endocrine system –  stress response –  catecholamines, etc.

– = carbohydrate, fat & protein catabolism, glucose intolerance, insulin resistance & hyperglycemia

Preemptive analgesia may decrease this harmful effect

• Cardiovascular – Sympathetic nervous system dominance •  Stress response = Increased heart rate, BP, cardiac workload, myocardial oxygen consumption & hypercoagulability

– Cardiac morbidity is the primary cause of death after anesthesia and surgery in adults

Consequences: Physiological (cont’d) • Respiratory System – Voluntary immobility of abdominal and thoracic muscles – = poor respiratory exchange, decreased tidal volume, etc.

– = atelectasis & pneumonia

Aggressive pain control & incentive spirometry

• Genitourinary system – Excessive release of hormones – =  urinary output – Urinary retention – Fluid overload – Hypokalemia –  BP –  cardiac workload

20

8/22/2012

Consequences: Physiological (cont’d) • G.I. system

• Immune system

– Stress causes a suppression – Delayed gastric emptying of immune response – Decreased intestinal motility • Cognitive function – Pain increases risk for • Musculoskeletal system delirium & confusion – Muscle spasm – Infants may demonstrate  – Muscle atrophy attention/difficulty calming – Immobility or impaired function

Consequences: Quality of Life • Ratings > 5 (0-10) affect ADLs & QOL – Disruptive of social and recreational activities in children – Affects sleep, depression, socialization and mobility & function in older persons

• Serves as reminder of disease – Challenges coping of patient and caregivers – “How people die remains in the memories of those who live on” (Dame Cicely Saunders, founder of the hospice movement)

Consequences: Future Pain Failure to control pain may lead to chronic pain syndromes – Central Sensitization: spontaneous impulses may arise from the nervous system when pain is uncontrolled. Persists over time, unlike Wind Up which is short term.

21

8/22/2012

Cost of Unrelieved Pain

More than 50 million Americans suffer from persistent pain • Persistent pain costs society more than $100 billion annually in U.S. (decreased productivity & lost work time) • Chronic back pain $16.6 billion alone • Consider others costs to the person & family

Harmful Effects in Specific Patient Populations • • • • •

Pregnancy Infants/ children Elderly History of substance abuse disorder Low/fixed income

Pain and Pregnancy Unrelieved pain causes stress & hormone release, increasing oxygen consumption and metabolism – Catecholamines cause  perfusion to uterus and  blood flow to placenta • Risk of pre-term labor, suppression of milk production and dystocia

22

8/22/2012

Pain & Pregnancy (con’t) Nearly all drugs taken during pregnancy reach the fetus – 3rd to 12th week gestation most susceptible

Goals: – Pain relief for mother – Reduced risk to mother and fetus

Factors Influencing Labor Pain • Size of infant’s head • Size of mother's pelvis • Position of mother during labor • Mother’s fatigue

• Fear & anxiety • Knowledge • Relationship between mother and partner • Cultural influences

Developmental Effects of Unrelieved Pain Early pain experiences of the neonate may be recalled and influence later behavior – Studies show altered temperament with  somatization later • Severe pain in children can result in problematic changes in behavior • Behavior changes may outlast the pain itself

23

8/22/2012

Infants & Children • Unrelieved pain contributes to morbidity in neonates • Under treatment is well documented – Neonates – Infants – Children

• May cause long term changes – Physical – Biochemical – Behavioral

• May interfere with sleep, play, appetite, mobility

Pain in the Elderly: Myths and Misperceptions • Pain is a normal part of aging • Addiction is common • “Strong” medicine must be saved until last • The health care provider will know if I have pain

• Pain is punishment • Pain perception decreases with age • “Good” patients don’t report pain • Reporting pain takes away from other issues in care

Common Causes of Pain in Older Persons • Vertebral compression fractures • Injury from falls

• Diabetic neuropathy • Impaired circulation disorders

• Osteoarthritis

• Post-herpetic neuralgia

• Post-stroke pain

• Skin breakdown

24

8/22/2012

Consequences of Pain in Older Persons • • • •

Impaired gait & posture Impaired sleep Depression Impaired bowel & bladder function • Anxiety • Confusion & delirium

• Decreased socialization and ability to enjoy • Nutritional disturbances • Decline in ADLs

• Decreased QOL!

Patients with Addictive Disease: An Under-treated Population • Right to treatment with dignity, respect and same quality as all others • Balance between pain relief and inappropriate use

• Nurses are well positioned and are obligated to advocate for pain management in patients who are • Actively using • In therapy • In recovery

Patients with Addictive Disease: At Risk • With addiction disorder, larger doses of medication may be required • Requests often perceived as addiction • Do not withhold/reduce opioids with severe pain • Multidisciplinary approach is needed

25

8/22/2012

Consequences of Under Treatment of Pain in People with Addictive Disorders • Fear of worsening the addiction leads to withholding or reducing meds • Relapse may be a consequence of under treatment • Person may “self-medicate” if pain is not adequately managed

Guidelines for Treatment of Pain in patients with an Addictive Disorder • Define & treat pain syndrome • Identify history of substance abuse • Establish parameters – Frequent visits – More frequent prescriptions • Discuss consequences of noncompliance

• Provide non-opioid therapies • Use controlled release oral pure opioid agonists – Adequate doses – Adequate intervals • Recognize specific abuse behaviors (not weaning as instructed) • Get expert help

When It’s Time for an Addiction Referral: Persistent Pain and Addiction Disorders • Reluctance to negotiate agreement

• Concurrent use of alcohol or illicit drugs

• Selling, forging, losing, prescriptions- stealing or • Does not follow agreed upon borrowing drugs lines of communication • Injecting/ snorting oral • Increased opioid need for formulations recovery with acute pain • Resistance to changing • Deterioration in condition treatments with adverse effects • Violation of agreement

26

8/22/2012

Definitions •APS, AAPM, ASAM Consensus Statement •Addiction •Pseudoaddiction •Physical dependence •Tolerance

Addiction Chronic, relapsing, treatable, disease Characteristics – Impaired control over drug use – Compulsive use – Continued use despite harm – Craving Research shows strong association between stress and drug craving, and pain may contribute to increased stress

Addiction A primary, chronic, neurobiologic disease with genetic, psychosocial & environmental factors “A pattern of compulsive use characterized by a continuous craving for an opioid & the need to use the opioid for effects other than pain relief” (APS)

27

8/22/2012

Pseudoaddiction An iatrogenic misinterpretation caused by undertreatment of pain that is misidentified by the clinician as inappropriate drug-seeking behavior • Behavior ceases when adequate pain relief is provided – NOT addiction!

• Not a diagnosis, rather a description of a clinical interaction Weissman DE, Haddox JD. Pain. 1989;36:363-6.

APS, ASAM, AAPM, Consensus Statement, 2001

Physical Dependence •Normal physiologic response •State of adaptation that is manifested by a drugclass-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist •Management: Taper off medication (20% every 3-7 days).

Do not abruptly stop

Physical Dependence

28

8/22/2012

Tolerance Normal biologic adaptation • Exposure to drug induces changes that result in a decrease of one or more of the drug’s effects over time (effect and side effects) • May develop at different rates • NOT addiction

Sample Test Question Your 16 year old oncology patient is receiving 60mg oxycodone SR Q12h and 10mg of oxycodone IR Q3h PRN. He is ordered oxycodone IR Q3h PRN, and actually taking it Q3h ATC. Which of the following are you least likely to consider: A. He’s likes the effect of oxycodone IR & is addicted B. He’s tolerant and needs a higher dose of IR C. His disease is worsening and further w/u is needed

Sample Test Question Your 44 year old patient has been admitted to the hospital. She explains that she is addicted to caffeine because she has 3 cups of coffee every morning and will get a headache if she has to break that routine in the hospital. What is your best response?

A.You’re right, you’re a caffeine addict B.You may or may not be addicted, but you are probably physically dependent C.Here’s a cup of coffee to get you going

29

8/22/2012

Ethical Considerations

Ethical Considerations Concerned with right and wrong 7 values guide decision making

Ethics 1. Autonomy –

–

Respect for individual and their right to make decisions (refuse or choose care) Providers obligated to provide adequate information

2. Beneficence – Do good and avoid harm – Nurses MUST relieve pain – Balance between benefits and harmful effects

30

8/22/2012

Ethics 3. Justice

4. Nonmaleficence

– ALL patients receive impartial treatment and high quality care – Fair allocation of healthcare resources

– Do no harm – The doctrine of double effect recognizes that use of high doses of opioids for pain relief may hasten death.

Ethics 5. Veracity

6. Fidelity

– Tell the truth – Open communicationavoid lies and deception – Use of placebos violates this principle

– Obligations of patient and the healthcare providers – Responsible to keep promises

Ethics 7. Dignity – Esteem and respect for patients – See patients as individuals that are unique and important

31

8/22/2012

Regulatory Considerations

Standards and Scope of Practice •ANA Code for Nurses •ASPMN position statements •ANA pain management guidelines •ANA standards of care •Joint Commission standards of care •Institutional guidelines •ELNEC

ANA Code for Nurses (Summary) •Provide services with respect for human dignity and uniqueness •Safeguard patient’s rights to privacy by protecting information •Safeguard the public or individual in healthcare when they are affected by incompetence, unethical or illegal practice •Assumes responsibility and accountability for nursing judgment and actions •Maintain competence in their profession •Exercise informed judgment when obtaining consultation, accepting responsibilities, and delegating nursing activities to others

32

8/22/2012

ANA Code for Nurses (Summary) •Participate in the ongoing development of the profession’s body of knowledge •Participate in the professions implementation and improvement of standards of nursing •Participate in the profession’s efforts to establish and maintain conditions of employment that are safe and offer high-quality care •Protect the public from misinformation and maintain integrity of nursing •Collaborate with other health care professionals in promoting community and national efforts to meet health needs of the public.

ANA Standards of Care Standards of professional performance: Standard I – quality of care “The nurse systematically evaluates the quality and effectiveness of nursing practice” • Participates in quality care practices • Quality of care activities are used to change practice • Quality of care activities are used to initiate changes throughout health care delivery systems

ASPMN Position Statement: End of Life Care (2003) “It is an ethical obligation for pain management nurses to advocate and provide for effective pain relief and symptom management to alleviate suffering for the patient receiving end of life care”

33

8/22/2012

ASPMN Position Statement: Physician Assisted Suicide (1998) “ASPMN opposes the participation of nurses in the act of assisted suicide but advocates a supportive environment in which patients die with dignity and relief from pain”

ASPMN Position Statement: Neonatal Circumcision (2010) “ASPMN opposes the participation of nurses and other health care professionals in the performance of male neonatal circumcision without an anesthetic to treat the pain…”

No anesthetic violates the ethical principle of non-maleficence.

ASPMN Position Statement: Use of Placebos (2010) •“…placebos should not be used by any route of administration in the assessment and management of pain in any patient regardless of age or diagnosis” (ASPMN) •Placebo use violates the AMA Code of Medical Ethics and the ANA Code for Nurses.

•“Use of placebos violates patient rights” (TJC) •“Do not use placebos to assess the nature of pain (APS) •“Placebos should not be used in the management of pain (AHRQ)

34

8/22/2012

Sample Test Question One of the floor nurses tells you the husband of one of your patients asked her to administer a normal saline injection instead of an analgesic just to see if his wife would get pain relief. Which guideline helps you in your decision making regarding this request?

A. B. C. D.

ANA Code for Nurses TJC pain management standards ASPMN position statement regarding placebos ANA pain management guidelines

Questions

Questions

Pain Assessment & Reassessment 21% of exam

35

8/22/2012

Self-report of pain is the single most reliable indicator of pain

Principles of Assessment • Accept self-report • Screen for pain routinely

• Assess when pain is reported, suspected – Use self-report, whenever • Re-assess routinely to possible determine efficacy and – Use the same rating scale identify changes over time • Consider individual, – Document and track cultural differences, scores over time values & beliefs

Components of Assessment • Location – Have the pt point out the location – Does the pain radiate

• Description – How does the patient describe (words) – May help diagnose underlying pain mechanism • Words like “sore” or “achy” may indicate somatic pain • Words like “burning” or “electric” may indicate neuropathic pain

• Intensity – Use the same assessment tool over the continuum

• Duration – When does the pain start – When is pain worse or better

• Alleviating factors – What makes the pain better – Any home remedies being used

36

8/22/2012

Components of Assessment • Associated aggravating factors - signs and symptoms of pain – – – – – –

• Pain Goal – A numerical number the pt thinks is reasonable to achieve – Develop a plan with the goal as an outcome

Nausea &Vomiting Constipation Sleeping problems Depression Immobility Anorexia

• Functional Goal – May be a better measurement of pain relief – Pain will increase with activity – How does the pain interfere with ADLs – Pt should keep a pain diary

Pertinent Medical History • Past pain experiences • Current or past chemical uses, illicit or prescription substance abuse • Surgical History

• • • • •

Psychiatric History Medication History Lab findings Imaging Other tests

Barriers to Assessment • Patient/Clinician • Cultural • Psychological Conditions – Coping – Depression

• Spiritual

• • • • • •

Behavioral Issues Developmental Level Language Cognitive Ability Physical Condition Verbal or Nonverbal

37

8/22/2012

Patient Barriers • • • •

Misinformation Fear Underreporting Culture/language differences

• Finances • Impaired communication • Pain behaviors • Coping style

Clinician Barriers • • • • • •

Disbelief of patient Fear of regulatory bodies Concerns for “Addiction” Lack of knowledge of the medications Lack of understanding of pain Nursing knowledge deficits about pain assessments

Cultural Barriers • Perception & response to pain influenced by cultural background, values and beliefs • Ask about and respect health beliefs and practices – Promote feeling of acceptance – Avoid stereotyping – Respect differences in eye contact, touch, etc.

– Pain expression differences – Meaning of pain differences

• Ask about and record goals and expectations • Use language-appropriate pain assessment tools

38

8/22/2012

Psychological Barriers • • • • • •

Employment Financial status Fulfillment of family roles and expectations Personal self image Children—missed school days Presence of depression and/or anxiety, difficulty coping, spiritual distress

Depression Assessment • Ability to manage daily lives • Mood • Sleep patterns • Appetite/weight changes – Changes in daily life or interest in activities

• Increased irritability

• Separation from close friends or possessions • Suicidal/homicidal thoughts • Tools – Beck Depression Inventory (BDI) – Hamilton Rating Scale for Depression (HAM-D)

Coping Assessment • • • • • •

Previous experience Present attitude Presence of depression/anxiety Usual coping strategies Willingness to try new strategies Preferences and wishes

39

8/22/2012

Coping Strategies • Strategies with poor outcomes – Catastrophizing – Negative self-statements – Disastrous thoughts or images – Passivity

• Strategies with better outcomes – – – –

Prayer Hope Decreased catastrophizing Rational thinking that imparts a sense of control

• Wish-fulfilling thoughts • Restriction of activity • Dependence on others

Spiritual Assessment • Religious beliefs and practices related to health concerns – Do beliefs encourage or prevent participation in care?

• Beliefs related to pain and pain relief – Therapies that forbidden?

• Evidence of spiritual/existential distress • Desire for support or referral?

Sample Test Question During your initial assessment of Mrs. Jones’ pain, she tells you that she is in terrible pain, but she just wants to endure it.

The best response to this statement would be to: a. b. c. d.

Tell her not to endure the pain.

Further explore what she means by this statement.

Provide information about the harmful effects of unrelieved pain.

Offer her analgesic medication.

40

8/22/2012

Acute Pain Assessment Tools

Qualities of Acute Assessment Tools • Simple and easy to use • Allow for quick assessment and reassessment • Provide for easy documentation • Understandable for patients of different cultures or languages

Unidimensional Assessment Tools • Measure only one • Limitations aspect of pain – Oversimplify pain – Quantifying severe • Quick, easy to use pain is difficult • Easy to score – Decreased reliability at • Originally developed age extremes, with for research trials non-verbal & cognitively impaired

41

8/22/2012

Visual Analogue Scale (VAS) Pain as bad as it could possibly be

No pain

10 cm

(AHCPR 1994)

Visual Analogue Scale • Valid & reliable for adults and children 8 and over who can quantify or understand rank and order • Person must be able to hold a pen & write • Requires visual acuity • Not easy to track • Originally designed for use in research studies

Verbal Descriptor Scales (VDS) No pain

None

Mild Pain

Mild

Moderate Pain

Discomforting

Severe Pain

Distressing

Very Severe Pain

Horrible

Worst pain possible

Excruciating

42

8/22/2012

Numeric Pain Intensity Scale (NPI) No pain

0

Worst possible pain

Moderate pain

1

2

3

4

5

6

7

8

9

10

(AHCPR 1994) (AHCPR 1994)

0 -10 Scale • • • •

Response is quick Simple to use Easy to make comparative pain ratings Provides a method for consistency of pain assessments • Patient must understand numerical concept

Pain Thermometer Pain as bad as it could be Extreme pain Severe pain Moderate pain Mild pain Slight pain No pain Used with permission, K. Herr, U. Iowa, 2005

43

8/22/2012

Chronic/Persistent Pain Assessment Tools

Multidimensional Pain Assessment Tools • Assess more than one component of the pain experience • Address the nature and location of pain • Degree of functionality may provide better indication of pain relief than intensity rating: – Mood – Medication efficacy – Impact on activity and sleep

• Often used with a multidisciplinary approach to pain care

Multidimensional Tool Examples • • • • •

McGill Pain Questionnaire Brief Pain Inventory (BPI) West Haven-Yale Multidimensional Pain Inventory The Pain Outcomes Questionnaire Others – Dartmouth Pain Questionnaire – Minnesota Multiphasic Personality Inventory (MMPI) – UAB Pain Behavior Scale

44

8/22/2012

Assessing Pain Using an Interview • Review patient record first • Approach as courteous, interested, willing to help, be open, non-judgmental, display empathy and be calm with eye contact • Assure patient comfort – Room temperature – Alter light, respect privacy and allow visitors per patient request – Favorite “security object” for children – Decrease noise, & distractions

Assessing Pain Using an Interview • Use suitable language • Ask open ended questions • Pursue unclear responses by “What do you mean?”

• Be aware of non-verbals, patients and your own • Observe patient/family/caregiver interactions • Identify expectations

Assessing Pain Using an Interview • Address sensitive topics – ETOH, drugs, abuse, sexual history (use CAGE, ORT, SOAPP) • Older adults – assess functionality, home safety, include family • Leave time for questions or additional information • Be aware of HIPAA rules

45

8/22/2012

Special Circumstances (True for all ages) • Accommodate for vision, hearing, response time impairments • Consider developmental characteristics

Assessment Challenges • • • • • • •

Infants Pre-verbal children Cognitively impaired individuals Critically ill individuals Chemically sedated individuals Those receiving neuromuscular blockade Anyone unable to self-report

Assessing Infants & Children • Infants & children feel and remember pain • Under treatment persists due to old misconceptions

46

8/22/2012

Assessing Infants & Children • Use age & developmentally appropriate assessment tools – NIPPS – FACES Scale • Bieri FACES • Wong-Baker FACES

– CRIES – FLACC

• Observe behaviors – Infant – Toddlers

• Ask parents/child • Observe – Sleep – Feeding – Interactions / play

• ? Source of pain

Assessing Children • School aged children – Self report – Encourage to provide as much detail as possible about the experience

• Adolescents – Usually able to provide similar information as an adult

FLACC – Pediatric Rating Scale U. Michigan Medical Center

• Observational scale for ages 2 months to 7 years with or without cognitive impairment • Evaluate: – Face – Legs – Activity – Crying – Consolation

47

8/22/2012

FLACC Pain Scale

Faces Pain Scale-Revised

Faces Pain Scale-R: Hicks CL et al. (2001) Pain 93, 173-183. Instructions for administering are at www.painsourcebook.ca

Notes on Interviewing Children • Children – > 5 years old, interview with or without parent – Usually able to accurately give own history & severity

• Adolescents – Express genuine interest – Focus on the individual (hobbies, friends, school), not the problem – Confidential conversation is appropriate – Avoid silence…rarely useful – Keep informal and comfortable – Avoid confrontation

48

8/22/2012

Critically Ill Patients • Critical-Care Pain Observational Tool (CPOT) – Applies to both ventilated and non-ventilated patients

• Payen Behavioral Pain Scale – designed for intubated patients

Assessing the Cognitively Impaired • Tools in development • Behaviors and behavior changes – Combativeness, restlessness, pacing, refusal to eat, withdrawal and other changes in behavior – Wide variation in pain behaviors

• Review past and current history • Suspect pain may be present

Assessment Non-Verbal Elderly • Observe 3-5 minutes • Note pain behaviors – – – –

noisy breathing negative vocalization sad face expression frightened facial expression – frown – tense body language – fidgeting

• Info from family • Reevaluation after interventions

49

8/22/2012

Some Available Tools • Pain Assessment in Advanced Dementia (PAINAD) » Warden, Hurley, & Volicer, 2003

• Discomfort Scale in Dementia of the Alzheimer Type (DS-DAT) » Hurley & colleagues, 1992

• Checklist of Nonverbal Pain Indicators (CNPI) » Herr, 2000

• Assessment of Discomfort in Dementia (ADD) » Kovach, 2002

Hierarchy of Pain Intensity Measures 1. Patient self-report using rating scale 2. Pathologic conditions or procedures usually causing pain 3. Behaviors Facial expression, body movements, crying, etc.

4. Collateral report (proxy) Parent, family member etc.

5. Physiologic measures Least sensitive!

Sample Test Question The least reliable tool for assessing pain in cognitively intact adults is: a. b. c. d.

Changes in vital signs Observations of patient’s behavior Assuming pain present with painful procedures Patient self report

50

8/22/2012

Physical Examination 1. Local/regional pain focused examination 2. Generalized musculoskeletal and neurological examination 3. Attention to functional limitations

Physical Exam (cont’d) • Location of pain • Quality/character of pain – Recent changes

• Presence of rebound • Effects of weight bearing • Functional status • Range of motion

• Trigger points • Inflammation • Associated sensory deficits • Exacerbating factors • History of trauma • Referred component of pain

Adapting the Exam: Persistent Pain & the Elderly Look for: • Signs & symptoms of de-conditioning • Poor posture • Gait abnormalities • Splinting of body part • Self-restriction of movement – Verbalized – Non-verbalized

51

8/22/2012

Functional Assessment • Evaluate impact of pain on physical function, quality of life and ability to perform ADLs – Self care abilities – ADLs across lifespan – Ability to enjoy life, socialize, play

Functional Assessment • • • • •

Can you get up and down from the toilet?

Can you go up an down steps, curbs, etc.?

Can you dress, groom, bathe yourself?

Have you fallen or almost fallen?

Do you require help to do things you once did independently?

Putting It All Together • Report using assessment data • Review the plan based on assessment – Is plan working?

• Design interventions – Multi-modal and specific to each patient

• Identify outcomes/goals

52

8/22/2012

Outcome Domains for Pain Care • • • •

Pain levels Function Psychosocial status Quality of life

• Efficacy of therapy is measured against goals of each domain • Identify what is achievable • Identify time frame for achievement

Goal Setting • Identify individual patient goal – – – – –

Use the scale Use function Use patient preferences Be realistic Consider disease and pain state

• Measure effect of therapy against the goal – Were goals attained?

– Evaluate and amend – May be progressive goals – Willingness to participate and make changes

Assessment: Summary • • • •

Use the nursing process Gather pertinent objective and subjective data Accept self report Use assessment data to develop individual plan of care • Reassessment is key in order to evaluate and revise the plan

53

8/22/2012

Questions

Questions

Interventions: Managing Pain

Pharmacological Treatment

54

8/22/2012

Understanding Pharmacological Interventions • Pharmacokinetics – Process by which a drug is transported to target sites, detoxified and eliminated • Absorption • Distribution • Metabolism • Elimination

• Pharmacodynamics – The effect of a drug at its site of action • Drug receptor interactions • Dose-response relationships • Drug interactions • Physiologic variation

Absorption • Determines when a drug is available to produce effect – Rate affects duration & intensity of drug – Many variables

Absorption Variables • Drug solubility – Water soluble drugs are easily absorbed

• Concentration – Higher concentrations absorb more rapidly

• Patient’s gastric pH

• Gastric emptying • Blood flow – Amount of blood flow to site of administration

• Surface area of cell membrane

– pH of drug has effect on gastric absorption

55

8/22/2012

Bioavailability • The percentage of active drug absorbed and available following administration – Oral • Dependent on gastric absorption and first pass metabolism small intestines and liver

– Sublingual/buccal • Minimal first pass effect

Bioavailability (cont’d) • Rectal

• Transdermal

– Minimal first pass metabolism – Absorption depends on rectal contents, localized irritation of rectal mucosa, drug retention

– Lipid soluble compounds absorbed through skin – No first pass effect – Must have intact skin for normal absorption

Bioavailability (cont’d) • Intravenous, subcutaneous, intramuscular – No first pass metabolism via the liver – Absorption of I.M. injection is widely variable

• Intraspinal – Intrathecal medications by-pass blood-brain barrier – Epidural medications undergo vascular uptake and diffusion through dura

• NOT recommended

56

8/22/2012

Volume of Distribution • The drug concentration in the body • Variables: – Alterations in cardiac output – Regional permeability of capillaries in muscle, skin, organs – Drugs distribute first to organs with highest volume of blood flow (heart, kidney, liver, brain), then to lesser blood flow areas

• Blood brain barrier – Limits distribution of hydrophilic drugs to CSF – Lipid-soluble drugs are capable of crossing the bloodbrain barrier

• Placenta – Barrier between blood vessels of mother and fetus – Many drugs cross

Volume of Distribution (cont’d) • Ability of drug to submit to protein binding determines if it will cross tissue membrane – Unbound drug will cross tissue membrane for effect – Competitive binding allows one drug can replace another – Low serum albumin allows more unbound drug to circulate  toxicity

• Tissue binding – Fat soluble drugs like fentanyl bind with fatty tissue or adipose – Accumulation may occur due to less blood flow in fat

Metabolism • Biotransformation of a drug – Series of chemical reactions to transform a drug into usable form

• Sites – Liver • Cytochrome p450 enzymes

– – – –

Intestinal mucosa Kidney Skin Lungs

57

8/22/2012

Liver Metabolism • Cytochrome p450 enzymes – CYP2C19 – CYP2D6

• “Poor metabolizers” will have higher than normal plasma concentrations of drug • Certain populations inherit enzyme activity unique to their population

Elimination (Excretion) • Process of excreting drugs and metabolites • Elimination half-life – Time it takes for amount of drug to decrease by 50% – Dependent on volume of distribution and clearance of drug – May occur via liver, bile, lungs, feces, sweat, salivary and mammary glands

Pharmacodynamics • Effect of a drug at its site of action – Lock and key effect – Efficacy is dependent on ability to bind at drug receptor site – Agonist = drug that produces an effect – Antagonist = drug that will reverse the effect of an agonist – Competition for receptor sites may occur • Receptor sites located in periphery, CNS, spinal cord, pituitary, GI tract

58

8/22/2012

Mu Opioid Receptors • Mu receptor agonists – – – – – – – – –

Morphine Fentanyl Hydromorphone Meperidine Alfentanil Sufentanil Codeine Methadone Levorphanol

• Most potent of opioid receptor sites • Effects = analgesia,  respirations,  GI motility, nausea & vomiting,  heart rate, physical dependence, euphoria

Agonists- antagonist opioids • Agonists at kappa opioid receptor site • Antagonists at mu opioid receptor site • Effects: – – – – –

Analgesia Sedation  respirations Miosis Diuresis

• • • • •

Butorphanol Nalbuphine Dezocine Pentazocine Buprenorphine

Side Effects, Adverse & Allergic Reactions • Side effect – Dose related predictable reaction that is somewhat expected – May dissipate with time

• Adverse reaction – Exaggerated response affecting major organ systems • Idiosyncratic • More or less potency

• Allergic reaction – Hypersensitivity reaction – Rare with opioids

59

8/22/2012

Aging & Pharmacokinetics • Absorption slows with age –  in gastric pH –  intestinal blood flow –  in gastric emptying time

• Distribution changes –  lean body mass –  body fat –  total body water –  plasma protein

Using Medications in Older People “Start Low and Go Slow” • Lipid soluble drugs may accumulate • Protein binding potential of drug is influenced by nutrition (serum albumin) • Metabolism is influenced by altered hepatic blood flow & changes in renal function that increase elimination half-life

• Implications: – Choose drug with short halflife – Choose drug with fewest side effects – Start initial dose 25-50% lower than younger adults – Titrate up more slowly than with younger adults – Consider increasing dosing interval – Monitor for efficacy and adverse events

Principles of Analgesia • Individualize the regimen – Expect wide variation in response from person to person – Develop plan based on individual needs – Select analgesic based on individual needs

• Routinely reassess pain relief, side effects, function • Goal: – Best relief with manageable/acceptable side effects

60

8/22/2012

Opioid

Titrated Opioid

Titration • Goal:

• Consider:

– Adjust the amount of medication to achieve a serum level that achieves maximum analgesia with minimal side effects

– Individual response – Age – Illness – Hepatic function – Renal function – Other variables

Dosing • Intermittent and breakthrough pain – Dose PRN

• Persistent continuous pain, opioid tolerant patients, and those who do not obtain relief from PRN – Dose on a schedule with medication for breakthrough pain, not PRN

• Expect wide and variable individual responses

61

8/22/2012

Principles of Dosing & Interval • Consider intensity of pain, medication used, effects of titration, individual variations • Intervals are determined by half-life and duration of action of drug & patient condition

Breakthrough Pain: Dosing “Rules of Thumb” With controlled released analgesics, evaluate patient for increase in maintenance dose of controlled release med. if requiring > 2 breakthrough doses a day, for other than incident pain.

Two Rules of Thumb: Adjusting Maintenance Analgesics First way: • Dosing is based on current total 24 hour requirement • Rescue dose is 10-15% (1/10th to 1/6th) of total daily dose q 1-2 hours Second way: • If pain remains mild – Increase dose by 25%

• If pain remains moderate – Increase by 50%

• If pain remains severe – Increase by 100%

Monitor and document response to analgesia

62

8/22/2012

Sample Titration Case • Janet’s pain is a 5 on a 0-10 scale.

• Medications: – Oxycontin CR 40 mg every 12 hours – Oxycodone 10mg every 2 hours PRN X5 doses in last 24 hours

• What do you want to do?

“Around-the Clock” Dosing & Continuous Infusions in the Opioid Naive • Approach with caution in opioid naive • Monitor for immediate or delayed side effects – Studies are inconsistent • Some show improved pain control with continuous rate infusions with less fluctuation in pain/sedation • Other studies show continuous infusion does not provide better relief but may increase side effects

Patient Controlled Analgesia (PCA) • For intermittent and continuous analgesia • Self-administration of pre-programmed doses of medication “just when pain begins” • Reduces peaks and troughs

• Goal: – Adequate relief and safe administration

• Patient serves as own safety factor – No med. while asleep or drowsy

63

8/22/2012

ASPMN Position Statement: PCA by Proxy Authorized and Unauthorized Dosing of Analgesic Infusion Pumps • Medically sophisticated parent/family member only • Teaching – DO NOT push button if patient’s sleeping – Only one person assumes PCA responsibility

• Nurse medicates after assessment of pain and sedation levels • Institute of Medicine/TJC identifies PCA by proxy as high risk medication safety issue

PCA By Proxy Authorized Agent • • • •

ONE person Consistently with patient Willing to learn Demonstrates ability to perform

Balanced (Multi-modal) Analgesia • Combining a variety of interventions to address pain – Combination of medications based on individual need • Non-opioid • Opioid • Adjuvants

64

8/22/2012

Opioid Rotation • Poor analgesia is usually dose related – Try adding a non-opioid, increasing the dose of the opioid, or shortening the dosing interval

• Goal of rotation –  side effects – Promote adherence to regimen – Allow ongoing treatment via different route – Reduce costs

The Equianalgesic Table Drug

Oral

IV

Morphine

30mg

10mg

Hydromorphone

7.5mg

1.5mg

Oxycodone

20mg

-

Meperidine

300mg

75mg

Not recommended

Methadone

10mg

5mg

Dosing differs for high dose & chronic use

APS, Principle of Analgesic Use… 6th Ed., 2008

Opioids & Cross Tolerance • Equianalgesic charts provide a “guess-timate” • Cross tolerance may not be completea patient who is tolerantto one opiate may not be tolerant to an equal dose of another

• Adjust dose and titrate based on individual response • Re-assessment, titration & documentation must follow any changes

65

8/22/2012

Opioid Rotation & Equianalgesia • Based on large intra-individual variation in response to different opioids • Reduce equianalgesic dose by 25%–50% with provisos: – – – – –

Reduce less if pain severe Reduce more if medically frail Reduce less if same drug by different route Reduce fentanyl less Reduce methadone more: 75%–90%

Routes of Administration

Oral • Preferred route in patient with functioning GI tract, who’s conscious and can swallow – For acute or persistent pain – For mild to severe pain

• Dose must account for first pass effect in liver • For children: – Must be able to swallow/chew

66

8/22/2012

Transmucosal • Primary absorption into the systemic circulation & some absorption via GI tract

• Disadvantages – Few commercial preparations – Wide variation in absorption – Children may refuse because of taste – High doses not possible for most medications

– Minimal first pass effect

• Lipid soluble drugs absorb best – Fentanyl, buprenorphine, methadone

• Absorption is affected by contact time

• Advantages – Easy, requires little preparation

Transmucosal (cont’d) • Buccal – Medicine placed between gum and mucous membrane or swabbed on oral mucosa

• Sublingual – Under the tongue – Higher absorption than buccal

Rectal • Advantages – Limited first pass effect – Relatively non-invasive – Effective delivery of medication

• Disadvantages – Not widely accepted by patient/families – Contraindicated with neutropenia or thrombocytopenia – Absorption depends on rectal contents, drug retention, local irritation – Can’t cut to “reduce” dose – Children often find it objectionable

67

8/22/2012

Transdermal • Administration of medication through the skin, to a depot in upper skin layers, fat and skeletal muscle, and gradually into the systemic circulation • Requires fat soluble drug and intact skin • Few transdermal options for children – None for opioid naive small children

Intramuscular • Not recommended !!

– Painful administration – Unreliable absorption – Possibility of sterile abscesses – Especially poor choice for frail, or elderly – Unacceptable for children, regardless of age, developmental level

Intravenous • Most efficient route when immediate relief is needed & for severe pain • Allows for rapid titration • Via central or peripheral access • Bolus, continuous infusion, PCA • No first pass effect

68

8/22/2012

Intravenous (cont’d) • Intermittent administration – Must maintain steady serum levels – Need repeated dosing

• Continuous – Steady serum levels with predictable absorption – Careful monitoring needed

• Use in infants less than 2 months of age requires monitored setting

Subcutaneous • No first pass effect • Viable route for people when oral or intravenous are not possible • Onset is slower than IV • High concentration opioid formulations available for continuous infusions – Most people can absorb up to 2-3 ml/hr and as much as 5 ml/hr

Nebulized Medication • Not recommended for pain control due to poor absorption of analgesics into the systemic circulation – Sometimes used for dyspnea at end of life

• Mode of action is not known

69

8/22/2012

Topical • Limited to mucous membranes and skin • For some localized conditions – Neuropathic pain, arthritis, diabetic neuropathy

• Local anesthetics are useful for procedures like I.V. starts • Patch formulation (5% lidocaine) for persistent neuropathic pain

Intraspinal Medication administered into the epidural space or the intrathecal space surrounding the spinal cord • Epidural “space” • Intrathecal space – Potential space outside the intrathecal space and separated by arachnoid mater – No fluid present – Space is created when fluid or air injected

– Filled with CSF that continually circulates around spinal cord

Intraspinal Analgesics MUST be Preservative Free • Opioids – Lipophylic • Diffuse rapidly through dura • Less rostral spread in CSF, narrow segment of analgesia

– Hydrophylic • Diffuse slowly through dura to CSF • Wider rostral spread and segment of analgesia

• Local anesthetics – Lipophylic • Synergistic with opioids

– Block pain impulses at sympathetic chain ganglion outside cord – Level of analgesia evaluated via dermatomes

70

8/22/2012

Evaluating Levels of Analgesia

Intraspinal Medications: Complications • Post-dural puncture headache • Intraspinal catheter migration • Neurologic complications form trauma to tissue • Infection • Hematoma • Risk of inadvertent injection of neurotoxic agents

Epidural Analgesia • Epidural space = potential space between ligamentum flavum and dura – Vast venous network, fat and nerve extensions from cord

• Needle inserted into the epidural space, catheter threaded, med. infused • Med. diffuses through dura • Bolus, continuous, PCEA

71

8/22/2012

Intrathecal (sub-arachnoid) Analgesia • Needle penetrates dura into intrathecal space • Free-flowing CSF can be aspirated if properly placed • Lower doses of medication needed intrathecally than epidurally

72

8/22/2012

Types of Infusion Devise – Intraspinal Infusions • External percutaneous catheter with external pump • Implanted epidural portal system – Epidural catheter threaded percutaneously and connected to implanted port. Accessed with non-coring needle

• Implanted infusion pump – Pump continuously infuses medication to epidural or intrathecal space

Implanted Intraspinal Pump

Implanted Epidural Port

73

8/22/2012

Analgesic Agents

Analgesic Agents for Pain • Adjuvants – Local anesthetics – Anxiolytics – Anticonvulsants – Antidepressants

• Non-opioids – Acetaminophen – Non-steroidal anti-inflammatory drugs (NSAIDs)

• Opioids

Adjuvants

74

8/22/2012

Local Anesthetics • Blocks nerve impulse conduction – limits permeability to sodium – e.g.: Lidocaine, Bupivacaine, Ropivacaine – Administered via different routes • • • •

Systemic: Parenteral or Oral Local: injection or topical Regional: Nerve block , Bier Block, Paravertebral Neuraxial: Epidural or Intrathecal (subarachnoid)

• Used with opioids to lower dose needed – opioid-sparing epidural or intrathecal infusions

Local Anesthetic: Epidural Pharmacology • •

Onset 5-20 minutes Peak 60 minutes Duration 4-6hrs Side Effects • • • •

Hypotension, orthostasis Sensory/motor block Proprioceptive block Urine retention

•

Early Toxicity:

•

Late Side Effects: (rare)

•

•

Abnormal lip & tongue sensation, metal taste, tinnitus Seizures, cardiac arrhythmias or cardiac arrest

Epidural Anatomy Dura Mater Epidural Space

Ligamentum Flavum Most Common Placement - L2-3 interspace

Spinous process

-T6-7 interspace

75

8/22/2012

Intraspinal Local Anesthetics: Adverse Effects • Allergy is rare • Cardiotoxicity • Circumoral tingling and numbness, bradycardia, dysrhythmias, acidosis and cardiovascular collapse

– Action: • Stop infusion, aspirate catheter • If + for blood, stop infusion and monitor patient carefully

Intraspinal Local Anesthetics: Adverse Effects (cont’d) • Sensory or motor deficit – At dermatome covered by infusion • Decrease infusion • Reposition patient • Lower or d/c local anesthetic from infusion

– Most common with catheter placement at L2-3 or lower, thoracic placement preferred

• CNS toxicity – Ringing in ears, metallic taste, mental status changes, myoclonus, seizures – Stop infusion, monitor patient

Intraspinal Local Anesthetics: Adverse Effects (cont’d) • Postural Hypotension • Sympathetic blockade results in vasodilation in lower extremities • May be severe with hypovolemia – Infusion may be decreased or stopped until fluid resuscitation occurs – Other meds for pain given

• Treatment – Ephedrine or phenylephrine with fluid correction – Get up slowly with assist – With sudden nausea, recline and evaluate for hypotension

76

8/22/2012

Local Anesthetics

by Percutaneous Catheter • Increasingly common in ambulatory setting due to availability of disposable pumps • Wound infiltration • Perineural infusions – – – –

Interscalene Infraclavicular Femoral Lumbar and/or sciatic

Local Anesthetic: Topical Agents • Needle pain – – – – – – –

• Neuropathic pain

Apply before needed Time depends on product EMLA LMX4 Synera Numby Stuff (Iontophoresis) J-tip

• Topical lidocaine gel for postherpetic neuropathy • Capsaicin

– Lidocaine patches – 12 hours on -12 hours off

• Lidocaine, epinephrine & tetracaine (LET) – Used for suturing face & scalp – Apply to wound bed and around edges. Wait 10 -30 minutes – Do not apply to end arterioles or mucous membrane – causes vasoconstriction and possible ischemia

Muscle Relaxants • For acute musculoskeletal pain • Sedative effects may potentiate sedation from opioids or other CNS depressants • Start low and titrate upward

– Baclofen • Dizziness, GI upset, sedation, hypotension • Do not stop abruptly – will precipitate seizures

– Carisprodol (Soma) – Chlorbenzaprine (Parafon Forte) – Methocarbamol (Robaxin)

77

8/22/2012

Anxiolytics and Sedatives • For relief of anxiety • NOT analgesic • Benzodiazepines – Relax muscles

• Examples: – – – –

Alprazolam (Xanax) Flurazepam (Dalmane) Clonazepam (Klonopin) Midazolam (Versed)

• Side Effects: – – – – – – – – – – – –

Drowsiness Fatigue Cognitive impairment Rebound anxiety Depression Tachycardia Chest pain Xerostomia Constipation Nausea/Vomiting Diaphoresis Decreased libido

Anticonvulsants for Pain • Inhibit high-frequency neuronal firing by blocking sodium channels • Reduce hyperexcitability neurons (sensitized C fibers) •  lancinating or paroxysmal pain

• Titrate to effect/side effect • Individual efficacy • Teach why person is taking this medication

Using Anticonvulsants • Each has its own unique effect • Start with low doses and gradually titrate upward • Evaluate side effects – Specific to each drug – Monitor liver function for many

• May take 1-2 weeks to work, even with titration • Unpredictable efficacy

78

8/22/2012

Anticonvulsants: Side Effects • • • •

Sedation Ataxia Fatigue Concentration and memory difficulty for some

Monitoring Anticonvulsants • Baseline CBC and LFTs at initiation of therapy, 3-4 weeks after, and every 3-4 months afterwards • Monitor for – Leucopenia – Thrombocytopenia – Aplastic anemia

Tricyclic Antidepressants for Pain • Alter neurotransmittors affecting pain pathways • Inhibit presynaptic neuronal reuptake of serotonin and norepinephrine at descending pain pathway

79

8/22/2012

Tricyclic Antidepressants: Side Effects • Orthostatic hypotension • Sedation • Mental clouding • Anticholinergic effects & withdrawal • Sexual dysfunction

• Arrythmias – Baseline EKG to monitor for prolonged QT interval

•  risk seizures •  appetite & weight gain

Other Antidepressants • Selective Serotonin Reuptake Inhibitors (SSRIs) – Often less effective for pain than tricyclic antidepressants – Overall lower incidence of side effects • • • • •

Sertraline (Zoloft) Paroxitene (Paxil) Fluoxetine (Prozac) Citalopram (Celexa) Trazadone ( Desyrel)

Other Antidepressants (cont’d) • Selective Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) – Antidepressant & antianxiety • Venlafaxine (Effexor) • Nefazodone (Serzone) • Duloxetine (Cymbalta) – approved for diabetic neuropathy)

• Bupropion (Wellbutrin) • Mirtazepine (Remeron)

80

8/22/2012

Steroids • Multiple antiinflammatory actions – Block production & release of cytokines • Interleukins and tumor necrosis factor

– Inhibit immunoglobulin E (IgE) – Suppress endogenous glucocorticoid – Effects on water and electrolyte balance

• Adrenal insufficiency after > 10 days • Must taper dose • Examples: • • • •

Betamethasone Dexamethasone Cortisone Hydrocortisone

Clonidine • Opioid sparing in epidurals • Sedation, bradycardia, – Activates the descending hypotension, dry mouth

• Alpha-2 adrenergic agonist

pain pathways supraspinally & terminates in dorsal horn – Activating receptors stimulates acetylcholine release/inhibits substance P release

– Minimize side effects by low doses and continuous epidural infusion

Non-Opioid Analgesics

81

8/22/2012

Non-Opioid Analgesics • Have a ceiling effect • Used alone or in combination • Variable risk of side effects – Gastrointestinal

– Renal

– Cardiovascular

– Hepatic

– Respiratory

– Hematological

– Neurological

– Respiratory

– Dermatological

Acetaminophen • • • •

Analgesic (less potent than ibuprofen), antipyretic Weak peripheral anti-inflammatory action (acts centrally) 1st line non-opioid choice for children and older persons Growing concerns about hepatic toxicity – Multiplicity of doses / concentration – Inadvertent exposures from multiple sources – A co-ingredient in many opioids (unauthorized dose escalation)

• Maximum dose per day 4GM (90mg/kg in children) – Lower maximum dose per day to 3GM in vulnerable populations • Alcohol drinkers • Liver disease • Elderly

• Dehydration • Neonates

Non-steroidal Anti-Inflammatory Drugs (NSAIDs) • Blocks cyclooxygenase production – Cyclooxygenase 1 (COX-1) – Good prostaglandins • • • •

Protects stomach lining Improves renal blood flow Regulates platelet function Blocking increases risk of side effects

– Cyclooxygenase 2 (COX-2) – pain-related prostaglandins • Produced after tissue injury • Increases inflammation-producing cytokines

82

8/22/2012

NSAIDs Classes • Nonselective NSAIDs – Block COX-1 and COX-2 – Decrease inflammation & pain – Greater risks of serious side effects

• Selective NSAIDs – Selectively block COX-2 – Reduced, but not eliminated risks • Risks similar at 1 year of therapy • More cardiovascular risks

NSAID: Ketorolac (Toradol) • Non-selective NSAID – Parenteral and oral

• Five day limit on use due to side effect risk • Children – Use is increasing – Dose: 0.5mg/kg q6h for 24-48 hours

Precautions with NSAIDs • COX-2 selective products – Have fewer side effects, – Particularly less GI bleeding

• Proton pump inhibitors (PPIs) cut GI risks • Cardioprotective aspirin + NSAID – Increases risk of GI bleed – May negate benefit of aspirin

• Monitor GI, Renal & CV effect if used > 2 wks – Monitor liver function with acetaminophen

83

8/22/2012

Aspirin • Analgesic, antipyretic, anti-inflammatory • Irreversible inhibitor of platelets – Binds for life of platelet (~2 weeks)

• Cardioprotective effects negated by some other NSAIDs (e.g. ibuprofen) • Linked to Reye’s syndrome in children – Dose for juvenile RA is 10-15 mg/kg q4-6h

Opioid Analgesics

Opioids • Indicated for moderate & severe pain • Some products lack analgesic ceiling • Classifications – Mu agonists (pure, full or morphine-like agonists) – Dual action products (e.g. tramadol, tapentadol) – Agonist/antagonists (mixed or partial agonists) • Not recommended for first line therapy

– Combination products (opioid & non-opioid)

84

8/22/2012

Opioid Actions • Periphery – Reduce release of inflammatory products

• Spine – Cuts presynaptic Ca++ and Na+ influx – Lowers the production and release of EAA – Lowers postsynaptic excitability (K+ escape)

• Brain – Activates descending pain inhibitors

Opioids: Key Assessment Data • Past opioid exposure and responses • Recent opioid exposure – Opioid naïve vs. opioid tolerant patient?

• Comorbid conditions – Pulmonary, neurologic, psychological, sleep

• Concurrent medications

Respiratory depression in opioid naïve patients • Defined: <6/min or apnea>20sec • Research estimates ~1% prevalence – Most often on first dose

• Sleep apnea raises risk considerably – 1/3 sleep apnea Dx’d / postop complication – 31% opioid naïve pts with sleep apnea experience respiratory depression – Capnography & RR monitoring detects 96% Hutchinson & Rodriguez (2008) AJN 108 (2): 35-39

85

8/22/2012

Mu Agonist Opioids • Most clinically useful opioids • No ceiling on analgesia or dose when given alone – Ceiling from non-opioid limits dosing in combination opioid/non-opioid medications

• Titrated to pain relief or unmanageable side effects – Pain relief is dose related

Examples of Mu Agonists • • • • • • • •

• Codeine • Meperidine • Propoxyphene

Morphine Fentanyl Hydromorphone Oxycodone Methadone Hydrocodone Oxymorphone Levorphanol

• Atypical opioid – Tramadol – Tapentadol

Morphine • The “gold standard” for severe pain • 10 mg parenterally = 30 mg p.o.

• First line for cancer pain • M6G metabolite may accumulate, especially with renal impairment

• Available in a variety of routes – Parenteral – Intraspinal – Oral • Immediate release • Controlled release

– Rectal

86

8/22/2012

Hydromorphone • 5-7 times more potent than morphine – 1.5mg parenteral = 7.5mg oral = 30mg oral morphine

• Variety of routes – Oral: Immediate or controlled release – Parenteral: IV, SQ • PCA, Continuous infusion, &/or bolus • IM not recommended

– Neuraxial: epidural, intrathecal

Fentanyl • 80-100 times more potent than morphine • Available in a variety of routes – IV or SQ: Continuous, bolus &/or PCA – Transdermal sustained release systems – – – –

Opioid tolerant with stable persistent pain Must have med for breakthrough pain Heat increases absorption rate Use and dispose of appropriately

– Transmucosal, rapid onset systems – Breakthrough or procedureal pain – Approved only for people with cancer pain

Oxycodone • Single agent or in combination with nonopioids – Non-opioid limits dose when using combined products

• Oral – Immediate release – Controlled release

• Parenteral not available in U.S.

87

8/22/2012

Hydrocodone • Combined with non-opioid – Dose limiting and toxic implications

• Metabolized to hydromorphone – Know when interpreting toxicology screens

• Not available parenterally

Codeine • Mild to moderate pain only – Similar potency to aspirin (1mg IV morphine)

• Often combined with non-opioid • Need CYP2D6 enzyme to metabolize – Converts to a form of morphine – Many non-metabolizers – Some ultra-rapid metabolizers

Methadone • Excellent oral bioavailability • Long and unpredictable ½ life – 24-36h or more

• May accumulate with repeated dosing • Use with caution, especially in elderly • Use conversion charts with caution

• Pediatrics – Used to wean children from long term opioids & for severe pain – Careful monitoring needed due to slow elimination, and low clearance rate • May need dose reductions

88

8/22/2012

Others: Tramadol & Tapentadol • Titration • Atypical opioid – Binds weakly to mu receptors in CNS – Inhibits reuptake of norepinephrine & serotonin – May be helpful for some with neuropathic or mixed neuropathic/nociceptive pain

• Can  seizure threshold • Naloxone does not completely reverse respiratory side effects

– Gradually over several weeks – Never in doses > 400mg/day (300mg/day in older persons)

• Use cautiously with tricyclic antidepressants, neuroleptics, SSRIs and those with history of seizures or head injury

Others: Meperidine, Propoxyphene • Meperidine – Not recommended as 1st line therapy – Restricted to < 48 hour use – Normeperidine toxicity a risk • Naloxone will not reverse

• Propoxyphene – Combined with nonopioids – Norpropoxyphene metabolite accumulates – Not recommended for older person or those with renal impairment

Agonist/Antagonist Agents • Bind to more than one opioid receptor • Analgesic effects less than with mu agonists • Examples – – – –

Pentazocine Nalbuphine Butorphanol Buprenorphine

• Side effects – Sedation – Psychomimetic effects

• May precipitate withdrawal in person on pure agonist • Not recommended for persistent pain

89

8/22/2012

Abstinence Syndrome & Opioids • Physical dependence: an expected effect • Abstinence syndrome occurs if opioids – are abruptly stopped or rapidly reduced – reversed with an antagonist

• May occur unintentionally • Predicted by half life of drug

Withdrawal Symptoms • Anxiety • Irritability • Chills alternating with hot flashes • Salivation • Nausea, vomiting, abdominal cramps • Diarrhea • Insomnia

Management – PREVENT IT – Taper doses by 10-20% daily for chronic therapy – Clonidine for persistent autonomic symptoms – In ICU, dexmedetomidine

Abstinence Syndrome Assessment • Previous opioid use, dose, frequency, duration of treatment and last dose • Use of other addictive substances – ETOH, marijuana, CNS stimulants, cocaine etc.

• History of recent use of agonist/antagonist • Evaluate withdrawal symptoms • Identify goal of treatment

90

8/22/2012

Minimizing Abstinence Syndrome • Discontinuing chronic opioid therapy – Taper daily dose by 10-20% daily

• Clonidine for anxiety, tachycardia, sweating etc.

• If in ICU, IV dexmedetomidine (Precedex) – Alpha-2 agonist used for ventilation sedation during withdrawal

Mu Opioid Side Effects • More frequent – – – – –

• Often dose related – Decreasing dose/adding coanalgesic may help.

Nausea, vomiting Sedation Constipation Mental clouding Pruritis

• Assess, anticipate, prevent & manage side effects when possible • Tolerance to many occurs rapidly • Tolerance does not occur to constipation

• Less frequent – Myoclonus – Urinary retention – Delirium

• Adverse effects – Respiratory depression – Seizures

Constipation • Most common side effect of opioids – Decrease peristalsis, delaying gastric emptying & increase fluid absorbed yields hard, dry stool

• Anticipate & PREVENT constipation • Use stimulant laxatives and softener • Increase aggressiveness of regimen if needed – Hyperosmotic laxative – Subcutaneous methylnaltrexone

91

8/22/2012

Nausea • Opioids stimulate the chemoreceptor trigger zone in brain, slow GI motility & sensitize labryinthsvestibular system • Often occurs within 1st 24-48h of therapy • Often subsides with time

• Management – Assessment – Anti-emetic therapies • Select carefully due to increased sedation of some • Non-drug interventions

– Decreasing dose of opioid while assessing pain relief

Pruritis • May be from opioid or vehicle carrying opioid • Allergic reactions rare

• Management – Decrease the opioid dose – Antihistamines if not intraspinal route – Intraspinal

– Histamine mediated

• More common with intraspinal opioids

• Ondansetron • Low dose naloxone

Urinary Retention • Increased smooth muscle tone with opioids

• Management – – – – –

Assessment Decrease dose Change opioid Bethanechol chloride Urinary catheterization

92

8/22/2012

Myoclonus • Myoclonic jerks – May be an accumulation of opioid metabolites – May be neurotoxicity – Often seen with multisystem failure

• Most common offenders – Meperidine (metabolite normeperidine) – Morphine and hydromorphone

Mental Status Changes • Hallucinations, disorientation, mental clouding – May resolve with time

• May be indication of other problems • Intraspinal opioids thought to cause less changes

• Management – Rule out other causes – Lower the dose and assess – Add co-analgesic

Sedation • Common at initiation of opioid therapy, increases in doses, or with renal insufficiency • Rare in opioid tolerant individuals • Sedation does not equal pain relief

• Management – Assess cause(s) – Carefully monitor level of arousal and respiratory rate and depth – Recognize and treat it early

93

8/22/2012

Risks for Sedation • Continuous infusion of opioids in opioidnaïve patients • Large or repeated opioid doses • Rapid IV administration • Rapid titration • Concurrent use of other CNS depressants • Intrathecal administration of opioids

Steps to Prevent Sedation 1. Identify risk factors 2. Understand physiological effects from CNS depressants 3. Titrate the right dose 4. Avoid additional sedatives 5. Monitor the patient

Sedation Scale

McCaffery & Pasero, 1999

Scale Finding

Action

S= 1= 2=

Sleepy, easy to arouse Awake & alert Slightly drowsy, easily aroused Frequently drowsy, arousable, drifts off to sleep in conversation

Acceptable, no action Acceptable, no action Acceptable, no action

Somnolent, minimal/no response, unarousable

Unacceptable: Stop opioid Add non- opioid Consider naloxone

3=

4=

Unacceptable:  opioid by 25-50% Add opioid sparing med Monitor closely

94

8/22/2012

Respiratory Depression • May occur with opioids via any route • Increased risk: – Infants less than 6 months of age – Opioid naïve older adults – Pre-existing diseases • Sleep apnea • Pulmonary or renal disease

• Assess with standard sedation scale – Respiratory rate • One full minute

– Quality of respirations • Depth

– Look for slow, shallow breathing

Sedation Always Precedes Respiratory Depression!

Administering Naloxone • Indication – Respiratory rate below predefined rate • e.g.: <8/min

– Shallow, poor quality respirations – Patient difficult to arouse

• Stop opioid • Dilute naloxone with normal saline to 0.4mg/10ml or 0.04mg/ml

• Administer – 0.1-0.2 mg – Repeat q 1-5 minutes to max. dose 10 mg or until respirations improve – Re-assess • Opioid effect may outlast naloxone effect

• Continuous administration – 2.5 to 3.5 micrograms/kg/h continuous infusion

95

8/22/2012

Opioids & The Nurse’s Role in Patient Safety • Understand patient history & its relationship to medications to be used • Understand medications used & impact on individual patient • Use national standards & guidelines to select appropriate medications.

– Avoid those not recommended

• Clarify over-the-counter and other remedies currently used • Herbals • Homeopathy

Questions

Questions

Nonpharmacological Therapies

96

8/22/2012

Non-pharmacological Interventions • • • • • • • •

Decrease emotional distress Enhance coping skills Empower the patient and family Adjust expectations Increase overall comfort Improve sleep Decrease anxiety and fatigue Improve perceived quality of life

Using Non-pharmacological Interventions • Integrate systematically in multimodal approach for all pain • Effective alone for some types of pain • Sensitive to cultural and religions beliefs • Education, reinforcement & support usually needed

Assessment for Nonpharmacological Interventions • Assessment: – What have you used in the past?

• Efficacy • Time utilized

– What are you interested/willing to try?

– What skills do you already know?

• Routine assessment • Consider age, cognitive capacity, type of pain, and acceptance of intervention

97

8/22/2012

Physical Therapy • Active & passive activities, exercise, massage, superficial heat, cold, positioning, splinting, TENS and others • Goal: – Maintain or regain function

Superficial Heat • Mechanisms for relief uncertain • Useful for wound care, boils, thrombophlebitis, anorectal pain, hematomas, arthritis, joint pain & muscle aches – May be applied contralaterally , above or below site

• Contraindicated with irradiated skin and with bleeding from traumatic injury

Superficial Cold • Useful for acute trauma, bleeding, swelling, acute rheumatoid arthritis, episiotomy, other incisional pain, muscle aches, joint pain, itching » May be applied contralaterally, above or below site

• Contraindicated with peripheral vascular disease or sickle cell disease

98

8/22/2012

Transcutaneous Electric Nerve Stimulation (TENS) • Use of electrodes and electrical impulses to activate peripheral pain fibers and spinal neurons causing release of endogenous opioids • Electrodes placed on or around painful area • Low voltage electrical current is delivered • Patient self-adjustment as needed

Chiropractic Care • Research on effects are minimal • Anecdotally helpful to some • Indication: – Musculoskeletal dysfunction

• Techniques – – – – – –

Muscle stretching Heat/cold Joint mobilization Traction Massage Manipulation

Cognitive Behavioral Therapies • Assumption that individuals are active and passive participants in care • Thoughts can influence mood, physical parameters and change behaviors • Adopting more positive thoughts, attitudes and behaviors can influence physical and emotional health

99

8/22/2012

Steps to Using Cognitive Behavioral Interventions • • • • • •

Initial assessment Collaboration with patient Skills acquisition and consolidation Generalization & maintenance of skills Relapse prevention Follow-up and reinforcement

Cognitive Behavioral Interventions • • • • • •

Promote rest and relaxation Decrease anxiety Strengthen coping skills Control depressive symptoms Improve function Return control to person

Distraction • Sensory shielding/cognitive refocusing – Focus away from pain – Useful for short term relief only – Will not usually eliminate severe pain

• Benefits –  pain intensity,  pain tolerance, improved mood, reduced anxiety

• Examples: – Music, art, crafts, books, games – Focus on thoughts, breathing etc.

100

8/22/2012

Relaxation • Reduces muscle tension, stress & anxiety, improves coping – 3-20 minute sessions/day most effective

• Techniques – Rhythmic breathing • Slow, deep breathing & concentration +/- imagery

– Progressive muscle relaxation • Progressively tense & relax muscle groups

Other Non-pharmacological Strategies • • • • • •

Hypnosis Self-hypnosis Acupressure Music therapy Art therapy Water therapy

• • • • •

Pet therapy Meditation Reiki Therapeutic touch Psychotherapy Individual Group

101

8/22/2012

Non-pharmacological Interventions and Children • Alone or with medications – Origin of pain, age and developmental level of child direct the selection of interventions

• Involve parents when possible • Assess interests of child when possible

Infants: Positioning • Can improve neurobehavioral and physiologic parameters • Lateral or side lying position promotes proper flexion,  oxygenation, tidal volume and lung compliance

• Containment (swaddling) – Promotes self-regulating behaviors

• Vestibular interventions – Rocking, water beds

• Kangaroo care

Infants: Nonnutritive Sucking • Pacifier – With and without sucrose • Reviews of RCTs support use of 12-24% sucrose 2 minutes prior to painful procedure to reduce crying time & observational pain scores in term and pre-term infants – Volume of sucrose varies between dipping the pacifier in the sucrose to 2 ml—varies with the age of the infant – Increased sucrose volume may cause necrotizing enterocolitis in preterm infants

• Calming effects stop immediately when sucking stops

102

8/22/2012

Other Strategies for Children • Distraction • Music therapy • Relaxation, breathing – Bubbles, kazoos, pinwheels for younger children

• • • •

Guided imagery Biofeedback Heat Cold – Not recommended for infants & young children – risk of thermal injury

Integrative Medicine • Definition: – A comprehensive, primary care system in which wellness and healing of the whole person are the major goals--as opposed to suppression of symptoms or disease

Complementary and Alternative Medicine (CAM) • Definition: – “A group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine” National Center for Complementary and Alternative Medicine

103

8/22/2012

Complementary and Alternative Medicine (CAM) • Four Domains – Mind-body therapies • Ex: Humor, imagery, meditation, prayer, yoga

– Biologically based therapies • EX: Herbs, vitamins, nutritional supplements

– Manipulative and body-based practices • Ex: acupuncture, chiropractic, massage

– Energy therapies • Ex: healing touch, therapeutic touch, Reiki, magnets

Complementary and Alternative Medicine (CAM) • May reduce need for analgesics & their side effects • Physiological effects--decreased sympathetic nervous system stimulation • Require health care professional to interact with the patient in a manner that offers hope • Evaluate reason for using CAM therapies • Assess use of CAM and possible interactions with other therapies or adverse effects • Document use of CAM • Educate patients/families

Acupuncture • Efficacy: as strong as many western therapies • Adverse effects: lower than many drugs and other therapies • Restores energy pathways (Qi) • Performed with needles alone or needles + electrical stimulation • Electrical stimulation activates pituitary and hypothalamus gland • Blood flow regulated both centrally and peripherally • Opioid peptide release – Reversed by naloxone

104

8/22/2012

Acupuncture (cont’d) • Used for: – Fibromyalgia – Menstrual pain – Headache – Myofascial pain – Osteoarthritis – Low back pain – Carpal tunnel syndrome

Summary • If patient wishes to use CAM and there is no adverse effect, it should be the patient’s option to use.

• Promotes closeness & control without harm • Provides personal interaction and physical touch

Questions

Questions

105

8/22/2012

Interventional Techniques

Non-neuroablative Interventions • • • • •

Trigger point injection Joint & bursa injections Intercostal blocks Epidural steroid injections Facet blocks – Reduce inflammation & create localized numbness

• Sympathetic ganglion blockade – Stellate ganglion block – Lumbar sympathetic block – Celiac block

Peripheral Nerve and Spinal Cord Stimulation • Low voltage electrical stimulation along a nerve or nerve root, using varying pulse width and amplitudes to decrease pain transmission and perception – Based on Gate Control Theory – Spinal leads implanted in epidural space – Produces low voltage electrical stimulation

106

8/22/2012

Spinal Cord Stimulation

Spinal Cord Stimulation Used for: • Failed back syndrome • CRPS • Direct nerve injury • Phantom limb pain • Intractable angina pectoris • Multiple sclerosis

Neuroablative Interventions Risk of high failure rates and neurologic complications • • • • •

Neurolytic nerve blocks (nerve killing blocks) Surgical sympathectomy Rhizotomy Radiofrequency electrocoagulation Intradiscal electrothermal annuloplasty

107

8/22/2012

Additional Interventions • • • •

Percutaneous vertebroplasty Kyphoplasty Percutaneous discectomy Bier block – Sympathetic block

• Botulism toxin, type A – Denervation muscle paralysis

Questions

Questions

Patient & Family Education & Collaboration 32% of the exam

108

8/22/2012

Patient/Family Education • Key concepts – Teaching and learning strategies • Age appropriate • Addressing different styles of learning – Visual – Verbal – Demonstration

– Evaluation • Comprehension • Competency

Patient Education Goals • Improve pain relief • Increase knowledge and awareness • Decrease misconceptions • Increase adherence to pain control regimens ASPMN Core Curriculum, 2010

Patient Education Goals (cont’d) • Voluntary adaptation of optimum health behaviors • Facilitate effective communication • Develop patient skills in pain control techniques • Family-centered care ASPMN Core Curriculum, 2010

109

8/22/2012

Components of Pain Management Education • Patient motivation, readiness to learn • A clear plan with goals and objectives • Individually identified SMART goals – – – – –

Specific Measurable Attainable Realistic Time-framed

• Feedback and support

Assess need to learn

Dynamic Process of Teaching

Diagnostic statement & set goals with patient

Assess motivation & readiness

TeachingLearning

Evaluating & re-teaching prn

Teaching-Learning Assessment • Timing….

• Current knowledge & understanding • Readiness & motivation to learn • Preferences for receiving information • Potential barriers • Myths & misperceptions ASPMN Core Curriculum, 2010

110

8/22/2012

Teaching-Learning Assessment • Demographics – Age, family status, past & present employment, formal education, stage of life

• • • •

Cultural values & beliefs Meaning of pain Psychosocial issues Spiritual beliefs

Pain Management Education Process • Inform that pain can & should be treated • Examine patients’ personal meaning of pain • Correct misconceptions about addiction & tolerance • Identify goals for pain management • Teach patients/caregivers…

– Importance of prevention of persistent pain – How to use a rating scale & how to describe pain – Options specific to individualized treatment

Content • Provide specific directions for each medication – Purpose, dose, schedule – Safe use & storage of medications – Possible side effects & their management

• Demonstrate use of non-pharmacological techniques • Provide contact information for questions & help • Plan for follow-up

111

8/22/2012

Instructional Methods • • • • • • • •

Lecture Demonstration Discussion Role Play Self-learning modules Group discussion One-on-one teaching Simulation

• • • •

Printed material Videotape Audiotape Computer-assisted instruction • Checklists • Models • Handouts

Adapting Teaching Throughout the Lifespan

Education: Children • Adapt for – Age – Maturity level – Cognitive development – Language & reading development – Concrete vs. abstract thinking – Parental involvement

112

8/22/2012

Education: Older Persons • Adapt for: – Cultural meaning – Hearing and vision changes – Cognitive changes – Language – Family involvement

Education: Low Literacy • Simplify content – What is my problem?

– What do I need to do?

– Why is it important for me to do it?

• Selecting materials – Evaluate reading level – Add pictures, diagrams, visual cues, white space – Use short words & sentences • Words with less than 3 syllables

– Involve the learner – Give clear action messages – Place important information first & last

Evaluating Teaching-Learning • Provides evidence about patient’s understanding or skills • Provides patients ability to progress to other settings • Reinforces correct behavior for learners • Helps determine if teaching approach was successful

113

8/22/2012

Strategies for Evaluation • • • • •

Test & retest Return demonstration Repetition of information Quality of life & other surveys Written evaluation

Partnering with Patients & Families • Assist families in making informed decisions • Provide a comprehensive education program – – – –

Importance of pain management How to report pain How to use a pain rating scale Importance of setting realistic and desirable pain relief goals – How to use pharmacologic and non-pharmacologic interventions – When and whom to contact about problems

Patient/Caregiver Barriers to Education – Age, gender – Socio-economic status, educational level – Language – Culture – Disease process – Emotion • Anxiety, grief, anger

– Misconceptions, concerns, and beliefs – Secondary gain • Patient involved in legal proceedings that distract efforts in getting well

114

8/22/2012

Patient/Caregiver Barriers to Education • Environmental Barriers: – Weather – Temperature – Light – Noise – Timing – Distractions • Other persons • Activity in room

• • • • • •

Health Care Professionals’ Barriers to Patient/Caregiver Education

Low priority Time constraints Lack of accountability Practitioner’s lack of knowledge and skill Omission of assessment of learning needs Misconceptions, concerns, biases and beliefs

Limitations of Education Patient factors • Education does not = knowledge • Knowledge does not = behavior change • People respond in ways that are socially acceptable

Prescribed therapy • Inadequately prescribed ineffective treatment • Treatment may affect cognitive function Disease factors • Progressive or unmanageable disease

115

8/22/2012

Sample Test Question Your 14 year old cancer patient presents to your clinic with post op site pain as well as sharp shooting pains in his feet. You decide to add a long acting opioid as well as a neuropathic pain medication. What will you teach him?

A. Specific directions for each medication B. Possible side effects & their management C. The goal of pain therapy is not only pain relief but pain prevention D. All of the above

Sample Test Question You spent ½ hour teaching the parents of your patient about the pain medications. You gave written and verbal instructions.

Mom mentions she does not believe in medication, you provide education. During a follow up phone call, you learn mom did not follow your instructions. Which of the following concepts regarding education may best help to explain why?

A. B. C. D.

You only spent 1/2 an hour, mom needed longer Knowledge does not equal behavior There were too many people in the room when you were teaching Education plays an important role in pain management

Communication

116

8/22/2012

Communication • Key Concepts – Therapeutic communication and interview skills – Barriers

Therapeutic Communication • Fundamental to effective pain management • Key components – Mutual process – Interpersonal skills – Communication skills

Effective Communication • Promotes a feeling of acceptance • Builds towards a trusting relationship • Ensures understanding of patients’…

– Cultural differences in communication, values & beliefs – Levels of motivation – Goals and expectations

117

8/22/2012

Facilitating Communication • When language is a barrier – Use short words & sentences – Use interpreters appropriately

• With cognitive impairment – Ask about pain • Tests of cognitive function cannot predict the ability to self-report pain • Try a variety of screening tools & select one that works • Use a “show and tell” approach

– Ask family and caregivers about pain behaviors – If pain is possible, assume pain is present

Interviewing • • • •

Review health information beforehand Assure the person is comfortable Ask open-ended questions Follow the patient’s lead

Interviewing (cont’d) • • • •

Facilitation - action, eye contact, posture, words Reflection - repetition of patient’s words Clarification - ask questions to increase understanding Empathic responses – make comments that reflect understanding

• Confrontation - clarify cues of anger, anxiety, depression • Interpretation • Closure & follow-up plan ASPMN Core Curriculum, 2010

118

8/22/2012

Interviewing: Children & Adolescents

(ASPMN Core Curriculum, 2010)

• Children – Age 5 years or older usually able to portray their history & describe pain severity – Use open-ended questions

• Adolescents – Focus on the adolescent rather than the problem – Silence is rarely successful – Discussing feelings may be difficult – Don’t use open-ended questions

Interviewing: Older Adults • Pace questions – Response time may be slower

• • • • •

Be sure glasses and hearing aids are in use Ask about usual function Determine goals and priorities Evaluate home safety Include family when possible

Barriers to Communication • Differences in perception of the problem, points of view, feelings, values • Language barriers • Low literacy • Sensory impairments • Cognitive impairments • Developmental stage • Cultural differences

119

8/22/2012

Interdisciplinary Collaboration

Interdisciplinary Collaboration • Key Concepts – Goal setting • Patient goals • Interdisciplinary goals

– Advocacy • Appropriate consultation • Referrals • Roles and responsibilities of other professionals

– Crisis management

Establishing an Institutional Commitment • Identify stakeholders • Find administrative support • Establish clear lines of communication • Articulate the benefits of effective pain management to all stakeholders • Establish interdisciplinary work group • Choose your battles carefully • Persist!

120

8/22/2012

Establishing A Collaborative Approach to Pain Management • Inclusion of appropriate interdisciplinary people around the table • Steps – Common goals – Patient rights – Common language • Standard assessment tools

– Common knowledge base – Recognition of the value of collaboration – Continuous improvement

Interdisciplinary Pain Committees • Define and establish standards for: – Assessment – Treatment – Documentation – Accountability – Timeliness – Patient & staff education – Monitoring

Improving Systems • Establish institutional standards • Analyze current practice • Require staff education – Make literature available – Classes – Performance review

• Offer patient/public education

121

8/22/2012

Improving Systems (cont’d) • Implement specialized services/programs – Pain Clinics – Pain Resource Nurse Programs (PRN)

• Use the power of accrediting agencies – The Joint Commission – Commission on Accreditation of Rehabilitation Facilities (CARF) – American College of Surgeons accreditation for cancer programs

Goal Setting: The Patient In partnership with the patient, – Identify a numerical goal on a rating scale that is reasonable to achieve OR – Identify a functional goal that is realistic to achieve • Sleep, activity, self-care, mobility etc.

Goal setting: The Team • Obtain input from the patient & interdisciplinary team • Identify goals that are specific, measurable, achievable and realistic • Assign a timeframe for achievement • Evaluate progress toward reaching goal at each visit/re-evaluation • Develop mutually acceptable new goals as patient progresses

122

8/22/2012

Advocacy: Patient Rights in All Settings • Wishes honored and respected • Effective pain assessment and management • Advocacy for un-treated, under-treated or inappropriately treated pain – Across the lifespan – Throughout the illness trajectory

The Need for Advocacy • Patients with pain are ordinary people facing difficult circumstances • Severe pain: – Obliterates thought – Paralyzes relationships – Crowds out any other priority but relief.

• Nurses are well positioned to do something about pain • If we allow pain to be ignored, we discredit human dignity and ignore basic human rights (Core Curriculum for Pain Management Nursing, 2010)

An Advocate • A nurse who…

– “Speaks or writes in support of something” Webster

– Explores all pain management options within scope of practice – Initiates appropriate consultations, referrals as needed by the patient and family

123

8/22/2012

Core Attributes of Advocacy • Safe guarding patient autonomy • Acting on behalf of patients – Especially those who can not speak for themselves

• Championing social justice in provision of health care • Advocating for evidence-based practices – Clinical Practice Guidelines – Current knowledge and skills

Arenas for Advocacy • • • • • •

Clinical practice Interdisciplinary discussions Organizational policy Health systems policy Regulatory or legislative issues Media

Nurses as Change Agents • Skills for success – – – – – – – –

Clinical competence Personal awareness Innovative thinking Clarity of vision Strong leadership skills Excellent communication and relationship skills Skill in program development Willingness to work with interdisciplinary teams

124

8/22/2012

Change Theories • • • • •

Force Field (Lewin) Phases of Change (Lippitt) Diffusion of Innovations (Rogers) Health Belief Model (Redman) Transtheoretical Model of Change (Prochaska & DiClemente)

Process of Change • Types: – Planned – Unplanned

• Levels: – Grassroots – Organizational – Individual

Effecting Systems Change • • • • • •

Strategies for change Managing the change Resistance to change Acceptance of change Evaluation of change Monitoring of change—data collection

125

8/22/2012

Effecting Individual Change • Evaluate level of commitment – Formulate interventions based on stage of commitment & desire to change

• Apply interventions to…

– Produce self awareness – Intentional action to change – Continued motivation to sustain the change

Responsibilities for All Healthcare Professionals • • • •

Assess pain Believe reports Adequately treat Educate about effects of poorly managed pain • Seek consultation when unable to effectively relieve pain

• Lobby for effective pain programs • Mentor other professionals • Develop effective pain programs • Monitor effectiveness of such programs

Pain Management Nurses • Roles – – – –

Direct care Case manager Educator Manager

• Advance Practice Nurse – – – –

Multidisciplinary team member Collaborator Consultant Researcher

• Interpret, reinforce, assess the effectiveness of recommended or prescribed treatments and medications • Maintain communication with team, patient and family

126

8/22/2012

Other Team Members • Primary care MDs – Pain is primary reason people seek care

• Other medical specialists

• Medical Pain Specialists – Anesthesiologists – Neurologists, physical medicine & rehabilitation – Addiction specialists

– Physical therapists – Exercise specialists – Social workers – Counselors – Pharmacy services – Case managers

Pain Clinics • Multi-disciplinary Pain Centers – Largest, most complex, research & teaching, interdisciplinary, affiliated w/teaching institution

• Multi-disciplinary Pain Clinic – Usually chronic pain only, no education or research component, interdisciplinary, inpatient & outpatient

• Pain Clinic – Restrict practice to 1 or more chronic conditions, not interdisciplinary

• Modality-Oriented Pain Clinic – Single modality, not interdisciplinary

Crisis Management • Unrelieved severe pain – Advocate for timely & effective treatment

• Financial issues – Identify issues that impede pain management • Cost or availability of medications, other treatments • Lack of insurance coverage

– Refer to appropriate team members for assistance

127

8/22/2012

Assess for Suicide Risk Factors • S-A-D P-E-R-S-O-N-S – Sex: male – Age: older rather than younger – Depression – Previous attempts – Ethanol use – Rational thinking loss – Social support deficit – Organized plan – No spouse – Sickness

VHA/DOD, 2000

Crisis Management: Suicide • “Has your pain made you • If assessed as suicidal, feel as if you couldn't go on – Emergency referral to mental health another day?” professional • “Have you thought of • If not suicidal, but acting on those feelings?” depressed • “Do you have a plan?”

– Refer to mental health • “Do you have a way to counseling & support carry it out?”

Questions

Questions

128

8/22/2012

Pain Syndromes & Diagnoses

Chronic (Persistent) Non-Cancer Pain (CNCP) • Back/neck (47%) • Myofascial/ fibromyalgia (20%) • Headaches (8%) • Arthritis (6%) • Neuropathic pain (5%) Survey of Nat’l Chronic Pain Outreach Association

Low Back/Neck Pain • Acute or chronic • Nociceptive, neuropathic, mixed • Many causes - difficult to determine

– Direct injury to bones, tendons, ligaments, spinal nerves, joints, or fascia – Ischemia or irritation of nerves – Abnormalities of CNS, abnormalities or injury of peripheral nerves – Environmental factors • Muscle tension, posture, obesity, overuse, under use, improper lifting, smoking – Psychological factors • Depression, stress, anger – Referred pain

129

8/22/2012

Low Back/Neck Pain • Trauma or Fractures • Inflammation • Neoplasm • Infections • Degenerative • Congenital • Spinal stenosis

Neck and Back Pain- Treatment Individually based & may include: • Physical/Occupational therapy • Behavioral therapies/Counseling • Life style changes • Medications • Procedures: Epidural steroids, Facet injections, Radiofrequency ablation

Sample Test Question Which of the following causes of lower back pain is associated with iritis and conjunctivitis?

A. Ankylosing spondylitis B. Arachnoiditis C. Facet syndrome D. Lumbar spondylolysis

130

8/22/2012

Fibromyalgia (FMS, fibrositis, Diffuse Myofascial Pain Syndrome) • Chronic, diffuse musculoskelatal pain syndrome – Specific tender points (neck, shoulders, chest, hips, back) – Cause: unknown – Women 7 X > men

• Diffuse, constant aching, morning stiffness, fatigue, nonrestorative sleep • May be associated with other conditions such as irritable bowel, headaches, jaw pain, numbness & tingling sensations

Fibromyalgia: Diagnosis American Rheumatological Association criteria for diagnosis – Pain in all four quadrants for at least 3 months and have tender spots at least 11 of the 18 specific sites – The “tender” points are elicited by applying 4 kg of pressure to each of the 18 defined tender point sites

131

8/22/2012

Fibromyalgia Syndrome: Diagnosis/ Treatment • The diagnosis is made clinically; there are no specific blood tests or other tests to “prove” the presence of fibromyalgia syndrome • Physical exercise is vital to successful treatment • All medical therapies have been used with varying degrees of success

Myofascial Pain Syndrome • Pain of a regional nature beginning within a specific trigger point within muscle/fascia

• Contributing factors

– hypersensitive knotted muscle

• Pain can refer – Zones of reference – Referred pain zones

– – – – –

Poor posture Leg length differences Scoliosis Trauma Repetitive motion injuries – Muscle overload – Other internal chemical imbalances

Myofascial Pain: Treatment • Eliminate the trigger point – Trigger-point injections

• Physical modalities – Stretching, ultrasound

• Biofeedback • Pharmacotherapy--TCAs • Botox injections

132

8/22/2012

Temporomandibular Dysfunction (TMJ) • Variety of dental and medical conditions involving the temporomandibular joint, muscles of mastication, and contiguous tissue components • Acute, chronic or chronic with acute exacerbations • Variety of pain reports – May be self-limiting, episodic, and/or progressive

Headaches 6 major types 1. Migraine 2. Tension 3. Cluster 4. Chronic daily 5. Analgesic rebound 6. Occipital neuralgia

Migraines 3 Phases 1. Premonitory (hours or days before) 2. Main attack • •

Aura (15%) Headache – Unilateral (usually, not always), Gradual onset, peak, subside; throbbing or pulsating – Photosensitivity, nausea and vomiting

3. Resolution phase (flu-like)

133

8/22/2012

Headache Management: Adjuvant Medications • Serotonin agonists (5-HT1 agonist; Triptans) – Bind to serotonin receptors in trigeminal nerve – Reduces serotonin release – Results in vasoconstriction of dural blood vessels – Contraindicated with ischemic vessel disease – SE: chest pain, pressure, tightness, palpitations, tingling, etc.

Headache Management: Adjuvant Medications (cont’d) • Ergot alkaloids – Produce peripheral vasoconstriction by stimulating alpha-adrenergic receptors – Direct vasoconstriction of carotid artery & serotonin agonist – Ergotamine, Dihydroergotamine • M.I., cardiac events, rebound headache & others

Medications for Headache Algorithm • Mild • Intermittent • headaches

Acetaminophen, NSAIDS

• Moderate • Intermittent • Headaches

NSAID Combinations, Midrin

• Severe • Intermittent • Headaches

5-HT1 Agonists Ergotamine Derivatives

134

8/22/2012

Chronic Daily Headache • Cause: Unknown • Precipitating cause: trauma, anxiety, stress, depression, caffeine, medication use/disuse • Daily or at least 15 times per month. “I have a headache more days than not”

Analgesic Rebound Headaches • Cause: withdrawal from frequently used medications (or other substances) – Aspirin, acetaminophen, barbiturates, ergotamine, NSAIDS, caffeine – Vicious cycle of headache, medication ingestion, headache, more medication, more headache….

• Pain: – Frontal region, pressure, stabbing – Worse on awakening

• Difficult to differentiate from chronic daily headaches

Occipital Neuralgia • Cause: May be related to nerve root entrapment of C2 or C3 nerve root or cervical myofacial pain • Pain: – Recurrent, episodic – Neuralgic pain starting at base of skull and radiating to front of head. Dull pain follows high intensity pain – Tender spot over scalp covering occiput (Palpation of spot may cause radiation to ipsilateral eye)

135

8/22/2012

Sample Test Question Your 12 year old patient presents with reports of frequent headaches for the past several weeks. She describes the headaches as severe, “like a poker in her eye” and notices her eyes water from the pain. What type of headache do you suspect?

A. B. C. D.

Migraine Cluster Tension Occipital neuralgia

Neuropathies • Injury or disease of central or peripheral nervous system • Results in abnormal activation of nociceptive neurons or selfsustaining ectopic discharges across neuronal membrane • May be constant or intermittent, mild to severe • Description – Burning, tingling, pulling, freezing, buzzing, jabbing, twisting, boring, electrical, stabbing, shooting, hot, cold, lancinating, numb, “weird” – Touch may aggravate pain (hyperalgesia, allodynia) – May be associated with sensory loss, decreased vibratory sense, weakness, loss of reflex and/or sympathetic tone, muscle atrophy • May be associated with the development of smooth, fragile skin with hair loss. Muscle atrophy may be seen in later stages

Peripheral Neuropathy • Symmetrical peripheral neuropathy in which there is a gradual loss of sensory nerve fibers; a loss of axons • Causes: inflammation, ischemia, infarction, compression, neuromas • Pathogenesis often unknown or unclear

136

8/22/2012

Polyneuropathies • Causes: diabetes, drug toxicity, nutritional deficiencies, uremia, HIV • Pain – Sensed along the peripheral nerves – “Stocking glove” pattern – Toes, feet, lower leg, calf, then fingers & hands

Mononeuropathies or Plexopathies • Peripheral neuropathy related to damage of a specific nerve as a result of disease or trauma • Associated with sensory loss especially to pin prick or dull stimuli & temperature, loss of reflex or tone, development of smooth, fine skin and hair loss • Diagnostic W/U: Hx, PE, EMG • Treatment: As appropriate: stabilization of underlying disease, TCAs, anticonvulsants, local anesthetics, capsaisin, OT & PT, spinal cord stimulators

Post-Herpetic Neuralgia (PHN) • More common in adults over 50 years and immunocompromised • Incidence – 10-15% of all Herpes Zoster patients – Up to 80% of Zoster patients > 80 y.o.

• Predictors of PHN – Advancing age – Severity & duration of initial Zoster pain

137

8/22/2012

PHN (cont’d) • Inflammation of peripheral nerve due to active outbreak of herpes zoster (shingles) • Varicella-zoster virus is re-activated in dorsal root ganglion after initial chicken pox infection • Pain persists past the stage of healing lesions but usually diminishes over time (3 mo) • Chronic pain with skin changes along a dermatomal distribution after acute herpes zoster

PHN (cont) • Prodrome: – Severe itching, tingling, aching, or sharp pain up to a week prior to outbreak of vesicles

• Vesicular stage – Patch of blisters in dermatomal pattern at any dermatomal level – May appear as disseminated rash over entire body in immunocompromised

Trigeminal Neuralgia (TN, tic douloureaux) • Sudden onset, right side more common, recurrent pain of 5th cranial nerve • Excruciating, acute, chronically recurring pain – “lightening strike” in face, nose, lips, eyes, ears, scalp jaw, buccal mucosa • Short repetitive bursts lasting 1-2 minutes with a refractory period of 30 seconds to a few minutes • Brief duration of repetitive bursts throughout the day, rarely continuous • May be triggered by “light touch”

138

8/22/2012

Trigeminal Neuralgia (cont) • Diagnostic W/U: neurological exam negative; hypoesthesia or absence of corneal reflex during a flare • Treatment: TCAs, Anticonvulsants, NSAIDS, topicals, neurolysis • Remissions and exacerbations

Other Neuropathies • Phantom limb pain – Phantom limb sensation

• • • •

Postmastectomy pain syndrome Post-thoracotomy pain syndrome Post-radical neck dissection pain syndrome Post surgical site pain

Arthritis • Over 100 different kinds of arthritis • Osteoarthritis (OA) is degenerative, NOT inflammatory • OA most common • RA most virulent • Rheumatoid arthritis (RA) & Juvenile rheumatoid arthritis (JRA) are inflammatory

139

8/22/2012

Rheumatoid Arthritis (RA) & Juvenile Rheumatoid Arthritis (JRA) • American Rheumatism Association diagnostic criteria: – 6 weeks of the following: • Morning stiffness, pain on motion or tenderness at one of more joints, swelling of one or more joints

• JRA subtypes – – – –

Systemic Polyarticular (> 5 joints) Pauciarticular (<4 joints) Severity of pain varies by individual and by subtype

RA & JRA • Inflammatory disease • Systemic disease affecting synovial joints, muscles, ligaments, tendons • Chronic joint deformity & dysfunction • Cause unknown – Genetic & environmental

• Women affected twice as often as men • Begins in adulthood, peaks during middle age • JRA has 3 subtypes

• Pain: – Inflammation (initially) – Erosion of cartilage and bone (later) – Aching & burning joint pain – Associated with: • > 30 min. am stiffness • Fatigue • Tenderness, swelling, decreased ROM • SQ nodules • Chronic fatigue • Inflammation may affect eyes, heart, or lungs

Osteoarthritis (OA) • Non-inflammatory – Use NSAIDS for pain, not inflammation

• Degenerative joint disease – Later stages-deformity, hypertrophy, contractures, joint space narrowing on x-ray

• Incidence increases with age • Progressive loss of articular cartilage • Hypertrophy of bone due to wear & tear

• OA Pain – Acute, chronic (persistent), or both – In distal and proximal interphalangeal joints of hands, knee, hip, spine, etc.

– Deep ache – Present at rest, with initiation of activity, at night in later stages – May refer to adjacent muscles – Weather may affect pain – Associated with: • < 30 min. am stiffness • Initiation of activity • Night (advanced)

140

8/22/2012

Sample Test Question Your 64 year old patient with osteoarthritis (OA) reports pain in the morning, at rest, and with activity. You recommend a NSAID for pain. You explain that the NSAID will: A. B. C. D.

Decrease the inflammation associated with OA Help with his pain Both A & B, which will help him feel better None of the above

Post-Stroke Syndrome 1. Nociceptive shoulder pain due to musculoskeletal changes from paresis 2. Severe, continuous neuropathic pain associated with brain lesion or ischemia – Also called “thalamic pain” and “central pain” – Located at same distribution as the sensory loss – May occur immediately or months to years later

Post Stroke Pain: Clinical Picture • Continuous, diffuse, unilateral, pain, contralateral to the brain lesion – May be associated with motor impairment and sensory deficits – Vasomotor atrophic changes often present

• Allodynia, hypoesthesia, hypoalgesia, hyperpathia, dysesthesia may be present

141

8/22/2012

Multiple Sclerosis • Demyelination of neurons, spinal cord & brain cause ectopic nerve impulses and pain – Acute or persistent – Location dependent on level of cord involvement of MS – 23-80% experience pain • Women twice as often as men

Spinal Cord Injury/Disease Pain • Causes: – Injury, trauma, inflammatory lesions, skeletal pathology, neoplasms, demyelinating diseases, abscesses, congenital lesions

• Clinical picture – Dyesthetic pain syndrome (“central pain syndrome”) • Neuropathic in nature • Often felt below the level of injury • Cramping & spasticity may also occur

– Nociceptive pain may also occur

Reflex Sympathetic Dystrophy (RSD) Complex Regional Pain Syndromes (CRPS) Sympathetically Maintained Pain Syndrome • Primary difference between CRPS I and II is the predisposing factor • Pain persists longer than expected • Dysregulation or overactivity of sympathetic nervous system causing pain and tissue wasting • Sympathetic hyperactivity – Initially vasodilation, increased temperature, hyperhidrosis, edema – With progression, atrophy of skin & nails, loss of hair, persistent coldness, pallor, cyanosis, atrophy of tissue & stiffness of joints

142

8/22/2012

Complex Regional Pain Syndromes (CRPS) • CRPS I (RSD)

– Injury to bone or soft tissue – Pain persists much longer than expected – Not limited to single peripheral nerve – Pediatrics: often only minor injury or no precipitating cause

• CRPS II (Causalgia) – Injury to nerve is predisposing factor – Limited injury to single nerve or branch – No precipitating cause ID’d in ~ 1/3 patients

Complex Regional Pain Syndromes (CRPS) • Patients may not have all of these symptoms – Symptoms may progress & involve additional limbs

• Aggravated by use, relieved by immobilization • Need to R/O cellulitis, DVT • Most often in adults – Children • > 9 years of age • Placing high demands upon themselves

143

8/22/2012

Complex Regional Pain Syndromes (CRPS)

• Diagnosis

– Physical exam – Bone scan – May show on plain xrays in advanced disease

• Treatment – – – –

Sympathetic blocks Physical therapy Corticosteroids Medications” TCAs, anticonvulsants, NSAIDs, Opioids, topicals

Cancer-Related Pain • Origin – Tumor involvement of nerves, pressure or obstruction – Procedures/treatment: surgery, chemo – Non-cancer pain syndromes • Diabetic neuropathy, post-herpetic neuralgia, arthritis, chronic back pain, etc

Cancer Pain in Children • Treatment related rather than cancer related – Increased number of hematological tumors vs. solid tumors – Procedural pain: diagnostic, treatment

• Less able to speak for themselves = greater risk for unrelieved pain

144

8/22/2012

HIV-Related Pain • Similar to cancer-related pain – Acute, chronic, procedure & treatment related – Nociceptive, neuropathic, and/or mixed

• Management is complicated by potential for drug-drug interactions

HIV-Related Pain • Multiple causes, multiple locations – – – – – –

Infection Neuropathies may be caused by HIV itself Antiretrovirals may cause neuropathic pain Rheumatologic disorders HIV related neoplasms Procedural: Often more painful than disease itself

Sickle Cell Disease • Inherited vaso-occlusive disease characterized by intermittent pain or “crises” • RBCs change to sticky, rigid sickle shapes that clump together due to  O2 tension • Clumping causes ischemia and tissue death anywhere in the body

145

8/22/2012

Sickle Cell Disease (cont) • Sickling

clogging of small vessels ischemia & cell death

Pain !

Sickle Cell Disease (cont) • Anything decreasing oxygenation may precipitate crisis – Infection, dehydration, overexertion, altitude changes

• • • •

Somatic pain: muscle, bones, tendons Visceral pain: spleen, liver, lungs Unpredictable as to location, severity, duration Management is often inadequate

Sickle Cell Disease (cont) • Persistent pain associated with – Boney avascular necrosis, vertebral collapse, priapism, chronic non-healing wounds – Organ infarcts

146

8/22/2012

Sample Test Question Compared to adults, cancer related pain in children is often treatment related rather than tumor related due to which of the following: A. Increased number of hematological tumors vs. solid tumors B. Cancers are highly responsive to aggressive therapies C. Demise tends to be rapid for cancers refractory to treatment D. All of the above

Pancreatitis • Cause: Inflammatory process in or near the pancreas destroying ductal structure in the pancreas, fibrosis or obstruction of adjacent structures, end-stage endocrine/exocrine failure – Adults: chronic alcohol abuse, hypertriglyceridemia – Children: trauma – Other causes: tumors, strictures, infection, medication, dietary

• Pain: varied, severe, at times refractory to opioids – Visceral, deep, gnawing, RUQ or midepigastrium, radiates to back – May  when leaning forward – Commonly associated with nausea and vomiting

Crohn’s Disease • Idiopathic intestinal inflammatory disease • Cause: unknown – ? Genetic, Bacterial, viral, obstruction, inflammation • Pain: – – – – – –

Acute or persistent pain, mild to severe RLQ abdominal pain Soreness, cramping May radiate to RU thigh Perinanal pain may be present Postprandial cramping common

147

8/22/2012

Chronic Pelvic/Abdominal Pain • • • •

Multiple causes Visceral, somatic May refer Look for both physical and psychological factors • 10% of recurrent abdominal pain in children has a clearly definable cause

Cardiac Pain • Ischemia from M.I. or angina – Chest pain – Referred pain

• Acute nociceptive pain • Mild to severe • Short lasting or intermittent

• Pain – Pressure, squeezing, fullness or pain – In one or both arms, back, neck, jaw or stomach – Dyspnea may be present – Fatigue, sweating, nausea, vomiting, light headedness

Wound Pain • Combination of nociceptive and neuropathic pain • May become persistent pain

• Causes – Debridement , drain removal dressing changes, pressure, movement – Irritating topical therapy, body’s own chemicals from damaged tissue – Stitches, staples

148

8/22/2012

Orthopedic Pain May be Acute or Chronic in Nature • • • •

Fracture Sprain Torsion injury Surgery

• Post-amputation (phantom) pain – Neuropathic in nature – May have muscle spasms – Greater in those with long term pre-op pain – Occurs in 90% of amputees

CONGRATULATIONS AND GOOD LUCK!

Questions

Questions

149

Back Pain Chart Description Ankylosing Spondylitis

Chronic inflammatory changes

Associated S&S Associated symptoms may include

Gradual onset Pain worse in morning Stiffening of joint structure in low back and pelvis

Arachnoiditis

Causes: Infection, surgery, intrathecally injected medications, trauma Pain Starts local, constant, dull or aching but progresses to an intense burning sensation Neck: stiffness Low back: extend into diffuse bilateral legs May be described as “like a band” – constricting, burning, gnawing, stinging

Peripheral joint disease, conjunctivitis and iritis

Diagnosis Limitation of motion of lumbar spine in all three planes, anterior flexion, lateral flexion and extension Hx of presence of pain at the dorsolumbar junction or lumbar spine

Limitation of chest expansion to 2.5cm or less at the 4th intercostal Worse with Diagnostic W/U: CSF movement, & blood to r/o coughing, sneezing, infection, MRI or CT bed rest & morning time

Other Considerations 90% + HLA-B27 (genetic marker)

Facet Syndrome

Junction of two vertebrae with heavily innervated joint Caused by twisting sprain of the facet joint Low back pain with or without radiation

Muscle spasms and aching, radiating into lower back, hip, buttocks, thigh but not below the knee

Absence of paresthesia

LBP or stiffness w or w/o radiation

Depressed deep tendon reflexes

Pain with hyperextension of the spine

Straight leg raise causes hamstring pain and/or muscle spasm in the hip, buttock or low back

Herniated Intervertebral Disk

Disk places mechanical May have pressure on nerve root neurological & causes irritation symptoms: Sudden, severe pain, sharp, lancinating, may radiate along anatomic distribution

Lumbar Spondylolysis

Defect in the pars interarticularis of vertebrae Typically low back pain and sciatica are bilateral. Deep ache, poorly localized

L4-5 or L5-S1 most common

weakness, loss of motor function, diminished deep tendon reflexes, loss of sensation Pain decreases with decreased activity Common in active teens, more common in males

Spondylosis

Radiculopathy

Stiffness, aching, dull, tight w/intermittent sharp, pinching or spasms

Many possible causes Compressionherniation or osteophytes Diabetes mellitus (neuropathy)

Worse with movement, extension, flexion, twisting or with standing, sitting too long

Types of spondylosis causing chronic back pain

Pain follows involved nerve root

Hyperalgesia or allodynia, loss of sensation or motor function may or may not be present

– “shooting down the leg or arm”, burning, prickling, weakness

Osteoarthritis, disc degeneration, loss of height, osteophytes

Herpes zoster (post herpatic neuralgia) Neoplasms Infectious diseases Spinal Stenosis

Congenital or degenerative Pain: Gradual increasing back pain and pain in legs and buttocks

Deep aching with heavy & numb feeling in leg from buttock to foot; weak or tired legs; clumsiness

Worse with activity, difficulty walking May have dermatomal paresthesia, bowel or bladder disturbances

Headache Chart Signs and Symptoms

Pathology

Predisposing Factors

Treatment

General Information

3 phases: Pre: hoursdays before Headache: aura 15% Resolution: headache gone, flu-like S&S Hard to differentiate from rebound headaches

Migraine Throbbing, pulsating pain; photophobia and N & V occur Adults unilateral; children bilateral

Vasodilation, neurogenic inflammation, change in serotonin metabolism

Stress, change in sleep, diet, bright lights, certain foods, smoking, menstrual migraines

Diet changes, awake and go to sleep same time every day, Nsaids, triptans, ergotamines

Tension

Bilateral, symmetrical, dull tightness around head, pressing, nonpulsating, no N &V

Sustained muscle contraction

Depression Family history Sleep issues

Non-opioid analgesics, TAD

Cluster

Autonomic S & S; watery eyes; nasal stuffiness; unilateral pain, orbital, intense, excruciating, episodic

Unsure, but autonomic S & S

ETOH; seasonal changes

TAD, Lithium, O2 therapy?

Feels like “poker in the eye”, attacks last 15-30” up to 2-3 hrs, rapid onset, peaks in 510”

Nonopioid Analgesics Drug Adult > 50 kg Dose(mg)*

Dose Interval (hours)

Maximal Daily Dose(mg)

Pediatric Dose (mg/kg) < 50 kg

Analgesic Efficacy Compared to Standards Comparable to aspirin

Plasma HalfLife (Hours) 2-3

Comments

0.25

Because of risk of Reye’s syndrome, do not use in children under 12 with possible viral illness. Rectal suppository available for children and adults. Sustainedrelease preparation available Dose in elderly 500–1,000 mg/day; dose does not yield salicylate

Acetaminophen

500-1,000

4-6

4,000

10-15

Salicylates Aspirin Acetylated

500-1,000

4-6

4,000

10-15 Q4-6 hr

1,000 initial, 500 subsequent

8-12

1,500

—

500 mg superior to aspirin 650 mg, with slower onset and longer duration; an initial dose of 1,000 mg significantly shortens time to onset

8–12

1,000– 1,500

12

2,000– 3,000

25mg/kg bid

Longer duration of action than aspirin 650 mg

9-17

Diflunisal (Dolobid) Modified

Salts*** Choline magnesium trisalicylate (Trilisate, Tricosal)

Rectal suppository available for children and adults.

Sustained-release preparation available

Unlike aspirin and NSAIDS, does not increase bleeding time

NSAIDs Drug

Propionic Acids Ibuprofen (Motrin, Rufen, Nuprin, Advil, Medipren, others) Naproxen (Naprosyn, Naprolan) Naproxen sodium (Anaprox) Naproxen sodium OTC (Aleve) Fenoprofen (Nalfon) Ketoprofen (Orudis) Ketoprofen OTC (Actron, OrudisK+) Oxaprozin (Daypro) Indolacetic Acids Indomethacin (Indocin, Indocin SR, Indochron E– R) Sulindac (Clinoril)

Adult > 50 kg Dose(mg)*

Dose Interval (hours)

Maximal Daily Dose(mg)

Pediatric Dose (mg/kg) < 50 kg

Analgesic Efficacy Compared to Standards

Plasma Half-Life (Hours)

Comments

200–400

4–6

2,400

5-10mg/kg q6hr

Superior at 200 mg to aspirin 650 mg

2–2.5

—

500 initial, 275 subsequent

6–8

1,500

5-10mg/kg bid

—

12–15

—

550 initial, 250 subsequent

6–8

1,650

5-10mg/kg bid

—

—

220 mg

8–12

—

—

275 mg comparable to aspirin 650 mg, with slower onset and longer duration; 550 mg superior to aspirin 650 mg Comparable to aspirin

2–3

—

200

4–6

3,200

—

—

—

—

25–50

6–8

300

1.5 q8-12hr

—

—

—

12.5–25

4–6

—

—

Superior at 25 mg to aspirin 650 mg

1.5

Sustained-release preparation available

600

12–24

1,200

—

—

24–69

—

25

8–12

200

1mg/kg q8h

Comparable to aspirin 650 mg

2

150

12

400

3-4mg/kg/day in divided

Not routinely used because of 650 mg high incidence of GI and CNS side effects; rectal, IV, and sustained-release oral forms available for adults

7.8 active metab = 16

doses q12 hr Etodolac (Lodine)

300–400

Pyrrolacetic Acids Ketorolac 30 or 60 (Toradol) mg IV initial, 15 or 30 mg IV or IM subsequent

Tolmetin (Tolectin)

200–600

Anthranilic Acids Mefenamic acid 500 initial, (Ponstel) 250 subsequent Phenylacetic Acids Diclofenac 50 mg potassium (Cataflam) Enolic Acids Meloxicam (Mobic)

7.5–15

hr

8–12

1,000

1520mg/kg/day q12h

More potent than sulindac and naproxen, but less potent than indomethacin

6

150 first day, 120 thereafter

1 mg/kg as a single loading dose IV up to 60 mg

In the range of 6–12 mg of morphine

0.5 mg/kg, up to 30 mg for initial and subsequent doses 15 to 30mg/kg/day in 3 or 4 divided doses

8

1,800

6

1,500

—

Comparable to aspirin 650 mg

8

150

1 to 2mg/kg/dose

Superior in efficacy and analgesic duration to aspirin 650 mg

24

15

See Comments

6

Limit treatment to 5 days; may precipitate renal failure in dehydrated patients; average dose in elderly 10–15 mg IM/IV q6hr

5

2

In U.S. use is restricted to 1-week intervals

—

15–20

Juvenile rheumatoid arthritis, polyarticular arthritis (2 years and older) 0.125 mg/kg orally once daily; maximum dose of 7.5 mg daily; dosing should be individualized

Piroxicam (Feldene)

20–40

Naphthylalkanone Nabumetone 1,000 (Relafen) initial 500–750 subsequent Cox 2 selective Celecoxib 200–400 (Celebrex)

50

based on the child’s weight

24

40

0.2– 0.4mg/kg/day maximum dose is 15 mg/day

8–12

2,000

-

Pain relief equal to aspirin, indomethacin, naproxen, and sulindac

Unknown Active metab = 24

Fewer side effects

12–24

400

See Comments

Antiinflammatory and analgesic effect similar to naproxen

11

Juvenile rheumatoid arthritis – 2 years and older, 10 to 25 kg – 50 mg orally, BID Juvenile rheumatoid arthritis – 2 years and older, greater than 25 kg – 100 mg orally, BID

*All doses are oral unless otherwise specified. ** Maximun drug dose is lower in fasting patients and in patients regularly consuming alchohol. ***Magnesium and sodium salicylate tablets also are commercially available, but are used less commonly today.

Use lowest effective dose for shortest possible duration.

Anticonvulsants for the treatment of pain Drug

Starting dose

Usual effective dose

Gabapentin (Neurontin)

100-300 mg HS

300-1200 mg tid

Pregabalin (Lyrica)

150 mg daily

300-600 mg bid

Pediatric Dose 2mg/kg/d in 3 divided doses titrate to 530mg/kg/day Dose may be approximately 1/6 of gabapentin dose + 10 mg/kg/day in 2 or 3 divided doses

Carbamazepine (Tegretol) 100-200 mg daily

300-800 mg bid

Topiramate (Topamax)

25 mg daily

100-200 mg bid

25 mg or less q HS (range of 1 to 3 mg/kg/day)

Lamotrigine (Lamictal)

25 mg daily

100-200 mg bid

Phenytoin (Dilantin)

300 mg HS

100-150 mg tid

Valproate (Depakene)

250 mg tid

500-1,000 mg tid

Dosing for seizures: 0.15 mg/kg/day (round down to the nearest whole tablet) Dosing for seizures: 5 mg/kg/day divided equally into 2 or 3 doses 10-15 mg/kg/day, in divided doses tid

Levetriracetam (Keppra)

250-500 mg bid

500-1,000 mg bid

Zonisamide (Zonergran)

100 mg daily

100-200 mg bid

Dosing for seizures is 10 mg/kg twice daily +

Adapted from American Pain Society (2008) Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, Sixth Edition Glenview, IL APS Press. & Dworkin RH, Connor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS, et al. (2007).

Pharmacologic management of neuropathic pain: Evidence-based recommendations. Pain, 132 :237-251.

Abbreviations: bid = twice a day; tid = three times a day; HS = every night; + Safety and effectiveness not established in children * Doses are guidelines only. Dosage recommendations came from published literature; manufacturerâ&#x20AC;&#x2122;s package inserts, adjustments from adult dosing guidelines, or reflects clinical practice experiences. Actual dose requirements may vary based on clinical indication, age, and weight of patient. Therefore, dose should be individualized and titrated based on clinical response and adverse effects.

Antidepressants for the treatment of pain Drug

Starting dose

Usual effective dose Pediatric Dose

Tricyclic antidepressants Amitriptyline (Elavil) 10-25 mg HS Nortriptyline (Pamelor) 10-25 mg HS Desipramine (Norpramin) 10-25 mg HS Selective Serotonin Reuptake Inhibitors (SSRIs) Paroxetine (Paxil) 10-20 mg daily Citalopram (Celexa) 10-20 mg daily Serotonin Nor-epinephrine Reuptake Inhibitors (SNRIs) Venlafaxine (Effexor) 37.5 mg daily Duloxetine (Cymbalta) 20 mg daily Dopamine agonists Buproprion (Wellbutrin) 50-75 mg bid

50-150 mg HS

0.05-1mg/kg/day

50-150 mg HS 50-150 mg HS

0.05-1mg/kg/day 1-3 mg/kg/day (divided doses) +

20-40 mg daily 20-40 mg daily

+ +

150-225 mg daily 60 mg daily

1-2 mg/kg (divided dose) + +

75-150 mg bid

+

Topical local anesthetics, oral anesthetics, and other topical anesthetics Drug

Starting dose

Usual effective dose

Topical lidocaine 5+ patch 1 patch 12 hours/24 (Lidoderm)

1-3 patches 12hours/24

Mexilitine (Mexitil)

150 mg daily

100-300 mg tid

Lidocaine intravenous (Xylocaine)

2mg/kg over 30 mins

2-5 mg/kg

Capsaicin cream (Zostrix) 0.025% tid-qid

0.075 tid-qid

Pediatric Dose Cut to fit, no more than 1 patch for 12 hours/24 hours + Initially 150 mg at HS, titrate to 10-15 mg/kg 2mg/kg over 30 mins, with a subsequent infusion of 1mg/kg/hour +

Adapted from American Pain Society (2008) Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, Sixth Edition Glenview, IL APS Press. & Dworkin RH, Connor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS, et al. (2007). Pharmacologic management of neuropathic pain: Evidence-based recommendations. Pain, 132 :237-251.

Abbreviations: bid = twice a day; tid = three times a day; HS = every night; + Safety and effectiveness not established in children * Doses are guidelines only. Dosage recommendations came from published literature; manufacturerâ&#x20AC;&#x2122;s package inserts, adjustments from adult dosing guidelines, or reflects clinical practice experiences. Actual dose requirements may vary based on clinical indication, age, and weight of patient. Therefore, dose should be individualized and titrated based on clinical response and adverse effects.

Skeletal muscle relaxants for the treatment of pain Drug

Starting dose

Usual effective dose

Cyclobenzaprine (Flexeril, 5 mg tid or Amrix) 15mg daily Carisoprodol (Soma) 350 mg HS-tid

10-20 mg tid or 15-30mg daily 350 mg tid-qid

Orphenadrine (Norflex) Tizanidine (Zanaflex) Metaxalone (Skelaxin)

100 mg bid Variable 800 mg tid-qid

100 mg bid 2 mg HS 400 mg tid-qid

Pediatric Dose + Use in children under 12 yrs is not recommended + + +

Methocarbamol (Robaxin) 500 mg qid

500-750 mg qid

Chlorzoxazone (Parafon forte)

250 mg tid

500-750 mg tid-qid

Anti-spasmodic agents Baclofen (Lioresal)

5 mg tid

10-20 mg tid

Spasticity: 10 to 15 mg/day in 2 to 3 divided doses

Benzodiazepines Diazepam (Valium)

1 mg bid

2-10 mg bid-qid

Skeletal muscle spasm; 1 to 2.5 mg tidqid

Clonazepam (Klonopin)

0.5 mg tid

1-2 mg tid

Seizure: up to 10 y of age or up to 30 kg, initial, 0.01 to 0.03 mg/kg/day divided into 2 to 3 daily doses

Lorazepam (Ativan)

0.5 mg bid

1-2 mg bid-tid

0.02-0.09 mg/kg tid

Alprazolam (Xanax)

0.25mg tid

0.5 mg tid

+

+ 125 to 500 mg tid-qid (or 20 mg/kilogram/day or 600 mg/square meter/day in 3 to 4 divided doses)

Adapted from American Pain Society (2008) Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, Sixth Edition Glenview, IL APS Press. & Dworkin RH, Connor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS, et al. (2007). Pharmacologic management of neuropathic pain: Evidence-based recommendations. Pain, 132 :237-251.

Abbreviations: bid = twice a day; tid = three times a day; HS = every night; + Safety and effectiveness not established in children * Doses are guidelines only. Dosage recommendations came from published literature; manufacturerâ&#x20AC;&#x2122;s package inserts, adjustments from adult dosing guidelines, or reflects clinical practice experiences. Actual dose requirements may vary based on clinical indication, age, and weight of patient. Therefore, dose should be individualized and titrated based on clinical response and adverse effects.

Other Medication used as adjuvants in the treatment of pain Drug

Starting dose

Usual effective dose Pediatric Dose

Corticosteroids Dexamethasone 4 mg bid (Decadron) Methylprednisolone (Solu- 10 mg tid Medrol) Stimulants Caffeine (Cafcit) 65 mg daily Dextroamphetamine 10 mg daily (Dexedrine) Methylphenidate (Ritalin) 2.5 mg qam Modafinil (Provigil) Atomoxetine (Strattera)

100 mg qam 40 mg daily

variable 10-20 mg tid

0.02 to 0.3 mg/kg/day in 3 or 4 divided doses 0.5 mg/kg up to initial adult doses of 10 to 40 mg

variable variable

2.5 mg - 5 mg qd or bid

variable

2.5mg/day * + 0.5 mg/kg/day*

variable 80 mg daily

Alpha-2-adrenergic agonists Clonidine (Catapres) 0.1 mg PO daily variable N-methyl-D-Aspartate (NMDA) Receptor Blockers Dextromethorphan 15-20 mg tid unknown Ketamine (Ketalar) 0.1-0.15 mg/kg iv 0.1-0.15 mg/kg/hour Amantadine (Symmetrel) 100 mg daily 100-150 mg bid Memantine (Namenda) 5 mg daily 10 mg bid Bisphosphonates and Calcitonin Pamidronate (Aredia) 60 mg IV q month 60-90 mg iv q mo Alendronate (Fosamax) 70 mg every week 70 mg every week Ibandronate (Boniva) 50 mg daily 50 mg daily Zoledronic acid (Zometa) 4 mg IV every 3 weeks 4 mg IV every 3 weeks Calcitonin (Miacalcin) 1 IU/kg sc daily 200 IU intranasal daily Radionucleotides Strontium-89 (Metastron) 4 millicurie (mCi) IV 153-lexodronam 0.5 or 1.0 mCi/kg (Samarium) Cannabinoids Dronabinol 2.5 mg bid 5-10 mg bid

2-5 mcg/kg in 4 divided doses + + + + + + + + + Chemotherapy-induced nausea and vomiting; Prophylaxis: 5 mg/m(2) 1 to 3 hr before chemotherapy and every 2 to 4 hr after chemotherapy

Adapted from American Pain Society (2008) Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, Sixth Edition Glenview, IL APS Press. & Dworkin RH, Connor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS, et al. (2007). Pharmacologic management of neuropathic pain: Evidence-based recommendations. Pain, 132 :237-251.

Abbreviations: bid = twice a day; tid = three times a day; HS = every night; + Safety and effectiveness not established in children

* Doses are guidelines only. Dosage recommendations came from published literature; manufacturerâ&#x20AC;&#x2122;s package inserts, adjustments from adult dosing guidelines, or reflects clinical practice experiences. Actual dose requirements may vary based on clinical indication, age, and weight of patient. Therefore, dose should be individualized and titrated based on clinical response and adverse effects.

NEUROABLATIVE INTERVENTIONAL TECHNIQUES PROCEDURE

PHENOL/ALCOHOL

Intercostal Blocks

X

RADIOFREQUENCY COAGULATION

Spinal Facets

OTHER

X

Peripheral Nerve Blocks

X

X

Cryoanalgesia

Intradiscal Electrothermal Therapy (IDET) Intradiscal Electrothermal Annuloplasty (IDA) Stellate Ganglion Block

X

Celiac Plexus Block

X

Lumbar Sympathetic Block

X

Hypogastric Block

X

Ganglion Impar Block

X

NON-NEUROABLATIVE INTERVENTIONAL TECHNIQUES PROCEDURE Trigger Point Injections Joint Injections Bursa Injections Intercostal Blocks Epidural Injections Intrathecal Injections/Infusions Facet Injections Peripheral Nerve Blocks

LOCAL ANESTHETIC X X X X X X

STEROID

BOTOX

X X X X X

X

X X

X

Intravenous Regional Block (Bier block)

X

Stellate Ganglion Block Lumbar Sympathetic Block Vertebroplasty Kyphoplasty Peripheral Nerve Stimulators Dorsal Column Stimulators Transcutaneous Electrical Stimulators

X X

OPIOIDS

OTHER MEDICATION

Other

Hyaluronate

X X

Clonidine Baclofen

Bretylium reserpine clonidine

Surgical Cement Surgical Cement

Electrical Stimulation Electrical Stimulation Electrical Stimulation

Of note, for a more extensive list of nerve blocks and procedural interventions, please refer to an Interventional Pain Management Text.