8-30-06PainMgmt-Levine

8/3/2019 8-30-06PainMgmt-Levine

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Pain Management WorkshopPain Management Workshop

Stacie Levine MD

Section of GeriatricsDepartment of Medicine

Stacie Levine MDStacie Levine MD

Section of GeriatricsSection of GeriatricsDepartment of MedicineDepartment of Medicine


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OutlineOutline

Pain assessment

WHO analgesic ladder

Opiate conversions

Barriers

Management of side effects Potential pitfalls in prescribing

Case examples

Pain assessmentPain assessment

WHO analgesic ladderWHO analgesic ladder

Opiate conversionsOpiate conversions BarriersBarriers

Management of side effectsManagement of side effects

Potential pitfalls in prescribingPotential pitfalls in prescribing

Case examplesCase examples


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An unfolding case (L.T.)An unfolding case (L.T.)

75 y.o. female CAD, spinal stenosis

Recent hospital discharge for angina,precipitated by severe lumbar radicular

pain

Discharged home with medicalmanagement, T#3 and neurontin for pain

Sees you first time for follow-up, c/onausea from T#3, did not help pain

WHAT DO YOU DO?

75 y.o. female CAD, spinal75 y.o. female CAD, spinal stenosisstenosis

Recent hospital discharge for angina,Recent hospital discharge for angina,precipitated by severe lumbarprecipitated by severe lumbar radicularradicular

painpain

Discharged home with medicalDischarged home with medicalmanagement, T#3 andmanagement, T#3 and neurontinneurontin for painfor pain

Sees you first time for followSees you first time for follow--up, c/oup, c/onausea from T#3, did not help painnausea from T#3, did not help pain

WHAT DO YOU DO?WHAT DO YOU DO?


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Rule #1:Choose your medRule #1:Choose your med

Pain history

Nociceptive vs. Neuropathic

Use a pain scale wheneverpossible

Choose a route of administration

Pain historyPain history

NociceptiveNociceptive vs.vs. NeuropathicNeuropathic

Use a pain scale wheneverUse a pain scale whenever

possiblepossible

Choose a route of administrationChoose a route of administration


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No Pain Worst Pain

0 1 2 3 4 5 6 7 8 9 10

Numeric ScaleNumeric Scale


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No Pain0

Mild1

Moderate2

Severe3

Very Severe4

Worst5

Verbal Descriptive ScaleVerbal Descriptive Scale


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Faces Pain Scale andPain ThermometerFaces Pain Scale andPain Thermometer


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WHO 3-stepLadderWHO 3-stepLadder

1 mild1 mild

2 moderate2 moderate

3 severe3 severe

MorphineHydromorphone

Methadone

LevorphanolFentanyl

Oxycodone

Adjuvants

MorphineHydromorphone

Methadone

LevorphanolFentanyl

Oxycodone

Adjuvants

A/CodeineA/Hydrocodone

A/Oxycodone

Tramadol Adjuvants

A/CodeineA/Hydrocodone

A/Oxycodone

Tramadol Adjuvants

ASA/NSAIDs

Acetaminophen

Cox-2

Adjuvants

ASA/NSAIDs

Acetaminophen

Cox-2

Adjuvants


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Step 1: Non-opioidsStep 1: Non-opioids

Acetaminophen

NSAIDS

Cox-2

Adjuvants Non-systemic therapies

Non-medication modalities

AcetaminophenAcetaminophen

NSAIDSNSAIDS

CoxCox--22

AdjuvantsAdjuvants NonNon--systemic therapiessystemic therapies

NonNon--medication modalitiesmedication modalities


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Step 2: Mild Opioids,Opioid-likeStep 2: Mild Opioids,Opioid-like

Codeine (e.g. T #3)

Hydrocodone (e.g. Vicodin)

Oxycodone (e.g. Percocet)

Tramadol (Ultram) +/- Adjuvants

Codeine (e.g. T #3)Codeine (e.g. T #3)

HydrocodoneHydrocodone (e.g.(e.g. VicodinVicodin))

OxycodoneOxycodone (e.g.(e.g. PercocetPercocet))

TramadolTramadol ((UltramUltram)) +/+/-- AdjuvantsAdjuvants


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Step 3: Strong OpioidsStep 3: Strong Opioids

Morphine

Oxycodone

Hydromorphone (Dilaudid)

Fentanyl

Levorphanol Methadone

+/- Adjuvants

MorphineMorphine

OxycodoneOxycodone

HydromorphoneHydromorphone ((DilaudidDilaudid)) FentanylFentanyl

LevorphanolLevorphanol MethadoneMethadone

+/+/-- AdjuvantsAdjuvants


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Opioid PharmacologyOpioid Pharmacology

Block the release ofneurotransmitters in the spinal cord

Mu, delta, kappa Conjugated in liver

Excreted via kidney (90%95%)

First-order kinetics

Block the release ofBlock the release ofneurotransmitters in the spinal cordneurotransmitters in the spinal cord

MuMu, delta, kappa, delta, kappa Conjugated in liverConjugated in liver

Excreted via kidney (90%Excreted via kidney (90%95%)95%) FirstFirst--order kineticsorder kinetics


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PlasmaC

oncentra

tion

PlasmaC

oncentra

tion

PlasmaC

oncentra

tion

000 Half-life (t1/2

)HalfHalf--life (tlife (t1/21/2

)) TimeTimeTime

IVIVIV

po / prpo / prpo / pr

SC / IMSC / IMSC / IM

CmaxCCmaxmax


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Opioid pharmacology . . .Opioid pharmacology . . .

Cmax (peak) after

po, pr 1 hSC, IM 30 minIV 6 15 min

half-life at steady state

po / po / SC / IM / IV 3-4 h

CCmax (peak)max (peak) afterafter

popo, pr, pr 1 h1 hSC, IMSC, IM

30 min30 min

IVIV 66 15 min15 min halfhalf--life at steady statelife at steady state

popo // popo / SC / IM / IV/ SC / IM / IV 33--4 h4 h


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. . . Opioid pharmacology. . . Opioid pharmacology

Steady state after 45 half-lives

steady state after 1 day (24 hours)

Duration of effect of immediate-release formulations (exceptmethadone)

35 hours po / pr

shorter with parenteral bolus (1-2 hours)

Steady state after 4Steady state after 45 half5 half--liveslivessteady state after 1 day (24 hours)steady state after 1 day (24 hours)

Duration of effect of immediateDuration of effect of immediate--release formulations (exceptrelease formulations (except

methadone)methadone)

335 hours po / pr5 hours po / pr

shorter with parenteral bolus (1shorter with parenteral bolus (1--2 hours)2 hours)


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Opioid management forcontinuous painOpioid management forcontinuous pain

PRN not appropriate

Dose find:

-begin with short-acting opioid ATC-know if patient is opioid nave or not

-allow breakthrough based on Cmaxand patients metabolism

PRN not appropriatePRN not appropriate

Dose find:Dose find:

--begin with shortbegin with short--actingacting opioidopioid ATCATC--know if patient isknow if patient is opioidopioid nave or notnave or not

--allow breakthrough based onallow breakthrough based on CmaxCmaxand patients metabolismand patients metabolism


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What do we do for L.T.?What do we do for L.T.?

Lets use Morphine IR

Morphine 15 mg po q 4 hr, ATC

Breakthrough

-With normal metabolic function

-Morphine 15 mg po q 1 hr, prn

What else do we write for?

Lets use Morphine IRLets use Morphine IR

Morphine 15 mgMorphine 15 mg popo q 4 hr, ATCq 4 hr, ATC

BreakthroughBreakthrough

--With normal metabolic functionWith normal metabolic function

--Morphine 15 mgMorphine 15 mg popo q 1 hr,q 1 hr, prnprn

What else do we write for?What else do we write for?


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Rule #2: Address concernsRule #2: Address concerns

Addiction

Dependence

Pseudoaddiction

Tolerance Side effects

AddictionAddiction

DependenceDependence

PseudoaddictionPseudoaddiction

ToleranceTolerance

Side effectsSide effects


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Opioid adverse effectsOpioid adverse effects

Common UncommonConstipation Bad dreams / hallucinations

Dry mouth Dysphoria / deliriumNausea / vomiting Myoclonus / seizures

Sedation Pruritus / urticaria

Sweats Respiratory depression

Urinary retention

SIADH

CommonCommon UncommonUncommonConstipationConstipation Bad dreams / hallucinationsBad dreams / hallucinations

Dry mouthDry mouth Dysphoria / deliriumDysphoria / delirium

Nausea / vomitingNausea / vomiting Myoclonus / seizuresMyoclonus / seizures

SedationSedation Pruritus / urticariaPruritus / urticaria

SweatsSweats Respiratory depressionRespiratory depression

Urinary retentionUrinary retention

SIADHSIADH


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Managing GI Effects of

Opioids

Managing GI Effects of

OpioidsConstipation

Prevent with scheduled softeners PLUS stimulantsAvoid bulking agents

Nausea and Vomiting

Encourage patients to eat frequent, small mealsProvide promotility agents (metoclopramide),

serotonergic blocking agents (odansetron,granisetron) or dopaminergic blocking agents

(haloperidol, metoclopramide, prochlorperazine)

If symptoms are related to head movements, considermeclizine or scopolamine

ConstipationConstipation

Prevent with scheduled softeners PLUS stimulantsPrevent with scheduled softeners PLUS stimulants

Avoid bulking agentsAvoid bulking agents

Nausea and VomitingNausea and Vomiting

Encourage patients to eat frequent, small mealsEncourage patients to eat frequent, small mealsProvide promotility agents (metoclopramide),Provide promotility agents (metoclopramide),

serotonergic blocking agents (odansetron,serotonergic blocking agents (odansetron,

granisetron) or dopaminergic blocking agentsgranisetron) or dopaminergic blocking agents

(haloperidol, metoclopramide, prochlorperazine)(haloperidol, metoclopramide, prochlorperazine)

If symptoms are related to head movements, considerIf symptoms are related to head movements, consider

meclizine or scopolaminemeclizine or scopolamine


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Managing Sedation and

Delirium of Opioids

Managing Sedation and

Delirium of Opioids

If pain control is adequate, decrease dose by 25%

Change to a different opioid preparation

Use small doses of psychostimulants (2.5 to 5 mgmethylphenidate or dextroamphetamine) forexcessive somnolence

Use nonsedating antipsychotics (haloperidol,risperidone) for delirium

If pain control is adequate, decrease dose by 25%If pain control is adequate, decrease dose by 25%

Change to a different opioid preparationChange to a different opioid preparation

Use small doses of psychostimulants (2.5 to 5 mgUse small doses of psychostimulants (2.5 to 5 mgmethylphenidate or dextroamphetamine) formethylphenidate or dextroamphetamine) forexcessive somnolenceexcessive somnolence

UseUse nonsedatingnonsedating antipsychotics (haloperidol,antipsychotics (haloperidol,risperidone) for deliriumrisperidone) for delirium


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Managing Respiratory

Depression of Opioids

Managing Respiratory

Depression of OpioidsDoes not occur in patients on long-term

opioids

Can occur in opioid-nave patients and thosewhose opioid dose is rapidly escalated

Is always preceded by slowly progressivesomnolence

Tolerance to respiratory depressant effects

develops rapidly (48-72 hours)If you must treat:

-Dilute naloxone (10:1) in saline and infuse

until breathing pattern returns to normal

Does not occur in patients on longDoes not occur in patients on long--termtermopioidsopioids

Can occur in opioidCan occur in opioid--nanave patients and thoseve patients and thosewhose opioid dose is rapidly escalatedwhose opioid dose is rapidly escalated

Is always preceded by slowly progressiveIs always preceded by slowly progressivesomnolencesomnolence

Tolerance to respiratory depressant effectsTolerance to respiratory depressant effects

develops rapidly (48develops rapidly (48

--72 hours)72 hours)

If you must treat:If you must treat:

--Dilute naloxone (10:1) in saline and infuseDilute naloxone (10:1) in saline and infuse

until breathing pattern returns to normaluntil breathing pattern returns to normal


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AddictionAddictionA psychologic dependence on drugs and

a behavioral syndrome characterizedby compulsive drug use and continueduse despite harm to self and others

Opioids do NOT cause psychologicdependence

Use of opioids for pain managementdoes NOT cause addiction

A psychologic dependence on drugs andA psychologic dependence on drugs and

a behavioral syndrome characterizeda behavioral syndrome characterizedby compulsive drug use and continuedby compulsive drug use and continueduse despite harm to self and othersuse despite harm to self and others

Opioids doOpioids do NOTNOT cause psychologiccause psychologicdependencedependence

Use of opioids for pain managementUse of opioids for pain managementdoesdoes NOTNOT cause addictioncause addiction


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PseudoaddictionPseudoaddictionOccurs in context of

undertreatment of painbehavioral, family, or psychologic dysfunction

Consists of behaviors that are reminiscent ofaddiction but driven by untreated orundertreated pain

Disappears once pain control is adequate

Occurs in context ofOccurs in context of

undertreatment of painundertreatment of painbehavioral, family, or psychologic dysfunctionbehavioral, family, or psychologic dysfunction

Consists of behaviors that are reminiscent ofConsists of behaviors that are reminiscent ofaddiction but driven by untreated oraddiction but driven by untreated or

undertreatedundertreated painpain

Disappears once pain control is adequateDisappears once pain control is adequate


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ToleranceToleranceReduced effects of a given dose of medicationover time

Tolerance to analgesic effects is rare

Doses remain unchanged when pain stimulus

is stable

Tolerance to unwanted side effects is

observed and is desired

Disease progression (not tolerance), should besuspected when increasing doses arerequired for pain control

Reduced effects of a given dose of medicationReduced effects of a given dose of medication

over timeover time

Tolerance to analgesic effects is rareTolerance to analgesic effects is rare

Doses remain unchanged when pain stimulusDoses remain unchanged when pain stimulus

is stableis stable

Tolerance to unwanted side effects isTolerance to unwanted side effects is

observed and is desiredobserved and is desired

Disease progression (not tolerance), should beDisease progression (not tolerance), should be

suspected when increasing doses aresuspected when increasing doses are

required for pain controlrequired for pain control


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Physical Dependence on

Opioids/Withdrawal

Physical Dependence on

Opioids/Withdrawal

Develops if opioids are abruptly discontinued

or dose is rapidly decreased

Results from neuropsychologic changes fromexogenous opioids

Symptoms: Nausea, vomiting, diarrhea,abdominal pain, body aches, psychosis andhallucinations

Treatment: If pain stimulus lessens, reducedose by 50% every 2 to 3 days

Develops if opioids are abruptly discontinuedDevelops if opioids are abruptly discontinued

or dose is rapidly decreasedor dose is rapidly decreasedResults from neuropsychologic changes fromResults from neuropsychologic changes from

exogenousexogenous opioidsopioids

Symptoms:Symptoms: Nausea, vomiting, diarrhea,Nausea, vomiting, diarrhea,abdominal pain, body aches, psychosis andabdominal pain, body aches, psychosis andhallucinationshallucinations

Treatment: If pain stimulus lessens, reduceTreatment: If pain stimulus lessens, reducedose by 50% every 2 to 3 daysdose by 50% every 2 to 3 days


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Rule #3: Adjust the doseappropriatelyRule #3: Adjust the doseappropriately

24 hours later: L.T. still c/o pain

What do you want to know?

How do you adjust the dose?

adjust dose daily

mild / moderate pain 25%50%severe / uncontrolled pain 50%100%

adjust more quickly for severe

uncontrolled pain

24 hours later: L.T. still c/o pain24 hours later: L.T. still c/o pain

What do you want to know?What do you want to know?

How do you adjust the dose?How do you adjust the dose?

adjust dose dailyadjust dose daily

mild / moderate painmild / moderate pain 25%25%50%50%severe / uncontrolled painsevere / uncontrolled pain 50%50%100%100%

adjust more quickly for severeadjust more quickly for severe

uncontrolled painuncontrolled pain


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L.T. next day after doseadjustmentL.T. next day after doseadjustment

Feels great on new regimen

-Morphine IR 15 mg 2 tabs po q 4 hr

Wants to take less pills

How do we switch to long-acting

oral? How do we calculate the

breakthrough dose?

Feels great on new regimenFeels great on new regimen

--Morphine IR 15 mg 2 tabsMorphine IR 15 mg 2 tabs popo q 4 hrq 4 hr

Wants to take less pillsWants to take less pills

How do we switch to longHow do we switch to long--actingacting

oral?oral? How do we calculate theHow do we calculate the

breakthrough dose?breakthrough dose?


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Routine oral dosingextended-release preparationsRoutine oral dosingextended-release preparations

Improve compliance, adherence

Dose q 8, 12, or 24 h (product

specific)dont crush or chew tablets

may flush time-release granules down

feeding tubes

Adjust dose q 24 days (once steady

state reached)

Improve compliance, adherenceImprove compliance, adherence

Dose q 8, 12, or 24 h (productDose q 8, 12, or 24 h (product

specific)specific)dont crush or chew tabletsdont crush or chew tablets

may flush timemay flush time--release granules downrelease granules down

feeding tubesfeeding tubes

Adjust dose q 2Adjust dose q 24 days (once steady4 days (once steady

state reached)state reached)


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Breakthrough dosingBreakthrough dosing

Use immediate-release opioids

10% of 24-h dose or 1/3 of one ER dose

offer after Cmax reached

po / pr q 1 hSC, IM q 30 minIV q 1015 min

Do NOT use extended-releaseopioids for breakthrough

Use immediateUse immediate--release opioidsrelease opioids

10% of 2410% of 24--h dose or 1/3 of one ER doseh dose or 1/3 of one ER dose

offer after Coffer after Cmaxmax reachedreached

po / prpo / pr q 1 hq 1 hSC, IMSC, IM q 30 minq 30 minIVIV q 10q 1015 min15 min

Do NOT use extendedDo NOT use extended--releaserelease

opioidsopioids for breakthroughfor breakthrough


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Clearance concernsClearance concerns Conjugated by liver

90%95% excreted in urine

Dehydration, renal failure, severe

hepatic failure dosing interval (extend time) or dosage sizeif oliguria or anuria

STOP routine dosing of morphine

use ONLY prn

Conjugated by liverConjugated by liver

90%90%95% excreted in urine95% excreted in urine

Dehydration, renal failure, severeDehydration, renal failure, severe

hepatic failurehepatic failure dosing interval (extend time)dosing interval (extend time) oror dosage sizedosage sizeif oliguria or anuriaif oliguria or anuria

STOP routine dosing of morphineSTOP routine dosing of morphine

use ONLY prnuse ONLY prn


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Ongoing assessmentOngoing assessment

Increase analgesics until painrelieved or adverse effectsunacceptable

Be prepared for sudden changes inpain

Driving is safe if

pain controlled, dose stable, no adverseeffects

Increase analgesics until painIncrease analgesics until pain

relieved or adverse effectsrelieved or adverse effects

unacceptableunacceptable

Be prepared for sudden changes inBe prepared for sudden changes in

painpain

Driving is safe ifDriving is safe ifpain controlled, dose stable, no adversepain controlled, dose stable, no adverse

effectseffects


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Methadone, an exceptionMethadone, an exception

Mu, kappa, delta agonist

NMDA receptor antagonist

Inhibits reuptake of serotonin andnorepinephrine

Significant inter-individual variability Drug interactions (coumadin-like)

MuMu, kappa, delta agonist, kappa, delta agonist

NMDA receptor antagonistNMDA receptor antagonist

Inhibits reuptake of serotonin andInhibits reuptake of serotonin andnorepinephrinenorepinephrine

Significant interSignificant inter--individual variabilityindividual variability Drug interactions (Drug interactions (coumadincoumadin--like)like)


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MethadoneMethadone

Initial rapid tissue distribution

Slow elimination phase

Long and variable half-life (13-58hours)

Dose interval is variable (q 6 or q 8 h) Dose usually adjusted q 47 days

Minimally impacted by renal disease

Initial rapid tissue distributionInitial rapid tissue distribution

Slow elimination phaseSlow elimination phase

Long and variable halfLong and variable half--life (13life (13--5858hours)hours)

Dose interval is variable (q 6 or q 8 h)Dose interval is variable (q 6 or q 8 h) Dose usually adjusted q 4Dose usually adjusted q 47 days7 days

Minimally impacted by renal diseaseMinimally impacted by renal disease


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Not recommended . . .Not recommended . . .

Meperidine

poor oral absorption, short half-life

normeperidine is a toxic metabolite

-longer half-life (6 hours), no analgesia

-psychotomimetic adverse effects,myoclonus, seizures

-if dosing q 3 h for analgesia,normeperidine builds up

-accumulates with renal failure

MeperidineMeperidine

poor oral absorption, short halfpoor oral absorption, short half--lifelife

normeperidine is a toxic metabolitenormeperidine is a toxic metabolite

--longer halflonger half--life (6 hours), no analgesialife (6 hours), no analgesia--psychotomimeticpsychotomimetic adverse effects,adverse effects,

myoclonusmyoclonus, seizures, seizures

--if dosing q 3 h for analgesia,if dosing q 3 h for analgesia,normeperidine builds upnormeperidine builds up

--accumulates with renal failureaccumulates with renal failure


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Not recommended . . .Not recommended . . .

Propoxyphene (Darvon)no better than placebo

low efficacy at commercially availabledoses

toxic metabolite (norpropoxyphene) athigh doses

PropoxyphenePropoxyphene ((DarvonDarvon))no better than placebono better than placebo

low efficacy at commercially availablelow efficacy at commercially available

dosesdoses

toxic metabolite (toxic metabolite (norpropoxyphenenorpropoxyphene) at) at

high doseshigh doses


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. . . Not recommended. . . Not recommended

Mixed agonist-antagonistspentazocine, butorphanol, nalbuphine,

dezocine

-compete with agonists withdrawal-analgesic ceiling effect

-high risk of psychotomimetic adverseeffects with pentazocine, butorphanol

Mixed agonistMixed agonist--antagonistsantagonistspentazocine, butorphanol, nalbuphine,pentazocine, butorphanol, nalbuphine,

dezocinedezocine

--compete with agonistscompete with agonists withdrawalwithdrawal--analgesic ceiling effectanalgesic ceiling effect

--high risk of psychotomimetic adversehigh risk of psychotomimetic adverse

effects with pentazocine, butorphanoleffects with pentazocine, butorphanol


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Pain poorly responsiveto opioidsPain poorly responsiveto opioids

If dose escalation adverse effects-more sophisticated therapy to

counteract adverse effect

-alternative

route of administration

opioid (opioid rotation)-coanalgesic

-use a nonpharmacologic approach

If dose escalationIf dose escalation adverse effectsadverse effects--more sophisticated therapy tomore sophisticated therapy to

counteract adverse effectcounteract adverse effect

--alternativealternative

route of administrationroute of administration

opioid (opioid rotation)opioid (opioid rotation)--coanalgesiccoanalgesic

--use ause a nonpharmacologicnonpharmacologic approachapproach


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Bolus effectBolus effect

Swings in plasma concentration-drowsiness 1 hour after ingestion

-pain before next dose due Must move to

-extended-release preparation

-continuous SC, IV infusion

Swings in plasma concentrationSwings in plasma concentration--drowsiness drowsiness 1 hour after ingestion1 hour after ingestion

--pain before next dose duepain before next dose due

Must move toMust move to

--extendedextended--release preparationrelease preparation

--continuous SC, IV infusioncontinuous SC, IV infusion


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Rule #4 Changing routesof administrationRule #4 Changing routesof administration

Equianalgesic tableguide to initial dose selection

Significant first-pass metabolism ofpo / pr doses

codeine, hydromorphone, morphine

po / pr to SC, IV, IM

23 1

Equianalgesic tableEquianalgesic tableguide to initial dose selectionguide to initial dose selection

Significant firstSignificant first--pass metabolism ofpass metabolism ofpo / pr dosespo / pr doses

codeine, hydromorphone, morphinecodeine, hydromorphone, morphine

po / prpo / pr toto SC, IV, IMSC, IV, IM

2233 11


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. . . Changing opioids. . . Changing opioids

Cross-tolerancestart with 50%75% of published

equianalgesic dose

more if pain, less if adverse effects

Methadone

start with 10%25% of publishedequianalgesic dose

CrossCross--tolerancetolerancestart with 50%start with 50%75% of published75% of published

equianalgesic doseequianalgesic dose

more if pain, less if adverse effectsmore if pain, less if adverse effects

MethadoneMethadone

start with 10%start with 10%25% of published25% of publishedequianalgesic doseequianalgesic dose


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MethadoneMethadoneDaily Morphine Methadone:Morphine

1000 mg (1:20)

Gazelle. Methadone for the treatment of pain. J Pall Med.

2003;6(4):620

Daily MorphineDaily Morphine Methadone:MorphineMethadone:Morphine

1000 mg (1:20)(1:20)

Gazelle. Methadone for the treatment of pain.Gazelle. Methadone for the treatment of pain. J Pall Med.J Pall Med.

2003;6(4):6202003;6(4):620


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Back to L.TBack to L.T

Currently taking MSSR 90 mg po q 12 Wants the convenience of the duragesic

patch (Fentanyl)

Adjusting for incomplete cross-tolerance,what dose would you use?

Rule of thumb:

-1 mcg fentanyl patch roughly equals mg po morphine

-OR 25 mcg patch = 60 mg po morphine

Currently taking MSSR 90 mgCurrently taking MSSR 90 mg popo q 12q 12 Wants the convenience of theWants the convenience of the duragesicduragesic

patch (patch (FentanylFentanyl))

Adjusting for incomplete crossAdjusting for incomplete cross--tolerance,tolerance,what dose would you use?what dose would you use?

Rule of thumb:Rule of thumb:

--1 mcg1 mcg fentanylfentanyl patch roughly equals patch roughly equals mgmg popo morphinemorphine

--OR 25 mcg patch = 60 mgOR 25 mcg patch = 60 mg popo morphinemorphine


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Nonpharmacologic painmanagement . . .Nonpharmacologic painmanagement . . .

NeurostimulationTENS, acupuncture

Anesthesiologicnerve block

Surgical

cordotomy

Physical therapy

exercise, heat, cold

NeurostimulationNeurostimulationTENS, acupunctureTENS, acupuncture

AnesthesiologicAnesthesiologicnerve blocknerve block

SurgicalSurgical

cordotomycordotomy

Physical therapyPhysical therapy

exercise, heat, coldexercise, heat, cold


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. . . Nonpharmacologicpain management. . . Nonpharmacologicpain management

Psychological approachescognitive therapies

(relaxation, imagery, hypnosis)

biofeedback

behavior therapy, psychotherapy

Complementary therapiesmassage

art, music, aroma therapy

Psychological approachesPsychological approachescognitive therapiescognitive therapies

(relaxation, imagery, hypnosis)(relaxation, imagery, hypnosis)

biofeedbackbiofeedback

behavior therapy, psychotherapybehavior therapy, psychotherapy

Complementary therapiesComplementary therapiesmassagemassage

art, music, aroma therapyart, music, aroma therapy


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Common pitfalls to avoidCommon pitfalls to avoid

Changing meds/route on discharge

Writing the prescription

Medication cost

Educating patient/family

Appropriate follow-up

Changing meds/route on dischargeChanging meds/route on discharge Writing the prescriptionWriting the prescription

Medication costMedication cost

Educating patient/familyEducating patient/family

Appropriate followAppropriate follow--upup


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Palliative Care ConsultsPager: PALLPalliative Care ConsultsPager: PALL

Age 18 and older Whos appropriate?

-Seriously ill, prolonged hospital stay-Multiple hospitalizations and ICU stays for

same dx

-Difficult pain and other symptom control

-Challenging family dynamics

-Help with clarification of goals of care

Age 18 and olderAge 18 and older Whos appropriate?Whos appropriate?

--Seriously ill, prolonged hospital staySeriously ill, prolonged hospital stay

--Multiple hospitalizations and ICU stays forMultiple hospitalizations and ICU stays for

samesame dxdx

--Difficult pain and other symptom controlDifficult pain and other symptom control

--Challenging family dynamicsChallenging family dynamics

--Help with clarification of goals of careHelp with clarification of goals of care


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8-30-06PainMgmt-Levine