Pain Management: Acute and
Chronic
Rita Volochayev, FNP-C
Course Objectives
Upon completion of this presentation participants should be able
to:
Discuss the definition of pain, its prevalence
describe the pharmacology of opioids useful in the management
of acute and chronic pain
describe the pharmacological management of opioids used for
treating acute and chronic pain
Understand the 3-Step WHO guidelines
Prescribe proper doses of opioids and adjuvants
Anticipate and treat potential side effects
identify the indications for a referral or consultation with a pain
specialist.
discuss the role of the various health care professionals in the
management of pain
Pain Facts
76.5 million Americans affected (26%)
Annual cost to society 100 billion/year
Low back pain-27%
Migraine or severe headache- 15%
Neck pain- 15%
Pain is the most common complaint in
primary care offices
Uncontrolled pain = decreased quality of life
and increased morbidity
Pain foundation website, 2007
Pain Management Barriers
It is often under-reported
Fear of addiction
Physician misinformation
Fear of respiratory depression with use of
opioids
Fear of patient addiction
Fear of legal implications
Pain Management Goals
Treat acute pain aggressively and
prevent chronic pain
Identify and address the cause of pain
Treat chronic pain continuously
Improving function and sustaining
quality of life
Treat noninvasively as much as possible
Acute vs Chronic Pain
Pain is an unpleasant feeling that is conveyed to the
brain by sensory neurons as result of injury, disease,
or emotional disorder.
Acute Pain
Less than 6 months duration
Cause is usually known
Disappears when the injury heals
Chronic Pain
More than 6 months duration
Persists after injury heals
Cause may or may not be known
International Association for the study of pain website, 2007
Types of Pain
Neuropathic (burning, tingling, pins and
needles sensation)
Psychogenic
Idiopathic
Nociceptive (Bone, Muscle, Visceral)tissue damage/injury, localized
Pain Assessment
Comprehensive H&P
Assess pain for duration, intensity,
location, aggravating and relieving factors,
prior meds used, family or personal history
of drug or alcohol abuse-very important,
patients goal for pain control.
Labs- CBC, CMP, ESR, B12, Folate,
HgbA1C, FBS, Rheumatoid factor
Diagnostics (MRI, EMG, CT,X-ray)
Pain Assessment Tools
Visual Analog Scale (VAS)
Numerical Scale
Pain Faces Scale
Verbal Pain Intensity Scale
Categorical Scale
NCCN website, 2007
Non-Pharmacological Pain
Management
Transcutaneous Nerve Stimulation (TENS)
Cognitive and behavioral therapy
Heat and Cold
Physical and occupation therapy
Rehabilitation
Progressive Muscle Relaxation
Psychotherapy
Complimentary Medicine (massage, Accupuncture
and Accupressure)
Exercise therapy
Lifestyle changes
Pain ManagementInterventional
Kyphoplasty/Vertebroplasty (with vertebral fractures)
Epidural and caudal steroid injections (neck, back pain)
Nerve root blocks and transforaminal injections (neck, back pain,
migraines)
Peripheral nerve injections (migraines, trigeminal neuralgia, shingles
pain, localized pain, postsurgical incisional pain, post surgical
neuropathic pain, localized neuropathic pain, muscle spasms)
Disks and Discography (diagnostic, to find out where pain is
originating)
Radio-frequency lesioning (Rhizotomy)(neck, back pain)
Spinal cord simulation (neck, back, arm, leg pain, or migraines)
Spinal infusion/Spinal pumps (chronic pain)
Sympathetic blocks (SRPS syndrome, shingles pain)
Neurolytics of celiac plexus and cancer pain (abdominal pain)
Surgery
Pharmacological Management
of Pain
WHO Pain Treatment Ladder
Mild Pain
Moderate to Moderately Severe Pain
Non-opioid Analgesics
Adjuvant Agents (optional)
Weak opioid+ Non-opioid
Adjuvant Agents (optional)
Severe Pain
Strong Opioid + Non-opioid
Adjuvant Agents (optional)
Treatment of Mild PainNSAIDs
NSAIDs- Cox-2 inhibitors (Celebrex), Mobic, Naproxen, Relafen,
Elector (Diclofenac) patch 1.3%, Diclofenac topical (Voltaren
Gel) 1% , Solaraze 3% gel (Diclofenac)
Inhibit pain sensitivity caused by Cox-2 peripherally at site of
injury and centrally at spinal cord.
Do not block transmission of pain
Ceiling affect- increase in dose does not increase analgesia but
increases side effects.
Risks- GI toxicity (bleeding), renal toxicity (with dehydration),
cardiovascular risks
The last resort for people with cardiovascular disease- AHA
recommendation
Treatment of Mild PainNSAIDs cont.
Ketorolac (Toradol) 30mg IV q6h prn pain not to exceed total 5
days- use only for moderate to severe pain
Voltaren Gel 1% (Diclofenac)
UE 2 g qid; Max 32g/day; Total 8g/joint/day
LE 4 g qid; Max 32g/day; Total 16g/join/day
Mobic 7.5 (qd or bid), 15mg mg qd. Not GI protective as
Celebrex, but good choice if patient does not tolerate Celebrex.
Relafen- harder on GI, good for acute pain for short term use
Solaraze 3% gel (Diclofenac) tid prn
Elector patch 1.3% bid
Mild Pain ManagementAcetaminophen (Tylenol)
Centrally acting increases pain threshold
Full mechanism of action not known
Well-tolerated
Minimal anti-inflammatory effects
Fewer GI side effects than NSAIDS
Risks- hepatotoxicity at high doses. Caution using
with meds that increases P450 system activity
(phenytoin, carbamazepine, rifampin, isoniazid,
phenobarbital, barbiturates). Caution with alcohol
use.
Patients not to exceed 3 grams/day (for chronic pain)
Adjuvants
Lidoderm patch (Lidocaine 5%)
Capsaicin cream 0.025% or 0.075%
Indicated for peripheral neuropathy
1-3 patches once daily for 12 hours
Well tolerated
Tid/qid prn
Muscle relaxants- Flexeril, Skelaxin, Baclofen, Robaxin, Soma
Sedation main concern
Bid, tid, qid dosing
Robaxin least sedating, followed by Skelaxin and Flexeril
Baclofen most effective but most side effects, start at slow doses
Soma very potent but can be addictive, give only short-term,
unless all others failed
Adjuvants cont.
Anticonvulsants- Neurontin, Lyrica,
Carbamazepine- for neuropathic component
of pain or as adjuvants to pain medications
Neurontin- cheaper, tid/qid dosing, high dose
titration, increased s/e, longer titration time.
Lyrica,expensive, newer, fast titration, bid/tid
dosing, less s/e.
Carbamazepine- excellent medication for
trigeminal neuralgia
Sedation and dizziness- the main concern these
medications resolves over time.
Start at bedtime to deal with side effects
Adjuvants cont.
Antidepressants-Tricyclics, MAOIs, Serotonin
Reuptake Inhibitors (Cymbalta).
Elavil- for depression,neuropathic component of
pain and for insomnia. Do NOT give to patients
with heart disease or emotionally
unstable/suicidal. Check EKG prior ordering this
drug. Can change cardiac conduction.
Cymbalta works well for neuropathic component
of pain and depression.
Sedation is side effect for these medications
Moderate to Severe PainOpioids
Morphine Sulfate (Moprhine, MSIR, MSContin,
Roxanol, Kadian, Avinza) IR/ER
Oxycodone (Oxycontin, OxyIR) IR/ER
Oxymorphone (Opana) IR/ER
Fentanil (Duragesic) (IR/ER)
Methadone
Tramadol (Ultram, Ultracet) IR/ER
Hydromorphone (Dilaudid) IR
Hydrocodone/Acetaminophen (Vicodin, Lorset,
Lortab, Norco) IR
Percocet (Oxycodone/Acetaminophen) IR
Moderate to Severe PainOpioids cont.
Morphine Sulfate IR/SR
Metaboline (morphine 3-glucuronide)
Adverse events - seizures, myoclonus, pruritis, risk increased with low
GFR
Avoid in renal failure
SR- MS Contin, Kadian, Avinza
IR- MSIR, Roxanol, Morphine
MS Contin bid dosing can be given tid, about 30% immediate release component,
not good choice for patients with history of drug abuse.
Kadian qd or bid dosing can be given through NG tube, no immediate release
component better choice for patients with personal or family history of drug
abuse
Avinza qd dosing can be given bid (but devide qd dose into bid dosing), about
10% releases immediately, good choice for patients with personal or family
history of drug abuse to be given once a day.
Roxanol is liquid form given to those who have difficulty taking pills (used in
hospice frequently)
MSIR starts at 15 mg do not give to opioid nave patients
Moderate to Severe PainOpioids cont.
Methadone- tid/qid dosing
NMDA antagonist, inhibits serotonin and norepinephrine, works well for neuropathic
component of pain
Cheap
Very dangerous if patient is noncooperative, can result in death.
36-72 hours half-life, sedation occurs day 2 or3 taking medication main s/e.
Adverse events: sedation, dizziness, n/v, urinary retention, QT prolongation and multiple medication
interactions with other meds (SSIRs, quinolones, Lyrica, TCAs, Rifampin, Phenytoin, Phenobarbital,
some CCBs, macrolides, anteretrovirals, antifungals and others)
NOT a prn drug. Dosing tid/qid, effects last between 4-8 hours, onset within 30 minutes.
Quick dosing can result in death. Dosing start slow 2.5 mg bid/tid elderly, and 5 mg bid/tid adults
then titrate every 4-7 days by 30-50%, watch patient reaction, sedation. See patient weekly for
evaluation. Have office call a patient on days 2 and 3 and inquire regarding s/e.
Available in po, liquid and IV form.
IV form does not have 36-72 hour half-life, sedation effects are immediate. Potent drug for pain
management.
Methadone gtt excellent for managing severe chronic pain, especially cancer pain can be managed
within 24 hours and patient discharged to home.
80% oral biovailability
Lipophillil
Excretion mostly fecal therefore advantageous to use in renal failure
Moderate to Severe PainOpioids cont.
Fentanyl IR/SR- parenteral, trandermal, transmucosal, spinal, nebulized
Lipophillic, high 1st pass effect, low oral bioavailability,
SR-Duragesic, transdermal patch q3day dosing
excellent choice for patients with memory problems
Excellent choice for patients with history of drug abuse
Less side effects than pills
Not a good choice if patient is active in sports, fever, obese due to altered
absorption
IR- Fentora, and Actiq, transmucosal/buccal
For breakthrough cancer pain
No more than 4 doses a day. May redose in 30 minutes.
200-400mcg Actiq=100mcg Fentora
Onset of action within 15 minutes
NEVER give to opiod naive patients, respiratory depression is a concern.
Actiq comes in lollipop form, suck between cheek and lower gum. Be very careful
giving it to patients who have pets or children around. Start with 200 mcg/unit
Fentora comes in tablet form. Place the tablet above rear molar between upper
cheek and gum and allow to dissolve. Do not chew, suck or swallow. Start with
100mcg.
Moderate to Severe PainOpioids cont.
Oxycodone IR/SR
SR- OxyContin bid/tid dosing
Renally safer than Morphine
About 37% is in immediate release form
Not a good medication for people with history of substance or drug
abuse.
Can be given to opioid naive patients in severe pain (start at 10 mg
bid)
Most sought after drug by drug abusers and on the market
Literature says it has the same potential for addiction as other longacting pain medications- I tend to disagree based on my professional
experiences.
IR-OxyIR
I usually give this drug if a patient is allergic to hydrocodone, failed
hydrocodone, or cannot take tylenol (liver disease) in Percoset.
Moderate to Severe PainOpioids cont.
Opana (Oxymorphone HCI) IR/SR, bid dosing
Long half-life (9-11h)
Extended release (5, 10, 20,40mg)
Opana IR (5, 10mg)
NOT to be given to opioid naive patients.
Not to be given if allergic to codeine (metabolite of oxycodone)
Respiratory depression is a risk
Strenth 2x oxycodone, 3x morphine
Must take 1 hour prior or after meals (can increase blood levels
dangerously)
Structurally related to hydromorphone (Dilaudid)
Injectable form Numorphan/Opana inj (10mg/ml)
Moderate to Severe PainOpioids cont.
Hydromorphone (Dilaudid)- IR.
Synthetic opioid
Metabolite hydromorphone 3-glucuronide- same
adverse events as Morphine but much more
potent.
Caution with renal failure
Hydrocodone (Vicodin, Lorcet, Lortab,
Norco)-IR
Acetaminophen/Oxycodone (Percocet)- IR
Moderate to Severe PainOpioids cont.
Meperidine (Demerol)- IR, use no more than 2-3 days, short
half-life (2.5-3.5hours)
neurotoxic metabolite formation can cause seizures with impaired
renal function.
Tramadol (Ultram)- IR/SR, combination with acetaminophen
(Ultracet), as potent as codeine
Mu-receptor agonist
Blocks reuptake of serotonin and norepinephrine
Caution with SSRIs or SNRIs risk of serotonin syndrome.
Adverse effects- somnolense, dizziness, seizures, HTN.
Ultram ER qd dosing 100, 200, 300
Ultram/Tramadol IR 50mg 1-2 po tid/qid prn (Can order Tylenol 325500 mg with each dose if patient cannot afford Ultracet or if not on
formulary)
Ultracet 1-2 po tid/qid prn- more expensive than Tramadol
Moderate to Severe PainOpioids cont.
IONSYS. Patient controlled transdermal
system- new medication on the market
Credit card size with 80 doses of fentanyl
Pre-programmed and disposable
Can be used for acute pain
Battery charged system when used pushes
pre-programmed amount into dermis
Placed on upper outer area of chest where
patient can reach the button
Leave in place for 24 hours
Managing Moderate to Severe
Pain
Give baseline medications round the clock
Give 10% of total daily dose prn
If taking more than 2 doses of prns/24h then
increase baseline by total of prns
Opioid naive patients stabilize pain with short-acting
medications first
usual starting dose in special populations
Elderly 65 years or older
Patients with hepatic or renal disease
Opioid Conversion
Calculate equianalgesic doses
Reduce the dose by 30-50%
Opioids- Potential Risks
Nausea, vomiting, stomach upset
Respiratory depression
Constipation
Dizziness, delirium, amnesia
Itching, hives
Addiction, dependence, tolerance
Hyperalgesia- pain out of proportion
Managing Opioid Risks
Most side effects resolve with continued use of medications
except constipation.
Treat constipation with laxatives, stool softeners (Colace,
Pericolace, Miralax, Senocot, Senocot S), encourage patient to
drink fluids and eat fiber reach foods
Somnolence treat with stimulants (Provigil, Ritalin)
Pruritis treat with antihistamines
Respiratory depression- titrate medications slowly by 20-30%, in
elderly (65 years or older) by 15-20%. Start low, go slow.
Narcan is the last resort only.
Treat nausea, vomiting with nausea medications (Reglan,
Zofran, Phenergan).
Opioids
Opioids can relieve moderate to severe pain
No ceiling effect
For continuous pain use long-acting meds
For breakthrough pain use short-acting meds
If taking meds 10 days or longer on regular
bases withdrawal symptoms may occur, wean
off meds slowly.
Preventing and Managing
Withdrawals
Withdrawal results in hypertension, nausea, vomiting,
body aches, diarrhea, anxiety, tremors, tachycardia,
diaphoresis, abdominal pain.
Preventing-Taper off meds slowly by 50% first 2-4
days, then by 20-30% every 2-4 days.
Managing Dr. Hilliards RX
Clonidine (Catapres) 1 patch x7days #1
Librium 10 mg 1 po tid prn #21 or Klonopin 1 mg tid prn
#21
Equianalgesic Dose Table
Morphine is used as a gold standard in opioid
conversion
Morphine 1 mg IV = 3 mg PO
Dilaudid IV 20 times stronger than IV Morphine and
PO 4-7 times stronger than PO Morphine
Oxycodone PO 1.5 times stronger than PO Morpine
Fentanyl patch 100 times stronger than Morphine
1 mg IV MSO4=10mcg IV Fentanyl=50mcg Actiq
Intrathecal dose is 100 times stronger than IV dose
Oxycontin 20 mg PO = Dilaudid 7.5 mg.
Equianalgesic Dose
Conversion
Formula
Examples
Converting Oxycontin to MS Contin
Patient is taking 60 mg bid MSContin. Total 24 hour dose = 120mg. Oxycontin is 1.5
times stronger than MSContin. 120mg x1.5 = 180mg Morphine/24 hours. 180 divided
by 2 =90 mg bid dosing
Converting MSContin to IV Dilaudid
current 24h dose divided by equivalent dose= new 24h dose divided by number of
times drug to be given per day (bid, tid, qid) = new individual drug dose.
Patient is taking 60 mg MSContin/24h. 60mg divided by 3 (po MSO4 3 mg =1 mg IV)
= 20 mg IV Morphine x 0. 15 (dilaudid equanalgesic dose) = 3mg/day Dilaudid. 3mg
divided by 24 hours = 0.125mg basal rate dilaudid for PCA for continuos background
long-acting med in addition to prn PCA Dilaudid.
Converting MSContin PO to IV
Patient is taking MSContin 60 mg bid. 60mg x2=120mg/24h. 120mg divided by 3 (3mg
po Morphine=1 mg IV Morphine)= 40mg IV Morphine/24h. Morphine IV is given every
hour. 40mg divided by 24h = 1.66mg/h can be given as basal rate to PCA in addition
to PCA prn.
Drug Dependency vs Addiction
vs Pseudo-addiction
Physical Dependence
Physiological Problem
Addiction
Psychological Problem
Behavior Pattern of Drug Abuse
Hoarding medications
Seeking prescriptions from multiple providers
Requesting more medications
Pseudo-addiction
Due to undertreatment of pain
Mimics addiction behavior
Resolves once pain is treated
Preventing Drug Abuse
Written consents/treatment agreements with patients
Teach patients on how to dispose unused medications or
request patients to bring unused medications and dispose them
in your office
Have guidelines in place on preventing diversion of prescribed
medications
Urine screening
Regular visits and pill counts during those visits
Know which pharmacy your patient uses to obtain medications
Use patient risk assessment tools (CAGE, ORT, SOAPP)
Use multidisciplinary approach- refer patients to other members
of health care team- pain management specialist,
addictionologist, OT/PT, Rehab, alternative treatment
specialists.
Pain Management- Legal
Aspects
DEA and licensing board scrutiny are a result of poor
documentation
Document, document, document- very important
Must cover 5 areas when documenting
H&P
Informed consent and treatment agreement
Treatment plan
Reassess patient on regular bases
Consultation and referrals when needed ( pain management
specialist, Rehab/physiatrist, OT/PT, addictionologist,
psychologist, psychiatrist, alternative medicine etc).
Pearls
NEVER give long-acting opioids to opioid naive patients except
Oxycontin 10 mg bid if patient is in severe pain and is poorly
managed with PRN meds.
Always start low and go slow
When converting from one opioid to another always decrease
dose by 25-50%
When giving Narcan, dilute it with 10 cc NS and give it at 2 cc
increments/min- will prevent rebound pain
If patient has preference or insists on certain opioid that is a red
flag (addiction maybe an issue).
Any suspicion of drug abuse refer to psychologist for evaluation
for drug abuse, if report confirms drug abuse refer to
addictionologist
Document, document, and document- very important
Pearls cont.
Patients with addiction are treated the same way as non-addicted
patients, but they must see addictionologist, if history of alcohol abuse,
must attend AAA meetings (must provide phone number for a group
leader) monthly visits for f/u, and closer monitoring, avoid short-acting
drugs and drugs with immediate release component (OxyContin,
MSContin), Kadian, Avinza and Methadone are better choices
Use combination of non-pharmacological modalities along with
pharmacological modalities in treating pain
Random urine drug screen at least twice a year-never let a patient
know when it is going to occur. If patient states cannot give urine, then
insist on serum drug screen
Hold prescription until patient provides specimen for drug screen
When titrating medications always start or add dose at bedtime first,
that way if they have s/e they will sleep through them
Pain Management
Questions?
Pain Management
THANK YOU!
