Professional Documents
Culture Documents
Coyne Pain Management
Coyne Pain Management
2001
Therapeutic Procedures
Surgery
Only 50% of post-operative pain is adequately managed Post-operative pain syndromes
Traumatic neuroma
Principles of Assessment
Assess and reassess
Severity of pain?
Date of onset?
Duration?
What aggravates or relieves pain?
Decreased autonomy
Impaired physical and social function
Decreased enjoyment and quality of life Challenges to dignity Threat of increased physical suffering
Neuropathic Pain
Neuropathic pain is pain transmitted over damaged nerves. Patient Description of Neuropathic Pain: Burning, electric, searing, tingling, and migrating or traveling. Causes of Neuropathic Pain: Amputation, shingles (herpes zoster), AIDS (peripheral neuropathy), diabetic neuropathy, fibromyalgia, and cancers that affect the spinal cord, among others.
Westbrook 2005
Opioids
Codeine Fentanyl Hydrocodone Hydormorphone Methadone Morphine Oxycodone Oxymorphone
Generic
morphine
Dose
30 mg q4h
Cost/30 days
$186.84 ($58.75)
Cost/day
$6.23 ($2.00)
Morphine IR
Oramorph SR MS Contin Morphine SR Avinza Kadian Duragesic Oxydose Oxycontin Dilaudid
morphine
morphine morphine morphine Morphine morphine fentanyl oxycodone oxycodone
30 mg q4h
100 mg q12h 100 mg q12h 100 mg q12h 200mg q24h 200 mg q24h 100 mcg q72h 30 mg q4h 80 mg q12h
$147.62
$307.20 $328.20 $293.75 $433.80 $365.00 $482.72 $514.85 $7.32
$4.92*
$10.24 $10.94 $9.79* $14.46 $12.18 $16.06 $10.32* $17.16
309.78($259.97)
Dolophine
methadone
20 mg q8h
$ 30.26
$1.01
($0.51-4.54)
Do not label a patient psychologically dependent, addicted, if you mean physically dependent on / tolerant to opioids
Be alert to psychological side of patient
(APS,2005)
Equianalgesia
Determining equal doses when changing drugs or routes of administration Use of morphine equivalents
Pentaxocine (Talwin)
Codeine
30mg
32mg
Meperidine (Demerol) po
Propoxphene (Darvon)
50mg
65mg
Calculation:
Baseline Pain = Extended release morphine 200 mg/24 hrs Breakthrough - 10-20% = 20-40 mg
Methadone
91-299 mg (1:10)
>300 mg (1:12 or 20)
Properties of Methadone
Well absorbed from all routes of administration
oral rectal subcutaneous IV Sublingual
Over 50% of patients required more than one route of drug administration during the last four weeks of life. N. Coyle 12/90
Co Analgesics
Definition
Agents which enhance analgesic efficacy, have independent analgesic activity for specific types of pain, and / or relieve concurrent symptoms which exacerbate pain
Analeptics
Benzodiazepines Antispasmodics
Anticonvulsants
Corticosteroids
Muscle relaxants
Systemic local anesthetics
Neuroleptics
Antihistamines
Toxicities
Dizziness, nausea, tremor, nervousness, incoordination, headaches, paresthesias
Drugs
Lidocaine, mexiletine
Local Anesthetics
Lidocaine Infusion
More effective in neuropathic pain but can be used for all pain syndromes. Starting dose 0.5mg-2 mg/kg per hr IV or SC. Some studies demonstrate longlasting pain relief even after drug has been stopped. Need to decrease opioids when starting. (Ferrini,Paice, 2004)
Tricyclic antidepressants
nortriptaline (1st choice)
Anticonvulsants
Gabapentin, Carbamazepine, Pregaba
Local anesthetics
Parenteral, oral, topical
Ketamine
N-methyl-D-aspartate receptor antagonist (NMDA) Used as an anesthetic for years
Case reports show effectiveness when traditional and invasive techniques fail
Starting IV dose 150mg qd (0.1-0.2mg/kg) with reduction of opioid achieved or 10-15 mg q6 increasing by 10 mg dose each day Appears to have a synergistic effect with opioids
Opioid Delivery
Pain persisting or increasing Step 3 Opioid for moderate to severe pain Nonopioid Adjuvant Pain persisting or increasing
Step 2 Opioid for mild to moderate pain Nonopioid Adjuvant Pain persisting or increasing Step 1 Nonopioid Adjuvant
Pain
Deer, et al., 1999
Methadone
Sedation Spinal cord stimulator
Q&A