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Improving Quality of Life Through Effective Pain and Symptom Management The Consortium for Advancements in Health & Human Services, Inc. Educational Program Development Team: BC Farnham, MSW, MBA; Debbie Favel, RN, MSN, CHPN; Dr. Denise Green; Sheryl Matney, MS; Jenny Gilley Carpenter, LPN. ; Karina Lemos, RN. ; Elizabeth R. Pugh, LBSW. This program is made possible through a collaborative community-education partnership between The Consortium for Advancements in Health & Human Services, Inc. and the presenting agency. The primary goal of this effort is to increase public awareness and access to hospice care, through the provision of community-based education. Contact Hours are awarded to professionals who complete this program by The Consortium for Advancements in Health & Human Services, Inc. © 2011 The Consortium for Advancements in Health & Human Services, Inc.
Important Information This education program for healthcare professionals was developed by The Consortium for Advancements in Health and Human Services, Inc. (CAHHS) and is facilitated by the presenting agency via a community education partnership agreement. CAHHS is a private corporation and is solely responsible for the development, implementation and evaluation of its educational programs. There is no fee associated with receiving contact hours for participating in this program titled, Improving Quality of Life Through Effective Pain and Symptom Management. However, participants wishing to receive contact hours must offer a signature on the sign-in sheet, attend the entire program and complete a program evaluation form. The Consortium for Advancements in Health and Human Services, Inc. is an approved provider of continuing nursing education by the Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. The Consortium for Advancements in Health & Human Services, Inc. , is approved as a provider of c ontinuing education in Social Work by the Alabama Board of Social Work Examiners, #0356, Expiration Date: 10/31/2014. In most states, boards providing oversight for nursing and social work recognize contact hours awarded by organizations who are approved by another state's board as a provider of continuing education. If you have questions about acceptance of contact hours awarded by our organization, please contact your specific state board to determine its requirements. Provider status will be listed on your certificate. CAHHS does not offer free replacement certificates to participants. In the event that CAHHS elects to provide a replacement certificate, there will be a $20. 00 administrative fee charged to the individual who requests it.
Learning Objectives The attendee will be able to: ◦ Assess patient pain and differentiate between types of pain. ◦ Identify appropriate medications for treatment of pain. ◦ Utilize equianalgesic table for titration of opioids.
PAIN – Why Discuss It? “Pain is a more terrible lord of mankind than even death itself. ” - Albert Schweitzer
Pain Defined Pain is “whatever the experiencing person says it is, existing whenever s/he says it does”. (Mc. Caffery, 1968)
PAIN DEFINED Unpleasant Somato-Psychic Experience No Fun It originates in the body (most of the time) It affects the mind It is what the patient says it is
Barriers to Effective Pain Management Problems related to ◦ Healthcare professionals ◦ Patients ◦ The health care system
Pain Myths Behavioral signs of pain is more reliable than self-report. Pain teaches a person to be more tolerant of pain. Non-cancer pain is not as severe as cancer pain. Use of opioids for pain causes addiction. Infants have decreased pain sensation.
Opioids = Addiction? Tolerance Physical Dependence Addiction Pseudo-addiction
Opioid Facts Patients in pain do not get addicted May develop tolerance
Pain Management Partnership Professional, Patient and Family Team Assess pain and associated symptoms regularly and systematically. Asking patient to identify most troublesome symptom. Believe patient and family reports of pain and what relieves the pain.
Pain Management Partnership Choose pain-control appropriate for the patient, family and setting. Deliver interventions in a timely, logical, coordinated fashion. Empower patients and families. Develop effective plan of care
PAIN CYCLE Pain Decreased Tolerance of Pain Anxiety Sleeplessness Increased Anxiety Feelings of Hopelessness Decreased Appetite Decreased Mobility Hopelessness Decreased Psychological Functioning Despair Loneliness
Principles of Pain Assessment JCAHO: Right to appropriate assessment and management of pain. Self-report of pain is the single most reliable indicator of pain. Use pain scales appropriate to patient population. Chronic pain patient maybe more sensitive to pain Unrelieved pain has adverse physical and psychological consequences
ASSESSMENT OF PAIN ACUTE PAIN – “complex, unpleasant experience with emotional and cognitive, as well as sensory, features that occur in response to tissue trauma. ” Elevated pulse, blood pressure and respirations, diaphoresis, dilated pupils, moaning, crying, rubbing
Assessment of Pain CHRONIC PAIN –a persistent pain that “disrupts sleep and normal living, ceases to serve a protective function, and instead degrades health and functional capability. ” After more than 4 months, adaptive mechanisms, no measurable indications of pain
TYPES OF PAIN Somatic – ◦ Pain in the muscles, bones, ligaments or joints ◦ Described as aching, gnawing, constant and localized ◦ Examples: Bone metastasis, surgical pain ◦ Responds to opioids, but may require adjuvant medications such as anti-inflammatories or muscle relaxers
TYPES OF PAIN Visceral – ◦ Pain in smooth muscles and organs ◦ Caused by infiltration, compression, distention, or the stretching of tissue ◦ Described as aching, constant, not localized, may radiate to other areas ◦ Examples: Pancreatic cancer, liver metastasis ◦ Responds to opioids, but may require corticosteroid or anti-spasmodic adjuvant therapy.
TYPES OF PAIN Neuropathic – ◦ Painful nervous system discharges ◦ Caused by inflammation, damage or pressure around a nerve ◦ Described as burning, aching, shooting, shocklike ◦ Examples: Peripheral neuropathy, spinal cord compression ◦ Responds poorly to opioids alone, but opioids may be used with an anti-depressant, anticonvulsant, anti-arrhythmic or other adjuvant
Tools for Assessment of Pain Site – Where is your pain? Character – What does it feel like? Onset – When did it start? Duration – How long does it last? Frequency – How often does it occur Intensity – ◦ What is the worst your pain gets? ◦ What is the rate of your pain one hour after taking your pain medication?
Tools for Assessment of Pain Exacerbation – What makes the pain worse? Associated symptoms – Does your pain cause you to have nausea, fatigue, dyspnea or weakness? Alleviation – What helps relieve your pain? Effect on quality of life – Does your pain cause you to have anxiety, fear, depression or spiritual stress? What does the pain keep you from doing?
Tool For Assessment of Pain
PHYSICAL EXAMINATION Non verbal cues Examine sites of pain Palpation Auscultation, percussion Neuro exam
REASSESS Changes in pain Assess pain relief Make pain visible
PATIENTS AT RISK FOR UNDERTREATMENT Children and elderly Cognitively impaired Patients who deny pain Non English speaking Different cultures History of substance abuse
COMMUNICATING ASSESSMENT FINDINGS Communication improves pain management Describe intensity, limitations, and response to treatments
Principles Regarding Use of Analgesics WHO 3 Step Analgesic Ladder STEP 3, severe pain STEP 2, moderate pain STEP 1, mild pain Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone + Nonopioid analgesics Acet or ASA + Codeine Hydrocodone Oxycodone Dihydracodeine Tramadol (not available with ASA or Acet) + Adjuvants Aspirin (ASA) Acetaminophen (Acet) Nonsteroidal anti-inflammatory drugs (NSAIDS) + Adjuvants
NON-OPIOIDS/NON-STEROIDAL ANTI-INFLAMMATORIES Acetaminophen (Tylenol) ◦ ◦ ◦ Toxicity Maximum Mild pain, 4, 000 mg qd short term 3, 200 mg qd long term 2, 400 mg qd in elderly or debilitated poor anti-inflammatory capacity
ACETAMINOPHEN Extra Strength Tylenol Darvocet N 100 Vicodin ES Lortab 2. 5, 5, 7. 5 Lorcet Plus 7. 5 Percocet 5 500 mg 650 mg 750 mg 500 mg 650 mg 325 mg 8 6 5 8 6 12
NON-STEROIDAL ANTIINFLAMMATORIES Risk of GI Ulcer decreases 15% after 3 months continuous care For long term use, protect with misosprostol (Cytotec), omeprazole (Prilosec), lansoprosole (Prevacid) or pantoprazole (Protonix) OR Use Cox-2 inhibitor celecoxib (Celebrex) or rofecoxib (Vioxx) meloxicam (Mobic)
WEAK OPIOID/NON-OPIOID COMBINATIONS Hydrocodone and Oxycodone combination products (Lortab, Tylox, Percocet, Vicoprofen, Percodan) All have ceilings due to acetaminophen, aspirin or ibuprofen content Considerations: skip this step and add acetaminophen, aspirin or ibuprofen separately
STRONG OPIOIDS Short-acting BEST CHOICE- ◦ Morphine, oxycodone, hydromorphone (Dilaudid) ◦ No ceiling ◦ Morphine and oxycodone come in tablet, liquid, concentrate and suppository form
Morphine: Pharmacokinetics/Pharmacodynamics Morphine Formulation Half-life (t ½ ) Typical Dosing Analgesia Immediate release (IR) 2 -3. 5, q 4 h Onset: 0. 5 -1 h Peak: 1. 5 -2 h Duration: 3 -5 h Sustained-release (SR) 2 -4* q 12 h Onset: 1. 5 h Peak: ~ 4 h Duration: 8 -12 h *Terminal elimination half-life for morphine SR
SHORT ACTING STRONG OPIOIDS Used for occasional moderate to severe pain Used PRN to determine long acting dose (add amount needed in 24 hrs, divide by 2, give q 12) Initially uses 80 mg Oxylr in 24 hrs, Oxtcontin 40 mg q 12 hrs with 10 mg Oxylr q 4 hrs for breakthrough pain Current Oxycontin dose 40 mg q 12 hrs, Used 40 mg Oxylr in last 24 hrs. New Dose- Oxycontin 60 mg q 12 hrs. New breakthrough dose- Oxylr 15 -20 mg q 4 hrs. Used to control pain that breaks through longacting dose (dose should be 1/3 -1/4 12 hr dose)
BREAKING THE PAIN CYCLE SEDATION ANALGESIA PAIN 1 2 3 4 5 6 7 8 9 10 11 12
LONG ACTING STRONG OPIOIDS ONLY TO BE USED FOR CONTINUOUS PAIN, NEVER GIVEN PRN ◦ M. S. Contin, Oxy. Contin, Oramorph SR 12 hour relief Cannot be crushed or cut ◦ Kadian 24 hour relief Time-released sprinkles
LONG ACTING STRONG OPIOIDS Duragesic (fentanyl patch) Lasts 72 hours Takes up to 24 hours to peak Must have subcutaneous tissue to absorb Fevers cause rapid absorption Cost prohibitive Slow and careful titration necessary
DOSE ESCALATION By percentage After peak effect Morphine resistant pain versus psychological component
ROUTES OF ADMINISTRATION Oral Mucosal Rectal Transdermal Topical Parenteral ◦ Intravenous ◦ Subcutaneous ◦ Intramuscular
EQUIANALGESIA Determining equal doses when changing drugs or routes of administration Use of morphine equivalents
EQUIANALGESIC DOSES OF OPIOIDS DRUG Morphine Codeine recommended) Fentanyl Hydrocodone Hydromorphone Levorphanol Methadone Oxycodone PARENTERAL ROUTE 10 mg 130 mg *see below not available 1. 5 mg 2 mg acute 1 mg chronic 10 mg acute 2 -4 mg chronic not available ENTERAL ROUTE 30 mg 200 mg (not OTFC available 30 mg 7. 5 mg 4 mg acute 1 mg chronic 20 mg acute 2 -4 mg chronic 20 -30 mg Fentanyl 100 mcg patch = 200 mg oral morphine/24 hrs = 4 mg IV morphine/hour. To convert from Fentanyl 100 mcg/hour patch to IV Fentanyl, begin at 100 mcg/hour IV and titrate as needed
OPIOID SIDE EFFECTS Sedation, light-headaches, nausea, vomiting, itching, dry mouth, urinary retention, constipation and respiratory depression Most side effects diminish 3 days after opioid started or increased Minimal side effects noted if dose is correct Bowel protocol should be initiated at the beginning of opioid therapy
BOWEL PROTOCOL Mild vegetable laxative and softener routinely (Senekot S) Stronger laxative if no BM by the end of the 2 nd day (Senekot Xtra) Increase as needed to achieve soft, form BM q 2 -3 days
OPIOID ADVERSE EFFECTS Nausea and Vomiting ◦ Use an anti-emetic prophylactically in patient who: Currently has nausea and vomiting Has nausea and vomiting from a weak opioid Experienced nausea and vomiting in past with strong opioid ◦ Always rule out obstruction ◦ Haldol, Reglan, vestibular
SEDATION Catch up on sleep Other medications Other medical problems
DELIRIUM If opioid is at steady state, then think of other causes: ◦ ◦ Dehydration Infections CNS event Other medications
REPIRATORY DEPRESSION A change in rate or depth Sedation precedes respiratory depression Level 3 – drifts off to sleep during conversation
PRURITIS Immediate hypersensitivity
OPIOID ADVERSE EFFECTS In general, all strong opioids have similar side effects ◦ Strategies: Different route Different opioid Decrease dose, increase frequency Add a second drug
ADJUVANT DRUGS Adjuvant medication are not analgesics, but have properties that either assist in blocking pain impulses or potentiates the effects of analgesics.
TRICYCLIC ANTIDEPRESSANTS Prevent re-uptake of serontonin and norepinephrine – block neuropathic pain Amitryptyline (Elavil)S, doxepin (Sinequan)S, desipramine (Norpramin) Start with small dose, titrate to ½ therapeutic dose for depression SSRI’s have less effect on neuropathic pain but may be somewhat effective. (Effexor)
ANTICONVULSANTS Block nerve impulses by limiting sodium ions Carbamapezine (Tegretol) 200 -1600 mg qd Phenytoin (Dilantin) 300 -600 mg qd Gabapentin (Neurontin) up to 3200 mg qd
OTHER ADJUVANTS Clonidine (Catapres) 0. 1 mg qd-tid Decadron 4 mg qd-tid or 100 mg IM x 1 Donnatal 1 -2 tabs bid-tid (GI spasms) Baclofen (Lioresal) up to 80 mg qd Lorazepam (Ativan) 4 -6 mg qd Hydroxyzine (Vistaril) 25 -50 mg tid Promethazine (Phenergan) 25 -50 mg q 4 prn Dextromethorphan up to 1000 mg qd Ketamine 2% ointment tid
ADJUVANT PRINCIPLES Choose the adjuvant that will benefit the patient’s other symptoms as well as the pain For severe pain use, use an adjuvant out of several different categories Remember that often using adjuvant therapy provides improved pain relief with smaller doses of opioids and fewer side effects
ADDICTION Addiction – Psychological craving for the drug’s psychic effect Dependence – Natural physical response to continue use of an opioid Tolerance – The body’s legitimate need for larger doses of an opioid to produce the same effect during an extended period of use Pseudo-addiction – drug seeking behavior caused by poor pain management
Pain relief is contingent on adequate assessment and use of both drug and nondrug therapies Pain extends beyond physical causes to either causes of suffering and existential distress Interdisciplinary care
EFFECTS OF PAIN ON QUALITY OF LIFE Physical – ◦ ◦ Decreased functional capability Diminished endurance and strength Nausea, poor appetite Poor or interrupted sleep
EFFECTS OF PAIN ON QUALITY OF LIFE Psychological – ◦ ◦ ◦ Diminished leisure, enjoyment Increased anxiety, fear Depression, personal distress Difficulty concentrating Somatic preoccupation Loss of control
EFFECTS OF PAIN ON QUALITY OF LIFE Social – ◦ ◦ Diminished leisure, enjoyment Decreased sexual function and intimacy Altered appearance Increased caregiver burden
EFFECTS OF PAIN ON QUALITY OF LIFE Spiritual – ◦ Increase suffering ◦ Altered meaning ◦ Re-evaluation of religious beliefs
INTERVENTIONS FOR PAIN MANAGEMENT Physical – Movement, Thermal, Touch, Relaxation, Environment, Aromatherapy, Acupuncture Psychological – Distraction, Meditation, Visualization, Staying Attitude, Hope, Spiritual Support Palliative Treatments – Radiation Therapy, Chemotherapy, Nerve Blocks, Surgery Pharmacological – Analgesic and Adjuvant Medications
Guidelines For Follow Up to Pain Management All patients admitted to hospice will receive the best level of pain control that can be safely provided.
Guidelines For Follow Up to Pain Management Assessment – ◦ At time of admission, a comprehensive pain assessment will be conducted, including use of numeric pain rating scale ◦ When pain is identified as a problem, individualized pain management goals will be established (some patients find a level of 4 acceptable in order to remain awake and alert while others wish to be pain free is possible). ◦ Pain assessments will be conducted on each nursing visit with reassessments occurring until pain goal is achieved.
Guidelines For Follow Up to Pain Management Interventions – ◦ If pain is scored at greater than 3 or if pain level is unacceptable to patient, there will be an intervention to reduce the pain. ◦ Follow up to determine the success of the intervention MUST be done within 24 hrs of the intervention. In many cases, follow up will be necessary in a much shorter time frame depending on the severity of the pain and the interventions required. Nursing judgment is crucial in determining the time frame. Follow up may be done via telephone call or by visit at the discretion of the nurse. Documentation must be evident on the medical record. Follow up via telephone should generate a progress note, while a visit should generate a nursing note.
Guidelines For Follow Up to Pain Management Interventions cont’d – ◦ If pain is not improved, additional interventions should be taken and documented. ◦ Follow up within the determined time frame will be conducted until pain goal is achieved. NOTE: Follow up MUST be done within 24 hrs. Documentation of this must be evident in the medical record. ◦ Alternative pain relief measures may be implemented as well as pharmacological interventions. (Massage, relaxation techniques, guided imagery, etc. )
Guidelines For Follow Up to Pain Management Interventions cont’d – ◦ Unless pain is occurring occasionally, scheduled analgesics are indicated with additional medication available on demand for breakthrough pain. ◦ Oral meds are the preferred routes ◦ Opioids are considered the analgesic of choice for moderate to sever pain. ◦ Adjuvant therapies must be considered.
Guidelines For Follow Up to Pain Management Documentation – ◦ The initial pain assessment must be completed at time of admission. Pain sites are to be numbered with a designation of the probable cause of the pain at each site. ◦ Subsequent assessments/reassessments must be clearly documented ◦ Progress notes should clearly delineate the plan and the rationale for treatment
Guidelines for On-Call Follow Up All patients and their families admitted to Hospice will receive the best level of individualized care and personalized service that may be safely provided, regardless of the time of day. Hospice staff is available 24 hours a day, 7 days a week, 365 days per year. All calls made to Hospice will be promptly answered. Those received after hours or on -call, will be responded to within thirty (30) minutes.
Guidelines for On-Call Follow Up Assessment – ◦ Once staff is notified by the service that a call has been made, a response to the call MUST be initiated within 30 minutes. ◦ If the call is of routine nature and at the staff’s discretion can be handled safely and effectively over the phone, it may be appropriate to do so. ◦ If a second call comes in regarding the same patient or family, even if the subject of the call is different, a visit must be made. ◦ If the on-call staff receive notification that the patient is going to or is in the emergency room, the staff member MUST either accompany the patient to or meet them at the emergency room. There should be no exceptions to this. ◦ All deaths will be attended without regard to location.
Guidelines for On-Call Follow Up Interventions – ◦ All calls will be documented on the on-call log and it should be notated if a visit was made or of the situation was resolved via telephone consultation ◦ If it was determined that the situation could appropriately be handled via telephone call, a Progress Note (if a non-clinical problem) or an On Call Note should thoroughly explain the reason for the call, the action or intervention taken in response to the call (keep a supply of Progress Notes and On Call Notes with you).
Guidelines for On-Call Follow Up Interventions cont’d – ◦ Follow up to determine the outcome of the intervention MUST be done within 24 hrs of the intervention (requires passing off to next on-call nurse). Follow up may be done via telephone call or by visit at the discretion of the nurse. Documentation must be evident on the medical record. ◦ If it was determined that a visit be made, an On Call Note should thoroughly explain the nature of the call and all pertinent information regarding the call should be documented. All interventions should be documented, the rationale for such interventions and a report of the nursing assessment/observations that prompted the intervention.
Guidelines for On-Call Follow Up Documentation – ◦ Follow up to ALL calls for a clinical nature received during the on-call hours require follow up within 24 hrs. ◦ Documentation of this must be evident in the medical record.
“If we know that pain and suffering can be alleviated, and we do nothing about it, then we ourselves become the tormentors” – Primo Levi
References Meuser T, Pietruck C, Radbruch L, et al. : Symptoms during cancer pain treatment following WHOguidelines: a longitudinal follow-up study of symptom prevalence, severity and etiology. Pain 93 (3): 247 -57, 2001. Patrick DL, Ferketich SL, Frame PS, et al. : National Institutes of Health State-of-the-Science Conference Statement: Symptom Management in Cancer: Pain, Depression, and Fatigue, July 15 -17, 2002. J Natl Cancer Inst 95 (15): 1110 -7, 2003. Bruera E, Willey JS, Ewert-Flannagan PA, et al. : Pain intensity assessment by bedside nurses and palliative care consultants: a retrospective study. Support Care Cancer 13 (4): 228 -31, 2005.
References Miaskowski C, Dodd MJ, West C, et al. : Lack of adherence with the analgesic regimen: a significant barrier to effective cancer pain management. J Clin Oncol 19 (23): 4275 -9, 2001 .