Pain Management in Palliative Care. Peg Nelson, RN-BC, MSN, NP, ACHPN

Transcription

1 Pain Management in Palliative Care Peg Nelson, RN-BC, MSN, NP, ACHPN

2 Contact Hour To receive contact hour for the Palliative Care Pain Assessment and Management webinar you must: Join the live webinar, login individually via your computer*. Attend the entire Webinar presentation. Complete and submit the evaluation form which is auto generated at the end of the live webinar. The evaluation is only available electronically to attendees who join the live webinar via computer. *NOTE: MiPCT is not able to issue Nursing contact hour(s) for multiple attendees viewing the webinar on one computer. MiPCT is only able to issue Nursing contact hour(s) for participants who attend and login individually to the live Webinar (i.e. viewing the recorded Webinar will not provide Nursing contact hours) This continuing nursing education activity was approved by the Michigan Nurses Association, an approver by the State of Michigan Board of Nursing.

3 Disclosure Statement of Financial Interest I, Margaret (Peg) Nelson, Have reported no relevant conflict of interest for the purpose of the MiPCT Webinar, Palliative Care Pain Assessment and Management

4 Objectives By the end of the session the learner will: 1.Describe the incidence of pain and issues with people suffering from serious illness 2.Identify the barriers to pain management and common myths regarding opiate use at end of life 3.Define types of pain and describe assessment and understanding of the pain experience 4.Differentiate tolerance, physical dependence, addiction and pseudo-addiction 5.Discuss common treatment approaches multimodal dimensions 6.Identify when to get a pain specialist involved

5 Access to All

6 Scope of the Problem 100 Million in U.S. with Chronic Pain % with pain lasting over one year 33% report pain as disabling % have seen primary care physician for help From Scope of Pain Course Boston University American Academy of Pain Medicine Institute of Medicine Relieving Pain in America. Washington DC $600 Billion Annual Costs Healthcare expenses Lost income Lost productivity

7 Incidence and Issues I in 5 people are over 65 years of age An average of 43% of patients with cancer are undertreated. Approximately 12-51% of cancer patients have poor pain control. Up to 85% of patients with heart failure have pain and other distressing symptoms such as fatigue, dyspnea and nausea. Arthritis is the number one cause of pain in the elderly

8 Michigan Department of Community Health, Michigan Public Health Institute and Michigan Institute for Public Policy and Social Research looked at end of life suffering within Michigan came together to complete a statewide needs assessment of end-oflife care.

9 State Report on Suffering and Death: The primary problem at end-oflife, as reported by caregivers and hospice contacts, is severe pain, regardless of where patients were when they died. 38 percent of patients in all locations reported persistent severe to excruciating pain over 60 days prior to death.

10 Distribution of Decedents by Location and Average Pain Level for Final 3 Months, MI 2004 All Locations (N=370) Home Setting (N = 303) Hospital (N = 30) Nursing Home (N = 24) Other (N = 13) Percentage None Mild to Moderate Severe to Excruciating

11 State Report on Suffering and Death: If the patient s death was reported not to be peaceful, physical pain was listed as the reason approximately 56 percent of the time, at any site of death. End-of-life experts and hospice clinicians report that 90 percent of the time the reason for unrelieved pain is ineffective medications (drug, dose or frequency).

12 State Report on Suffering and Death: Hospice reports that in the 70 percent of patients with unrelieved pain prior to death, the cause is lack of clinician knowledge of opiates, dosing and how to manage atypical pain as well as RN reluctance to give the prescribed dose.

13 State Report on Suffering and Death: For patients who eventually get to hospice, 85 percent have no, or very poor, understanding of their prognosis, illness and treatment options. Less than 25% of patients receive hospice care before they die. The length of stay in hospice is less than 2 weeks and has declined over the last 3 years.

14 Where people die Michigan n = 87, 424 (% of deaths displayed) Hospital Extended Care Facility Home Other 24 Unknown

15 Barriers Lack of Accountability Lack of Education and Knowledge Lack of Assessment and Engagement and Understanding of suffering Fears of Addiction Fears of Respiratory Depression Regulatory Issues Layman attitudes Healthcare Provider Attitudes

16 Common Myths and Truths Sick people at end of life will become addicted to pain medicine. (Truth: Less than 1% of all patients who did not have addiction before using opiates will become addicted.) If you take pain medicine too soon in the course of your illness, there will not be pain medicine strong enough later if it really gets bad. (Truth: There is always effective pain medicine available.) Pain medicine will make me too sleepy, confused or unable to think or do what I want to do. (Truth: If people become too sleepy or confused on pain medicine it can be changed or adjusted, but most people within 2 days on therapy lose these symptoms.) Pain medicine taken at end of life, is unsafe and will make me die quicker. (Truth: Studies show pain medicine is safe and often patients live longer if pain is well controlled.)

17 Common Myths and Truths All doctors know how to manage pain. (Truth: Most doctors receive little if no formal education in medical school about pain medicine and studies show many doctors do not have this knowledge.) If I take pain medicine it is a sign of weakness and that I m giving up. (Truth: Reducing pain allows patients to be more active and more involved in their fight of their illness) The side effects of pain medicine such as constipation and nausea are so bad that the only way to get rid of them is to stop the pain medicine. (Truth: Constipation and nausea are often preventable and always controllable.) Narcotics or opiates like morphine are the only treatments for pain. (Truth: There are many treatments for pain but narcotics are the mainstay for severe pain.)

18 Common Myths and Truths If one pain medicine makes you feel bad they all will! (Truth: Everyone responds differently to each pain medication.) A good patient doesn t complain or report pain or other symptoms. (Truth: It is important to always report pain and other symptoms in order to best manage your illness.) Pain medicine like aspirin, ibuprofen and acetominophen are always safe. (Truth: All medication even over the over the counter medication can be unsafe, high doses over time of aspirin, ibuprofen and Acetominophen can lead to serious problems in some patients.)

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20 Begin first by understanding

21 Definition of Pain (IASP and APS) Pain is and unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. pain has multiple components impacts psychological and physical functioning complex experience not predictable

22 Clinical Definition of Pain Pain is whatever the experiencing person says it is, existing whenever he says it does. McCaffery, 1968

23 Types of Pain Acute, Chronic, Malignant vs. Nociceptive, Neuropathic) Early conceptualizations of pain focused on three basic causes of pain: Acute trauma or injury, chronic painful conditions for which cures were unknown, and malignant processes (cancer, arthritis) Modern research shows two types of pain: Nociceptive pain/inflammatory pain Neuropathic pain

24 Pain based on onset and persistence Acute pain identified event, resolves days weeks usually nociceptive Chronic pain cause often not easily identified, multifactorial indeterminate duration nociceptive and / or neuropathic

25 Nociceptive pain... Direct stimulation of intact nociceptors Transmission along normal nerves Sharp, aching, throbbing somatic easy to describe, localize visceral difficult to describe, localize

26 ... Nociceptive pain Tissue injury apparent Management opioids adjuvant / coanalgesics

27 Neuropathic pain... Disordered peripheral or central nerves Compression, transection, infiltration, ischemia, metabolic injury Varied types peripheral, deafferentation, complex regional syndromes

28 ... Neuropathic pain Pain may exceed observable injury Described as burning, tingling, shooting, stabbing, electrical Management opioids adjuvant / coanalgesics often required

29 Let s think What type of pain is it? a. Phantom limb pain b. Pancreatitis Nociceptive Pain? Or Neuropathic Pain?

30 In order to adequately manage pain, we must understand the definitions and distinctions of: Addiction Tolerance Physical Dependence

31 Addiction: - Psychological Dependence. It is a pattern of compulsive drug use characterized by continued craving for an opioid and the need to use the opioid for effects other than pain relief.

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33 Who is the addict? 56% benzo/barbituate abusers white women % opiate abusers white males year old

34 Addiction Definition Psychological drive (desire) to take drug (opioid) for euphoric effects Less than 0.1% of patients using opioids of medical purposes become addicted to them Research findings show only 4 out of nearly 12,000 patients treated with opioids for medically indicated purposes developed a problem with addiction

35 Tolerance Definition Tolerance: increased dose required to produce the same effects when pain stimulus remains unchanged

36 Physical Dependence - The occurrence of withdrawal symptoms when the opioid is suddenly stopped or an antagonist such as naloxone is given. (The withdrawal sx are usually easily suppressed with gradual withdrawal of the opioid.)

37 PSEUDO-ADDICTION BEHAVIORS INDICATIVE OF UNCONTROLLED PAIN OR FEAR OF UNCONTROLLED PAIN ARE OFTEN MISINTERPRETED AS ADDICTION PSEUDO = false such as demanding, clock watching or drug seeking WHY? Doses too low interval greater that drug s duration of action past pain experience NON belief of clinicians ACTING out the pain

38 Issues Providers report preventing Opioid Prescribing Issues Prevalence Potential for patients to become addicted 89% Potential for patients to sell or divert 75% Opioid side effects 53% Regulatory/law enforcement monitoring 40% Hassle and time required to track/refill 28% Upshur CC, Luckmann RS, Savageau JA. J Gen Intern Med Jun;21(6): From Scope of Pain Course Boston University

39 Assessment and Engagement It s not just what s your number? Its connecting, accepting, understanding and caring and building trust

40 Patient Issues Building Trust Patients will assume that you don t believe their pain complaints Often demonstrated by exaggerating pain scores From Scope of Pain Course Boston University

41 Patient Issues Building Trust Some patients with adequate pain relief Believe it is not in their best interest to report pain relief Fear that medication will be reduced Fear that physician/clinician may decrease efforts to diagnose or treat problem From Scope of Pain Course Boston University Evers GC, et al. Support Care Cancer Nov;5(6):

42 Clinician Strategies Building Trust Assume patient fears you think pain is not real or not very severe After you take a through pain history Show empathy for patient experience Educate patient about need for accurate pain scores to monitor therapy Validate that you believe pain is real Discuss factors which worsen pain and limit treatment Believing patient s pain complaint does not mean opioids are indicated

43 Words that Engage, Assess, set reasonable expectations and Care I am so sorry you are so miserable Please help me understand We are going to do everything we can to make the pain tolerable and make sure you are safe What helps you the most? Is what we are doing helping at all? We aren t likely going to make it perfect but we are going to keep trying to make it tolerable The best pain management happens over time and we will keep working at it and do everything we can to safely and effectively manage it. The goal today is: I am going to be with you we are connected

44 Assessment of Pain Location Character Intensity - Numeric Pain Scale NPS = 0 is no pain, 10 is the most severe pain. Is the pain medication/plan acceptable? Does it make it tolerable? What makes the pain better? Worse? After you take the pain medication what happens after one hour? Pain Diary is helpful to find patterns and causes Pain in the nonverbal patient

45 PAINAD nonverbal pain tool PAINAD Assessment Behavior Score Breathing independent of vocalization Normal Occasional labored breathing; short period of hyperventilation Noisy labored breathing; long period of hyperventilation; Cheyne-Stokes respirations Negative Vocalization None Occasional moan/groan; low level of speech w/a negative/disapproving quality Repeated troubled calling out; loud moaning/groaning; crying Facial expression Smiling inexpressive Sad, frightened, frowning Facial grimacing Body language Relaxed Tense, distressed pacing, fidgeting Rigid; fists clenched, knees pulled up; pulling/pushing away; striking out Consolability No need to console Distracted or reassured by voice or touch Unable to console, distract or reassure

46 Goals of Acute Pain Management Safety Efficacy Safety Efficacy Safety Efficacy

47 Exercise Integrative Modalities Manual therapies Orthotics Cultivate Wellbeing NSAIDS Anticonvulsants Antidepressants Topical agents Opioids Others Multidimensional Care It s more than medications! Physical Medication Restore Function SELF CARE Improve Quality of Life Psychobehavioral Procedural Cognitive behavioral/act Tx mood/trauma issues Address substances Meditation Reduce Pain Nerve blocks Steroid injections Trigger Point Injections Stimulators Pumps

48 Non-opioids Co analgesics Most Common: Aspirin, Acetaminophen and NSAIDS Useful for acute and chronic pain Ceiling effect to analgesia I Do not produce tolerance Antipyretic Side Effects limit amount Aspirin - 6gm/day Acetaminophen - 4 gm /day (3gm/day for older adults and likely everyone) Ibuprofen mg/day

49 Aspirin - ASA Recommended for mild or moderate pain if not contraindicated Gastric side effects Bleeding 4-6 Gm / Daily Max (and not recommended over 325mg/day for 75 years or older) Hypersensitivity reactions include: hypertension, shock, syncope

50 Acetaminophen No gastric mucosal damage Analgesia and antipyretic Overdose= hepatic necrosis Contraindicated: Liver disease Helpful if scheduled for chronic pain Useful for osteoarthritis and musculoskeletal pain Max dose is likely going to change, 4 gm daily (3gm/day for older adults)

51 Non Steroidal Anti Inflammatory NSAIDS EXAMPLES: Ibuprofen (Motrin, Advil), Naproxen (Aleve, Anaprox) Choline MagnesiumTrisalicylate (Trilisate), Indomethacin (Indocin), Ketorolac (Toradol), Diclofenac (Voltaren), Diflunisal (Dolobid), Ketoprofen (Orudis), Sulindac (Clinoril) NEWER: Celebrex, (COX 2 inhibitor) goodbye Vioxx Perhaps more effective than ASA for arthritis and musculoskeletal pain Sometimes used in chronic pain (inflammation) Combined with opiates as treatment for bone metastasis

52 NSAIDS Cautions ALL NSAIDS INHIBIT PLATELET AGGREGATION do not combine with anticoagulation treatment, or if patient thrombocytopenic, or has coagulopathy Long term use associated with GI Toxicity (ulcers, bleeding, etc) ->107, 000 GI bleeding hospitalizations/year (up to 4% of patients treated for 1 year Long Term use associated with Renal insufficiency and acute renal failure especially with dehydrated older people NSAIDS are not recommended for chronic/long term use in people over 75 years May contribute to hypertension Dosing Ibuprofen: Start with mg TID. Max is 2400mg/day Dosing Naproxen: Start with 225 to 375mg BID. Max is 550mg BID

53 General Opiate Guidelines Only absolute contraindication true allergy (and nausea is not a true allergy) No ceiling effect or end organ damage so there is no maximum dose except for intolerant side effect All opiates may have the common side effects (constipation, nausea, itching, sedation, respiratory depression) to different degrees. IM is not ever recommended (IV/ PO/ SC or rectal are usually tolerated well and sublingual (SL) is not generally effective) Appropriate use of opiates does not facilitate death or decrease life expectancy, actually at end of life, there is evidence that controlling pain with opiate medications prolongs life!

54 Opioid Choices with Examples Opioids Full mu agonists Mixed agonist/ Morphine, Oxycodone, Hydrocodone, Hydromorphone, Fentanyl, Methadone, Oxymorphone Partial mu agonist Buprenorphine Dual mechanism Tramadol, Tapentadol opioid analgesics antagonists Pentazocine From Scope of Pain Course Boston University

55 Opiate Conversion Name Oral IV/SC Morphine 30mg 10mg Hydromorphone 7.5 mg 1.5mg Oxycodone 20mg (30mg) none Codeine 200mg (not recommended) 130mg Fentanyl none 100mcg Methadone?????? Oxymorphone 10mg none Hydrocodone 30mg None

56 Nausea and vomiting Managing Opioid Adverse Effects Usually resolves in few days, antiemetics, switch opioids Sedation Mostly during initiation or change in dose Constipation Most common and should be anticipated Pruritis Urinary Retention Decrease dose Senna laxatives, bowel stimulants, switch opioids; avoid bulking agents Switch opioids, antihistamines Switch opioids Benyamin R, et al. Pain Physician 2008;11:S105-S120.

57 Managing Opioid Side Effects Opioid induced Delirium: Vivid Dreams Nightmares Patient knows he is confused or hallucinating Closes his eyes and sees hallucinations Very different from other types of confusion/delirium. Typically need to reduce or change opioid

58 Other Medications Commonly Used For Pain Local Anesthetics Bisphosphonates Calcitonin Capsaisin Calcium Channel Blockers Baclofen Anitdepressants Anticonvulsants Corticosteroids

59 Impact of Pain on Quality of Life Physical Functional ability Strength, fatigue sleep and rest Nausea appetite Social Caregiver burden Roles and relationships Sexual function appearance Psychological Anxiety Sleep deprivation Fear Cognition/attention Spiritual Meaning of pain religiosity

60 The person: Consequences of Unrelieved Pain Fear Anxiety Helplessness Depression Suffering Hopelessness Distress Decreased will to live (euthanasia, suicide)

61 Referral If pain is not controlled, in a patient with a serious end stage disease, to a tolerable level, and/or provider is not comfortable with escalating pain management plan then referral should be made to: Palliative Care Pain Specialist Hospice

62 Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has. Margaret Mead

63 References National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines, 3rd Edition, Pain Assessment and Pharmacological Management by Chris Pasero and Margo McCaffery Mosby/Elsevier