G. Jay Westbrook, M.S., R.N., CHPN - Clinical Director Compassionate Journey: An End-of-Life Clinical & Education Service CompassionateJourney@hotmail.com 818/773-3700 Arresting Pain without Getting Arrested (Advance for Nurses Career Fair Pasadena - 9 September 2010) The Problem: Many patients suffer needlessly due to poorly managed pain Costs of Inadequate Pain Management: 1. spiritual 2. psychological 3. social 4. physiological 5. ethical 6. financial/litigational 7. regulatory/legislative 8. relational 1
Barriers To Pain Management: 1. cultural 2. patient & provider fears of addiction: physiological dependence addiction pseudo-addiction 3. non-standardized & inaccurate pain assessments -try: 1) Do you have any pain, right now? 2) Where is your pain? 3) On a scale of 0-10, with 0 being no pain and 10 being the worst pain possible, what number is your pain right now? 4) Prior to what was your most physically painful experience? 5) And on a scale what number was that pain? then compare 4. inappropriate medications and improper dosing -examples: -Vicodin ES ii po q 4h ATC (around the clock) -Morphine Sulfate 4 mg iv q 12h ATC -MS Contin 240 mg po q 12h ATC with Roxanol (MSIR) 10 mg po q 3h prn BTP (break through pain) -Duragesic Patch 50 mg/h TD q 72h -Morphine Sulfate 4 mg iv q 4h prn pain/sob, changed to Morphine Sulfate 4 mg iv q 8h prn pain/sob -Dx: Pancreatic cancer - DC Morphine Sulfate 20 mg/h iv ATC, and discharge home with MS Contin 60 mg po q 12h ATC 2
5. to Demerol (meperidine HCl) or not to Demerol (meperidine HCl) -benefits and burdens -for Pts with adverse reactions to 1 st line opiates -for Pts experiencing treatment-failure with 1 st line opiates -onset of action slightly more rapid than morphine sulfate -duration of action slightly shorter than morphine sulfate -has the unique ability to interrupt post-operative shivering -helps prevent shaking or rigor sometimes associated with either amphotericin B or platelets -may produce less smooth muscle spasm, constipation, and depression of the cough reflex than equivalent doses of morphine sulfate -CNS stimulant, excitant, irritant -confusion in the elderly -seizures -tremors -use for < 48h and not > 600 mg/24h -high dose #s make switch to other opiates difficult for Pt -what the experts say -NCCN National Comprehensive Cancer Network -not recommended for cancer-related pain -IASP International Association for the Study of Pain -not recommended for sickle cell pain -APS American Pain Society -not an opioid of choice for the management of pain -Cochrane Library -multiple articles -Mayday Pain Center - City of Hope -multiple articles 3
-now what? - approaches: -assess meperidine use - is there really a problem? -if so, options include: -outlaw meperidine use by regulation & formulary removal -use by exception only - regulated -reduce meperidine use by education -assess meperidine use -conduct educational program -with periodic reinforcement -reassess meperidine use Qualitative Aspects of Pain: - I m going to give you three sets of words, and I want to know if any one or more than one of these sets of words describe your pain: 1) Is your pain sharp and stabbing? 2) Is your pain dull, aching, or throbbing? 3) Is your pain burning, searing, electric, or tingling, and does it travel or migrate? 4
Pain Management Principles: 1. What is Pain (Acute vs. Chronic, BTP) 2. ATC vs. PRN dosing 3. equianalgesic dosing 4. titration 5. proportionality 6. nociceptive pain 7. neuropathic pain assessment by diagnosis by qualitative report treatment(s) TCAs Anti-Convulsives Methadone 5
Methadone -Benefits: -Burdens: -Other: -89% UK PC MDs use it -it works, and works quickly -works for nociceptive and neuropathic pain -cheap -SEs lower incidence and less intense -no active metabolites -lipophilic -requires little or no dose escalation -long duration -multiple forms -multiple routes of administration -high bioavailability -stigma x2 -cheap -lack of understanding re: pharmacokinetics and dosing -escalating duration of analgesia -tremendous inter-patient variability -multiple conversion protocols -sliding scale conversion -SEs -1/2 life > analgesic duration Questions and Answers 6
G. Jay Westbrook, M.S., R.N., CHPN - Clinical Director Compassionate Journey: An End-of-Life Clinical & Education Service CompassionateJourney@hotmail.com 818/773-3700 Equianalgesic Dosing of Opiates 1) iv, im, sq -- po, pr, sl = 1:3 (for morphine) 2) dilaudid -- morphine = 1:5 3) Demerol -- morphine = 10:1 4) MS Contin (MSC) -- Oxy Contin = 1:1 5) MS Contin 30 mg po q 12h = Duragesic Patch 25mcg/h q 72h 6) 1 Percocet (5/325 mg) = MSIR 5 mg = Oxycodone IR 5 mg 7) 1 Vicodin or Lortab (5/500mg) = MSIR 5 mg = Oxycodone IR 5 mg 8) 1 Tylenol #3 (30/300 mg) = MSIR 4.5 mg = Oxycodone IR 4.5 mg 9) 1 Tylenol #4 (60/300 mg) = MSIR 9 mg = Oxycodone IR 9 mg 10) BTP (Break Through Pain) or Rescue dose: MS Contin:MS Immed. Release 1/3 the q 12h dose (or 1/6 the q 24h dose), e.g., with MS Contin 30 mg po q 12h, use MSIR 10 mg sl/po q 3h prn with MS Contin 90 mg po q 12h, use MSIR 30 mg sl/po q 3h prn 7
G. Jay Westbrook, M.S., R.N., CHPN - Clinical Director Compassionate Journey: An End-of-Life Clinical & Education Service CompassionateJourney@hotmail.com 818/773-3700 Equianalgesic Dosing of Opiates 11) Methadone (to switch from other opiates to methadone): a) convert all other opiates to po Morphine Sulfate (MS) equivalents/24h b) use the following sliding scale: 24 h po MS equivalents MS:Methadone ratio < 500 mg 5:1 500 1,000 mg 10:1 1,001 5,000 mg 20:1 5,001 10,000 mg 30:1 > 10,000 mg 40:1 c) divide the resulting 24h Methadone dose into two (2) equal q 12h po doses Although this rarely occurs, if the patient experiences end-of-dose failure during the last 60-90 minutes of the 12-hour dose, divide the 24h Methadone dose into three (3) equal q 8h po doses. d) if the daily po MS equivalents are > 1,000 mg/day, you may want to consider reducing the existing opiates by 1/3 each day while introducing & increasing the Methadone at 1/3 of the calculated dose per day e) if the daily po MS equivalents are > 3,000 mg/day, you should reduce the existing opiates by 1/3 each day while introducing & increasing the Methadone at 1/3 of the calculated dose per day 8