Managing Pain after Transplant Denice Economou, RN,MN,CHPN,AOCN Oncology Clinical Nurse Specialist, Senior Research Specialist City of Hope
Definition of Pain Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. International Association for the Study of Pain and the American Pain Society
Major Barriers to Pain Management Healthcare providers need to recognize pain management as a priority Lack of knowledge about pain management Fear of addition, tolerance & dependence Distraction for the physician Bad patient Myths share by providers and patients
Multiple Meanings of Pain Past experience w/ pain Culture / Age / Sex Family position Financial concerns Fear of growing disease Career goals Somatic/ Neuropathic mechanisms Physical disability Psychological state and traits
Major Myths Tolerance Dependence Addiction
Tolerance If I use pain medicine now, it won t work when I really need it Tolerance is a physiological response to medications used over a length of time. It only means that you may need to increase the dose to get the same response. Opioids have no ceiling on dosage. The correct dose is the one that gives the best relief, with little or no side effects
Dependence A Physiologic response There is a discontinuation response when the medication is stopped abruptly. DOES NOT MEAN ADDICTION!! Antihypertensive medications, Insulin, steroids can also have discontinuation symptoms
Addiction Addiction is a psychological response to medication usage. Going to any extreme to get the medication even when it may be harmful to you. Addiction has genetic and environmental components
Pain Impacts Quality of Life Physical Well Being & Symptoms Functional Ability Strength/ Fatigue Sleep & Rest Nausea Appetite Constipation Psychological Well Being Control Anxiety Depression Pain Distress Happiness Fear Cognition/Attention QOL Social Well Being Family Distress Caregiver Burden Roles and Relationships Affection/Sexual Function Apprearance Finances Spiritual Well Being Suffering Meaning of Pain Religiosity Transcendence Hope Uncertainty
Income, Age and Cultural Background Influence Ability to Receive Effective Pain Management Children and older adults Non-verbal or cognitively impaired Patients who deny pain Non-English speaking Different cultures History of addictive disease
Pain Associated with BMT Acute Pain < 6 Mo. Duration Associated with chemotherapy, radiation therapy or procedures Chronic Pain/GVHD Musculoskeletal Symptoms/ Rheumatalogic Gastrointestinal discomfort Skin changes
Pain Sources Somatic vs. Neuropathic Somatic pain refers to two types of nociceptive pain. Somatic pain may start in the skin and deep tissue. Receptors sense temperature, vibration, swelling of skin, joints and muscles. Usually easy to diagnose - can point to the location Experienced over a long period of time may lead to chronic pain issues.
Pain Sources Somatic vs. Neuropathic Somatic pain - Visceral pain refers to pain related to internal organs where the viscera surrounding the organ becomes stretched from swelling or tumor. This pain is more difficult to locate because the sensation may be vague or feel all over. Responds really well to opioids.
Pain Sources Somatic pain - Bone Pain Bone pain is nociceptive pain described as dull, achy pain. Usually associated with tumor or bone damage Responds to different types of medications - not just opioids
Pain Sources-Neuropathic Pain Results from damage to a nerve centrally or peripherally. Described as burning, sharp, shooting. pins & needles May require multiple classes of medication to help relieve the pain. Exercise and physical therapy are important.
Major Medications Used for Pain Opioids NSAIDS/Acetaminaphen Compounded Opioids Morphine, Hydromorphone, Oxycodone, Fentanyl, Actiq, Methadone, Avinza, Opana, Tramadol Celebrex, Trilisate, Naprosyn, Motrin, Advil Percocet, Vicodin, Lorcet, Norco
How do the Opioids work Opioids are narcotics We have many receptor sites throughout the body from the brain, through the spinal cord and gastro-intestinal (GI) tract and skin. Opioids control pain by locking onto receptors and blocking the release of neurotransmitters (lock & key) that go back to the brain to tell you the pain is better or not.
How NSAIDs & Acetaminophen Work Non opioids include NSAIDs, acetaminophen and aspirin. They act on somatic pain-nociceptive pain. NSAIDs reduce inflammation to relieve pain. Acetaminophen does not have an antiinflammatory effect. Like aspirin, it relieves pain and reduces fever only. Side effects include: GI irritation, possible kidney toxicity. Acetaminophen can cause liver toxicity. That is why the maximum daily dose is limited.
Short Acting Oral Pain Medications Provide analgesia w/in 30 minutes. Morphine, Dilaudid (common) Actiq - fastest acting oral medication-onset w/in 5 min. Rubbed on the mucosa inside the mouth. Liquid pain medication is helpful for patients with difficulty swallowing. Easy to increase and decrease doses as needed.
Advantages of Long-Acting Opioids More predictable serum levels more predictable pain relief avoids mini-withdrawals Easier to use; improved compliance Greater patient satisfaction Less reinforcement of drug-taking behavior
Breakthrough Pain Pain that may come through your regular pain management relief. It may be related to movement, prolonged walking or sitting. Called incidental pain. May occur throughout the day and be quick or prolonged pain. If occurs often throughout the day may need to reassess your pain and the medications you are using.
What might help Medications Anti-inflammatory medications Pain medications Antidepressants
Additional Medications Used for Pain Relief Corticosteroids Antidepressants Anticonvulsants Benzodiazepines Bisphosphonates Radiopharmaceuticals NMDA Receptor Agonists Topicals Miscellaneous Decadron, Solumedrol Amitriptyline, Desipramine, Nortriptyline Gabapentin (Neurontin), Pregabalin, Lyrica Ativan (Lorazepam) Klonopin (Clonazepam) Pamidronate (Aredia) Zoledronate (Zometa) Strontium-89(Metastron) Samarium lexidronam (Quadramet) Dextromethorphan,Ketamine Lidocaine, (EMLA, Lidoderm) lidocaine/prilocaine,capsaicin Baclofen, calcitonin, Dextroamphetamine
Non-Medications that Might Help Heat, Cold, Massage Application Complementary therapies Behavioral interventions Exercise Strength training Cognitive - behavioral therapies Relaxation Imagery Distraction Support groups Pastoral counseling
Assessment is the Key The source of pain is essential to understanding the correct way to manage it. Different sources of pain respond to different types of medications or interventions
Pain Assessment in the Older Adult Worst possible pain (severe) 0-10 Visual Analog Scale 0 1 2 3 4 5 6 7 8 9 10 No pain Worst possible pain Very bad pain (moderate) Faces Pain Rating Scale Little pain (mild) Faces Pain Scale-Revised (FPS-R) Verbal Scale No pain Mild Moderate Severe pain No pain
Describing Your Pain is Key to Effective Treatment Where is the pain located? How intense is it on a scale of 0-10? How often does it occur & how long does it last? Constant Intermittent When doing certain activities Certain times of the day Describe how it feels Burning, itching, dull ache, throbbing, etc.
Multidimensional Approach - Necessary for Pain Management Physiologic - etiology of the pain Sensory - intensity, location, quality Affective - depression, anxiety Cognitive - what does pain mean Behavioral - how does the pain effect you Sociocultural - cultural background, past experiences with pain Your answers will guide your pain relief needs.
Medication Principles Around the clock dosing provides better relief for frequent or continuous pain and requires the use of less opioid. Using a long acting or timed release medication is more effective for continuous pain Everyone responds to medications differently. INDIVIDUAL DOSING
Principles: Prevent and Treat Side Effects Anticipate Prevent Treat
Conclusion Pain relief is contingent on adequate assessment and use of both drug and non-drug therapies Pain extends beyond physical causes to other causes of suffering and existential distress Interdisciplinary care
What to Report to your Doctor or Nurse Pain that interferes with your quality of life New pain or pain that has changed in character If pain is not relieved with medication Side effects you may be experiencing including constipation, nausea, itching or rash
Managing your symptoms Healthy lifestyle choices Get enough rest, eat a healthy diet Psychological and Emotional Support may be beneficial - Talk to a Social Worker! Tell your doctor or nurse you are concerned. We can t help you if we don t know what you are experiencing.
Communicate what you need Tools that describe where the pain is and what it feels like. http://partnersagainstpa in.com Brief Pain Inventory example
How to advocate for good pain management Speak up! Keep a diary to help describe your pain and how often you experience it What makes it better or worse Know how you cope with your pain Finding your Champion!