Fast Facts on Pain

Management
 What are the Fast Facts?
 There are 7 Fast Facts on Pain Management
1) Critical components for pain assessment
2) Types of pain
3) World Health Organization’s Step Ladder of Analgesic
Medication
4) General guidelines for analgesic medication orders
5) Dealing with neuropathic pain
6) Nurse-physician communication
7) How to increase an opioid dose
 FAST FACT #1: Critical
Components for Pain Assessment
CASE STUDY:
Mrs. S. is a 75 year old patient with advanced osteoporosis. She
lives in a long term care facility. She has been receiving extra
strength acetaminophen q am, and no other analgesics. She is
noted to be experiencing a marked decrease in her functional
ability attributed to back pain. She rates her pain as a 3/10.

What else do you need to know?

 FAST FACT #1 (Cont’d.)
In order to apply the principles of effective pain
management, you must first have done a pain
assessment. In order to do so, you need to know
the components for assessment.
 FAST FACT #1 (Cont’d.)
 The components of assessment are:
 Location/s of pain
 Description of pain
 Type of pain
 Impact on ADL
 Intensity (0-10, 0-5, etc.)
 Pattern:
 Continuous?
 Intermittent?
 Onset
 Duration
 What makes pain worse?
 What makes pain better?
 Patient's perception of pain
 Patient's goal for pain relief
 Analgesics that have been used in the past
 Analgesics receiving in past 24 hours
 FAST FACT #2: Types of Pain
CASE STUDY:
Ms. J. is a 74 year old patient with advanced cancer. She is a resident in a
nursing home and having pain that begins in her abdomen that is always
there, like a sore tooth, it aches all the time. She pinpoints the pain rates it
as frequently a 8/10.. She wants her pain at 3/10. The pain is keeping her
awake at night, which is making her irritable during the day.

What are the key adjectives that characterize her pain?

What type of pain does she have?
Why is that important to know?
 FAST FACT #2: (Cont’d.)
 There are 6 primary types of pain:
1) Visceral Pain
2) Muscle Pain
3) Bone Pain
4) Neuropathic Pain
5) Pleuritic Pain
6) Colic Pain
 FAST FACT #2: (Cont’d.)
 Visceral Pain
 Usually localized to the site of the injury/tumor.
Pain can be referred to the somatic area supplied
by the same nerve root.
 Description/clue to this kind of pain:
 “I ache all the time.”
 FAST FACT #2: (Cont’d.)
 Muscle Pain
 Sometimes difficult to isolate as it may be due to
an underlying disorder, a systemic or metabolic
cause.
 Description/clue to this kind of pain:
 “I’m sore and stiff.”
 “It feels like a Charlie-horse.”
 FAST FACT #2: (Cont’d.)
 Bone Pain
 Local bone pain can range from a dull ache to
deep, intense pain. Usually well localized and
worse on movement and weight-bearing, it may be
worse at night. Bone pain can be masked by
muscle pain arising from involuntary, protective
spasm of the surrounding muscles.
 Description/clue to this kind of pain:
 “It hurts when I move.”
 “It aches at night.”
 FAST FACT #2: (Cont’d.)
 Neuropathic Pain
 Constant, superficial burning pain is usually caused by
actual damage to peripheral nerve, plexus, root, or spinal
chord. When a specific nerve is involved, pain is in
relatively constant are of the body surface (dermatome) but
may also be referred to the somatic area supplied by the
nerve. The degree of nerve pain will be effected by the
degree of nerve compression or infiltration.
 Description/clue to this kind of pain:
 “It feels like my skin is burning.”
 “It feels like someone stabbed me.”
 “It’s a shooting pain.”
 FAST FACT #2: (Cont’d.)
 Pleuritic Pain
 Patient may complain of pain on inspiration of my
present with guarded, shallow breathing.
 Description/clue to this kind of pain:
 “The pain is worse when I breathe in.”
 FAST FACT #2: (Cont’d.)
 Colic Pain
 Partial or complete obstruction of a hollow viscus
can result in intermittent cramps.
 Description/clue to this kind of pain:
 “The pain comes and goes like cramps.”
 FAST FACT #3: World Health
Organization Step Ladder
CASE STUDY:
Gloria has compression fracture of T 12 for which she has
been taking Tylenol without adequate pain relief? You have
done an assessment that found Gloria's pain is described as a
constant ache that increases with ambulation and movement,
moderate in severity (5 to 6/10). She is more aware of the pain
at night so that it interferes with sleep. Because it hurts more
with walking she is spending more time lying down and
watching TV to distract her which seems to help a little.

What is the next step in treating Gloria’s pain?

FAST FACT #3: (Cont’d.)
 FAST FACT #3: (Cont’d.)
 Keep it simple: The WHO “Analgesic Ladder”
 "STEP 1 - patients with mild to moderate pain should be
treated with nonopioid analgesic, which should be
combined with adjuvant drugs if indication for one exists.
 "STEP 2 - patients who have limited opioid exposure and
present with moderate to severe pain or who fail to achieve
adequate relief after a trial of a nonopioid analgesic should
be treated with an opioid conventionally used for moderate
pain.
 "STEP 3 - patients who present with severe pain or who
fail to achieve adequate relief following appropriate
administration of drugs on the second step of the analgesic
ladder should receive an opioid conventionally used for
severe pain.
FAST FACT #4: General Guidelines
for Analgesic Medication Orders
Basic principles to guide your practice:
 Administer medications routinely, not PRN
 Use the least invasive route of administration first
 Begin with a low dose. Titrate carefully until comfort is
achieved
 Reassess and adjust dose frequently to optimize pain
relief while monitoring and managing side effects
 Fast Fact #4: (Cont’d)
 Critical Points for Analgesic Medication Orders
 The character (quality) of the pain has been documented on
assessment (e.g.- burning/shooting pain) so that the health care
provider can determine the type of pain (e.g.- neuropathic pain).
 The oral route is the first choice for analgesic orders. If a
patient is unable to take PO medications, buccal, sublingual,
rectal and transdermal routes are considered before intravenous
or subcutaneous routes.
 Patients who report constant moderate to severe pain receive a
long-acting medication and have a short acting medication
ordered prn for breakthrough pain.
 Patients who report intermittent pain have medications ordered
on a prn basis.
 Fast Fact #4: (Cont’d.)
 Only one combination analgesic (opioid and non-opioid, e.g.-
Vicodin, Tylenol #3) is ordered for prn breakthrough pain.
 Only one opioid is ordered for continuous moderate to severe
pain (e.g.- MS Contin, Oramorph SR, Kadian, Oxycontin, or
Duragesic.)
 Short acting oral opioids are ordered at intervals no longer
than 4 hours.
 Dose escalation’s are calculated as a percentage of the
current dose, based upon the patient’s pain rating
 A rough guideline, assuming normal renal function is pain
rated as 3-6/10, dose escalation is 25-50% of current does;
pain rated as 7-10/10, dose escalation is 50-100% of current
dose
 Fast Fact #4: (Cont’d.)
 The frequency of dose escalation is dependent on
the opioid preparation in dose. Doses of
oral/rectal/transdermal opioids can be safely
escalated: (assuming normal renal function).
 Every 1-2 hours-short acting oral/rectal products:
morphine, oxycodone, hydromorphone.
 Every 24 hours--long-acting oral opioids MS
Contin, Oramorph SR, OxyContin.
 Every 48-72 hours-- Duragesic Patch, methadone,
levorphanol.
 Fast Fact #4: (Cont’d.)
 Prescribe adjuvant analgesics for opioid non-responsive
neuropathic pain.
 Always have an order for breakthrough pain. Use an
immediate release opioid at a strength equivalent to 10-
20% of the 24 hour dose of the sustained release dose.
Order q1-2 hours prn.
 Never have more than one sustained release preparation at
one time.
 An appropriate plan for a bowel regimen is ordered to
prevent constipation.
 Fast Fact #4: (Cont’d.)
 A plan is in place for a pharmacological and/or a non-
pharmacological analgesic intervention prior to activities
that are reported to cause or increase pain.
 A pain management flow sheet is initiated on all patients
rating pain as moderate (e.g.- 5/10, 3/5, or 2/3) on
admission.
 Orders for non-pharmacological interventions are present
and are clearly stated as part of the analgesic plan.
 The metabolites in Demerol and Darvocet are toxic in long-
term use and should not be used.
 Fast Fact #5: Neuropathic Pain
CASE STUDY:
Gloria is having pain that is radiating down her right
leg. The morphine has helped a little but is still
sharp and shooting.

What would you consider for improving pain

management?
Which drug would you choose?
 Fast Fact #5: (Cont’d.)
 Definition of Neuropathic Pain
 Pain characterized by sharp, shooting, burning, numbness
and tingling, hyperalgesia (slight pain like pinprick felt as
severe), allodynia (light touch that feels painful). The pain
is severe and continuous and often disturbs sleep, but it can
fluctuate in severity and can be reduced by diversional
activity or elevation of mood. At times position may have
an effect on the pain because of pressure on nerve roots.
The pain typically will occur in the arm when there is
involvement of the brachial plexus or in the leg when there
is involvement of the lumbo-sacral plexus with pelvic
tumors.
 Fast Fact #5: (Cont’d.)
 Distinct features of neuropathic paine\
 Neuropathic pain can be bilateral with sacral pain,
which is aching pressure-like sensation, weakness
in the leg/s, burning or stabbing pain in the leg,
numbness or tingling.
 Describing the pain will give clues to the best
management of the pain. It is also important to
know if the pain responds at all to analgesics of
acetaminophen or opioid.
 Fast Fact #5: (Cont’d.)
 Management Options:
 Opioids, antidepressants, anticonvulsants, if these do not
work, a local anesthetic.
 Opiods: Some of the neuralgic pains will respond partially. If the
patient becomes drowsy without any pain relief then it is not
responsive to the opioid then use the adjuvant.
 Anticonvulsants (this would be the next step):
 Gabapentin (Neurontin) po Starting dose 100mg q 8hrs.
 Clonazepam (Klonopin) po Starting 0.5 mg q 8hrs.
 Carbazine (Tegretol) po Starting dose 100mg BID
 Antidepressants:
 Desipramine (Norpramin) po Starting dose 10mg q hs
 Nortriptyline (Pamelor) po Starting dose 10 mg po qd
 Fast Fact #6: Nurse-Physician
Communication
CASE STUDY:
Mr. M.C. is a 65 year old patient of Dr. Jones with advanced prostate
cancer and metastasis to the bone. He has been rating his pain
between 4 and 6 over the past few hours in his lower back. The
pain is preventing him from getting out of bed and he has not been
able to sleep. It seems to be relieved only by lying still. MC would
like his pain level to be at 3 or less on a 0-10 scale so that he can
sleep through the night and get out of bed to walk around. He is
taking MS Contin 100mg q 12h with breakthrough dose of MS IR
30mg q2h which he has needed 4 times today. Other adjuvant
medication is Vioxx 50mg QD and gabapentin 300mg tid.

How would you suggest the nurse communicates with the physician
about Mr. M.C.?
 Fast Fact #6: (Cont’d.)
 The following communication steps are helpful in
communicating with the physician:
 Identify physician by name.
 Give your name.
 State the general nature of the call.
 Identify the patient by name and diagnosis.
 State the pain management goal: pain rating and activities.
 Summarize the current pain ratings and effect of pain on
activities.
 List the current analgesic doses and relevant side effects.
 Suggest a solution (on the basis of a clinical practice
guideline, if possible).
 Fast Fact #7: (Cont’d.)
 Guidelines
 There are guidelines that can help in the
understanding of opioid dose escalation. Review
guidelines for opioid dose escalation before
discussing your recommendations with the
physician.
 Fast Fact #7: (Cont’d.)
 Guidelines for analgesic escalation:
 Dose escalation of opiods should be done on the basis of a
percentage increase. In fact, this is easily done when combination
products are prescribed by going from one to two tablets. Going
from 1 to 2 tablets represents a 100% dose increase.
 In general, patients do not notice a change in analgesia when dose
increases are less than 25% above baseline.
 Reasonable guidelines include: for moderate to severe pain
increase by 50-100%, for mild-moderate pain increase by 25-50%,
irrespective of starting dose. When dose escalating long-acting
opioids do not increase the long-acting drug more than 100% at
any one time, irrespective of how many breakthrough doses have
been used. For elderly patients, or those with renal/liver disease,
dose escalation percentages need to be reduced.
 Fast Facts #7: (Cont’d.)
 The recommended frequency of dose escalation
depends on the half-life of the drug. Short-acting
oral single-agent opioids (e.g.- morphine,
oxycodone, hydromorphone), not combination
products, can be safely dose escalated every 2
hours. Sustained release oral opioids can be
escalated every 24 hours. Duragesic (Fentanyl
transdermal), no less than every 72 hours is
recommended.
 Fast Facts #7: Increasing an
Opioid Dose
CASE STUDY:
Mr. S. is a 70-year old patient with lung cancer and metastases
to the bone. He is receiving MS Contin 30mg q 12 hours for
pain with a rescue dose of Morphine 5mg q 2 hours prn.
Today he reports that the pain is getting progressively worse,
rating it at 7/10. There is some relief with the rescue dose of
Morphine for about 3 hours to a 3/10 and then it gets severe
again. The pain is in his lower back at the same location that
he has been having in the past month.

What would you recommend to the physician for pain relief?