|
Part
4:
Adult Pain Management Staff Education
Barriers
to Effective Pain Management
Both
patients and providers establish barriers
Provider
Barriers
- Health care
professionals often fail to routinely assess and document pain.
- Due to inadequate
training, health care professionals often lack knowledge and skills
to assess and manage pain effectively.
- There is
a lack of practical, effective treatment protocols.
- Health care
professionals lack sufficient knowledge to employ safe equianalgesic
principles.
- Health care
professionals may have exaggerated concerns related to the side
effects of opiods, especially about tolerance and addiction.
- Health care
professionals may undertreat pain because of belief in common
misconceptions regarding pain:
- Myth:
A patient’s pain perception can accurately be correlated
with vital sign changes and evidence of injury.
- Myth:
Patients in pain readily express their pain to health care providers.
- Myth:
Patients of certain cultural, ethnic, or socioeconomic backgrounds
consistently underreport or over-report their pain.
- Myth:
Opioids are addictive and a treatment of last resort because
of unmanageable side effects.
- Myth:
Patients experiencing chronic pain over-report pain because
they are addicted to opioids.
- Myth:
Older patients, and cognitively impaired patients do not perceive
pain as intensely as other patients.
- Myth:
If a patient is able to sleep, they must not be in very much
pain.
- Myth:
The goal of chronic pain management is to keep the dose of medication
as low as possible.
- Myth:
Patients with a history of substance abuse who require IV opioids
should never be allowed to control their own dose of medication
(i.e. patient controlled analgesia).
- Myth:
There is no physiological basis for the moderating effects of
emotions on pain perception.
Patient
Barriers
Patients
often share similar concerns and all too often seem willing to
"tough it out" rather than complain about their pain. A patient
may be reluctant to report pain because of a belief in these myths:
- Myth:
Severe or chronic pain cannot be effectively controlled.
- Myth:
Opioids are always addictive and a treatment of last resort
( "I must really be dying.").
- Myth:
Pain is always evidence of disease progression.
- Myth:
It is more admirable or socially acceptable to ignore pain.
- Myth:
Pain is an unavoidable result of aging or disease.
- Myth:
Pain is a deserved punishment.
Basic
Concepts Of Pain Management
- The patient
is the authority on his own pain.
It
is very important to know and recognize the patient’s physiological,
psychological, and emotional responses to pain when developing
a pain management plan. Without addressing these important issues,
it is often difficult to develop an adequate pain treatment plan.
Changes
in vital signs do not occur with all patients who are experiencing
severe pain. Do not rely on vital signs to determine the severity
of a patient’s pain.
Patients
with pain, even severe pain, can be distracted from thinking about
their pain, and may even be able to sleep. Don’t trust that a
patient isn’t having pain because he "looks comfortable."
Always ask, and believe the patient’s assessment of his own pain.
- The patient
has the right to expect a rapid and effective response to a complaint
of pain.
Treat
the pain, reassess frequently, and continue to treat until the
patient is comfortable or side effects prevent further treatment.
If this occurs, consult a pain expert- don’t leave a patient in
pain without a treatment plan.
- A history
and physical examination of the pain is very helpful. Details
of the pain’s location, duration, radiation, and character often
provide valuable clues about how to treat the pain most effectively.
- Medications
are best given orally for long-term management of pain. For short-term
management, like postoperative pain, the IV route is preferred
(especially with severe pain).
- Most pain
medications have side effects. Effective pain relief is often
accompanied by at least some of these side effects. Be prepared
to treat the side effects of opioids if they occur (e.g., nausea
or itching).
- A balanced
approach to pain management combines nonpharmacologic and pharmacologic
therapy, and frequently utilizes multiple analgesics which work
by different mechanisms.
- Chronic pain
patients are usually on a specific regimen of pharmacologic and
nonpharmacologic therapy. This regimen must be continued during
their hospitalization. Superimposed acute pain (e.g. acute postoperative
pain) should be treated with additional opioids.
Pain
Assessment and Documentation
Pain
Assessment
A
physician, nurse, and/or other health care professional should
identify the presence of pain for each patient encounter at UMHHC
. If pain is present, its intensity is scored, typically using
a standardized 0 to 10 scale. (See "pain scales" below).
Pain scores are documented in writing, just like vital signs,
making them readily available to all members of the health care
team. The JCAHO actually suggests that pain should be thought
of as the 5th vital sign.
In
the hospital setting, the patient’s pain is assessed at least
as often as vital signs are taken, because ongoing assessment
is necessary to evaluate changes in pain and the effectiveness
of its treatment. Pain should be assessed at intervals appropriate
to the severity of pain and the patient’s situation. For many
patients, this will mean assessment of pain every 4 hours, but
the time between assessments must be individualized to the patient’s
need.
In the ambulatory care setting, pain assessment should be
completed with every new episode of care. Repeated visits or contacts
for the same problem may not require repeated pain assessments
(unless a current pain problem is being followed).
Pain
Scales
Scales should
be developmentally, physically, emotionally and cognitively appropriate
for the given patient.
Suggested
standardized tools with 0 to 10 scoring are listed below.
Other scales may be adopted for specific UMHHC units.
- Numeric
rating scale
- Color
scale
- Word
graphic scale
- Wong-Baker
FACES Pain Rating Scale (3 years of age and older)
- FLACC
(ages 3 months to 7 years)
(See
the instructions and illustrations that follow.)
Numeric
Rating Scale
Ask the patient
to rate their pain intensity on a scale of 0 (no pain) to 10 (the
worst pain imaginable). Some patients are unable to do this with
only verbal instructions, but may be able to look at a number scale
and point to the number that describes the intensity of their pain.
Color
Scale
This scale
is a colored stripe in which color gradually changes from white
(no pain) through shades of pink to dark red (worst possible pain).
Ask the patient to point to the area on the scale that shows their
level of pain. To obtain a number for documentation use the scale
parallel to the color stripe to find the number corresponding to
the area where the patient points.
Word Graphic Scale
This
scale can be used with patient as young as 6 years of age. It uses
a line with words to describe pain intensity from "no pain"
to "worst possible pain". Show and explain the scale to
the patient and then ask him or her to point (or mark) anywhere
along the line that shows how much pain they have. To find a number
for documentation count the black dots, starting with zero at the
far left, to the area where the patient points, up to ten at the
far right.
Wong-Baker
FACES Pain Rating Scale
From Wong
DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, Ahmann E, DiVito-Thomas
PA: Whaley and Wong’s Nursing Care of Infants and Children, ed.
6, St. Louis, 1999, Mosby, p. 1153.
This scale
can be used with young children (sometimes as young as 3 years
of age). It also works well for many older children and adults
as well as for those who speak a different language. Explain that
each face represents a person who may have no pain, some pain,
or as much pain as imaginable. Point to the appropriate face and
say:
(0) "This
face is happy and does not hurt at all."
(2) "This face hurts just a little bit."
(4) "This face hurts a little more."
(6) "This face hurts even more."
(8) "This face hurts a whole lot."
(10) "This face hurts as much as you can imagine, but
you don't have to be crying to feel this bad."
Ask the patient
to choose the face that best matches how she or he feels or how
much they hurt.
FLACC Scale
This is a behavior scale that has been tested with children age
3 months to 7 years. Each of the five categories (Faces, Legs, Activity,
Cry, Consolability) is scored from 0-2 and the scores are added
to get a total from 0-10. Behavioral pain scores need to be considered
within the context of the child's psychological status, anxiety
and other environment factors.
| Face |
0
No particular expression or smile
|
1
Occasional grimace or frown, withdrawn disinterested
|
2
Frequent to constant frown, clenched jaw, quivering chin
|
| Legs |
0
Normal position or relaxed
|
1
Uneasy, restless, tense
|
2
Kicking, or legs drawn up
|
| Activity |
0
Lying quietly, normal position, moves easily
|
1
Squirming, shifting back and forth, tense
|
2
Arched, rigid, or jerking
|
| Cry |
0
No cry
(awake or asleep)
|
1
Moans or whimpers, occasional complaint
|
2
Crying steadily, screams or sobs, frequent complaints
|
| Consolability |
0
Content, relaxed
|
1
Reassured by occasional touching, hugging or "talking
to, distractible
|
2
Difficult to console or comfort
|
The FLACC is a
behavior pain assessment scale
©University of Michigan Health System (can be reproduced for clinical
or research use)
Pain
Documentation
Pain
assessment results can be charted in a variety of places.
Inpatient:
1.
24 hour flow sheet
Place pain score below the charting area for vital signs.
Updates can be entered every hour. ( See sample)
On the reverse side of the flow sheet is an area labeled "cognitive/perceptual"
or "rest and comfort". (See sample) This charting space
allows documentation of pain score, comfort level AND patient
satisfaction with their current level of pain. Any additional
information can be noted in the "other" section at the
bottom of this page.
2.
Analgesia flow sheet
When
a PCA or Epidural is being utilized, pain scores can be documented
here.
3.
Progress notes and discharge summary
The
note may indicate the intensity and characteristics of the
patient’s pain, along with current treatment and future pain
plan.
Ambulatory
care
1. Clinic notes
Classification
of Pain
Pain
is defined as "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)
Pain
can be separated into two broad categories: acute pain and chronic
pain. This distinction is not perfect- cancer pain, for example,
may have components of both. Nevertheless, it remains a useful way
to classify pain.
Acute
Pain
Acute
pain is the symptom of a larger disease process, and is usually
nocioceptive in nature. This means that a noxious (unpleasant) event
stimulates the intact nervous system to produce the sensation of
pain. Examples of this noxious event include a surgical incision,
labor pain, acute pancreatitis or a myocardial infarction.
Acute
pain can be somatic or visceral or neuropathic in origin. Somatic
pain is sharp and well localized in nature, usually to an external
site. Visceral pain tends to be dull and vaguely localized to a
deep site, and is frequently associated with nausea. Acute pain
is self-limiting, and resolves when the noxious stimulus ceases.
Physiological
and psychological responses to acute pain are directed toward
escape from the painful situation. Acute pain usually triggers
a neuroendocrine stress response, which is proportional to the intensity
of the pain. This is a variant of the fight-or-flight response.
Catecholamines are released, increasing heart rate, blood pressure,
and systemic vascular resistance. Other effects of this catecholamine
release may include urinary retention, ileus, stress ulcers, increased
work of breathing, nausea, and constipation.
The
predominant emotional response to acute pain is anxiety,
although anger toward caretakers may also be expressed. These emotional
responses indicate that the patient believes the pain to be temporary
and "fixable", and represent an attempt to escape from
the painful stimulus.
Acute
pain usually responds well to non-steroidal pain relievers and/or
narcotics. Frequently, neural blockade can effectively relieve acute
pain and de-
crease the likelihood of developing a chronic pain syndrome.
Chronic
Pain
Chronic
pain is pain that persists beyond the expected time of healing.
The time course for the development of chronic pain is variable,
and arbitrary time classifications (e.g., longer than 6 months)
will often be inaccurate. The ongoing pain itself has now become
a significant disease process, not just a symptom of a disease process.
The transition to chronic pain is marked by changes in both physiological
and psychological responses. Instead of trying to escape the painful
situation, the patient is now trying to adapt to ongoing
pain.
The
neuroendocrine stress response is typically exhausted in chronic
pain states, and catecholamine induced changes are now absent. Vegetative
responses predominate, including sleep disorders, irritability,
depression, and decreased motor activity. Patients often appear
subdued, sleepy or sad in appearance.
Psychological
factors are important in chronic pain. Withdrawal and depression
are common, causing severe strain on social and family support systems.
Narcotic tolerance is frequent, further complicating the treatment
of this patient group.
While
chronic pain can be somatic or visceral, it is very often neuropathic
in nature. Nervous system tissue has been damaged, and abnormally
maintains the sensation of pain without any external stimulus. Neuropathic
pain is usually associated with some form of sensory deficit, and
is described as typically raw or burning in nature.
Unlike
acute pain, narcotics alone are usually ineffective in relieving
chronic pain. Treatment of chronic pain states involves the use
of antidepressants, anticonvulsants, and/or corticosteroids. Additionally,
diagnostic and therapeutic nerve blocks can be helpful.
BASIC
PHARMACOLOGIC PAIN MANAGEMENT PRINCIPLES
- Use IV
medications when the pain is severe and acute. Chronic or moderate
pain is usually treated with oral medications. Avoid IM medications
whenever possible.
- Base the
initial choice of analgesic on the severity and type of pain
|
Pain
Severity
|
Analgesic
Choice
|
Examples
|
|
Mild
(pain score 1-3)
|
Acetaminophen,
Nonsteroidal Anti-inflammatory Agents
|
Tylenol®,
ibuprofen (Motrin®), naproxen (Naprosyn® )
|
|
Moderate
(pain score 4-6)
|
IV
Ketorolac, oral acetaminophen/opioid combinations
|
Toradol®,
Vicodin®, Tylox®, Tylenol® with codeine
#3
|
|
Severe
(pain score 7-10)
|
Opioid
|
Morphine,
hydromorphone (Dilaudid®), fentanyl
|
- For elderly
patients, "start low and go slow". Initial doses should
be 25-50% lower, with frequent reassessment and careful titration.
- Administer
analgesics on a scheduled basis (around the clock) rather than
on an as needed basis for moderate to severe pain.
- Allergy
to opioids is rare, with patients often mistaking side effects
such as nausea, vomiting and itching for an allergy. A true
allergic reaction is more likely to occur with morphine and
codeine and least likely with meperidine, fentanyl, methadone
and propoxyphene. (See Preventing and Managing Common Opioid
Side Effects for list of opioid classes.)
- Physical
dependence will develop with chronic opioid therapy. Doses
must be tapered to prevent withdrawal.
- Monitor
and manage any side effects
- Reassure
the patient that addiction during opioid use is extremely
rare. Less than 1% of patients develop addiction, even during
treatment for chronic nonmalignant pain.
- When selecting
a dose of an opioid, consider whether the patient is opioid-naïve
or opioid-tolerant. Patients who have used opioids regularly
for approximately 7 days or more are considered opioid-tolerant
and will require higher doses for acute (e.g., postoperative)
pain control.
- Increase
the dose if necessary every 1-2 days until pain relief is achieved
or side effects are unmanageable before changing medications.
There is no maximum or ceiling dose for analgesia with opioids
unless the opioid is in combination with acetaminophen
or aspirin, which have a maximum dose of 4 grams/day of acetaminophen
(e.g. Tylox® , Vicodin®)
- Manage
breakthrough pain, increasing the maintenance dose of the opioid
if more than 2 rescue doses/day are needed.
- Addition
of hydroxyzine (Vistaril®) or promethazine (Phenergan®)
to meperidine does not provide additional analgesia.
Respiratory depression, mental status depression and hypotension
occur more frequently when this combination is administered
- Both
meperidine and morphine cause constriction of the sphincter
of Oddi and the biliary tract. In humans, morphine and meperidine
caused a rise in bile duct pressure of 52.7% and 61.3%, respectively.
Therefore, meperidine is not preferred over morphine for pancreatitis
or cholecystis pain
- Meperidine
(demerol) is metabolized to normeperidine, which is renally
excreted. Large doses (doses greater than 400-600mg / day) and
longer duration's of administration (greater than 48 hours)
can result in accumulation of normeperidine in patients with
normal renal function. Accumulation of normeperidine
can occur with lower doses and shorter duration in patients
with compromised renal function. Normeperidine can cause tremors
and seizures in susceptible patients which is not reversed
by naloxone (it may even worsen seizures).
- Administration
of naloxone:
Dilute
the naloxone and administer it very slowly in increments.
Giving too much naloxone or giving it too fast can precipitate
severe pain (which is extremely difficult to control) and
increase sympathetic activity leading to hypertension, tachycardia,
ventricular arrhythmias, pulmonary edema and cardiac arrest.
Withdrawal can be precipitated in physically dependent patients.
Use
of The Equianalgesic Table
It is often necessary to change the route of a patient’s pain
medication or the drug itself. Examples of this include a patient
who:
- is
on IV medications, but must be converted to oral medications
prior to discharge,
- has
chronically taken oral medications but cannot now, or
- has
developed intolerable side-effects to one narcotic, and
must be switched to another.
By
using the relative potency estimate (equianalgies dose), one can
rationally change from one opioid to another or from one route
of administration to another in an attempt to maintain or improve
analgesia.
The
equianalgesic table was developed to determine the appropriate
dose of the new medication. In order to calculate the new dose,
three pieces of information are necessary:
- the
route and name of the old medication,
- the
24 hour dose of the old medication, and
- the
route and name of the proposed new medication.
A
sample calculation follows the equianalgesic table.
APPROXIMATE
OPIOID EQUIANALGESIC DOSES (ADULT)***
|
DRUG
|
DOSE
(mg)
Parenteral
|
DOSE
(mg)
Oral
|
DURATION
(hour)
|
|
Morphine
|
10
|
30 a
|
4 -6
|
|
Morphine
– Sustained Release
(MS
Contin, Oramorph SR)
|
---
|
30
|
8 –12
|
|
Morphine
– Sustained Release (Kadian)
|
---
|
30
|
24
|
|
Hydromorphone
(Dilaudid)
|
1.5
|
7.5
|
4 - 5
|
|
Meperidine
(Demerol) b
|
75
|
300
|
2 -4
|
|
Fentanyl
(Sublimaze, Duragesic)
|
0.1
|
|
1 – 2
|
|
Codeine
c, h (Tylenol with codeine
#2, #3 or #4)
|
120
|
200
|
4 - 6
|
|
Hydrocodone
d (Vicodin, Lortab)
|
---
|
30
|
4 - 6
|
|
Oxycodone
e (Percodan, Percocet,
Tylox, Roxicet, Roxicodone)
|
---
|
20
|
4 - 6
|
|
Oxycodone
Controlled Release (Oxycontin)
|
---
|
20
|
8 - 12
|
|
Methadone
(Dolophine) f
|
|
3
|
4 – 8
|
|
Propoxyphene
(Darvon, Darvocet) g, h
|
---
|
180 –
240
|
4
|
|
These
following agents are NOT opioids. In general, they are weaker
analgesics. The equianalgeisa dose is for information only
and, with the exception of ketorolac, it is NOT a reasonable
or appropriate dose.
|
|
Tramadol
(Ultram)
|
---
|
300
|
4 - 6
|
|
Ketorolac
(Toradol)
|
10-30
|
10
|
6
|
|
Rofexocib
(Vioxx)
|
---
|
160
|
24
|
|
Ibuprofen
(Motrin)
|
---
|
1300
|
6 – 8
|
|
Acetaminophen
(Tylenol)
|
---
|
3900
|
4
|
|
Aspirin
|
---
|
3900
|
4
|
a
IM:PO ratio is 1:6 (10mg IM = 60mg po) with single or intermittent
dosing. With chronic dosing, the ratio changes to 1:3 (10mg IM
= 30mg po).
b
Not recommended for pain management. Keep doses under 600mg/day
and do not use for > 48 hours.
c
Most preparations contain either 15, 30 or 60mg of codeine
with 300mg acetaminophen. Do not exceed 4 grams/day of acetaminophen.
d
Preparations contain either 5, 7.5 or 10mg of hydrocodone in combination
with acetaminophen (500, 650 or 750mg) or aspirin (500mg). Do
not exceed 4 grams/day of acetaminophen or aspirin.
e
Preparations contain 5mg oxycodone in combination with acetaminophen
or aspirin (325 or 500mg). Do not exceed 4 grams/day of acetaminophen
or aspirin.
f
Methadone is much more potent than previously described in
the literature and it accumulates with repeated dosing. A highly
individual and cautious approach when switching from another potent
opioid must be taken. Please consult the Acute Pain Service.
g
Darvocet N 50 contains 325mg acetaminophen; Darvocet N 100
contains 650mg acetaminophen. Do not exceed 4 grams/day of
acetaminophen.
Equianalgesic Dose
Conversion Formula ***
Dose
for current drug
(from equianalgesic chart) |
=
|
24-hour
dose of current drug (scheduled and rescue doses) |
| ----------------------------- |
|
-------------------------------- |
Dose
for new drug
(from equianalgesic chart) |
=
|
24-hour
dose of new drug |
***
These are NOT suggested starting doses; these are doses of opioids
that produce approximately the same amount of analgesia. Published
trials vary in the suggested doses that are equianalgesic to morphine.
By using this table, you can determine a dose of a new opioid
and/or route of administration that is approximately equal in
analgesic effect to the dose of the former opioid. Titration to
clinical response is necessary. Recommended doses do not apply
to patients with renal or hepatic insufficiency or other conditions
affecting drug metabolism and kinetics. Elderly patients generally
require lower doses, titrated slowly to the desired effect or
intolerable side effects.
Selected
References:
Principles
of Analgesic Use in the Treatment of Acute Pain and Cancer Pain,
American Pain Society, 1999
Acute
Pain Management in Adults: Operative Procedures. Quick Reference
Guide for Clinicians. AHCPR Pub. No. 92-0019. 1992
Micromedex
® Healthcare Series Drugdex Drug Evaluations
Example
of equianalgesic conversions:
A
patient is on PCA morphine and is now able to take oral medications,
such as Tylox (acetaminophen 500mg + oxycodone 5mg). Over the
past 24 hours, the patient has used 24mg of morphine. To calculate
an equianalgesic dose:
x
= 48 mg of oxycodone/day
-since oxycodone is administered every 4-6 hours, divide 48mg/day
by 4 doses/day = 12mg/dose.
-Each
Tylox tablet contain 5mg oxycodone so 2 tablets every 6 hours
would be an equianalgesic dose. This is also the maximum dose
(4 grams/day of acetaminophen.)
Preventing
And Managing Common Opioid Side Effects
The
use of opioids is associated with the occurrence of drug side
effects, which become more common as doses of opioids are increased
to treat severe pain. These side effects include nausea and vomiting,
constipation, pruritis (itching), mental confusion, sedation,
respiratory depression and hypersensitivity reactions. Proper
use of opioids includes management of these side effects, rather
than discontinuation of opioids in a patient with severe pain.
1.
Nausea and Vomiting
-
If
analgesia is satisfactory, reduce dose (by 10-25%). May
need to add or increase the nonopioid for additional pain
relief.
-
Administer
an antiemetic such as:
-
Prochlorperazine
(Compazine)
-
Metoclopramide
(Reglan), especially if nausea and vomiting are caused
by slowed GI motility
-
Diphenhydramine
(Benadryl), especially if nausea and vomiting are associated
with motion
-
Ondansetron
(Zofran)
-
Dexamethasone
(Decadron) if nausea persists
-
Switch
to another opioid. Individual variation in response to opioids
exists.
-
Tolerance
to this side effect occurs over time.
2.
Constipation
-
All
patients on around-the-clock opioids should also receive
a stool softener and mild stimulant laxative (start on postoperative
patients as soon as permissible).
-
Tolerance
to constipation does not occur over time.
3.
Pruritus
-
If
analgesia is satisfactory, reduce dose (by 10-25%). May
need to add or increase the nonopioid for additional pain
relief.
-
Can
treat with:
-
Tolerance
occurs over time.
4.
Mental confusion, Delerium, Hallucinations
-
Evaluate
the underlying cause and treat appropriately.
-
Eliminate
nonessential CNS-acting drugs
-
If
analgesia is satisfactory, reduce dose (by 25%). May need
to add or increase the nonopioid for additional pain relief.
-
Switch
to another opioid. Individual variation occurs with different
opioids.
-
Avoid
using naloxone, even if the delerium is thought to be due
to the opioid.
5.
Sedation
-
Evaluate
the underlying cause. It is most likely due to the opioid
if opioid therapy has just started or there has been a recent
increase in dose.
-
Eliminate
nonessential CNS-acting drugs.
-
If
analgesia is satisfactory, reduce dose (by 10-25%). May
need to add or increase the nonopioid for additional pain
relief.
-
Consider
giving a lower opioid dose more frequently to decrease peak
serum concentration.
-
Tolerance
to this side effect occurs over time.
-
If
excessive sedation persists, switch to another opioid.
6.
Respiratory Depression
-
Monitor
sedation level and respiratory status. Vigilant monitoring
is critical:
-
during
the first 24 hours in opioid-naïve patients being
treated (with opioids) for moderate to severe pain
-
following
large initial doses, even in tolerant patients
-
in
elderly or debilitated patients
-
in
patients on concurrent respiratory depressant drugs (e.g.
benzodiazepines, tranquilizers), significant pulmonary
disease or history of sleep apnea
-
Administer
IV dose slowly to avoid high peak serum concentration.
-
Physical
stimulation (being awake, pain) reduces risk.
-
Reduce
dose (by 25%) when excessive sedation is detected. (In general,
sedation occurs before respiratory depression.) May need
to add or increase the nonopioid for additional pain relief.
-
If
patient is unresponsive to stimulation, respiration's are
shallow or less than 8 breaths/min or pupils are pinpoint,
stop opioid administration and administer naloxone (Narcan).
-
Dilute
the naloxone and administer it slowly in increments.
(e.g.. 100 mcg at a time).
-
Giving
too much naloxone or giving it too fast can precipitate
severe pain (which is extremely difficult to control)
and increase sympathetic activity leading to hypertension,
tachycardia, ventricular arrhythmias, pulmonary edema
and cardiac arrest.
-
Withdrawal
can be precipitated in physically dependent patients.
7.
Hypersensitivity Reactions
Non-Pharmacologic
ApproachesTo Pain
- Although
analgesics are the mainstay of pain relief, most pain
is best treated with a combination of drug (analgesic)
and non-drug approaches.
- Non-drug
approaches to pain management can enhance comfort, promote
sleep and enhance the quality of life.
A. Non-pharmacologic interventions should routinely
be used. Although these strategies alone are frequently
insufficient for moderate to severe pain, they are usually
helpful in conjunction with pharmacological therapy. Such
strategies may include:
B. Cognitive-behavioral
Education
Relaxation, imagery
Psychotherapy, counseling
Hypnosis
Biofeedback
Music, literature, art, play
Prayer, meditation
C. Physical
Massage
Acupuncture, acupressure
Application of heat or cold
TENS
Immobilization, graded mobilization
Therapeutic exercise
D. Nonpharmacologic interventions may be provided,
based on training, by:
Physicians
Nurses
Physical, occupational, recreation, art, music, child-life
or other therapists
Social workers
Religious or spiritual leaders
Clinical psychologists
Others
Addiction,
Physical Dependence and Tolerance
Addiction
to narcotics is rare (less than 1% of patients) and usually occurs
in patients with a prior history of substance abuse. Addiction
is defined as the continued use of a specific psychoactive substance
despite physical, psychological or social harm.
Physical
dependence differs from addiction. Patients taking opioids
on a chronic basis develop a physical dependence, and experience
withdrawal symptoms during sudden abstinence from the drug. Addiction
is primarily a psychological problem; dependence is a physical
response to continued use of narcotics.
Tolerance
is the need for higher opioid doses to maintain a constant effect.
While this is a poorly understood phenomenon, most patients on
chronic opioids do not experience tolerance. Alternative
explanations, such as a new source of pain or progression of an
existing lesion (especially a neoplasm), should be considered
when tolerance occurs.
Addiction
is a maladaptive behavior pattern, where the need to take a drug
interferes with other life activities. The individual is preoccupied
with a continuing drug supply, despite deterioration of family,
work, and other social relationships. Addiction should be suspected
if concurrent use of alcohol or illicit drugs, frequent visits
to the ER seeking additional medications, forging or losing prescriptions,
repeated noncompliance with medication regimens, and/or the unwillingness
to discuss changes in pain medication are present. These are difficult
patients to deal with and often psychiatry or chronic pain consultation
is helpful.
Use
of opioids in patients with a history of substance abuse is occasionally
necessary. In these cases, a treatment contract should be utilized.
This typically sets out basic terms, such as the single physician
who will prescribe medication, the medication schedule that the
patient is expected to adhere to, and the conditions which will
lead to discontinuation of narcotic therapy.
Pseudoaddiciton
must be differentiated from true addiction. Patients experiencing
continued pain will exhibit anxiety and drug-seeking behavior.
These behaviors typically disappear once the pain is relieved.
This pseudoaddictive behavior is extinguished by adequate pain
relief, unlike the continued drug-seeking behavior of true addiction.
|
