WELCOME TO THE STAFF EDUCATION PAGE OF THE PAIN WEBSITE

Welcome To The Staff Education Page
Of The Pain Website

Inadequate treatment of pain is a major problem, estimated to cost American society over $50 billion annually. Effective treatment of pain became a national issue during the debate over assisted suicide in the late 1990s. Unexpectedly, the repeating theme of the New York state hearings was that patients wanted assisted suicide available because they feared an agonizingly painful death, and did not trust the medical community to provide adequate pain relief. Pain surveys confirmed that, despite having the knowledge and technology available to treat pain effectively, patients were routinely allowed to experience significant pain.

The JCAHO has responded with a new set of standards, effective in 2001, that mandates the routine assessment and treatment of pain. This website is designed to provide you a basic pain knowledge base, and serve as a springboard for further learning in the area of pain management. We hope that you find it useful, and would appreciate your comments on improving the site for those who come after you.

Part 1- JCAHO Standards and intent

Part 2- UMHHC Pain Policy Highlights

Part 3- Pain information given to all patients

Part 4 Adult Pain Management staff education

Part 5 Pediatric Pain Management staff education

Part 1 JCAHO Standards

JCAHO has revised some of the existing standards and also added new ones to reflect a new emphasis upon pain management. In this section, we will list only the JCAHO standards relevant to pain management and summarize any changes in the intent language. Any completely new language will be underlined. The standards also include examples of implementation and evidence of performance. You may refer to the official handbook at the JCAHO site: www.jcaho.org for full details.

Standard RI.1.2 Patients are involved in all aspects of their care.
Relevant intent:

Hospital promote patient and family involvement in all aspects of their care through implementation of policies and procedures that are compatible with the hospital’s mission and resources, have diverse input, and guarantee communication across the organization. Patient are involved in at least the following aspects of their care:

Making care decisions, including managing pain effectively

Standard RI.1.2.8 Patients have the right to appropriate assessment and management of pain
Relevant intent:

Pain can be a common part of the patient experience; unrelieved pain has adverse physical and psychological effects. The patient’s right to pain management is respected and supported. The organization plans, supports, and coordinates activities and resources to assure the pain of all individuals is recognized and addressed appropriately. This includes:

Initial assessment and regular reassessment of pain;
Education of relevant providers in pain assessment and management;
Education of patients, and families when appropriate, regarding their roles in managing pain as well as the potential limitations and side effects of pain treatments;
After considering personal, cultural, spiritual, and/or ethnic beliefs, communicating to patients and families that pain management is an important part of care.

Standard PE.1.4 Pain is assessed in all patients
Relevant intent

In the initial assessment, the organization identifies patients with pain. When pain is identified, the patient can be treated within the organization or referred for treatment. The scope of treatment is based upon the care setting and services provided. A more comprehensive assessment is performed when warranted by the patient's condition. This assessment and a measure of pain intensity and quality (eg, pain character, frequency, location, duration), appropriate to the patient's age, are recorded in a way that facilitates regular reassessment and follow up according to criteria developed by the organization.

Standard TX.3.3 Policies and procedures support safe medication prescription or ordering.
Relevant intent

Procedures supporting safe medication prescription or ordering address:

Appropriate use of patient-controlled analgesia (PCA), spinal/epidural, or intravenous administration of medications and other pain management techniques in the care of patients with pain

Standard TX.5.4 The patient is monitored during the post procedure period.

Relevant intent

The patient is monitored continuously throughout the post procedure period. The following items are monitored:

Pain intensity and quality (for example, pain character, frequency, location, duration and responses to treatments.3

Standard PR.1.7 Patients are taught that pain management is a part of treatment
Relevant intent:

The hospital uses guidelines in educating patients on the following topics:

Understanding pain and the importance of effective pain management

Standard CC.6.1 The discharge process provides for continuing care based on the patient’s assessed needs at the time of discharge.
Relevant intent:

Discharge planning identifies patients’ continuing physical, emotional, symptom management (for example, pain, nausea, dyspnea), housekeeping, transportation, social, and other needs and arranges for services to meet them.

Standard PI.3.1 The organization collects data to monitor its performance
Relevant intent:

Data that the organization considers for collection to monitor performance include:

Appropriateness and effectivenss of pain management

Part 2 Pain Policy Highlights (Full Policy Link)

The UMHS policy is intended to assist practitioners in adhering to JCAHO standards. Important Highlights from this policy are:

Pain will be assessed in patients
A physician, nurse, and/or other HCP will identify the presence of pain as it relates to the purpose for a patient encounter at UMHHC
Where appropriate, pain intensity will be scored using standardized scales

Scores ranging from 0-10 are encouraged where appropriate
Documentation in the inpatient setting will be with other vital signs, while pain scores in ambulatory care will appear in the clinic notes

Ongoing assessment is necessary to evaluate changes in pain intensity or character as well as the effectiveness of treatment
A variety of pain management techniques will be employed i.e. pharmacologic and non-pharmacologic
Patients and families will receive information regarding pain assessment and management
Orientation, resource materials and ongoing opportunities will be provided to educate paient care staff at all levels.
QI monitoring will be established

Part 3 Pain Information given to all patients
Pain Management for Adult Patients at the University of Michigan Medical Center

Pain can have a serious impact on your quality of life. Pain can change your mood, cause you to lose sleep, and interfere with your daily activities. You have a right to good pain management. It is your responsibility to inform us about your pain in order to achieve the best results.

Our recommendations:

Make sure that a member of your health care team is aware of any pain you are having. Some patients are hesitant to discuss their pain, but we encourage you to do so.
Tell your health care team the following things about your pain:

where it is located
how bad it is
what has helped so far or in the past

If pain medications are prescribed for you, please:

make sure you know who and when to call if your pain is not well controlled
learn the possible side effects of your medication

Please ask your health care team for more specific information about pain and alternative methods of pain management appropriate for your personal condition. We are committed to treating your pain.

Pain Management for Children at the University of Michigan Medical Center

Pain can have a serious impact on your child’s quality of life. Pain can change your child’s mood, cause loss of sleep, and interfere with daily activities. Your child has a right to good pain management. It is the responsibility of you and your child to inform us about your child’s pain in order to achieve the best results.

Our recommendations:

Make sure that a member of your child’s health care team is aware of any pain your child is having. Some patients are hesitant to discuss their pain, but we encourage you and your child to do so.
Tell your health care team the following things about your child’s pain:

where it is located
how bad it is
what has helped so far or in the past

If pain medications are prescribed for your child, please:

make sure you know who and when to call if your child’s pain is not well controlled
learn the possible side effects of the medication

Please ask your child’s health care team for more specific information about pain and alternative methods of pain management appropriate for your child’s personal condition. We are committed to treating your child’s pain.

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 under-report 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 conitinue 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 conitnued 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 5^th 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."

"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 physiological status, anxiety and other environmental factors.

Pain Documentation

Pain assessment results can be charted in a variety of places:

Inpatient:

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.

Analgesia flow sheet

When a PCA or Epidural is being utilized, pain scores can be documented here.

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 (eg, 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 theraputic 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 Antiinflammatory Agents	TylenolÒ , ibuprofen (MotrinÒ ), naproxen (NaprosynÒ )
Moderate (pain score 4-6)	IV Ketorolac, oral acetaminophen/opioid combinations	ToradolÒ , VicodinÒ , TyloxÒ , TylenolÒ with codeine #3
Severe (pain score 7-10)	Opioid	Morphine, hydromorphone (DilaudidÒ ), fentanyl

For elderly patients, "start low and go slow". Initial doses should be 25-50% lower, with frequent reassessment and careful titration.

Administer anaglesics 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 (eg, 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. TyloxÒ , VicodinÒ ).

Manage breakthrough pain, increasing the maintenance dose of the opioid if more than 2 rescue doses/day are needed.

Addition of hydroxyzine (VistarilÒ ) or promethazine (PhenerganÒ ) 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 durations 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 durations 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:

Naloxone (NarcanÒ ) should only be used in emergencies situations:

Patient is unresponsive to physical stimulation

Respirations are shallow or respiratory rate is < 8 breaths/min

Pupils are pinpoint.

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.

^cMost 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.

^gDarvocet 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 untolerable 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.

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.

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 permissable).

Docusate + casanthranol (Pericolace)

Docusate + senna (Senokot-S)

Tolerance to constipation does not occur over time.

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:

Diphenhydramine (Benadryl)

Low dose nalbuphine (Nubain) (e.g.. 2.5mg IV in adults)

Tolerance occurs over time.

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.

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.

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, respirations 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. (eg. 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.

Tolerance occurs over time.

Hypersensivity Reactions

True allergic reactions to opioids are rare, but can occur.

Change to a different class of opioid.

Morphine derivatives: morphine, codeine, oxycodone, hydromorphone, hydrocodone

Meperidine derivatives: meperidine, fentanyl

Methadone derivatives: methadone, propoxyphene

Non-Pharmacologic Approaches To 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.

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:

Cognitive-behavioral

Education
Relaxation, imagery
Psychotherapy, counseling
Hypnosis
Biofeedback
Music, literature, art, play
Prayer, meditation

Physical

Massage
Acupuncture, acupressure
Application of heat or cold
TENS
Immobilization, graded mobilization
Therapeutic exercise

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.

Part 5 Pediatric Pain Management staff education

Top Ten things you need to know about pediatric pain management:

Babies do have PAIN.

If a pediatric patient is lying still, pain is probably an issue. Children may not always be willing or able to communicate the fact that they are in pain.

When there is pain, there is usually nausea. Treat both.

Don’t UNDERMEDICATE. Pediatric patients often require more pain medication than adults (in milligrams/ kilogram) do to achieve pain control. Repeat patients usually need more medication to attain the same degree of pain relief.

Incorporate the family into the pediatric patient’s care, since family insights are very helpful at all ages and developmental stages.

When assessing the effect of pain medications, remember to consider the patient’s normal routine. If it’s naptime the child may not arouse easily. Pain medication may not be the problem.

Titrate pain medication in increments is when possible. Monitor respiratory status if narcotics are being used.

Always consider other reasons for patient discomfort besides pain. Is the child wet or hungry? Does she want her parents? Does he need to be burped?

Communicate at the child’s level when assessing pain and response to pain, remembering that many children regress when in pain.

Seek other pediatric personnel as consultants whenever necessary.

Barriers to Effective Pain Management

Provider Barriers (Pain Management in Children with Cancer, Texas Cancer Center, 1999)

MYTH: Young Infants do not feel pain. Children’s nervous systems are immature and are unable to perceive and experience pain the way adults do. (Texas Cancer Council, 1999)

FACT: The Central nervous system of a 26 week old fetus possess the anatomical and neurochemical capabilities of experiencing nociception (Anand, 1998)

MYTH: Children easily become addicted to narcotics.

FACT: Less than 1% of children treated with opioids (Narcotics) develop addiction. (Foley, 1996)

MYTH: Children tolerate pain better than adults.

FACT: Younger children experience higher levels of pain during procedures than older children. Children’s tolerance for pain increases with age. (Bromme, Rehwalt and Fogg, 1998; Broome and others 1990)

MYTH: Children are unable to tell you where they hurt.

FACT: Children may not be able to express their pain in the same manner as adults. Children are able to point to eh body area where they are experiencing pain or draw a picture illustrating their perception of pain.

MYTH: Children become accustomed to pain or painful procedures.

FACT: Children exposed to repeated painful procedures often experience increasing anxiety and perception of pain with repeated procedures (Zeltzer, 1990).

MYTH: Children will tell you when they are experiencing pain.

FACT: Children may not report pain due to fear of administration of a painful analgesic (injection) or fear of returning to the hospital. Children who have experienced chronic pain may not be aware that they are experiencing pain. Young children may not have adequate communication skills or others may not think it is necessary to tell health professionals about the pain (Favaloro and Touzel, 1990).

MYTH: Children’s behaviors reflect their pain intensity.

FACT: Children are unique in their ways of coping. Children’s behavior is not a specific indication of their pain level (Beyer, McGrath and Berde, 1990).

Basic Concepts of Pain Management

The patient is the authority on his own pain.

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.

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.

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).

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 (narcotics).

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 5^th vital sign.

Pediatric Pain assessment should be appropriate to the developmental level. All pediatric patients should be assessed for pain. Pain can be communicated by words, expressions, and behavior (crying, guarding a body part, grimacing).

Using the QUEST Principles of pain assessment (Baker and Wong, 1987) may be helpful in assessing pediatric pain.

Question the child.

Use pain rating scales.

Evaluate behavior and physiological changes.

Secure parent’s involvement.

Take cause of pain into account.

Take action and evaluate results.

Neonates:

Situations that are painful for older children and adults can be expected to be painful for babies. Neonates that are ill may not be able to cry.

Signs Of Acute Pain	Signs of Chronic Pain
Crying and moaning	Apathy
Muscle rigidity	Irritability
Flexion or flailing of the extremities	Changes in sleeping and eating patterns
Diaphoresis	A lack of interest in their surroundings
Irritability
Guarding
Changes in vital signs, and pupillary dilatation

Older Children:

Children less than 3 years old or unable to communicate, clinicians should use the FLACC scale.

Children over 3 may use the Faces scale. The clinician can create this at the bedside with a pencil and paper and draw different faces.

Children over 5 may be able to use descriptor words (stinging, burning).

Children over 6, who understand the concepts of rank and order, can use numerical scale.

Factors Influencing Pain Ratings:

Because each child may regress when they are in pain, it is important to use whatever tool meets the cognitive level of the child.

Children may fear consequences (e.g., physical exam or injection) if they admit to having pain.

Children may not understand the relationship between pain assessment, treatment and the relief of pain.

Observation of behavior is a complimentary way to evaluate pain as well. Including the patient’s family or guardian may help in the assessment of pain. Observation is the only way to assess a non-communicative child.

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

Color Scale

Word Graphic Scale

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.

(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

Pain Documentation

Pain assessment results can be charted in a variety of places:

Inpatient:

24 hour flow sheet

Place pain score below the charting area for vital signs. Updates can be entered every hour. (See sample)

Analgesia flow sheet

When a PCA or Epidural is being utilized, pain scores can be documented here.

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 by Inferred Pathology

Two Major types of Pain

Nociceptive Pain

a. Somatic Pain

b. Visceral Pain

Neuropathic Pain

a. Centrally Generated Pain

b. Peripherally Generated Pain

Nociceptive Pain: Normal processing of stimuli that damages normal tissues or has the potential to do so if prolonged; usually responsive to nonopioids and/ or opioids.

Somatic Pain: Arises from bone, joint, muscle, skin, or connective tissue. It is usually aching or throbbing in quality and is well localized.
Visceral Pain: Arises form visceral organs, such as the GI tract and pancreas. This may be subdivided:

1. Tumor involvement of the organ capsule that causes aching and fairly well-localized pain.

2. Obstruction of hollow viscus, which causes intermittent cramping and poorly localized pain.

Neuropathic Pain: Abnormal processing of sensory input by the peripheral or central nervous system; treatment usually includes adjuvant analgesics.

Centrally Generated Pain

1. Deafferentation pain. Injury to either the peripheral or central nervous system. Examples: Phantom pain may reflect injury to the peripheral nervous system; burning pain below the level of a spinal cord lesion reflects injury to the central nervous system.

Sympathetically maintained pain. Associated with dysregulation of the autonomic nervous system. Examples: May include some of the pain associated with reflex sympathetic dystrophy/ causalgia (complex regional pain syndrome, Type I, type II).

Peripherally Generated Pain

1. Painful polyneuropathies. Pain is felt along the distribution of many peripheral nerves. Examples" Diabetic neuropathy, alcohol-nutritional neuropathy, and those associated with Guillain-Barre’ syndrome.

2. Painful neuropathies. Usually associated with a known peripheral nerve injury, and pain is felt at least partly along the distribution of the damaged nerve. Examples: nerve root compression, nerve entrapment, trigeminal neuralgia.

BASIC PHARMACOLOGIC PAIN MANAGEMENT PRINCIPLES

Analgesia should be administered in a manner that is not feared by the child. Oral or intravenous administration of pain medication is the preferred method. Most children would rather have pain than an intramuscular injection.

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 Antiinflammatory Agents	TylenolÒ , ibuprofen (MotrinÒ ), naproxen (NaprosynÒ )
Moderate (pain score 4-6)	IV Ketorolac, oral acetaminophen/opioid combinations	ToradolÒ , VicodinÒ , TyloxÒ , TylenolÒ with codeine #3
Severe (pain score 7-10)	Opioid	Morphine, hydromorphone (DilaudidÒ ), fentanyl

Morphine can be safely titrated to effect in the pediatric setting.

PCA or NCA are acceptable methods of administering pain medications. Patients and families should be educated on PCA delivered medication. Parents should be instructed never to push the PCA button when the child is asleep.

Use Of The Equianalgesic Table

APPROXIMATE OPIOID EQUIANALGESIC DOSES (PEDIATRIC)***

DRUG	DOSE (mg) Parenteral	DOSE (mg) Oral	DURATION (hour)
Morphine	1	3 ^a	4 -6
Morphine – Sustained Release (MS Contin, Oramorph SR)	---	3	8 –12
Morphine – Sustained Release (Kadian)	---	3	24
Hydromorphone (Dilaudid)	0.15	0.75	4 - 5
Meperidine (Demerol) ^b	7.5	30	2 - 4
Fentanyl (Sublimaze)	0.01		1
Codeine ^c (Tylenol with codeine #2, #3 or #4)	12	20	4 - 6
Hydrocodone ^d (Vicodin, Lortab)	---	3	4 - 6
Oxycodone ^e (Percodan, Percocet, Tylox, Roxicet, Roxicodone))	---	3	4 - 6
Oxycodone Controlled Release (Oxycontin)	---	3	8 - 12
Methadone (Dolophine) ^f		0.3	4 – 8
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.
Ketorolac (Toradol)	1-3	1	6
Ibuprofen (Motrin)	---	130	6 – 8
Acetaminophen (Tylenol)	---	390	4

^a IM:PO ratio is 1:6 (1mg IM = 6mg po) with single or intermittent dosing. With chronic dosing, the ratio changes to 1:3 (1mg IM = 3mg po).

^b Not recommended for pain management. Keep doses under 600mg/day and do not use for > 48 hours.

^cMost preparations contain either 15, 30 or 60mg of codeine with 300mg acetaminophen. Do not exceed 75mg/kg/day or 2.6 grams/day in children under 12 years of age. Do not exceed 4 grams/day of acetaminophen in children > 12 years of age.

^d Preparations contain either 5, 7.5 or 10mg of hydrocodone in combination with acetaminophen (500, 650 or 750mg). Do not exceed 75mg/kg/day or 2.6 grams/day in children under 12 years of age. Do not exceed 4 grams/day of acetaminophen in children > 12 years of age.

^e Preparations contain 5mg oxycodone in combination with acetaminophen (325 or 500mg). Do not exceed 75mg/kg/day or 2.6 grams/day in children under 12 years of age. Do not exceed 4 grams/day of acetaminophen in children > 12 years of age.

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

* ** This table is 1/10 of the value of the equianalgesic doses for adults. 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.

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

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, pruritus (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.

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.

Non-Pharmacologic Approaches to 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.

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:

Cognitive-behavioral

Education
Relaxation, imagery
Psychotherapy, counseling
Hypnosis
Biofeedback
Music, literature, art, play
Prayer, meditation

Physical

Massage
Acupuncture, acupressure
Application of heat or cold
TENS
Immobilization, graded mobilization
Therapeutic exercise

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.

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.

References:

Shapiro, B.S., Pain in Children
UMHHC Pain Policies and Procedures 03/03/01
Pain Management in Children with Cancer, Texas Cancer Council, 1999
McCaffery, M., Pasero, C., Pain Clinical Manual, second edition, 1999