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Palliative Care Summer Institute
Basic and Advanced
Pain Management for Clinicians
Margaret A. Jacobson, MD
Shaun Sullivan...
Palliative Care Summer Institute
Effective pain management is a moral imperative, a
professional responsibility, and the d...
Palliative Care Summer Institute
2010 Washington State Rules regarding chronic pain
management DO NOT APPLY to
 Chronic c...
Palliative Care Summer Institute
1986 WHO Pain Ladder
Palliative Care Summer Institute
2015 WHO Pain Ladder
Palliative Care Summer Institute
 Ongoing
 Individualized
 Documented
“Tell me about your pain….”
Pain Assessment: The ...
Palliative Care Summer Institute
OPQRST
“Tell me about your pain”
 Onset
 Provoking, Palliating
 Quality
 Region/ Radi...
Palliative Care Summer Institute
Universal Pain Intensity Assessment
Tool
Palliative Care Summer Institute
Analgesics should be given “by mouth, by the
clock, by the ladder, and for the individual...
Palliative Care Summer Institute
 It is not necessary to traverse each step of the ladder
sequentially
 For mild pain (1...
Palliative Care Summer Institute
 Safe
 Reliable
 Effective for all types of pain
 Have multiple routes of administrat...
Palliative Care Summer Institute
 Opioids follow first-order kinetics and pharmacologically
behave similarly
 Peak plasm...
Palliative Care Summer Institute
 Routine dosing: Dosing interval is 1 half life
4 hours
 Bolus/breakthrough dosing: dos...
Palliative Care Summer Institute
 Constant pain needs constant control
 Start an opioid naïve patient with a short actin...
Palliative Care Summer Institute
 Renal considerations
 Opioids and their metabolites are primarily excreted renally
 M...
Palliative Care Summer Institute
 Opioid metabolism is not as sensitive to hepatic
compromise
 With severe hepatic impai...
Palliative Care Summer Institute
DRUG IV PO
Morphine 10mg 30mg
Codeine 200 mg
Hydrocodone 30 mg
Oxycodone 20 mg
Hydromorph...
Palliative Care Summer Institute
Opioid side effects
Palliative Care Summer Institute
 Clinician barriers
Barriers to effective use of opioids
Palliative Care Summer Institute
 Patient barriers
Barriers to effective use of opioid
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Basic and Advanced Pain Management for Clinicians - Margaret Jacobson and Shaun Sullivan

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Basic and Advanced Pain Management for Clinicians - Margaret Jacobson, MD; and Shaun Sullivan, MD
Presented at the 2015 Palliative Care Summer Institute conference at Bellingham Technical College

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Basic and Advanced Pain Management for Clinicians - Margaret Jacobson and Shaun Sullivan

  1. 1. Palliative Care Summer Institute Basic and Advanced Pain Management for Clinicians Margaret A. Jacobson, MD Shaun Sullivan, MD Medical Directors, Whatcom Hospice
  2. 2. Palliative Care Summer Institute Effective pain management is a moral imperative, a professional responsibility, and the duty of people in the healing professions Relieving Pain in America: Institute of Medicine (2011)
  3. 3. Palliative Care Summer Institute 2010 Washington State Rules regarding chronic pain management DO NOT APPLY to  Chronic cancer pain  Acute pain caused by an injury or a surgical procedure  Palliative, hospice, and other end-of-life care Pain Management for whom?
  4. 4. Palliative Care Summer Institute 1986 WHO Pain Ladder
  5. 5. Palliative Care Summer Institute 2015 WHO Pain Ladder
  6. 6. Palliative Care Summer Institute  Ongoing  Individualized  Documented “Tell me about your pain….” Pain Assessment: The cornerstone of optimal pain management
  7. 7. Palliative Care Summer Institute OPQRST “Tell me about your pain”  Onset  Provoking, Palliating  Quality  Region/ Radiation  Severity  Treatment  Understanding
  8. 8. Palliative Care Summer Institute Universal Pain Intensity Assessment Tool
  9. 9. Palliative Care Summer Institute Analgesics should be given “by mouth, by the clock, by the ladder, and for the individual” (World Health Organization) Principles of Analgesia
  10. 10. Palliative Care Summer Institute  It is not necessary to traverse each step of the ladder sequentially  For mild pain (1-3) start at step 1  For moderate pain (4-6) start at step 2  For severe pain (7-10) start at step 3 …By the WHO ladder
  11. 11. Palliative Care Summer Institute  Safe  Reliable  Effective for all types of pain  Have multiple routes of administration  Are easily titrated Opioids: Mainstay of treatment of moderate- severe pain in advanced illness
  12. 12. Palliative Care Summer Institute  Opioids follow first-order kinetics and pharmacologically behave similarly  Peak plasma concentration (C max)  60-90 minutes after oral administration  5-10 minutes after IV administration  Opioids are eliminated from the body in a direct and predictable way, irrespective of the dose  The liver conjugates them  The kidney excretes 90-95% of the metabolites  Their metabolic pathways do not become saturated  Each opioid metabolite has a half life that depends on its rate of renal clearance  When renal clearance is normal, codeine, hydrocodone, hydromorphone, morphine, and their metabolites all have effective half lives of approximately 3-4 hours  When dosed repeatedly, their plasma concentrations approach a steady state after about 4-5 half lives (1 day) Opioid Pharmacology
  13. 13. Palliative Care Summer Institute  Routine dosing: Dosing interval is 1 half life 4 hours  Bolus/breakthrough dosing: dosing interval is time to peak effect 1 hour orally, 10 minutes IV  Steady state: achieved after 4-5 half lives 1 day Opioid pharmacology simplified
  14. 14. Palliative Care Summer Institute  Constant pain needs constant control  Start an opioid naïve patient with a short acting opioid, and dose every 4 hours, NOT prn  The best possible pain control for the dose will be achieved within a day (once steady-state is reached)  Provide the patient access to prn doses of the SAME medication that can be used should breakthrough pain occur  Every hour for oral opioids  Every 10 minutes for IV opioids  Do not use extended release opioids for rescue dosing  Longer intervals between breakthrough dosing only prolong a patients pain unnecessarily Opioid basics
  15. 15. Palliative Care Summer Institute  Renal considerations  Opioids and their metabolites are primarily excreted renally  Morphine has 2 principal metabolites: 3 and 6 glucuronide  Morphine 6 glucuronide is active and has a longer half life than the parent drug  With impaired renal clearance, excessive accumulation of the drug must be avoided by either  Increasing the dosing interval  Decreasing the dose  With oliguria or anuria, stop routine dosing and administer only as needed Renal Failure considerations
  16. 16. Palliative Care Summer Institute  Opioid metabolism is not as sensitive to hepatic compromise  With severe hepatic impairment  Increase the dosing interval  Decrease the dose Liver failure considerations
  17. 17. Palliative Care Summer Institute DRUG IV PO Morphine 10mg 30mg Codeine 200 mg Hydrocodone 30 mg Oxycodone 20 mg Hydromorphone 1.5 mg 7.5 mg Fentanyl 0.1 mg Equianalgesic conversions Important insights: 1. Oral morphine and oral hydrocodone are equally potent 2. Oral oxycodone is more potent than oral morphine 3. Hydromorphone is 4-7 X more potent than morphine
  18. 18. Palliative Care Summer Institute Opioid side effects
  19. 19. Palliative Care Summer Institute  Clinician barriers Barriers to effective use of opioids
  20. 20. Palliative Care Summer Institute  Patient barriers Barriers to effective use of opioid

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