THE RESIDENT’S
GUIDE TO PAIN
MANAGEMENT
AGS
Elizabeth Kvale, MD
Palliative Medicine
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
PAIN PHYSIOLOGY BASICS:
TYPES OF PAIN
• Nociceptive — arthritis,
fracture, laceration
• Visceral — pancreatitis,
MI, constipation
• Neuropathic — herpes
zoster, diabetic
neuropathy
• Complex regional pain
syndromes (RSD)
• Central pain
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PAIN PHYSIOLOGY BASICS:
ACUTE VS. CHRONIC PAIN
Acute pain
• Identified event, resolves
in days–weeks
• Usually nociceptive
Chronic pain
• Cause often not easily
identified; multifactorial
• Indeterminate duration
• Nociceptive and/or
neuropathic
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PAIN ASSESSMENT BASICS:
BELIEVE THE PATIENT
• Pain is a subjective experience ― the patient is
the best source of information about their pain
• Pain history ― site(s), intensity, temporality,
character, exacerbating and alleviating factors
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PAIN ASSESSMENT BASICS:
USE AN ASSESSMENT INSTRUMENT
Allows you to know and document whether you
have helped the patient
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PAIN MANAGEMENT BASICS:
Match the medication to the amount of the patient’s discomfort
3 Severe
2 Moderate
Morphine
A/Codeine
1 Mild
A/Hydrocodone
A/Oxycodone
ASA
Acetaminophen
A/Dihydrocodeine
Tramadol
NSAIDs
± Adjuvants
± Adjuvants
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
± Adjuvants
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PAIN MANAGEMENT BASICS
• Don’t delay for investigations or disease
treatment
• Unmanaged pain  nervous system changes
 Permanent damage
 Amplification of pain
• Treat underlying cause (eg, radiation for a
neoplasm)
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PAIN MANAGEMENT BASICS:
OPIOID PHARMACOLOGY (1 of 2)
• Conjugated in liver
• Excreted via kidney (90%–95%)
• First-order kinetics
• Time to Cmax
 PO dosing ― 1 hour
 SC or IM dosing ― 30 minutes
 IV dosing ― 6 minutes
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PAIN MANAGEMENT BASICS:
OPIOID PHARMACOLOGY (2 of 2)
• Steady state after 4–5 half-lives
 Steady state after 1 day (24 hours)
• Duration of effect of “immediate-release”
formulations (except methadone)
 3–5 hours PO or PR
 Shorter with parenteral bolus
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PAIN MANAGEMENT BASICS
Oral dosing of immediate-release preparations
Codeine, hydrocodone, morphine,
hydromorphone, oxycodone
• Dose q4h
• Adjust dose daily
• Mild or moderate pain: ↑ 25%–50%
• Severe or uncontrolled pain: ↑ 50%–100%
• Adjust more quickly for severe uncontrolled
pain
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PAIN MANAGEMENT BASICS
Oral dosing of extended-release preparations
• Improve compliance, adherence
• Dose q8h, q12h, or q24h (product-specific)
 Don’t crush or chew tablets
 May flush time-release granules down feeding tubes
• Adjust dose q2–4 days (once steady state
reached)
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PAIN MANAGEMENT BASICS
Breakthrough pain
• Use immediate-release opioids
 5%–15% of 24-h dose
 Offer after Cmax reached
• PO or PR: ~ q1h
• SC or IM: ~ q30min
• IV:
~ q10–15min
• Do not use extended-release opioids
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PAIN MANAGEMENT BASICS
• Ongoing assessment
• Increase analgesics until pain is relieved or
adverse effects are unacceptable
• Be prepared for sudden changes in pain
• Driving is safe if pain is controlled, dose is
stable, no adverse effects
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CONCERNS ABOUT OPIOID USE:
POOR RESPONSE
If dose escalation  adverse effects:
• Use more sophisticated therapy to counteract
adverse effect
• Use an alternative:
 Route of administration
 Opioid (“opioid rotation”)
• Use a co-analgesic
• Use a nonpharmacologic approach
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CONCERNS ABOUT OPIOID USE:
CLEARANCE
• Conjugated in liver
• 90%–95% excreted in urine
• If dehydration, renal failure, severe hepatic failure
develops:
 dosing interval,  dosage size
• If oliguria or anuria develops:
 Stop routine dosing of morphine
 Use only PRN
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CONCERNS ABOUT OPIOID USE:
TOLERANCE
• Reduced effectiveness to a given dose over
time
• Not clinically significant with chronic dosing
• If dose requirement is increasing, suspect
disease progression
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CONCERNS ABOUT OPIOID USE:
ADDICTION
• Psychological dependence
• Compulsive use
• Loss of control over drugs
• Loss of interest in pleasurable activities
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CONCERNS ABOUT OPIOID USE:
PHYSICAL DEPENDENCE
• A process of neuroadaptation
• Abrupt withdrawal may  abstinence
syndrome
• If dose reduction required, reduce by 50%
q2–3 days
 Avoid antagonists
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CONCERNS ABOUT OPIOID USE:
SUBSTANCE ABUSERS
• Can have pain too
• Treat with compassion
• Protocols, contracting
• Consult with pain or addiction specialists
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CONCERNS ABOUT OPIOID USE:
THINGS TO AVOID
• Meperidine — accumulates toxic metabolite
normeperidine
• Mixed agonists/antagonists – Nubain, Talwin
• Do not use naloxone (Narcan) unless true
respiratory crisis (RR < 6)
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SUMMARY: BASIC PRINCIPLES
OF PAIN MANAGEMENT
• Ask the patient
 Palliative medicine corollary ― believe the patient
• Match the pain medicine to patient’s level of
pain
• Increase pain medicine (with awareness of
Cmax and half-life) until patient is comfortable
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MRS PAINE
• Very pleasant 68-year-old admitted with
COPD exacerbation
• Home meds include 2 tablets of oxycodone
5 mg/APAP “whenever my back acts up” —
usually 4 tablets a day
• Appropriate pain medication order?
Slide 22
MRS PAINE
• Readmitted months later with stage IV nonsmall cell lung cancer
• Taking 2 oxycodone/APAP tabs every 6 hours
• Rates her pain as 7/10 “most of the time”
Slide 23
KEY POINTS
• Maximum acetaminophen dose in 24 hours is 4 grams
 Tylenol #3 (codeine 30 mg/APAP 325 mg)  24-hr maximum
= 12 tablets
 Percocet (oxycodone 5 mg/APAP 325 mg)  24-hr maximum
= 12 tablets
 Tylox (oxycodone 5 mg/APAP 500 mg)  24-hr maximum
= 8 tablets
 Lortab 5 (hydrocodone 5 mg/APAP 500 mg)  24-hr
maximum = 8 tablets
• How long does it take to get a PRN dose of pain
medication once it is requested?
Slide 24
KEY POINTS
• Mrs Paine’s total daily oxycodone dose is
40 mg (8 tablets  5 mg)
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THANK YOU FOR YOUR TIME!
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