Pain Management Summary

Dr. Elueze's Summary in a nutshell


Fig 1. Pain management summary

Fig 2. Management algorithm guideline for severe cancer pain-ACP

First, make an initial evaluation of the pain.

Click here for the form for initial pain assessment - AFP 10/01

There are 3 types of pain:
-Visceral
-Somatic
-Neuropathic

What if the patient is demented and is not able to say if she has pain?
Check this useful form for nonverbal pain assessment:


Nonverbal pain assessment

Second, attempt to control the pain.

How to control the pain? "30-50-10-10" rule
30% of the pain can be controlled with around the clock Tylenol 650 mg PO q 6-8 hr.
50% of the pain is controlled with around the clock long-acting opioid, e.g. Oxycontin or MS Contin.
10-20% of the pain is controlled with short-acting PRN opioid, e.g. MS 4 mg IV q 3 hrs PRN pain. ("30-30-30-10" was the old rule; no more than 10-20% of the pain relief should be provided by PRN meds)
The last 10% of the pain can be controlled with adjuvants, e.g. Desipramine, Elavil or Neurontin.

When the patient is on MS PRN, calculate the 24h dose and replace it with Oxycontin BID (slow release) + PRN MS.

Short-acting opioids:
MS 4 mg IV q 3 hr PRN pain
Dilaudid 2 mg IV q 3 hr PRN pain
Fentanyl 50 mcg IV q 2 hr PRN pain (advantages: very short acting - it can be given even every hour PRN, does not decrease the BP as much as MS, better in renal failure patients than MS)

Long-acting opioids:
Oxycontin
MS Contin
Fentanyl is a TD (transdermal) alternative. Start the patch at 25 mcg/hr q 3 d. Do not increase the dose every day, wait at leas 2-3 days for the medication to take effect (remember it is a slow release formulation). Never start a Duragesic patch in opioid-naive patients. First, you do not know the correct dose, it needs to be established initially by starting a short-acting opioid around the clock and calculating the 24-hour total dose. Second, the Duragesic works by creating a subcutaneous pool of medication, if you overdose your patient, there is no way to stop the drug delivery which is already inside the skin.

Use Tylenol PO q 6h if LFT are normal.
Use NSAIDs if no PUD.

Always give Senna 2 tabs PO QHS, if the pateint is on opioids.
Colace is not enough.

WHO (World Health Organization) rules:
Give meds by the
Mouth
Clock
Ladder

Third, evaluate how successful the pain management is.

Dr. Elueze’s 5 A to evaluate pain management:
A nalgesic level - 1-10?
A ttitude – sleepy or anxious?
A ctivity – ADL, e.g. taking a shower, walking, etc.
A dverse effects - constipation, N/V
A ddiction - aberrant behavior, watches the clock, often requests PRN meds

See the Patient chart for evaluation of therapy for chronic pain - AFP 01/00

Pain Management in Geriatric Patients

Do not use Demerol, Darvocet N and propoxyphene. FDA pulled propoxyphene-containing pain medications Darvon and Darvocet off the market in 2010: http://goo.gl/poApS

Remember this basic rule: when the right hand is writing a prescription for opioid, the left hand should write a prescription for Colace and Senna. Opioids affect the mesenteric plexus and have a negative peristataltic effect. Your patient will need both a stool softener (Colace) and a stimulant (Senna).

References:
ACP - Pain Management for the Internist - Assessment, Treatment, Follow-Up - 12/04
Management of Pain and Spinal Cord Compression in Patients with Advanced Cancer - ACP 1999
Challenges in Pain Management at the End of Life - AFP 10/01, There is a useful form for pain assessment
Ten Commandments for the Care of Terminally Ill Patients - AFP 03/98
Ten Guidelines for Assessing and Treating Pain - MGH Harvard
Equianalgesic Doses of Opioid Analgesics - MGH Harvard, Alberta,
Adult Pain Management Staff Education - University of Michigan
Pain chapter in Merck Manual of Geriatrics
Managing Pain in the Dying Patient - AFP 02/00
Treatment of Nonmalignant Chronic Pain - AFP 01/00
Oral Analgesics for Acute Nonspecific Pain - AFP 03/05
Battling the 'monster' - part 1, part 2 - MLive.com, Flint Journal 02/05
Conversion Among Different Opioids - Palliative Care Perspectives

Related:
Methadone may cause sudden cardiac death even in therapeutic doses. Notes from Dr. RW, 01/2008.

Published: 3/12/2005
Updated: 8/12/2005

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