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The relief of pain and suffering has always been an important goal in patient care. Pain is a problem for many people with many medical conditions, and it is the most feared symptom of any medical problem. Pain makes a person lose his or her appetite and become irritable, and it interferes with the quality of life. The medical care system is designed to focus on acute care, but many patients with incurable and dis- abling illnesses that progressively worsen over time need management. Chronic pain is one of the most common complaints in primary care facilities; many patients complain that their pain has persisted for more than 5 years, either as a constant discomfort or as frequent flare-ups. Frequently, depression accom- panies painful syndromes; depression may require separate medication and attention for the pain man- agement to be effective. Despite new and effective medications and new treatment procedures, pain is often undertreated. There are many reasons for this, including the Opioids have a well-known potential for abuse and Drug seekers go to extreme lengths to obtain nar- cotic medications that they do not need for any medical conditions. Some drug seekers are not truthful. Some abusers obtain medications from multiple physicians and clinics. Some pain medications are diverted to other persons. . Some practitioners refuse to write prescription refills for all of these reasons. Meanwhile, truly painful conditions are undertreated. In a patient with a terminal illness who is expected to live only a short time, tolerance and addiction to the pain medication must be of no concern, and the med ications should be dispensed according to increasing need, to provide as much comfort as possible. For a patient with a painful condition who does not have a terminal disease, the goals are different. Some issues to be considered in pain management for these patients include the following: A realistic goal for therapy. Total freedom from pain is rarely an achievable goal. Instead, the patient should be questioned as to his or her needs following: addiction and expectations. For example, one patient may wish to do simple housework and care for her chil- dren without excessive pain. Another patient may want to remain alert enough to drive his car and may accept some pain. A condition that has pro- gressed to a more severe level may require more pain relief at night so that the patient can get a good night's sleep to be more alert during the day. It is important to discuss and think through the goals of therapy and use them to assess progress. A means of evaluating and describing pain. Because pain is subjective (determined by the patient's per- ception), a method of measuring and communicat- ing issues related to pain must be found that is meaningful to both the patient and the health care professional. A pain intensity scale ranging from 0 to 10 is often used. On this scale, 10 represents the most pain that could be experienced while conscious, and 0 represents no pain. The progression of analgesia. Analgesic therapy should start with the agents that have lower potency and addiction potential and progress to more potent agents. Agreements with regard to the responsibility of the patient for the pain medication and the responsibil- ity of the physician to prescribe the medication. These are often in the form of a written contract, which is discussed in more detail later in this chapter. INVESTIGATION OF CAUSES OF PAIN A careful history of pain is crucial. This should include the history of the condition that is causing the pain, a record of all previous diagnostic procedures, the names of all previous treating practitioners, a determi- nation of the level of the pain, and an understanding of how the pain interferes with the patient's quality of life. Pain is subjective. The physical examination is extremely important in making the diagnosis, but it cannot be relied on to determine the amount of pain that the patient is experiencing. Chronic pain causes both physical and psychologi- cal limitations in the patient's ability to manage his or her daily activities. A careful psychological history should be taken, investigating for signs of depression; if these are found, the depression should also be trea- ted. Although it is important to diagnose and treat the underlying cause of the pain, in many cases it is equally important to treat the pain itself even when the diagno- sis remains in doubt. Early and aggressive treatment of pain reduces the patient's risk of developing a chronic pain syndrome. ASSESSMENT OF PAIN Pain needs to be assessed before a plan can be made for management. Considerable effort must be made to gather information on the type, location, and severity of the pain and its impact on the patiente ability to ASSESSMENT OF PAIN Agreements with regard to the responsibility of the patient for the pain medication and the responsibil- ity of the physician to prescribe the medication. These are often in the form of a written contract, which is discussed in more detail later in this chapter. ETIOLOGY OF PAIN Visceral pain from internal organs is generally poorly localized and can be due to an underlying condition such as cancer. Chronic pain that is not caused by can- cer is generally of two types: somatic pain, which arises by activation of the pain receptors in the skin and mus- culoskeletal tissue, and neuropathic pain, which is caused by a disease or injury to the peripheral nerves or their ganglia (groupings of nerve junctions) in the central nervous system Back problems and degenerative joint disease are common causes of somatic pain. Osteoporosis in elderly adults is often associated with collapsed tebrae and stress fractures, which are acutely painful. Degenerative joint disease is readily apparent in many instances because of signs of local inflamma- tion. More troublesome is is diagnosis of fibromyalgia, a musculoskeletal disorder that has no clear diagnos- tic markers. Examples of neuropathic pain include pain resulting from a herpes eruption or diabetic complications and pain resulting from many other conditions that cause inflammation or degeneration Pain needs to be assessed before a plan can be made for management. Considerable effort must be made to gather information on the type, location, and severity of the pain and its impact on the patient's ability to function and on the quality of life. Psychological, spir- itual, social, and family histories are important in the assessment. Because pain is subjective, the patient's assessment of the severity and quality of pain should be accepted. Family members tend to overestimate the pain of their loved ones, and health care providers tend to underes- timate it. Nevertheless, insight is all gained by including in the evaluation. The observation of grima- parties in cing, wincing, limping, profuse sweating, hypertension, pallor, or tachycardia is useful but not diagnostic. In the end, the clinician must accept the patient's report of painpain is what the patient says it is. Pain should be assessed for severity, for factors that ease the pain or make it worse, and for the timing and characteristics of the pain. The history should include any previous painful situations or diagnoses of painful conditions, recent attempts at cure, issues and con- cerns of substance abuse, and previous response to various methods of pain control. The patient's beliefs about the origin of the pain should be assessed and included in the history. Other issues involve how the pain affects the patient and how the patient responds to pain. What makes the pain worse, and what improves it? Does it interfere ver- of nerves. wivich the pain interferes with activities of daily living, with sleep? It is extremely important to assess the ways in work, hobbies, and social roles. The relationship be- Aveen high levels of pain and psychological illness should not be ignored in the assessment of the pain. De- pression and anxiety can magnify the expression of pain. physical well-being and underlying problems. Fatigue Quality-of-life assessment tools are useful in addressing is almost universal as a symptom in pain patients. Particular care should be taken when assessing patients unable to communicate well, including young infants and children, older adults, mentally incompe- fent patients, emotionally disturbed patients, and indi- widuals who speak only a foreign language. Children may be reluctant to report pain for fear of undergoing Further painful diagnostic procedures. Often agitation, fear, and other unusual symptoms are the only way these patients can express their pain. In some cases, agitated patients are given sedatives when their pain should be addressed instead. Patients may fear becoming addicted to controlled substances, and many health care professionals rein- force that fear. A patient may fear being labeled a problem patient" and so may not complain to his or her physician about pain or inadequate pain relief. Negative responses by health care providers may cause patients to describe their pain as less severe than what they actually feel. Effective communication with the patient is crucial. The most common reason for unrelieved pain in the U.S. health care system is the failure of staff to assess pain and pain relief routinely and accurately. Many patients tolerate unrelieved pain silently, especially if they are not specifically asked about it. The key to delivering high-quality pain management is effective communication. All team members must consistently communicate changes in patient status and become substances, known as counterirritants, may sting locally when applied, but they can relieve some painful stim- uli from musculoskeletal and arthritic conditions. A general rule is that when pain increases, a sus- tained-release form of a narcotic may be administered by mouth, and a shorter acting "rescue drug" may be given for breakthrough pain between doses. Frequent use of the rescue drug should be noted; if it is necessary for the patient to take the rescue drug more than three or four times a day, a larger dose of the baseline sus- tained-action drug should be given. The usual dose of the short-acting drug should be equivalent to 5% to 15% of the 24-hour dose of the long-acting drug. Patients should be told the name of the medication, and they should clearly understand how it is to be taken. If there are restrictions with regard to food or water or combining the pain reliever with other med- ications, these should be clearly explained. The side effects should be mentioned, and any concerns of the patient should be addressed. The patient should be encouraged to ask questions and to participate in his or her own care. Adult dosages are provided for all drugs listed in this chapter. Pediatric dosages may be obtained in the respective chapters where the drugs are covered in more detail. All are oral doses unless otherwise specified. MILD PAIN Mild pain generally can be treated with acetamino- phen, aspirin, a nonsteroidal anti-inflammatory drug (NSAID), or a nonopioid analgesic. Unless con- traindicated, any regimen should include one of these mild analgesics for baseline analgesia, even when pain is severe enough to require the addition of an opioid. Parenteral and rectal forms of some of these agents diflunisal (Dolobid) Dosage: (Oral) Up to 1500 mg/day in divided doses. pentazocine (Talwin) Dosage: (Oral, IM) 50 mg every 4 hours. etodolac (Lodine) Dosage: (Oral) Up to 1000 mg/day. tapentadol (Nucynta) Dosage: (Oral) 50 to 100 mg every 4 to 6 hours. ibuprofen (Advil, Motrin) Dosage: (Oral) Up to 2400 mg/day. tramadol hydrochloride (Ultram) Dosage: (Oral) 50 to 100 mg every 4 to 6 hours up to 400 mg/day indomethacin (Indocin) Dosage: (Oral) Up to 200 mg/day. ketorolac tromethamine (Toradol) Dosage: (Oral, IM, IV) Up to 120 mg/day. Limit treat- ment to 5 days. naproxen sodium (Anaprox, Naprosyn) Dosage: (Oral) Up to 1650 mg/day. sulindac (Clinoril) Dosage: (Oral) Up to 400 mg/day. MODERATE PAIN SEVERE PAIN Some agents for severe pain may need to be adminis- tered parenterally. Dosages are given for the beginning range used when these medications become necessary Tolerance may bring the dosages well above the levels listed if the medications are used for a prolonged pe- riod. Milder analgesics are often continued with these drugs, and the use of shorter acting moderate pain drugs for breakthrough pain is often necessary as well. DRUGS FOR SEVERE PAIN butorphanol (Stadol) Dosage: (IV) 1 to 2 mg: (IM) 2 to 4 mg; (Nasal Spray) 1 mg delivered per spray. fentanyl citrate (Actiq, Duragesic) Dosage: (Topical patch) 25 to 100 mcg/hr, patch applied every 72 hours; (IM, Slow IV) 50 to 100 mcg every 3 to 4 hours; (Oral) Lozenge, 0.2 to 1.6 mg: (Intra- nasal Spray) 50 to 200 mcg per spray every 48 hours. hydromorphone hydrochloride (Dilaudid) Dosage: Oral) 7.5 mg every 3 to 4 hours; (Parenteral) 1.5 mg every 3 hours. Short-acting agents for relief of moderate pain may be administered alone or in combination with a nono pioid analgesic as pain increases. Agents in this class are also used when breakthrough pain occurs, or the patient may need step-up therapy using all stronger analgesics. Starting dosages are given in most instances, which may be increased. DRUGS FOR MODERATE PAIN codeine sulfate, combined Dosage: (Oral) 30 to 200 mg every 3 to 4 hours. levorphanol tartrate (Levo-Dromoran) Dosage: (Oral) 4 mg four times daily; (Parenteral) 2 mg every 6 hours. hydrocodone bitartrate, combined (Lorcet Plus, Vicodin). Vicodin contains 5 mg/500 mg hydrocodone and acetaminophen. Lorcet Plus has 7.5 mg/650 mg hydrocodone and acetaminophen. Dosage: (Oral) One to two tablets every 3 to 4 hours. hydrocodone bitartrate and ibuprofen (Vicoprofen). This combination tablet contains 7.5 mg hydrocodone and 200 mg ibuprofen. Dosage: (Oral) One tablet every 4 to 6 hours. Maxi- mum 5 tablets a day. meperidine hydrochloride (Demerol) Dosage: (Oral) 100 to 150 mg every 3 to 4 hours; limit use to 1 to 2 days; (IV) 50 to 75 mg every 3 to 4 hours. methadone hydrochloride (Dolophine) Dosage: Oral, Parenteral) 10 to 20 mg every 6 hours, morphine sulfate Dosage: (Oral) 30 to 60 mg every 3 to 4 hours; (IV) 2 to 10 mg every 4 to 6 hours. oxycodone hydrochloride, combined (Percocet, Percodan). Percodan has 4.8 mg/324 mg oxycodone and aspirin. Percocet is available in 2.5 mg/325 mg, 5 mg/325 mg 7.5 mg/325 mg 75 mg/500 mg 10 mg/325 mg, and 10 mg/650 mg oxycodone and acetaminophen Dosage. (Oral) 5 mg every 3 to 4 hours. 4 morphine sulfate controlled-release (Kadian, MS Contin, Oramorph SR) Dosage: (Oral) 30 to 60 mg every 12 hours. marphine sulfate and naltrexone (Embeda). Three extended-release strengths are available: 20 mg/ 30 mg/1.2 mg, and 50 mg/2.6 mg morphine 08 me extended-release and naltrexone. Dosage: (Oral) Individualize dose every 12 to 24 hours. nabuphine (Nubain) Dosage: (IM, IV, Subcut) 10 mg every 4 hours. oxycodone (OxyContin, OxyFAST, OxyIR) Dosage: (Oral) 2.5 to 20 mg every 12 hours; dosage may be increased greatly according to needs. axymorphone hydrochloride (Numorphan) Dosage (Parenteral) 0.5 mg every 3 to 4 hours. LONG-TERM EFFECTS OF OPIOIDS arly in the process of analgesia, severe pain seems to counteract the sedative effects of opioids. Tolerance develops the sedating effects of opioids, the mechanism for developing dose-related tolerance when these agents are used for analgesia is more poorly understood. The need for dosage increases develops more slowly when the drugs are given for true pain relief than when they are taken by addicts for the e euphoria effect. There is no true ceiling or max- imum dose for opioids. Extremely large doses may be necessary to relieve severe pain. Physical dependence is a condition in which the patient requires continued use of a drug for proper functioning and would experience withdrawal symp- toms if it were discontinued. It is a physiologic phenomenon that occurs following regular use of opi- oids for more than 2 weeks and should be expected, OPIATES AND OPIOIDS As discussed in Chapter 12, an opioid is a synthetic administered by the IM route are shown in Table 13-1. Table 13-1 Doses of Various Opioids That Are Equivalent to Morphine 10 mg Intramuscularly Drug Equivalent Dose ORAL ANALGESICS morphine 60 mg codeine 200 mg hydrocodone 40 mg hydromorphone 7.5 mg 4 mg 300 mg 20 mg 30 mg TRANSDERMAL EQUIVALENT 25-mcg patch equivalent to 45-135 mg/day of oral morphine Pseudoaddiction is a term that has been used to describe the drug-seeking behaviors that may occur when a patient's pain is undertreated. Patients may "clock watch," may become focused on obtaining med- ication, and may otherwise seem to be inappropriately "drug seeking." This behavior resolves when the pain is adequately treated Many patients with acute pain are anxious but are calmed when the pain is relieved with analgesics. Antianxiety agents may be necessary as adjunctive medication. Withdrawal (a syndrome that occurs when a drug- dependent person discontinues the drug suddenly) must be prevented and can be avoided if drugs are tapered gradually. The time course of the withdrawal symptoms is a function of the half-life of the opioid. With drugs with a short half-life, such as morphine and hydro- morphone, the symptoms may appear in 6 to 12 hours and peak at 24 to 72 hours. With drugs with a longer half-life, such as methadone and levorphanol, symptoms may be delayed for several days and are generally less severe. A clonidine patch may decrease symptoms of levorghanol meperidine Methadone Oxycodone enlany pregabalin (Lyrica) Dosage: Adults: (Oral) 50 mg three times daily to maximum of 600 mg/day. withdrawal. The dose is 0.1 to 0.3 mg/24 hours, and the patch is applied once every 7 days. SIDE EFFECTS OF OPIOIDS Respiratory depression is an adverse effect of opioids, particularly with higher doses. Precautions should be taken against combining opioids with other sedating drugs or alcohol. Opioids may cause constipation, sleepiness, dry mouth, nausea, and vomiting. To manage constipation, the patient should be instructed to drink several 8-oz glasses of fluid per day and eat foods high in fiber, such as beans, lentils, and dried or fresh fruits. A stool softener should be given routinely when the patient requires daily opioids. Senna tablets or other laxatives may be come necessary and should be taken as needed. Antihis- tamines, such as over-the-counter cold preparations, are additives for the sleepiness and dry mouth side effects and should be avoided if possible. Alternatively, the side effects should be anticipated and managed. Except in unusual cases, the nausea and vomiting associated with opioid therapy generally go away within a short time. DEPRESSION AND PAIN There is a strong association between chronic pain and depression. Serotonin and norepinephrine, the neuro transmitters associated with depression, play key roles in the modulation of pain. Depressive symptoms have been shown to coincide with the development of chronic musculoskeletal pain. Somatic symptoms of de pression in patients with chronic pain include change in appetite, change in weight loss of energy, motor retar- dation, and sleep disturbance. Predictors of depression in patients with chronic pain may be the frequency that severe pain is experienced, functional disability, the number of painful areas in the body, and poor coping ability and problem solving. Tricyclic antidepressants seem to be most effective when combined with pain medications. Selective sero tonin reuptake inhibitors (i.e, fluoxetine, paroxetine, citalopram) are much less effective COANALGESICS A coanalgesic is any of a group of drugs that may be used to enhance pain relief. Numerous other classes of drugs may be used to increase the effects of opioids or NSAIDs, and some may have independent analgesic properties as well. NEUROPATHIC PAIN Neuropathic pain is burning or shooting pain that is usually caused by nerve injury or dysfunction from disease or trauma. Causes of neuropathic pain include diabetes, postherpetic neuralgia, phantom limb pain after limb amputation, trigeminal neuralgia, and spi- nal cord injury pain, but neuropathic pain can occur as a progressive condition in older adults without diabetes or other known causes of the neuropathy. Some drugs, when taken for long periods, have been implicated in causing neuropathic pain. Neuropathic pain often begins with pain in lower extremities, the pain ascends, and then the ex- tremities become numb. Individuals may lose propri- oception (the unconscious perception of bodily movement and spatial orientation) without realizing it at first and then have difficulty walking on narrow plat- forms such as steps, docks, or boats; they may fall cause of missteps. Individuals with neuropathic pain may have trouble driving because of decreased ability to distinguish the gas pedal from the brake pedal. In treating this type of pain, any analgesic agent may be used, but the following are particularly effective. gabapentin (Neurontin) Dosage: Adults: (Oral) 100 to 300 mg every 4 to 6 hours umum of 2600 mad ANTICONVULSANT DRUGS Examples: carbamazepine, gabapentin, lamotrigine, oxcarbazepine, phenytoin, sodium valproate, tiaga- bine, and topiramate. Anticonvulsant drugs reduce the spontaneous "fir- ing" of central motor neurons that causes seizures. This finding led researchers to note that these agents also de creased spontaneous firing of sensory neurons associ- ated with pain. They are useful in the treatment of various painful conditions and some psychiatric condi- tions. They are discussed in more detail in Chapter 12. BENZODIAZEPINES Examples: clonazepam, diazepam, and lorazepam. These tranquilizers may be useful for treating anxi- ety. They are discussed more completely in Chapter 14. Dosage: Adults: (Oral) 100 to 300 mg every 4 to 6 hours to a maximum of 3600 mg/day. lidocaine patches 5% (Lidoderm) Dosage: Adults: (Topical) Up to three patches applied to the painful area for up to 12 hours in a 24-hour period. They dle discussed more completely in Chapter 14. GLUCOCORTICOIDS Examples: dexamethasone and prednisone. Glucocorticoids have many concurrent uses in pain management. They may relieve nerve or spinal cord compression by reducing edema in tumor and nerve issue. They may produce euphoria and increase appe- bile in severely ill patients. Long-term use produces weight gain, cushingoid appearance, osteoporosis, myopathy, and psychosis. When therapy is discontin- wed, glucocorticoids should be gradually withdrawn rather than abruptly stopped. These agents are discussed in more detail in Chapter 18. The intrathecal pump is a specialized device that delivers a concentrated amount of medication into the spinal cord through a catheter. It delivers medica- tion around-the-clock and eliminates or diminishes breakthrough pain. In addition to cancer pain, this device is useful in the treatment of spastic disorders such as multiple sclerosis or spinal cord injuries associated with muscle spasms. TRICYCLIC ANTIDEPRESSANTS LOCAL ANESTHETICS Examples: capsaicin and lidocaine. Topical lidocaine patches and nerve blocks have been used extensively in management of acute pain. Epidural and IV infusions of local anesthetics may be useful acutely but not for ongoing therapy. They are discussed in Chapter 12. Capsaicin is found in hot peppers. When applied topically in an oint- ment formulation, it relieves neuropathic pain and arthritic pain. These nonprescription formulations may be useful as adjunctive therapy. Examples: amitriptyline, desipramine, doxepin, imipra- mine, and nortriptyline. These agents are used for treatment of neuropathic pain and for their antidepressant activity. Use of these agents alone is generally ineffective; they should be combined with other analgesics. Anticholinergic effects, such as dry mouth, urinary retention, constipa- tion, sedation, and orthostatic hypotension, must be considered as potential side effects. Administration of these agents at bedtime may promote a better night's sleep and may minimize daytime side effects. They are discussed in more detail in Chapter 14. AGENTS USED FOR METASTATIC BONE PAIN Examples: bisphosphonates and radiotherapy. Pamidronate disodium (Aredia) inhibits reduction of bone mass and has been shown to reduce skeletal complications such as pathologic fractures in meta- static bone lesions. It is administered as an IV infusion. Radiation of widespread bony metastases may be per- formed for pain relief, or targeted therapy may be performed with localized radiation using a radioactive isotope such as strontium, which may be taken up by the bony metastasis. SKELETAL MUSCLE RELAXANTS Examples: carisoprodol, cyclobenzaprine, and orphe- These agents may be useful in preventing pain from muscle spasms. They are sedating and may have anti- cholinergic side effects as well. nadrine. PATIENT MEDICATION USE AGREEMENT A written agreement made between the prescriber and the patient has become a useful tool in pain manage- ment. It has been found that a written agreement reinforces the serious nature of the patient's condition and points out the consequences if the patient does not comply with the agreed-on goals and conditions for long-term pain management. These agreements are generally written by the prescribing physician accord- ing to the needs of his or her practice and may include the statements shown in Figure 13-1. Informed consent is an essential part of the documentation. These agreements are particularly recommended for patients with a history of sub- stance abuse and patients receiving higher doses of opioids. Random drug testing may not be necessary for every patient, but it may be extremely helpful for patients at risk for drug diversion activities or whose behavior seems unusual. Drug testing confirms that the patient is taking the medications prescribed and is not taking other controlled or illegal substances. Before discussing unusual drug test results with the patient, it may be helpful to speak to the laboratory technician to confirm the proper interpretation of the results Drug testing techniques must follow acceptable standards to avoid mismanagement of samples. SPINAL CORD STIMULATOR IMPLANT AND INTRATHECAL PUMP IMPLANT For many patients, a spinal cord stimulator is the best option for the control of pain. This implant uses small electrical pulses that are able to interfere with the nerve impulses that are ascending with pain sensations. It is usually used when pain is chronic and long-lasting and other methods have failed CRITICAL THINKING QUESTIONS 1. A patient appears chronically ill and requests pain medication. He is pale and diaphoretic and was observed to be favoring his left leg when walking in. What questions would be important in the initial evaluation of his painful condition? 2. A patient is nervous and distracted and cannot answer most of the questions about his medical history. What additional considerations may be made with regard to his treatment? 3. A patient comes in with a grocery bag of medications. You notice there are many herbal remedies, cold products, antihistamines, and medications from several physicians. How would you approach this medical history? 4. A patient strongly resists a standard drug test as part of his medication agreement. He feels this means he is not trustworthy. How would you counsel him? End