(W1/2) Pain Management Flashcards
What are the dimensions of Total Pain?
1) Physical
2) Psychological
3) Social
4) Spiritual
How to assess Physical pain?
OLDCART/ SOCRATES SMM
Site
Onset
Characteristics
Radiation (where pain moves to)
Associated factors
Time
Exacerbating and reliving factors
Severity
Sleep/Function
Mood
Meaning
What are the types of physical pain?
1) Nociceptive (from tissue injury)
- Somatic (bones, joints, muscle, connective tissue)
- Visceral (organs)
2) Neuropathic (from nerve injury)
- Peripheral
- Central
When do you assess for physical pain?
- New onset
- Changing characteristics of pain
- Post-analgesia
~ Evaluation of effectiveness
How can you describe nociceptive pain?
- Stinging
- Heavy
- Suffocating
How can you describe neuropathic pain?
- Numbness, pins and needles
- Burning
- Aching
- Throbbing
- Pulling
What is Psychological pain?
- Anxiety of worsening pain
- Fear of dying
- Reminder of ill health
- Anger, despair, hopelessness
What is Social pain?
- Loss of role
- Restricted social activities and contacts
- Affects interpersonal relationships and their environment
What is Spiritual pain?
- Loss of sense of purpose, role and identity
- Feeling of being punished
- Altered relationship with god
What are the 3 basic principles of pharmacotherapeutic intervention?
1) By the mouth
- Oral is the least invasive and safest
- Only use injections if px cannot take orally or drug is not able to be absorbed via GIT
2) By the clock
- Most oral analgesics only last <4 hours
~ Tf must be prescribed every 4 hrs to achieve effects
3) By the ladder
- Following WHO’s pain ladder
- Dose titrated until:
~ Max recommended dose is reached
~ Pain is relieved or
~ Px has serious side effects
What is WHO’s pain ladder?
Step 1: Non-opioids
- NSAIDs, Paracetamol
- +- adjuvant analgesics
Step 2: Weak opioids
- TRAMADOL
- CODEINE
Step 3: Strong opioids
- Immediate releade
~ MORPHINE solution
~ Oxycodone
~ Methadone
- Controlled release
~ MORPHINE SULPHATE tab
~ Transdermal FENTANYL
~ Oxycontine
What are adjuvant analgesics?
- Treats neuropathic pain
- Can be added to any of the steps in the WHO Pain Ladder
- Tricyclic antidepressants
- Anticonvulsants
~ Gabapentin
~ Pregabalin - Topical
~ Lignocaine - Steroids
~ Dexamethasone
Why is it important to have opioid rotation?
- Resistance
- Side effects
- Morphine is available orally (tf least invasive)
- Fentanyl is not effective for acute pain
- Fentanyl takes longer to work (8-12 hours)
Is there a maximum dose for morphine and fentanyl in a palliative situation?
- No max dose
When is morphine used?
- Moderate to severe pain
- Dyspnea
What are the different forms of morphine?
1) Liquid
- Mist morphine (1mg/ml)
2) Tablet
- Morphine sulphate/MST (sustained-release)
~ Cannot be cut or crushed
~ Available in 10 or 30mg tabs
3) Injectable
- 10mg/ml ampoules
Comparison of morphine types
Onset of duration
- IV (5 min) -> SC (15 min) -> Mist (30 min) -> MST (1-2 hrs)
Maximal effect
- IV / SC (10-20 mins) -> Mist (60 mins)
Duration of action
- IV / SC / Mist (4-6 hrs) -> MST (8-12 hrs)
What are the side effects of morphine?
- Constipation
~ Tf laxatives are always given to px on morphine - N/V
- Sedation
- Confusion
- Morphine toxicity
What are signs of morphine toxicity?
- Myoclonic jerks
- Pinpoint pupils
- Respiratory depression
When is fentanyl used?
- When oral intake is not possible (Due to N/V)
- Difficult compliance to oral morphine
- Px has side effects/morphine toxicity
- Severe constipation with morphine
~ Fentanyl causes less const. - When px has renal or liver impairment
~ Safe to use fentanyl, unlike morphine
What doses are available for the fentanyl patches + injectable fentanyl?
- 12mcg/hr
- 25 mcg/hr
- 50 mcg/hr
- 100mcg/2ml
- 500 mcg/10 ml
Note: doses are the same for subcu, transdermal and IV routes
What are the usual start doses of transdermal and infusion fentanyl?
Transdermal: 6mcg/hr every 72 hours
~ Same patch will be used for the 3 days before being changed
Infusion: 10mcg/hr (0.2ml/hr)
Duration of fentanyl patches?
Maximal effects: 8-12hrs
Residual effect: 8-12 hrs after removal
Last for about 72 hours
Conversion of morphine to fentanyl patch?
eg Morphine syrup 5mg q4H
1) Total mist morphine/day: 5x6=30 mg/day
2) Morphine mg to mcg: 30x1000=30 000mcg
- As morphine is more potent
3) Morphine/hr: 30 000 / 24 = 1250 mcg / hr
4) Morphine to fentanyl ratio (1:100): 1250 /100 = 12.5 mcg
Tf: Px uses 12mcg/hr transdermal patch q72 hours
_______________OR________________
1) Total morphine: 5x6=30mg
2) Fentanyl needed: 30/2.4 = 12.5mcg/hr
(conversion factor 2.4 method)
How to convert fentanyl patch dose to morphine?
Eg Fentanyl 25mcg/hr patch
1) Total morphine daily dose: 25x2.4 = 60 mg
2) Morphine / 4 hrs = [(60/24) x 4] = 10 mg/4 hrs
Can opioids be used in renal and liver failure?
- Fentanyl recommended in mod to severe impairment
~ Caution req when estimated creatinine clearance <30ml/min
What non-pharmacotherapeutic interventions are there for pain?
- Radiotherapy
- Surgery
- PT/OT
- Transcutaneous Electrical Nerve Simulators (TENS)
~ Small electric pulses that reduces pain signals to spinal cord and brain - Massage therapy
- Acupuncture
- Art therapy
