Pain as the 5th Vital Sign Guidelines for Doctors Management of Adult Patients

Pain as the 5th Vital Sign Guidelines for Doctors (Management of Adult Patients)
Guideline 1 Pain assessment Guideline 2 How to differentiate acute from chronic pain Guideline 3 General guide for management of chronic pain Guideline 4 Medications for pain management Analgesic ladder for acute pain management Guideline 5 Titration of opioids for rapid pain relief: Morphine pain protocol

Appendix 1: Notes on analgesic medications 1. List of medications non opioids, opioids 2. Pharmacology of NSAIDs and COX2 inhibitors 3. List of Commonly used Opioids 4. Pharmacology of Morphine 5. Pethidine in acute pain management Appendix 2: Management of Side Effects 1. Nausea and Vomiting 2. Respiratory Depression

Guideline 1 Pain Assessment Guide: Taking a Brief Pain History

TELL ME ABOUT YOUR PAIN P A Place Aggravating factors Intensity Where is your pain? What makes the pain worse?

If 0 is no pain and 10 is the worst pain imaginable: What is your pain score now? What is the worst level of pain (score) you experience in a day? What is the least pain (score) you experience in a day?

Nature Neutralizing factors

Describe your pain e.g. aching, throbbing, burning, shooting, stabbing, sharp, dull, deep, pressure, etc What makes the pain better?

Other questions to ask on pain: Pattern of pain: Is the pain always there? (constant) or does the pain come and go? (intermittent or episodic pain) Associated symptoms: Do you have the following symptoms in the painful area or elsewhere? - numbness, tingling, allodynia (pain from a non painful stimulus), hyperalgesia (pain out of proportion to a painful stimulus) Impact of pain: How does the pain affect your sleep? Your appetite? Your mood? Your daily activities? Your relationships? Your work? Other important information to obtain from the patient: Past medical history, past and current medications, patients understanding about his/her pain and its cause. (Note: These are usually more important in chronic pain conditions than in acute pain.)

Guideline 2 Diagnosis of acute and chronic pain

Differences between acute and chronic pain Acute Pain A symptom of underlying damage or disease Acute pain begins suddenly, usually due to an injury Chronic Pain A chronic disease of the nervous system Chronic pain might have originated with an initial trauma/injury or infection, or there might be an ongoing cause of pain. However, onset may be insiduous and many people suffer chronic pain in the absence of any past injury or evidence of body damage. May be nociceptive (somatic or visceral) or neuropathic. Nociceptive somatic pain is that arising from skin, soft tissue and bones while visceral pain is that arising from viscera e.g. liver, pancreas, intestines. Neuropathic pain is pain resulting from damage to the central or peripheral nervous system Nociceptive pain may be sharp or dull, throbbing or aching. Neuropathic pain is usually burning, shooting or stabbing. Neuropathic pain may be associated with the following sensory symptoms: Numbness or Paraesthesia Allodynia: pain in response to a nonpainful stimulus, e.g. touch Hyperalgesia: pain out of proportion to a painful stimulus Dysasthaesia: unpleasant abnormal sensations Often has a psychosocial impact e.g. depression / anxiety, anger, fear, family and relationship stresses, sleep disturbances. Chronic pain does not signal damage. The nature of the disease is that the pain levels may be worse on some days and better on others so that patients have bad days and good days. Often associated with fear of re-injury resulting in fear avoidant behaviour.

General Onset

Types of pain

Usually nociceptive (somatic or visceral). Acute neuropathic pain may occur but is much less common

Characteristics of pain

Somatic pain is sharp in quality and well localised, and is worse on movement, while visceral pain is dull, aching and poorly localised.

Psychological effect when present is usually anxiety.

Meaning of Pain

Acute pain serves as a warning sign of damage e.g. injury, disease or a threat to the body.

Pain Duration

Acute Pain Acute pain resolves when the injury heals and/or when the underlying cause of pain has been treated. Unrelieved severe acute pain, however, might lead to chronic pain.

Chronic Pain Chronic pain persists despite the fact that the injury has healed. Duration of pain is usually more than 3 months. Patients often present to hospital with acute episodes which are actually flare-ups of pain. Common chronic pain conditions include:

Common Causes

Acute pain might be caused by many events or circumstances, including:

Surgery Fracture Burns or cuts Labour and childbirth Myocardial infarction Inflammation e.g. abscess, appendicitis

Headache Low back pain Cancer pain Arthritis pain Chronic pancreatitis Chronic abdominal pain from adhesion colic Neuropathic pain e.g. a. Post-herpetic neuralgia b. Diabetic peripheral neuropathy c. Post-spinal cord injury pain d. Central post-stroke pain

Summary Differences between Acute and Chronic Pain Acute Pain Symptom Tissue injury / inflammation Onset recognizable Short- term - resolves when tissues heal Warning sign Psychological impact (anxiety) is usually short term Chronic Pain Disease Tissue injury may not be present OR pain persists even after tissues have healed Gradual onset Long-term - does not resolve despite healing / no injury False alarm Associated with psychological problems e.g. depression, anger, fear.

Guideline 2: Diagnosis of acute and chronic pain

Guideline 3 General guide for diagnosis and management of chronic non-cancer pain
Remember chronic pain is different from acute painchronic pain wont kill your patients!

1. Firstly, you need to differentiate between acute and chronic pain. Ask the patient how long he/she has had the pain patients often tell you the duration of the current episode of flare up, so do not get misled by this one question you may ask is Have you ever had this kind of pain before or is this the first time you are having this pain? 2. Often, the patient is already known to have chronic pain e.g. in emergency department where he/she is a regular visitor or in the surgical or orthopaedic ward where the patient gets admitted every few weeks or months. When such a patient is readmitted for the same complaint you must still rule out any new acute condition this is easily done if you have already documented the site and nature of pain in previous admissions. You need to reinvestigate the patient ONLY IF THE PAIN IS IN A COMPLETELY DIFFERENT SITE OR IF THE PATIENT HAS NEW SYMPTOMS E.G. VOMITING, LOSS OF WEIGHT. 3. All patients with chronic pain who are coming for repeated admissions or treatment (often analgesic injections) because of pain should be referred to a Pain Clinic. However, in places where you do not have pain clinics you may have to manage the patient in an acute ward. 4. Principles to follow when you manage patients with chronic non-cancer pain include: a. Give regular oral analgesics eg. Tramadol, Aqueous or SR morphine and PCM. If you suspect neuropathic pain, add antineuropathic agents (antidepressants e.g. amitriptyline and anticonvulsants e.g. carbamazepine) b. Avoid Pethidine. Avoid injections as far as possible. c. Do not use NSAIDS / COX2 inhibitors longer than 1-2 weeks. You may use them for a few days to get control of a flare up (exacerbation) of chronic pain, but they should never be given for long term use as the patient will have a risk of developing renal failure and have a higher risk of CV problems (stroke and myocardial infarction). 5. Continued management of the patient involves the following: a. Refer to a physiotherapist for an exercise program (tailored to the patients current physical abilities) that he/she can do at home. b. Discharge the patient on a regime of regular analgesics (as in (4a) above). c. Refer to a pain clinic for assessment and follow-up. d. If a pain clinic is not accessible, you may have to follow up the patient in your clinic. You should emphasise to the patient that he/she should come for regular follow-up and not just when he/she has flare ups (severe pain). When the patient does come for follow-up, focus not just on the pain itself (it will always be there) but on function and mood, i.e. what the patient is doing (is he/she back to work?), how is he/she feeling and how is her/his relationship with his/her family and friends.

6. At a Pain Clinic, the following are carried out: i. Multidisciplinary Assessment of the patient, which includes e. Medical assessment, which includes making a diagnosis and deciding whether any further investigations are indicated, as well as reviewing current treatment. This is usually the task of a pain specialist. f. Physical assessment to look for primary and secondary musculoskeletal effects of chronic pain. This is usually done by a physiotherapist. g. Psychological assessment which includes looking at the psychological impact of the pain, level of anxiety and depression, how the patient copes with the pain, effect on family and work, etc. This is usually done by a clinical psychologist or psychiatrist. ii. Multidisciplinary multimodal management, which includes Review of current treatment Making a plan, together with the patient, regarding initial and long-term pain management. This usually includes more than one of the following modalities. pharmacotherapy, using appropriate drugs nerve blocks and other interventions, active physiotherapy, including exercises and activities that patients can do at home psychological therapy, including relaxation training and other pain mangement strategies In the management of chronic pain, emphasis is on self-management (what the patient can do for him/herself) and achieving long-term changes (e.g. from exercise) rather than short-term gains (e.g. from short acting analgesic medications).

Guideline 3: General guide for diagnosis and management of chronic non-cancer pain

Guideline 4 Drugs in Acute Pain Management: The Analgesic Ladder

Analgesic Ladder for Acute Pain Management

SEVERE 7-10

MODERATE 4-6 MILD 0-3 Regular No medicati on or PCM PRN PCM &/or NSAID / COX2 PCM 1gm QID oral NSAID / COX2 inhibitor Regular Weak Opioid PRN Additiona l weak opioid

Regular Higher dose of weak opioid Or IV/SC Morphine 510mg 4 hrly OR Aqueous morphine 1020 mg

PRN IV/SC Morphine 5-10mg OR Aqueous morphine *Oral or SC Morphine may be safely given

UNCONTROLLE D To refer to APS for: PCA or Epidural or other form of analgesia

Note: See chart below for dosages of analgesic drugs 1. 1.Weak opioids include Dihydrocodeine (DF118) and Tramadol. 2. In NBM patients oral drugs may be replaced by any of the following, depending on the pain levell a. Morphine sc or iv (Note that 10 mg IV morphine is equivalent to 20 mg oral morphine b. SC or IV Tramadol c. Rectal PCM d. Rectal Diclofenac or IV Parecoxib or IV Ketorolac 3. NSAIDS should be used with caution in patients with thrombocytopenia, coagulopathies, asthma and renal, hepatic or cardiac impairment. It is contraindicated for patients with hypovolemia, active peptic ulceration or with a history of sensitivity, eg. wheezing to aspirin or other NSAIDS. In the elderly (over 65 yrs) consider using a lower dose NSAID and buffer those at risk of Gl problems with Proton Pump Inhibitors. For patients with peptic ulcers, use COX2 inhibitors. 4. For those with severe pain, use SC or IV morphine and titrate to comfort (see Guideline 5, Morphine Pain Protocol)

Formulations And Dosage Of Commonly Used Analgesics

DRUG Paracetamol

FORMULATION AVAILABLE Tablet 500mg, Suspension 500mg/5ml, Suppositories

DOSAGE 500 mg 1gm qid

NSAID Diclofenac

Mefenamic Acid (Ponstan) Ibuprofen ( Brufen) Naproxen (Naprosyn, Synflex) Ketoprofen (Orudis, Oruvail) Ketorolac (Toradol) Meloxicam ( Mobic) COX 2 inhibitors Celecoxib Etoricoxib Parecoxib WEAK OPIOID Tramadol Dihydrocodeine (DF118) STRONG OPIOID Nalbuphine (Nubain) Morphine

Tablet 50mg & 25mg, Suppositories 12.5mg, 25mg, (50mg & 100mg)* Gel Capsule 250mg Tablet 200mg & 400mg* Tablet 250mg, 550mg

Oral: 50mg tds, Sup: 50mg-100mg stat Topical: PRN 250 mg 500mg tds 200 mg 400 mg tds 500mg-550 mg bd

Capsule 100mg *, Injection 100mg, Patch 30mg, Gel Injection 30mg/ml Tab 7.5mg

Oral: 100mg daily, IV: 100mg bd Patch: 30mg - 60mg bd, Topical: PRN 10mg - 20 mg bd max 3 days Daily or bd

Capsule 200 mg Tablet 90 mg & 120 mg Injection 20 mg/ml

200 mg bd (max 1 week) 120 mg daily (max 1 week) 40 mg bd ( 20 mg bd for elderly) max for 2 days

Capsule 50mg, Injection 50mg/ml Tablet 30 mg

50mg -100mg tds or qid (max 400mg/day) 30mg-60mg qid (max 360mg/day)

Injection 10mg/ml Tablet SR 10mg,30mg Aqueous 10mg / 5ml Injection 10 mg/ml,

Fentanyl Pethidine

Injection 50 mcg/ml, Patch 25 mcg, 50 mcg Injection 50mg/ml,100mg/2ml

Stat dose only: 10mg (equivalent to Morphine 10m patients on regular Morphine/ Pethidine/ Fentany SR and Aqueous to be used for cancer pain IV and Subcut : < 65yrs : 5mg -10mg 3-4hrly > 65yrs : 2.5mg -5mg 3-4hrly Reduce dose in renal and hepatic impairment IV only to be prescribed by APS team. Patch to be used in cancer pain; NOT in Acute Pai IV and Subcut : < 65yrs : 50mg -100mg 3-4hrly > 65yrs : 25mg -50mg 3-4hrly Reduce dose in renal and hepatic impairment. Use not encouraged because of Norpethidine tox

Oxycodone ( Oxycontin)

Tablet SR 10mg & 20mg

addiction. Mainly used for cancer pain

Guideline 5 Titration of Opioids for Rapid Pain Relief: The Morphine Pain Protocol
Rapid control of severe acute pain may be necessary in certain situations e.g. In the recovery ward, immediately after an operation In the emergency department, following acute trauma To cover episodes of incident pain e.g. dressing changes, physiotherapy In patients with severe cancer pain presenting with an acute exacerbation of pain Rapid pain relief can be achieved by titration, i.e. by giving repeated small intravenous bolus doses of opioid (e.g. morphine 0.5, 1 or 2 mg every 5 minutes) until the patient is comfortable. The smaller and more frequent intravenous doses permit a more rapid, predictable and readily observable response and allow titration of dose to response. Indeed, this is the rationale behind PCA and explains the success of this technique. The practical application of this is shown in the Morphine Pain Protocol. In Malaysia, doctors usually administer this, although in other countries trained nurses are able to safely administer morphine and other opioids using this protocol. MORPHINE PAIN PROTOCOL

MORPHINE PAIN PROTOCOL FOR NURSES: ONLY TO BE USED BY NURSES WHO ARE TRAINED AND ACCREDITED

Appendix 1 Notes on Analgesic Medications

1. List of analgesic medications: (See Guideline 4 for formulations available and dosages) NON OPIOIDS Paracetamol NSAIDs Diclofenac (Voltaren) Mefenamic Acid (Ponstan) Ibuprofen (Brufen) Naproxen (Naprosyn, Synflex) Ketoprofen (Orudis, Oruvail) Meloxicam (Mobic) Ketorolac (Toradol) COX2 inhibitors Celecoxib (Celebrex) Etoricoxib (Arcoxia) Parecoxib (Dynastat) OPIOIDS Weak opioids Dihydrocodeine (DF118) Tramadol (atypical opioid; also increases the levels of serotonin and noradrenaline in the CNS) Strong opioids Morphine Fentanyl Oxycodone Pethidine Partial agonist opioids Nalbuphine 2. Pharmacology of NSAIDs and COX2 inhibitors a. 4 major effects Analgesic Anti-inflammatory Anti-pyretic Anti-platelet b. 5 major side effects: Allergic reaction (cross allergy is common between different NSAIDs / COX2 inhibitors) Gastric irritation / ulceration (less with COX2 inhibitors) Reduced renal blood flow (long term use can lead to renal failure) Anti-platelet effect (can lead to bleeding; less with COX2 inhibitors) Cardiovascular effects increased risk of stroke and myocardial infarction Note: the main difference between NSAIDs and COX2 inhibitors is that COX2 inhibitors have a lower incidence of peptic ulceration and upper GI bleed, and COX2 inhibitors have less risk of bleeding.

3. Pharmacology of Morphine Acts on the mu and kappa opioid receptors in spinal cord and brain Potent analgesic agent the gold standard opioid analgesic Commonly used as an analgesic in moderate to severe acute pain Also used in moderate to severe cancer pain, and sometimes in chronic non-cancer pain.

Pharmacokinetics : Bioavailability of oral route is 30% due to first pass effect (metabolized in liver) Converted to morphine-6-glucuronide (active metabolite) and Morphine-3-glucuronide in liver Elimination half life is 3-4 hours Peak analgesic effect : IM / SC : 30 minutes IV : 5 minutes

4.

A note on Pethidine in acute pain management Pethidine is a popular analgesic in Malaysian hospitals, both in the wards as well as in the emergency department. HOWEVER, PETHIDINE IS NOT RECOMMENDED in postoperative pain relief and in chronic or recurrent pain conditions because of the active metabolite, norpethidine, which can accumulate in the body with prolonged use of high doses, and in renal impairment and give rise to convulsions.

Appendix 1: Notes on Analgesic Medications

Appendix 2 Management of Side effects

1. Nausea and Vomiting Nausea and vomiting is a common side effect of opioids. There is no need to stop the opioid (e.g. tramadol, morphine, codeine) but it is necessary to treat the nausea and vomiting with anti-emetics. Suggested first line anti-emetic is: o Metoclopramide (Maxolon) 10 20 mg IV / subcut / oral give one dose (STAT) and repeat if necessary 6-8 hourly If the patient continues to vomit or have nausea, then use Ondansetron 8 mg IV give one dose (STAT) and repeat if necessary 8 hourly OR Granisetron 2 mg IV give one dose (STAT) and repeat if necessary 8 hourly Alternatives if the above are not available are 1. Haloperidol 1.5 mg BD oral or 1 mg BD IV 2. Dexamethasone 4 mg IV stat

o o

2. Respiratory Depression Respiratory depression may occur with overdose of opioids. However, it is very uncommon, and is always associated with sedation; in fact, sedation may be present without a decrease in the respiratory rate of the patient. The risk of respiratory depression is minimal if strong opioids are titrated to effect and only used to relieve pain (i.e. not to help patients to sleep or to calm down agitated patients). The risk of respiratory depression is also minimal in patients on chronic opioid use (e.g. patients on morphine for cancer pain). Management of respiratory depression Diagnosis: Respiratory Rate <8/minute AND Sedation Score = 2 (difficult to arouse) OR Sedation Score = 3 (unarousable) Confirm opioid-induced respiratory depression check pupils (should be pin-point) Management 1. Administer oxygen face mask or nasal prongs 2. Stimulate the patient tell him/her to breathe 3. Dilute Naloxone 0.4 mg / ml in 4 mls water or normal saline. Administer Naloxone 0.1 mg (1 ml) every 1-2 minutes until the patient wakes up or Respiratory Rate is more than 10/minute. 4. Continue to monitor the respiratory rate and sedation score every hourly for at least another 4 hours. If respiratory depression or oversedation recurs, a second dose of naloxone may be required. After treating with the second dose of naloxone, you should refer the patient to the ICU or HDU for close monitoring as the patient may require a naloxone infusion. Naloxone Naloxone is a pure opioid antagonist. It is available in ampoules of 0.4 mg/ml (adult dose) or 0.02 mg/ml (paediatric dose). Doses for treating opioid-induced respiratory depression: o Adult 0.1 0.4 mg IV/IM/SC; IV dose may be repeated every 1-2 minutes o Paediatric 0.01 mg/kg IV (maximum 0.4 mg), repeat every 2 minutes. The half life of naloxone is 45-60 minutes; this is important to know because when used to antagonize respiratory depression due to morphine, the effect of naloxone may wear out before the effect of morphine (half life 3-4 hours). Therefore, after treating morphine-induced respiratory depression, the patient has to be monitored closely for at least another 4 hours. Naloxone should be available in every emergency drug trolley.