Basics of Pain

Management
Vanny Le, MD
Assistant Professor
Department of Anesthesiology
Basics of Pain Management
 Definitionof Pain
 Pain Processing
 Pharmacologic Management of Pain
 PO medications
 PCA
 PCEA
 Addiction Medicine vs. Pain Medicine
Definition of Pain
 “An unpleasant sensory and emotional experience
associated with actual or potential tissue damage,
or described in terms of such damage.” (IASP)
 Sensory experience
 Cognitive experience
 Acutepain generally resolves after 1 month
 Chronic pain is pain occurring ≥ 3 months
Definition of Pain
Nociception vs. Pain
 Nociception
 Physiologic process of activation of neural pathways
by stimuli that are potentially or currently damaging
to tissue
 Pain
 Conscious experience: perception of pain
 Composite of alterations in somatosensory
processing following injury to tissues and/or nerves
and psychosocial factors
 Pain Processing
Anatomy of Nerve Fibers

A alpha A beta A delta C

• Proprioception • Low threshold • “First pain” or • “Second pain” or
• Heavily Myelinated mechanical epicritic pain protopathic pain
• Large diameter (15-20 stimulation • Sharp/prickling • Burning or dull
µm) • Heavily Myelinated • Lightly Myelinated • Unmyelinated
• Large diameter (5-15 • Medium diameter (1- • Small diameter (<1
µm) 5 µm) µm)
Pain Processing

Activation of
Nociceptive Action
Voltage-sensitive
Stimulus Potential
Cation Channel

• Thermal • NaV
• Chemical • CaV
• Mechanical
Pain Processing
Perception
• Subjective sensation of
pain
Modulation • Activation of primary and
• Neural activity altered secondary somatosensory
and limbic cortices
along pain pathway
• Attenuation or
enhancement of pain signal
Transmission
• Action potential is
conducted through nervous
system
• Periphery (1st order) to
Spinal neurons (2nd order) to
Brainstem/Thalamus to
Transduction Cortex
• Peripheral terminals of
primary afferents
• Stimuli converted to
action potentials
Pain Processing
Transition from Acute to Chronic Pain
 Continued noxious stimulation
 Produces greater noxious sensation
 Reduces the stimulus threshold or intensity
necessary to perceive noxious sensation
 PersistentC fiber activation at Laminae I and V
enhances response to subsequent stimulation and
augments size of receptive field
Pain Processing
Spinal Modulation
 Central sensitization
 Neuronal plasticity
 Previous innocuous stimuli is perceived as painful
 Afferent input from adjacent dermatomal areas now
produces neuronal excitation
 Cellular damage and migration of inflammatory cells
increases inflammatory soup
 Axonal sprouting and the formation of neuroma
 Increased neuronal activation by cytokines, prostaglandins,
etc.
Pain Processing
Spinal Modulation
 Wind-up phenomenon
 Repeated stimulation of C fibers activates laminae I and V
 Progressive increase in number of discharges
 Expansion of receptive field
 Increase in spontaneous discharge rate
 Non-noxious stimuli can activate nociceptive neurons
 Phenotypic switch
 Activation of large-diameter Aβ fibers following injury
 A beta fibers now express substance P
 Transmit noxious stimulation from periphery
Different Types of Pain
Somatic Pain Neuropathic Pain Visceral Pain
• Constant, well- • Diffuse or follows • Vague distribution
localized pain nerve distribution and quality
• Aching, throbbing, • Shooting, burning, • Deep, dull, aching,
sharp, or gnawing electricity-like dragging,
• Tingling and squeezing, or
numbness pressure-like
sensation
Pharmacologic Management
Pharmacologic Management
Pharmacologic Management
Adjuvants
 NSAIDs
 Acetaminophen
 Muscle relaxants
 Tizanidine
 Baclofen
 Ketamine
 Lidocaine patch
 Capsaicin
Pharmacologic Management
Adjuvants
 Antidepressants – TCAs and SNRIs
 Duloxetine (Cymbalta)
 Nortriptyline, amitriptyline
 Anticonvulsants
 Gabapentin (Neurontin) and Pregabalin (Lyrica)
 Oxcarbazepine (Trileptal)
 Lamotrigine (Lamictal)
 Topiramate (Topamax)
 Zonisamide (Zonegran)
Opioids
 Morphine
 Hydromorphone (Dilaudid)
 Hydrocodone (Vicodin)
 Oxycodone
 Fentanyl
 Methadone
 Buprenorphine (Butrans, Subutex, Suboxone)
 Tramadol
 Tapentadol (Nucynta)
 Equianalgesic
Drug  Duration     Half-life    Route      
 Dosage
Codeine 4–6 h 3h IM 120 mg
      PO 200 mg
Fentanyl 1–2 h 1.5–6 h IM 0.1 mg
Hydrocodone 4–8 h 3.3–4.5 h PO 30 mg
Hydromorphone 4–5 h 2–3 h IM 1.3–1.5 mg
      PO 7.5 mg
Levorphanol 6–8 h 12–16 h IM 2 mg
      PO 4 mg
Meperidine 2–4 h 3–4 h IM 75 mg
      PO 300 mg
Methadone 4–6 h 15–30 h IM 10 mg
      PO 10–20 mg
Morphine 3–7 h 1.5–2 h IM 10 mg
      PO 30–60 mg
Oxycodone 4–6 h NA PO 15-30 mg (20 mg)
Oxymorphone 3–6 h NA IM 1 mg
      PR 10 mg
130-200 mg *
Propoxyphene 4–6 h 6–12 h PO
(Inconclusive data)
Opioid equivalents
 Morphine IV to Morphine PO = 1:3
 Dilaudid to Morphine
 Naïve 1:7
 Tolerant 1:5
 Dilaudid IV to Dilaudid PO
 Naïve 1:7.5
 Tolerant 1:5
 Morphine to Oxycodone = 1:1.5
Fentanyl patch conversion
Converting Opioids
IV to PO or Changing Opioids
 Calculate the total daily dose of the original opioid (add
long-acting and rescue doses).
 Use the Conversion Chart to convert from an IV to PO
dose.
 Or use the Conversion Chart to convert original opioid to
an alternative opioid.
 Adjust the dose for incomplete cross tolerance by
reducing dose by 25%-50%.
 Divide adjusted dose by 24 to obtain hourly opioid
infusion rate.
Converting Opioids
 A patient is taking sustained-release oxycodone,
100 mg every 12 hours, but has developed
intolerable sedation. She would like to try an
immediate-release opioid agent, hydromorphone.
 What is the equivalent dose of hydromorphone?
Converting Opioids
 Oxycodone 100 mg Q12 = 200 mg total/day
 Oxycodone to Morphine = 1:1.5
 Oxycodone 200 mg = Morphine 300 mg
 Morphine to Dilaudid = 5:1
 Morphine 300 mg = Dilaudid 60 mg
 Dilaudid 60 mg x .75 = 45 mg/day
 Dilaudid 45 mg/day / 6 doses per day = 7.5 mg
 ~Dilaudid 8 mg Q4 hours
Patient Controlled Analgesia
 PCA nomenclature
 Basal/demand dose/lockout/4 hour lockout
 Morphine PCA - 0/1/6/0
 Dilaudid PCA – 0/0.2/6/0

 No basal unless cancer patient or very opioid

tolerant
 Lock out times range from 6 min to 10 min
 No 4 hour lockout
Patient Controlled Analgesia
 Danger of basal rates
 Opioid naïve patients
 Elderly
 Obese
 History of sleep apnea
 Patients receiving other sedative drugs
 PCA by proxy
Morphine PCA 1 mg/mL
3 mg demand dose
10 min lockout
1 mg/hour basal rate
Context-sensitive half-time
Fentanyl Fentanyl

Morphine

Morphine
Remifentanil
Remifentanil
Long-Acting Opioid for Baseline Pain
 Long Acting Opioids
Pharmacologically long-acting Pharmaceutically long-acting

Levorphanol (Levo-Dromoran) Hydromorphone (Exalgo)

Morphine sulfate (Kadian, AVINZA, MS Contin, Oramorph

Methadone (Dolophine)
SR)

  >Oxycodone (Oxycontin)
  Oxymorphone (Opana ER)

  Transdermal fentanyl (3 day patch) (Duragesic)

  Transdermal Buprenorphine (7 day patch) (Butrans)

  Tramadol ER (Ultram ER, Ryzolt)

  Tapentadol ER (Nucynta)
Breakthrough Pain Patterns
Preferred Medication Plan
 Restart patients on home medications
 Adjuvants
 Acetaminophen 1000 mg Q8
 Ibuprofen 600 – 800 mg Q6
 Neurontin (for neuropathic pain, if warranted)
 Long-acting PO medication or Fentanyl patch
 Add breakthrough pain medication
 Intermediate release PO meds
 Oxycodone
 MSIR
 PCA
 Small doses of IV meds for PT/OT/OOB/dressing change
Patient Controlled Epidural Analgesia
 PCEA
 Most often thoracic epidurals for abdominal cases
 Risk of hypotension and bradycardia
 Commonly used infusions
 Bupivacaine 0.125% with Fentanyl 2 mcg/mL
 Bupivacaine 0.125%
 Bupivacaine 0.0625%
 Continuous intrathecal (spinal) infusions
Addiction Medicine vs. Pain Medicine
 Addiction medicine
 An addiction specialist is a physician certified by the American
Board of Addiction Medicine (ABAM) and/or a psychiatrist
certified by the American Board of Psychiatry and Neurology
(ABPN)
 Provide prevention, screening, intervention, and treatment for
substance use and addiction
 Addiction specialists can recognize and treat the psychological and
physical complications of addiction.
 Pts have increased requirement for opioids because of tolerance
 Increased risk of anxiety
Addiction medicine vs. Pain medicine
 Methadone for substance abuse
 Requires an addiction medicine license to prescribe for the
purpose of addiction
 Given once daily at methadone clinic
 Must contact methadone clinic to verify dose
 Buprenorphine (Subutex) or Buprenorphine/naloxone
(Suboxone)
 Physicians must complete 8 hours of specific training,
certified in addiction medicine or addiction psychiatry, or
participatein a clinical trial of buprenorphine
Do Not Trust Patients
Protect Yourself!
 www.njrxreport.com
 Frequent urine toxicology screens
 Opioid agreement
 Only 1 prescriber
 Prescribe small quantities
Thank you!