Event 3: Pain Management

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You now are at Mr. Gateway’s bedside and are meeting with him to assess his pain and come up with a treatment plan.

Mr. Gateway demonstrates some characteristics of pseudoaddiction (e.g running out of medication early because his pain was not adequately treated) and tolerance (despite not having taken any opioid for a week prior to his presentation to the hospital, tolerance can persist even if a patient has not taken opioids for an extended period).

Knowing what type and how much pain medication he was taking prior to his presentation will also be important when establishing a medication regimen to treat his acute pain.

Question: How are you going to assess his pain? (Choose the one best answer.)

Mr. Gateway's Specific Opioid Misuse Factors

Mr. Gateway's specific opioid misuse factors put him at high risk for aberrant medication behaviors and include:

1. Poor social support (one of the most important reasons a patient might be at risk for misuse)
2. Substance abuse history by the patient and by a family member
3. History of severe depression
4. Multiple psychosocial stressors
5. History of alcohol rehabilitation
6. Heavy cigarette smoking

Reference: Jamison RN, Edwards RR. Risk Factor Assessment for Problematic Use of Opioid for Chronic Pain. Clin Neuropsychol. 2012 Aug 30 https://www.ncbi.nlm.nih.gov/pubmed?term=22935011.

Possible Goals of Pain Management

Possible goals of pain management and concerns from Mr. Gateway's perspective could include the following:

• Good pain control
• Medications that work quickly
• Medications that do not have to be swallowed
• How to improve quality of life
• Ways to improve functioning
• Avoiding side effects
• Avoiding stigma

The 4 "A's"

Mr. Gateway's goals of pain management reflect his provider's goals as well.

You can think of these pain management goals in terms of the 4 "A's."

1. Analgesia - Decrease pain and suffering, safely manage a patient with opioid tolerance, and appropriately dose medications and use adjuvants as indicated.
2. Activity - Improve activity, quality of life, and function.
3. Adverse Effects - Effectively anticipate and manage medication side effects.
4. Aberrant Behaviors - Effectively manage a patient with a history of substance abuse and opioid risk factors and focus on medication effects on behavior and personality.

In addition, effective communication of treatment plans and inter-professional coordination are key goals in caring for Mr. Gateway.

Beginning Pain Medication Regimen

What opioid pain medication regimen do you recommend starting for Mr. Gateway's acute pain? (Choose the one best answer.)

• 1 Oxycodone elixir 10-15 mg PO Q4h PRN
• 2 IV Morphine by Patient Controlled Analgesia (PCA) 1.5mg every 7 minutes
• 3 IV Hydromorphone (Dilaudid) PCA 0.2mg every 7 minutes
• 4 Hydromorphone 0.5-1mg IV Q2h PRN
• 5 Transdermal fentanyl patch 25mcg/h

Monitoring Mr. Gateway While on Opioid Therapy

Treating acute pain with opioids and medication titration requires vigilant monitoring to ensure safe prescribing practices.

Mr. Gateway presents with risk factors for sedation and respiratory depression while on opioid therapy:

1. Smoking history and emphysema
2. History of opioid use and increasing opioid requirements
3. Surgical factors that may affect his breathing

Other patient risk factors can include:

1. Sleep apnea
2. Obesity
3. Older age
4. Major organ failure or cardiac or pulmonary disease

All patients should be monitored while on opioid therapy and especially during acute treatment. Some important considerations include:

1. Screening for risk factors and comprehensive medical history
2. Frequent monitoring of respiratory rate
3. 1. A low respiratory rate (e.g. less than eight breaths a minute) could be secondary to opioid therapy
   2. Technological monitors can be applied as supplements to vital sign monitoring such as capnography (wave-form measurement of expired carbon dioxide (ETCO2) or pulse oximetry (monitoring oxygen saturation))
4. Monitoring for sedation (there are different scales that can be used for this)
5. Monitoring for side effects (including constipation, mental status effects, nausea, etc.)

Reference

Jarzyna D, Jungquist CR, Pasero C, Willens JS, Nisbet A, Oakes L, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011 Sep;12(3):118-45 e10http://www.ncbi.nlm.nih.gov/pubmed?term=21893302.