Maria Dailey-Campbell reviews pain classifications including chronic pain, consequences of under treating pain, and the importance of prescribing appropriate analgesics based on the type of pain patients are dealing with.
Back to Symposium Page » Maria Campbell is a board certified acute care nurse practitioner and doctor of nursing practice. Maria Maria has over 33 years of experience in treating patients in the greater Los Angeles in San Diego communities. Maria is experienced in advanced practice, nursing and pediatrics, acute care, cardiology and palliative care. Maria is passionate about empowering people to live their best life possible. Maria inherently understands that satisfied patients are the single most beneficial asset and organization organization can have. And she is driven by patient focus care. Maria enjoys building relationships and partnering with individuals to help them achieve their personal goals. Building strong relationships is the corner Stone of Success. She understands the uniqueness of every individual, and there is not one single approach that works for everyone. She is dedicated to the integrity of her career and understands the importance of providing the fundamental building blocks of palliative care. Maria is a member of Sigma Theta Tau, California Association for Nurse Practitioners and has been a guest lecturer for various health related topics for many years. Please help me. Welcome Maria Campbell. Hello. I'm just going thio share my screen. Okay. Okay. So hi, I'm Maria Campbell. I'm very pleased to be here. It's a privilege to speak with you today. Let's talk about pain and opioids. I have no disclosures relevant to this presentation. All right, so few objectives. Andi, I'll let you read those. But really, we just I really want to focus on the difference between acute and chronic pain, understanding the consequences of pain that is untreated and recognizing the different types of pain. So what happened was when I was first asked to do this lecture, I was going to talk about pathways descending pain in inhibitory pathways, Interneuron C fibers, second order neurons. And then I realized I was the second to the last speaker in this Siri's. And so I thought, Forget it, I'm going to lose them with that. So I just revamped it, and I thought it would be better if we discussed how to actually treat pain and recognize it. Pain is, you know, I looked at this slide and I thought we could just fill this slide up with all kinds of reasons people would think What pain waas. But really, it is the most common reason for physician visits. I feel that pain is a nasty four letter word. Pain is very under recognized undertreated, and for a long time now it's been measured as the fifth vital sign. I believe that we're doing tremendous improvement on recognizing pain in patients. There's a lot of common misconceptions when dealing or talking about pain. People think pain is a normal part of aging. It is not. We have a lot of octogenarians that are very healthy and are able to do all of their activities of daily living, along with swimming, golfing, sailing, among many other things. Another misconception is paying can be determined objectively. It cannot. There are times when we can look at patients and see that they're in pain by their facial expressions or the way that they furl their brow or the way that they're sitting. But it's it. Pain is not objective. It's subjective. Chronic pain always indicates the presence of a serious disease. That is a misconception as well. You don't have to have a serious disease to have chronic pain. Another misconception is drug abusers or users overreact to pain. That's not true. Also, regular use of an algae six lead to addiction. We're going to talk about this later. But there's been so much research on the fact that if you have pain, it's almost impossible to get addicted to pain medicine. And I'll show you that later. Also, psychologically, our pain has no psychological pain, has no physiological basis. That is not true. Um, major illness or injuries are less painful than severe ones. Now that is definitely not true. I don't know if you've ever had a hangnail, but it really hurts. And that is not a severe injury, but it does cause severe pain. Uh, let's talk about consequences of untreated pain. So if you think about it, you have patients that are in severe pain, acute or chronic. They don't want to eat. They don't want to get out of bed. They suffer from maybe anger, sadness, depression. They're unable to do their activities of daily living. They start withdrawing from social aspect that they enjoyed at one point. Disturbed sleep patterns difficulty with ambulance a shin. There's just so many consequences of untreated pain. Now let's talk about pain assessment. I don't want to talk about the P Q. R s t of the pain assessment. I want to talk about other factors such as what are contributing factors to patient's having significant pain, pain, intervention, history. I always ask patients what worked for you in the past. I have a patient with severe pain from cancer and, believe it or not, coding works for her. We don't use coding in palliative care setting usually, but I did give it to this patient because this is what she told me that worked in the past. Look at pain measurement. Do they really understand the 1 to 10 scale? One Minimal? 10 Severe pain? Look at the data. How are you gathering this information? Is that from the patient subjectively, or is it from the caregiver family member? Some other person past. It's actually pain experience, but past pain experience as well. And what type of pain. And I think this is the most important part of understanding the pain assessment. What type of pain are they having? We're going to discuss that in a moment. In another slide. I think this is a great quote from Marcia Meldrum. She's from my alma mater, U C L. A. And she says, pain is a constant companion for humanity, and I really believe that to be true. In the 19 sixties, European doctors gave their patients opium for pain relief the 1950 or in the 15 hundreds. I think pain relief was just like a shot of whiskey. Thank God we came up with opium, opium for pain relief. And then look yes. By the 18 hundreds we got ether and chloroform were introduced for an anesthetics for surgery. And then who by the 19 hundreds, morphine and heroin came in, and we use that to treat pain. There are many definitions of pain, but it is an unpleasant sensory and emotional experience. It can be an actual or potential tissue injury. Medical diagnosis. We state that pain is regarded as a symptom of an underlying condition. It's always, uh, worthwhile to try and figure out what the underlying condition of the pain is. Pain alerts the body to injury and disease. If you step on, say a nail, your body is going to say, Hey, I've got pain in my foot. It's going to alert you to the injury so it can be addressed. Pain is whatever the person experiences says it is. I cannot say that enough. If a patient that you are speaking with is sitting, laughing, having coffee, Andi says. Her pain is 10. Its's a 10. If somebody is writhing in pain and states their pain is a one, then it's a one. So we have to believe what the patient is saying. And again, that is an opportunity thio opportunity to readdress how we're collecting the pain data. And does the patient understand the pain scale? Self reporting is the best indicator of the presence of pain and pain intensity. Let's talk about acute versus chronic pain, and we're gonna talk. Talk about other types of pain as well. But acute pain is usually associated with an identifiable condition. If I'm playing softball and I got, I get hit in the arm with a ball, I'm gonna have paint. I see that obvious trauma. It's usually well characterized. It's usually self limiting and short in duration. No septic pain is pain that is transmitted by no sectors. This is typically acute pain, chronic pain that may be present for an indeterminate amount of time. Oftentimes, we say, chronic pain is greater than three months. It may or not. It may or may not be identified with an event or any type of trauma mhm frequently caused by acute pain that has not been treated correctly. That turns into chronic pain. We're going to talk about cancer pain. That's a totally different beast. Pain associated with cancer is persistent. It's debilitating. ITT's degenerative condition it oftentimes is chronic with nerve damage. Neuropathy. These so just thio show the difference between acute pain and chronic pain. Acute pain is a symptom where chronic pain is a disease. Oftentimes acute pain has an identifiable source and a physical finding like a bruise or a lump, where often chronic pain has no identifiable, clear source. Acute pain has a protective function in response to to disease or injury. And I say that because you in acute pain, your body is able to realize I have acute pain. I need to produce something to protect the integrity of what has happened. Maybe skin integrity. Chronic pain. Often times is a disease. All in itself, Chronic pain has usually no observable symptoms signs and it typically does not has it does not respond. Thio run of the mill treatment. Acute pain is often associated with the economic response. If I get hit by a ball. When I'm playing softball, my blood pressure is going to go up. I'm gonna be sweating. My heart rate's going to be up. Eso Oftentimes the autumn autonomic response kicks in and result acute pain oftentimes will resolve with appropriate treatment. Okay, now we talked about acute and chronic pain, but there are different types of pain as well. There's no sect of pain. There's no rope, a thick pain. No septic pain is just normal pain that travels along the nerves. It's a direct stimulation of the no show scepters, and we have no show sectors everywhere. There are two types of no she except of pain. And this is where it becomes extremely important to understand the types of pain. Because if you have a patient that has somatic pain and you treat them with something that's mawr suited for visceral pain, you're not going to get a response that the patient needs needs tohave. If you try to treat neuropathic pain with opioids, you're not gonna have much luck. S O Matic pain is often pain that's associated with the skin, the bone, bone injury, bone pain, muscle pain, soft tissue pain and this type of pain is stimulated by the somatic nervous system. Usually a sharp, throbbing cramping. It's well defined by the patient. Visceral pain is organ pain. Oftentimes cardiac pulmonary lung G i. G. You in nature, and that is stimulation of the autonomic nervous system. Visceral pain often times is very difficulty to describe and localized. I'm going to use chest pain as an example. Chest pain is visceral pain. Cardiac heart. It is an organ, and so if you have visceral pain, oftentimes patients have a difficult time expressing their chest pain. Most patients will say it's a pressure type pain, so that's visceral pain. And then neuropathic pain is a loss of the myelin sheath. The myelin sheath sheath covers the spinal cord and some nerve damage results in loss of that myelin sheath patients often times will describe this type of pain as burning, tingling, shooting, stabbing, itching. Some patients can't even describe it. Many patients have neuropathic pain that is worse than visceral or somatic pain. Cancer pain again a completely different animal were in 2000 and 20 and one million cases are diagnosed annually, and now that figure has doubled with approximately 70% of cancer diagnosed in developing countries. Patients with cancer 70% suffer from pain related to the disease or related to their treatment. A lot of patients say I don't know what's worse, the disease or the treatment In patients with advanced cancer, About 50% complain of moderate pain and 25 of severe pain. I'm sorry something happened to the slide, but it's, um, wanted to tell you this. We're just talking about cancer pain. Um, often times 30% of patients with cancer do not receive the appropriate type of medication for their pain. Big study in China, France and the United States, we're looking at patients pain. And in the United States, 42% of patients were not adequately treated for their type of pain. Cancer pain is intractable, severe and non curable. We can treat it, but it's difficulty curing cancer pain. So we talked about acute and chronic and neuropathic pain. There's also psychogenic and phantom pain, psychogenic pain, for which there is little or no physical evidence. No evidence of organic disease, no identifiable injury. Nothing. It's just psychogenic is how we describe it or define it. Fan and pain is pain that feels like it's coming from a part of the body that's no longer there. If a patient has, oh, let's see a right below the knee amputation. They may complain of right foot pain, and that is phantom pain. So the World Health Organization came up with a three step ladder to really address pain and treat it so mild, moderate and severe. When we talk about mild pain, it looks like we look at a scale. 1 to 10. 123 mild, oftentimes treated with non opioids aspirin and said's Tylenol. Moderate pain for 26 oftentimes is treated with hydrocodone, oxycodone, tramadol coding and severe pain. Often 7 to 10 is treated with morphine, fentanyl, Dilaudid, methadone, oxycodone. We do not use Oxy more phone, just just to let you know that we use the other types of opioids. So what are some? So we talked about pain, so we know pain. We know it now we know acute from chronic pain. We know what type of pain, bone pain, muscle pain, organ pain so we know how to treat pain. But now why are we still having patients that have untreated adequately managed pain? Well, there are barriers look at patient barriers. There are patients that don't language barrier. They don't understand or we don't understand them. And at times they're not comprehending us. Cultural differences. Lack of Knowledge about pain Relief I have many patients who have a very difficult time acknowledging their cancer, and therefore they're having a difficult time acknowledging their pain. Even though it's there a socioeconomic status. There are patients that can't afford their pain, medication and physical. Um, if a patient is incapable of getting up or ambulance ing, oftentimes I will recommend a pharmacy that will deliver. There's also professional barriers. There's our priorities and values about pain that we may, um, discuss with the patient. But we look at our our views and our values first or lack of just general lack of knowledge regarding pain management. And then there's symptom barriers. Just we are doing so much better at a lack of a systematic approach. Um, at handling pain and treating pain were so much better than we have been in the past. I looked at this slide and I thought, This describes pain. I mean, it's just factors that influence paying our cultural factors. We discussed that age is a factor. Um, fatigue, genetic makeup and memory. Memory means, especially when you were a child. If you experienced some type of pain that's gonna influence how you look and perceive pain myself. I do not like going to the dentist because when I was a child and went to the dentist, I think my dentist thought, thought he anesthetized me and he didn't. So now I can't go to the dentist because I am so fearful of the pain that I may have. And so that kind of explains memory in influencing pain management. So let's look at concepts associated with pain, so you may hear threshold. You may hear pain, tolerance from individuals, professional and patients. You may just let's talk about threshold. It's the amount of stimuli needed for patient toe label. Their pain tolerance is the maximum amount of painful stimuli that a person is willing to withstand without seeking pain management. Some patients have very high pain tolerance. Some patients can tolerate pain of 7/10 and be fine. Some patients can only tolerate paying two out of 10. I usually ask patients when they have pain, and they rate their pain I ask them, Is that appropriate? Is that manageable for your lifestyle and your situations? Hyper an algae Zia is heightened response to painful stimuli. What that may mean is, I can whisper a cotton ball across someone's cheek, and they may experience pain from that where other patients would not. Al Adonia is non painful, painful stimuli, produces pain and then disses thes. Asia is an unpleasant, abnormal sensation to pain that most people may not experience. So when you're looking at principles of pain management, I put this three times because you must listen to the patient. Listen to the patient. Listen to the patient. The reason I put that three times is often times we go in kind of with our own agenda of what we want to dio patients having pain. I think I'll give him some Tylenol and then you get in and that's already in your mind and you forget toe. Listen to what the patients telling you. Remember, pain is very subjective. You need to reassess often patients pain levels, especially after administering some type of therapy. And then listen, um, toe what the patient is saying again, belief. My belief in most people is less the least amount of medication for the most amount of benefit pain management. Why is it so important? Untreated pain is really poor medical practice. It results in so many adverse side effects, which we talked about earlier. Also, untreated pain releases circulating Calico Cat Akula means which placed the patient at risk for elevated heart rate, elevated blood pressure bleeding. It can also put the patient at risk for myocardial infarction and or stroke other, you know, really debilitating. Um, very debilitating diagnosis. Okay, Pain pain management. Again, Why is it so important? Decrease length of stay. We all here that we need to decrease the length of state of the patient, so we need to be very effective in treating their pain toe help with early post op mobility. If it's a surgery patient, increased healing times, the patient gets out of the hospital sooner, and also they have, um, they have expectations when they're in the hospital and were able to meet those expectations. Also, remember, acute pain that is not treated oftentimes will result in chronic pain issues. So also drug administration. There are so many routes of administrating drug, the one that I didn't put in there was introduce IUs. You can also do that. Oftentimes we use that in Children as we put if we can't get an I V, we'll put a needle in their bone and the bone and give them medication, including pain meds. So also, just don't forget that there's epidurals. There's pain pumps, implantable pump, um, intra ethical ways of administering pain, pain management. Okay, so no sectors sell ending. So we're going to talk about how pain, How does pain begin, and where does that get transmitted and how How does it? How do we feel it? So it begins transmitting a painful stimuli is then transmitted to the dorsal horn of the spinal cord. From there, it's transmitted to the foulness and then to the sensory cortex in the brain where pain is actually received. So what we need to do is figure out in that pathway from the dorsal horn of the spinal cord to the thalamus to the cortex. Where in that pathway can we inhibit something? So actually, opioids inhibit pain signals at multiple steps? There is evidence that opioids can work peripherally at decreasing the activation of neurons and inhibiting the immune response. Opioids are so effective in treating pain because I think it looks at every neurological angle and treats pain. Okay, so let's talk about for done this. Come on. No way. I'm gonna have to say, let's wake up. Because this is a little bit, um I don't want to say boring, but it's just how pain evolved. And so it's transaction transmission perception of modulation. But listen, I made it very, very simple. I mean, we can spend a whole lecture on this, but I want you to get a little more out of this, um, than just the pathway. So a noxious stimuli I hit my hit My hand with a hammer triggers the reliefs of biochemicals. Cross the gland in serotonin, epinephrine, histamine and it sensitize is the no. Sectors also causes movement of cells across the membrane, which excites no she exception. Usually it's potassium. So during transaction, this is where pain medication works by blocking prostaglandins and during trans duck shin opioids can also decrease the movement of the ions. Between the cells, there are three phases of transmission. So we're now we're transmitting pain. Impulse is one phase or phase one is the pain travels from the peripheral nerve to the spinal cord. Two is from the spinal cord, via the spinal atomic track to the brain stem and the thalamus, and then from the thalamus. It is triggered to the sensory cortex, and that's Phase three transmission. We can block pain at Phase one. I'm sorry. Space to they. Opioids can block the release of Nure Oh transmitters and stop that pathway at the spinal level so it doesn't travel up to the thalamus and then to the sensory cortex modulation descending system. So what this is is it occurs in the thalamus and the brain stem. The reason it's descending is because it sends signals down to the dorsal horn of the thalamus and the spinal cord. These descending fibers then release endogenous opioids. We all have endogenous opioids in our system. Serotonin, norepinephrine, acetyl coleene on git can hib it a sending descending down a sending up noxious, painful stimuli so it can block that sensory cortex. Perception is exactly what it says. It's when the patient becomes aware of the pain. Let's talk about a few general rules is half life. Half life is Thea amount of half of the medication that is excreted now. What that means is, if I am giving an opioid that has a half life of two hours in two hours, half of that medication is going to be out of the patient's system in another two hours another half and another two hours another half. So if I haven't opioid that has a half life of two hours, and I scheduled that opioid every 12 hours. I'm doing the patient a disservice because by the time the 12 hours gets there, the patient's gonna already the medication will be out of their system. C Max is, uh, and this is why these concepts are so important to understand is if you do have a patient, that somebody is ordering an opioid every 12 hours. If it's not a long acting opioid, then you'll think, Hey, this, this is not going to treat the patient's pain. C. Max is the peak plasma concentration off a medication after it is administered and steady state. This is what we want all patients to reach when they're giving opioids. We want an opioid to reach steady state. That is the time in which the concentration of drug in the body remains consistent. What I tell patients is you get these peaks and valleys with pain management. When we introduce something that's long acting, then you have steady state. I tell them this is where steady state is, and we want your pain levels to be down here. So when we're looking at pain management, we have, we want steady state. But we also have breakthrough pain. Sometimes it's very spontaneous. Where there is no precipitating factors or events, the patient just developed some type of pain breakthrough pain without any warning. There's also in an incidental pain, volitional and non volitional. The volitional is patient perceived movement, so if a patient moves or turns or is having a addressing change, that's in an incidental pain. But there's also non volitional incidental pain where it's not under patients control. If a patient starts having pain in their ribs or or long pain and they sneeze or cough, that's completely beyond their control and they can have pain. Spontaneous breakthrough pain and dosed is also something to think about. It's actually pain that occurs before the next scheduled dose of opioid or pain management, often times that happens because the dose is sub therapeutic. Let's talk about common behaviors in elderly patients. It's sometimes cognitively impaired. Patients cannot tell us that they're feeling pain, but we can look at their facial expressions. We can look at their body movement or the way that they're sitting or acting or interacting or their activities. So be alert to patients that are cognitively impaired. It may be difficult to accurately assess their pain. Pharmacological therapies. Let's get into the good stuff. Administering of pain medications. You want to do that routinely, we do order medication. P R N r as needed. But you want to do routine administration of pain meds. I'll show you what we mean. In a minute. Use the least invasive route Orel Pio. Begin with low doses and try titrate up. I always say, Start low and go slow and then constantly reassess because in a 12 hour period, you know you can really reassess patients paying often and get them to therapeutic levels. So always ongoing. Let's talk about receptors, so receptors are found everywhere in the body brain, spinal cord, peripheral nervous system. So when you look at receptors, there's mu most most opioids attached to the mute receptor. There's Kappa Delta and no accepted or orphan in receptors in our body. And the reason it's so important is because this is how we're going to understand pain management. So Kappa receptor stimulation oftentimes is associated with hallucinations, anxiety. And I want you to remember this when we discuss Demirel. Because Demirel sits on the Kappa receptor, delta and mu receptors are oftentimes associated with pain and with the reward centers in the brain. However, what I want you to understand is the reason why we have respiratory depression when we use opioids. Because the mid brain suppresses the body's ability to detect carbon dioxide and often times carbon dioxide. Increasing co two levels is what prompts us to breathe and opioids suppressed that. So that's where respiratory depression comes in. You know, I was one states that the most catastrophic side effective opioids is tolerance. Here we go, these air the receptors and this is why I tell patients it's almost impossible to get addicted to opioids. Look at these beautiful receptors. They're open. They're waiting for a opioid to come and sit on. It s o I tell patients that. Look, look at the little blue round dot as medications and look at the receptors as pain. I tell them you take the medications, it sits on the receptor. I tell them the receptor closes, but it doesn't really close. It's just occupied. And what I let him know is. So now you actually have pain that is controlled. It's the individuals that don't have any pain. These receptors are not open these receptors air closed. So there's nowhere for these opioids to go except into your system. And sometimes I have to drama of a picture. So they understand. That s O because a lot of patients are worried about getting addicted to pay medicine and opioids. There are short, long and intermediate acting opioids. So we're gonna talk about non opioids, opioids and also coal energy. Six. We use adjunctive therapy with pain management. Like steroids. We use anti convulsive, pro kinetics bio phosphates. Non opioids are usually aspirin, Uh, see the min if in and, um and said and of course, we have all our opioids. So mild pain. Oftentimes 123 we can look at acetaminophen, Tylenol, aspirin will help, and it blocks the production of prostaglandins um, ask for out. I'm sorry. Tylenol or acetaminophen is effective against pain, but it is not an anti inflammatory and said, and acetaminophen are usually the most effective in treating pain. The thing is, you have to look at this because if their patients that are on Coumadin or some of your factor 10 inhibitors, you have to like factor 10 inhibitors like eloquence on Darrelle toe. You have to be careful because giving them an end said may cause them to have more bleeding. But Tylenol will not cause them to have more bleeding. So if you take aspirin, you know, if I'm sorry to take Tylenol and end or an end said, and you pair it with, like a weaker opioids, such as oxycodone or hydrocodone, you're going to get a better response. So Percocet is Tylenol and oxycodone. Norco and Vicodin are hydrocodone with Tylenol, and then VitaPro. Finn is hydrocodone with an end said, so moderate to severe pain. It could be acute or chronic. This is usually middle of the road, um 4 to 7 type of pain, so acute chronic it could be either it could be post op. It could be traumatic it could be chronic that we are treating also, just to let you know I spelled a jug of wrong. But I'm hoping you didn't realize. But I just brought to your attention that what you think that is not right. But anyway, antidepressants were developed to treat depression, but it's also effective in combating neuropathic pain in cancer patients and chronic headaches. Antidepressants have been shown to also help with pain, such as L. A. Bill is one of the ones we use most often and then anti convulsive medications like Dilaudid, Integra doll Tegra. It'll, however, the big anti convulsive medication, the big one that we use is oftentimes Gava Penton for neuropathic pain again. If you use Gabba Penton, you're going to get a better response from neuropathic pain than you would from an opioid. All right, let's talk about morphine. Morphine is the most common opioid used. It's a very strong an algae sick, and it binds to the mu receptor. Uh, if you increase the morphine dose, you're going thio increase, Um, the analgesic effects of morphine. It is, um, it morphine is utilized in dull, poorly localized, visceral pain. So if you have somebody with an organ pain. Such is just pain. Oftentimes, morphine is a better medication to give with visceral pain. It better relieves that it's better for visceral pain than somatic pain. It is metabolized by the liver. It's really excreted, so you have to be very careful in patients with renal disease and or elevated creatine in The big thing with morphine is very prominent nausea and vomiting. It could be given into posit Torrey and other forms. What I usually do when I first um, give patients opioids is I give them something like Zafran as well to combat the nausea. Dilaudid is hydromorphone, and it binds to the receptor as well. We oftentimes will give Dilaudid for severe pain. The reason is, it's faster acting. So if you have someone with acute pain, you definitely want to give Dilaudid. It's faster. Acting are faster onset. I'm sorry, but it is shorter acting than morphine. There are short and long acting Dilaudid. Dilaudid is also re Nelly cleared, but the concentration of Dilaudid is so minimal that it is the medication preferred in patients with renal insufficiency. Also, with I lot of less vomiting, less nausea now, coding also binds to the me receptor, but we just don't use coding. We don't use coding and kids, and we don't use it. It has a very limited role in palliative care. Demirel remember, he said. Demirel sits on the Kappa receptor. Well, it's interesting because we just don't give people Demirel much anymore. We used to give it a lot for post op pain, but guess what happened? Patients would get crazy. They would start hallucinating. Well, that's what happens when you bind to a Kappa receptor. So oftentimes Demerol is just not used for chronic pain management. Methadone? A lot of people, um, you know, they hear methadone and they think, Oh, it's on Lee for detoxing heroin or opioid addicts. That is not true. Methadone is one of the medications I use most frequently in chronic pain management. It has a very long duration, has a very long half life. It can last. I mean, the half life could be 12 hours to a week. It accumulates in the system with continued dozing. It is well absorbed in the G. I track. It does very well. You administered orally. Um, do you like with with methadone, you start slow. You give it over a period of time, but you all. We also give a rescue medication or breakthrough medication because methadone takes a while to get into your system. But it also takes a while to get out of your system. The one big big thing I want you to take home is methadone can cause QT prolongation. So you always must get an e k g first before you start methadone and then a couple weeks into it another e k g um que t c. If you prolong, it can cause Prasad v t. And you also be careful with methadone because it prolongs the q t. C. So other medications like you're you're pro rhythmic amiodarone Zo Fran can cause prolonged q t. Yeah, so we're gonna move on to fentanyl. I like fentanyl. I think it's a great medication. It's 100 times more potent than morphine. That's why we can give transdermal fentanyl that will last three days. So you give fentanyl and usually transdermal patch. You change it every 72 hours, but fentanyl also has launch injures We There are still fentanyl lollipops that we used to give Children. You could give it some bling. Well, there's many ways to give fentanyl. Let's talk about oxycodone. It's not a bad word. A lot of people here oxycodone, and they say, I'm not going to take oxycodone because I don't want to get addicted because there's so many people. And with the media and the war on drugs, people are always talking about oxycodone. But it has a short half life. Um, it can be short. We can use short end or long acting, and oxycodone can be used for acute and chronic pain. Hydrocodone also is a youth used in acute pain but often times not chronic. The great thing about hydrocodone is it also has an anti tough sieve affect mawr so than coding, So patients have problems with chronic cough. Hydrocodone is a very good, fast acting or short acting opioid, Tramadol and people. Tramadol is here nor there, but I believe it or not, I like Tramadol in certain incident. In certain patients. I'm a patient right now with cancer pain, and Tramadol takes away her pain. It binds with the new receptor, but it's also a serotonin, nor epi re uptake inhibitor. Tramadol is pretty low risk we do give it for a modern, severe pain. It's good for fibromyalgia pain and neuropathic pain. Um, it is 1/10 the potency of morphine, but it's very good in fibromyalgia, so this would be a good medication to choose instead of an opioid benzodiazepines we also give with opioids. I often tell patients you give it about two hours in between opioids before you take a benzodiazepine, but they're very good in in conjunction with opioids in helping patients with this chronic severe pain. Valium, uh, starts working without in 30 to 60 minutes but has very long half life. It's a matter of fact that last 123 days in the system, I don't like giving Valium to older patients. House Ian is a little shorter acting, and it only has a duration of 3 to 8 hours. So how? See, Inverse said, those are a little bit better and then lorazepam. Ah, Klonopin, Xanax. They last about 20 hours in the system. Tricyclic antidepressants. They're often times used for mood disorders. Um, O. C. D. PTSD, and as well as chronic pain. Tricyclic antidepressants are also good for fibromyalgia and neuropathic pain. Am a trip Dellin is the one that we use most often half life. 123 days. So it does stay in the system for a while. Cannabis. We do talk a lot. We would do talk a lot about candidates to our patients with C b D. In it, it's used. It's the most cited reason for use of medical marijuana. A Canadian survey showed participants medical marijuana 84% of their patients used it, and we have very, very good outcomes with cannabis. We do not prescribe it just to let you know we do prescribed Marinol. But we do not prescribed th THC opening antagonist. I wanna let you know that every time you we prescribe an opioid, we always prescribed Narcan and we teach the patient how to use it. In a emergent situation, you could give it ivy at home. We give it intern easily. It's an antagonist. It blocks the opioid side effects of opioids this week, and we can add many side effects. But oftentimes nausea, vomiting, itching, sedation, respiratory depression. I put in here neuropathic pain. It's kind of like the slide just came from Nowhere. Reason I put it in is because Usually it's the invisible illness. Patients suffer severe neuro empathic pain and are not treated adequately. Kind of a few take homes pain. It can have a drastic impact on our quality of life. Another thing about pain. We're always gonna have to deal with it. We always did, and we always will. It's not going away. Management of chronic pain. I want you to know you patients. You start patients out with a short acting opioids, and then you add a long acting opioid. So we give long acting opioids, and we add short acting for breakthrough pain. So it's not uncommon to see patients on oxycodone, short acting opioid and OxyContin, long acting form of oxycodone. There's also complementary therapies such as I mean, we used lavender in our clinic. Aromatherapy, music therapy, hypnosis, therapeutic touch. I also wanted to add two slides or three slides about interventional therapies for pain because there are interventional management for acute and intractable pain. Minimum minimally invasive procedure. I'm going to go to the next slide because I want to show you that it's a syringe that is injected in a nerve branch with medications. It is done by interventional radiology a celiac plexus block is phenomenal for patients with pancreatic pain. Nerve blocks giggle, Janek blocks. There are many other interventional therapies that we can use with opioids and benzodiazepines and other types of therapies. So lowest dose start low, titrate up. Start with a single agent. Remember older people who want to start with a little less scheduled the pain medicine. You want to do it around the clock. It's usually Q 12. I tell patients in the morning and at night you're gonna take your long acting and then you're short. Acting is for breakthrough pain. Remember, it's subjective. Believe and listen to your patient. This way we can get better pain control Goal is to manage chronic pain. We're not going to resolve it. If a patient can live with the pain of three, then that's our goal. Medications. Not always the answer. We can always look thio other therapies. I wanted to add one thing before the discussion is this takes a village. We use social workers, we use nurses. We utilize um uh, psychiatrist psychologist. It takes a lot of people to help the these chronically ill patients with chronic pain. So it's all about management. We we bring in everybody, and it's just like I said, It takes a village. I want to thank you for your time and attention. I know it's a lot, but I'm hoping that at least you the one thing I want to take home is what kind of pain is it? And what's the best way to treat it? Thank you. Thank you, Maria. That was a very informative presentation on pain. And you've given us a wealth of information on all the aspects of opioids and pain management. Looks like we have a question from one of the attendees here for you. It's it says I have had patients tell me that there are PCP will not prescribe opioids benzos, etcetera related to cures. Providers in my office also voiced frustration with cures and refer to pain management specialists to deal with it. Do you think this is a factor in adequate pain control? I dio And I'll tell you why Because most I mean, you know, with the crackdown on opioids and the whole war on drugs, when I was in cardiology, I could not. We were not allowed to prescribe opioids, and I think in primary care. They're really you know, the kind of what you have to go through. You have to look at cures every time, and it's so it's so in depth that most people just say I don't want to do it and I think that is a factor now I like pain management, but if you can't see a pain specialist for three weeks, then that's a problem. Often times are cancer patients will be. We will see them in palliative care for symptom management. But yes, it is definitely a factor that people just they're afraid they don't want Thio Andi It is for lack of a better word. It's a hassle. Thank you. I also have a question myself regarding the opioid crisis and how oncology patients have been affected by this. And if they still are, even in mist co vid. Yeah, that's a great question. And yes, they are. I have to say that when we prescribe opioids, there are times when we prescribe. I have a patient that takes 360 mg of morphine a day. There are times when we are giving 280 tablets of morphine, and we're I would say 90% of time were called by the pharmacist so that that delays the patient in getting their medication. So absolutely, um, cancer pain is really pain. When I when I given opioid, I always put cancer related pain and that's a great question. All right, we'll give it a few more seconds here to see is if anybody else have any comments or any other questions. Can I also say that we do a lot of telemedicine, which is great because we can start patients on opioids and then follow up with them the next day through telehealth See? And they don't need to come into the office because, you know, because they have cove it and they're they're all immune compromised. Do you find that those telemedicine appointments are just as effective as they were in person before? I I dio I like to meet the patient in person first, um, that way we could really get get to know people. We allow about an hour and a half for new consoles because we really want to get to know the patient. But then I find that Tele visits are very helpful and, you know, there are patients that can't get to the office. Sometimes we'll do it. I'll do a visit twice in one week with a patient. If I'm really concerned, we'll also do phone calls. I've called patients you know, every day for five days just to make sure that we're adequately treating them. Thank you. It looks like we have one question that came in from Connie or actually another one as well. So what can you say to patients who turn on their alarm clock just to wake them up and ask for pain Meds, as Anil Jesu is prescribed every two hours? Is this a really pain? The patient says it is. It is I. I think it do. You mean patients in the hospital? I'm not sure you're talking about patients in the hospital patients at home, But if patients are get prescribed medication every two hours and they're on, say their call bell every two hours to get the medication, it's not adequate patients at home. If I prescribed medication every four hours and they're waking up and taking medication every four hours around the clock, that's when I prescribe a long acting opioid and the other question looks like we have more questions coming in. Do you have your patients sign a pain agreement with you? That's a great question. Yes, we dio some patients. I don't, um there are some, you know, some patients, not everyone, but yes, I do have patients sign a pain contract stating that they will take the pain medicine as needed. Now, we look at cures all the time, and there are patients that you know, get their payments and filled with the first of the month and by the 15th there out. So those are the patients that we keep a very close eye on. Those most of time are the ones that we have signed a contract. I see. Thank you. Another question is one of the physicians I work with said that Gabba Penton has not proven Thio helps with neuropathic pain, even though we all use it for that reason. But he says Cymbalta, is he on Lee on proven help with neuropathic pain? What are your thoughts on using that? And it's effectiveness that you've seen. I use both Gabba, Penton and Cymbalta. I have better luck with Cymbalta. I'm sorry and I wanted to mention that earlier that I start out with 30 and I go up to 60. I think Cymbalta is extremely, extremely helpful in neuropathic pain. But I do have patients that have Gabba Penton. I find that low dose Gabba Penton does not work well 103 times a day. Oftentimes our patients are on, you know, 900 mg of gabapentin and three times a day. The problem is that causes them to be sleepy. So in higher doses I find that it works better. There are lots of things that you know are not proven but work. But I do use a lot of Cymbalta. I like it and I also use Lyrica and Gabba Penton. Well, interesting. Thank you for that. And we have a comment here as I work in surgery and we consul pain management pre operatively whenever we can't comfortably manage them post up. Um, that's I mean, I think that's fantastic. I think that is very good practice because if you have a post op patient and we can't manage their pain, they're gonna be in the hospital longer. They're gonna have more complications and it may turn into something chronic, but I think that is good practice. Well, thank you so much, Maria. You are a wealth of information. And if anybody has any remaining questions, you can email Maria at Dolly d a i l e y dash Campbell dot Maria at scripts health dot or GTA. Thank you very much, Maria. Thank you. Stay safe, everybody. Thank you, I