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Maureen A. Carling, RN (USA) SCM, NDN, HV, FET (England)
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Vulvadynia
I have been thinking about how I can best help those of you who are in chronic pain and for whatever reason not getting any help. I thought perhaps the best way I can help you is to cover a different topic every month and allow you to write in with your questions, which I will be glad to answer on the web site.
Recently, I have been dealing with a number of patients with vulvadynia and in each case they commented that there was nothing that would relieve this. This is NOT true. Vulvadynia can and should be relieved. I have not met a single patient that I was unable to help.
I invite you to write in with your questions and I am happy to help you in any way I can.
Maureen A. Carling
Success Stories in Cancer Pain Management by Maureen Carling, RN
Empowering Patients to Actively Participate In Their Own Pain Management
Many cancer patients suffer with pain needlessly." Often, they operate under the assumption that, when it comes to narcotics, "more is better."" Physicians may not be knowledgeable of research that shows pain can be effectively controlled, when the appropriate medications and dosages are administered." They, too, often misinterpret a patient's request for additional medication as a dependency, when the patient's pain has not been controlled.
Pain in malignant disease is common, yet in most patients pain can be effectively controlled. For effective pain management there are three basic things, which must be done.
1. Assessment – to identify the TYPES of pain being experienced.
(I have developed an evidence-based pain assessment, called the Carling Algorithm, which uses a detailed" Pain Assessment Sheet.)
There are eight types of pain:
"· only two of them are fully opioid responsive,
"· three are semi-responsive, and
"· three are opioid resistant.
Most patients have more than one pain. Indeed, one third have four or more different types of pain. Before medications are prescribed, we need to know which types of pain you are experiencing, so that the appropriate medications can be prescribed.
2. Titration – adjusting the dosage of medication, which can mean an increase or a decrease, to achieve pain relief with the minimum or no side effects. Once the medications are prescribed, the dosage has to be carefully adjusted until the pain is under control. If you have three types of pain, then you may need three different medications, which will need to be adjusted individually until each pain is brought under control. Some medications, such as opioids (morphine, oxycodone hydromorphone etc), can be titrated fairly quickly. Others, such as antidepressants and anticonvulsants may take several weeks to titrate. You need to be able to differentiate between the different types of pain so that you will know which medication to take.
3. Regular and frequent monitoring. Pain is dynamic – it increases, it decreases and it can change in nature. Your medications may need to be adjusted accordingly.
"
Pain should be ‘controlled’ rather than treated. Long acting opioids can control the same level of pain by as much as one third less dosage. It is false economy to wait until you have the pain before you take the medication and you are suffering needless pain.
The aim of using long acting opioid drugs is to obtain and maintain a level which lies inside the therapeutic window. (See diagram) As long as the level stays within the window, you will be pain free and you will have no mental clouding. If the level rises above the upper parameter, you will begin to feel ‘hung-over’ or sleepy and judgment will be cloudy. If it falls below the lower parameter, you will experience breakthrough pain.
Statistically, it takes about 30% of the 12 hour dosage of the SAME DRUG in immediate release form to lift the level back inside the window. If you are taking Morphine Sulphate 60mgs (long acting) 12 hourly, then for breakthrough pain you should be taking Morphine Sulphate Immediate Release (MSIR) 20mgs (short acting) for breakthrough pain.
If you are taking one of the 24 hour morphine medications (long acting) then for breakthrough pain, you should be taking" 5% - 15% of the 24 hour dosage of the SAME DRUG in immediate release form, (MSIR)
If you are taking Oxycodone 40mgs (long acting) 12 hourly, then for breakthrough pain you should be taking Oxycodone 10mgs (short acting). For this drug 25% - 30%" is sufficient.
As a ‘rule of thumb’, if the pain breaks through 2-3 times per day or more, it is an indication that the level is in the lower margin of the window and the 12 hour dose needs to be increased by 50%, with a corresponding increase in the breakthrough dosage to represent 30% of the NEW dosage. (Call your doctor or nurse about this)
Conversely, if your pain comes down, e.g., after radiation therapy, then the medication will need to be reduced. If you wake up feeling ‘hung-over’ and especially if you had no breakthrough pain the previous day or so, then this is an indication that your pain has come down. The 12 hour dosage is then reduced by 30% with a corresponding decrease in the breakthrough medication to represent 30% of the NEW reduced dosage. (Call your doctor or nurse about this).
If you are taking twelve hourly opioids –morphine sulphate, oxycodone - take the same dose in the morning as in the evening, otherwise the level is fluctuating constantly.
Side effects.
1." " " Constipation occurs in EVERYONE taking opioids. You need a ‘pusher’" such as Senokot and a softener from the first dose of opioid. Opioids slow the bowel down. Your ‘pusher’ speeds it up again. It puts the ‘push’ back that the opioid has taken out. Take it EVERY day."
2." " " Nausea and vomiting. If this occurs, it is usually for the first 48 hours after starting on an opioid for the first time. Taking an antiemetic with the opioid for the first couple of days can prevent this. The commonest cause of nausea and vomiting after that time is poor bowel management. Prevent it happening in the first place by taking your ‘pusher’ and softener regularly.
Call your doctors and nurses:
1." " " If the medication you are taking is not controlling the pain.
2." " " If you have breakthrough pain two to three times per day or more.
3." " " If you wake up feeling ‘hung-over’ and especially if you had no breakthrough pain the previous day.
4." " " If you have not had your bowels opened for three days or more.
5." " " If you have nausea and/or vomiting.
6." " " If you develop new pains.
Neuropathic pain occurs in about 15% of patients with Myeloma and in 8 out of 10 of them it precedes the onset of symptoms. Neuropathic pain can be controlled using antidepressants and/or anticonvulsants, which need to be titrated up slowly over several weeks."
These are now available in topical form along with drugs such as Guaifenesin, Clonidine, Ketamine and the NSAIDs and other medications. These have the advantage of reducing side effects considerably, and relief is speedier on considerably lower dosages."
A Compounding Pharmacist would help you with this." "
Remember:
- Pain CAN and SHOULD be controlled
- You have nothing to fear but fear itself
"
•" " " Work as Hospice Nurse, Community Nursing Sister, Nurse Midwife, Health Visitor (Nurse Practitioner Pediatrics and Public Health), Specialist Health Visitor for Handicapped Children and College Lecturer.
•" " " Served on the Management Committee that opened the first hospice in the area in the North East of England and member of the Advisory Committee for the Care of the Terminally Ill for that region
•" " " Own Radio Program with the BBC in England, broadcasting live for an hour, once monthly.
•" " " President of the Virginia Cancer Pain Initiative 1996."
Member of the National Speakers Bureau - Purdue Frederick Pharmaceutical Company.
•" " " Member of the Faculty of the American Society of Pain Educators 2006
•" " " Pain Management Coordinator for Riverside Regional Medical Center in Virginia for almost three years, up until April 1998, during which time, taught program of Pain Assessment and Management to nursing staff, physical therapists, pharmacists, medical students from EVMS, OB/GYN and Family Practice Residents."
•" " " Author of multiple articles published in the journals" Analgesia," International Journal of Pharmaceutical Compounding, and theInternational Myeloma Foundation Journal.
MA Carling "© 2009 All Rights Reserved
"
Success Stories in Cancer Pain Management by Maureen Carling, RN
A Foreward
I recently heard the news from the West Coast, where someone ended their life with assisted suicide. I find it ironic that so many fight for the right to assist suicide, which I understand having watched my dad die as he did, yet nobody mentions fighting for effective pain relief." Must we endure the Dr. Kavorkian issue all over again? How unnecessary!
I remember the P. Connor's quote: "Despite the recent advances in knowledge, pain control in the terminally ill remains a disgrace. What is needed is not a stunning whole new understanding of pain pharmacology, but the rational and consistent application of what we already know. History will judge us harshly if we fail to meet even this modest goal." I think that was written in 1987!!! How far have we come?
Success Story #1
This was a 42 year old woman with stage IV breast cancer with metastases to bone.
Assessment revealed pain in six sites:
The sternum, the lower ribs from sternum to vertebrae, the lumbar spine, the lower buttocks, the knees, and the anterior aspect of the lower legs.
She had been treated with opioids, which relieved the pain a little, but they made her feel very sleepy and ‘spaced out’ and the relief only lasted an hour, so she had discontinued taking them." She was also taking a NSAID twice daily, which she reported as having helped for about two weeks, but then became ineffective, so she discontinued taking that, too.
Assessment revealed pain, which was described variously as:
"Deep ache, like toothache, stabbing, very sensitive to light touch, worse on movement and sometimes pulling and tightening."
These descriptions suggests soft tissue pain, bone pain, muscle spasm and neuropathic pain. Most of her unrelieved pain was neuropathic and muscle spasm, which were severe at times and none of the above medications would relieve those types of pain.
The following medications were compounded in an anhydrous gel by a Compounding Pharmacist:
Clonidine 0.2 %
Amitriptyline 5%
Gabapentin 6%
Baclofen 5%
Ketoprofen 5% -10%
The gel was applied as a thin film to the site(s) of pain. Then, 0.2mls – 0.4mls was applied at spinal level to the corresponding dorsal horn of each dermatome involved. The gel was applied 3 times daily routinely, plus two hourly in between if necessary. Once the pain was under control, the gel was reduced to once or twice daily.
She was reassessed after using the gel for at least a week. She reported that the intensity of pain in all sites had reduced significantly. (She quoted 85% reduction). She reported that she had only been applying the gel twice daily, so she was advised to apply at least three times daily until the pain was under control. She was reassessed after another week. Pain was almost completely gone in all sites." Certain activities appeared to trigger the pain in one site, so she was instructed to apply the gel prior to carrying out that activity, which was highly effective.
One of the advantages to this approach is that once the neuropathic pain is under control, the need for opioids decreases. This has been a consistent finding.
Success Stories #2-5
Five patients with multiple myeloma, one man and four women, ages ranging between 42 and 57 years – mean age 52 years who developed chemo induced neuropathic pain in the hands, legs and feet were referred for Pain Consult.
Each patient had an Initial Pain Assessment carried out using the Carling Algorithm. The data collected then formed the basis for analysis, report and plan of care. All had been treated with opioids, which did little or nothing to relieve the pain. Some discontinued because of nasty side effects." Three of them had been taking Neurontin, but had discontinued because of side effects – mostly somnolence. Two had tried Cymbalta, which helped one of them a little, but the other one discontinued taking it because it upset her stomach.
The following medications were compounded in an anhydrous gel by a Compounding Pharmacist
Clonidine 0.1% - 0.2%
Nortriptyline 3% - 5%
Gabapentin 3% - 6%
Baclofen 2% - 5%
Ketoprofen 5% - 10%
All five patients used the above combination in varying strengths:
The gel was applied as a thin film to the site(s) of pain. Then, 0.2mls – 0.4mls was applied at spinal level to the corresponding dorsal horn of each dermatome involved. The gel was applied 3 times daily routinely, plus two hourly in between if necessary. Once the pain was under control, the gel was reduced to once or twice daily.
They were each reassessed after a week and, if the pain was not completely controlled, then Ketamine 5-10% was added. All achieved complete to excellent pain control.
One advantage of this method was that pain relief was achieved very quickly – some immediately, some within hours and some within days, but all achieved pain relief.
A second feature of this approach was that without exception, once the neuropathic pain was brought under control, the need for oral opioids decreased. This too was a consistent finding.