its assessment & concerns with a little bit of management · •recreational drugs? •medical...
TRANSCRIPT
John F. Manfredonia, DO FACOFP FAAHPM HMDCNational Medical Director Gentiva / Kindred Hospice
25th Annual Southwestern Conference on MedicineApril 28, 2016
Its Assessment & Concerns
with
A little bit of Management
Tucson Osteopathic Medical Foundation
It's Not About The Nail - YouTubehttps://www.youtube.com/watch?v=-
4EDhdAHrOg
https://www.youtube.com/watch?v=-4EDhdAHrOg
Disclosure Statement
Information presented is not a substitute
for
Common Sense
This in-service is intended for educational purposes only.
This presentation is in the context of chronic pain.
Objectives
►Pain Assessment
►Abbreviate Look
at
Pain Management• Non-Pharmacologic
• Pharmacologic
—Non-Opioids
—Opioids
—Adjuvant Medication
• Side-effects
• Breakthrough Pain & Rescue Dosing
Essentials of Pain Management
Upon completion of this presentation, participants will be better able to understand and describe the essential elements of…
Enhance Skills & Competencies
Promote Critical Thinking
Our Goals
Understand the basics of good optimal pain management.
With good assessment and communication skills this should assist
you in managing most patient with pain.
However
There are those patients with complex pain syndromes that require
advanced skills.
Remember
Thorough Assessment coupled with
Good Pain Management + Education and
Communication = ↓ suffering
Essentials of Pain Management
Prescription drug abuse is now the second leading cause of unintended death in the United States.
A flood of opioids, a rising tide of deaths N Engl J Med. 2010 Nov 18;363(21):1981-5.
The number of annual opioid prescriptions written in the United States is now roughly
equal to the number of adults in the population.
Centers for Disease Control and Prevention. Vital signs:opioid painkiller prescribing. July 2014 (http://www .cdc .gov/vitalsigns/ opioid-prescribing).
SAMHSA. (2013). Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.
NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD.
First-Time Use of Specific Drugs Among Persons Age ≥ 12 (2012)
8 | © CO*RE 2016
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Additional Goals and Concerns
Awareness & Management of chronic non-
malignant pain
Awareness & Management of Diversion—If suspect…need to address & document
—Responsibility to the community
—Pain Management Agreement
—Query state PDMP
—Regular visits
—Limited prescriptions (quantity)
Essentials of Pain Management
Substance Use
Disorder
Chemical Coping
Types of Pain
Essentials of Pain Management
NeuropathicNociceptive
Somatic Visceral
Intracranial
Psychogenic
Inflammation
Skin Wounds
Infection
Arthritis
Constipation
Neuropathy
Urinary Outlet Obstruction
Visceral MetastasesSpinal Metastases Bone Metastases
Bowel Obstruction
Trauma / InjuryCephalgia
Ischemia
DVT
Low Back Syndrome
Cancer Chemotherapy
Radiation Therapy Abdominal Colic
Immobility
Fracture
Renal Colic
Sciatica
What about Psychogenic Pain
►Amplification of Pain
• Contributory Co-morbidities —Depression
—Anxiety
—Post-traumatic Stress Disorder
—Substance Abuse
—Psychiatric Illness
Essentials of Pain Management
The above conditions are factors to be considered in the assessment and treatment of pain but should never contribute the dismissal of a
complaint of pain.
Assessing Pain IntensityComfortable / Uncomfortable
Severe Symptoms
Moderate Symptoms
Mild SymptomsNo Symptoms
Tolerable / Intolerable
Spontaneous…..Incidental……Continuous
Pain Scales• We should be familiar with the 10-point scale
• We also know some pts insist on 12+ points
Pain
Assessment
Essentials of Pain Management
Intensity
Location
Character
Onset
Duration
Exacerbates/Palliates
…Pain AssessmentEssentials of Pain Management
Know their Medications• Current Pain Regimen
• Dose• Route• Frequency
• Around-the-Clock• Rescue Dosing(PRN)
• Effectiveness?• Compliance• OTC
• Medications History• ETOH Consumption?• Recreational Drugs?• Medical Marijuana
Breakthrough Pain
►Definitions
• Breakthrough Pain - “a transient exacerbation of pain
that occurs either spontaneously, or in relation to a
specific predictable or unpredictable trigger, despite
relatively stable and adequately controlled background
pain”
Davies AN, Dickman A, Reid C, Stevens AM, Zeppetella G. The management of cancer-related breakthrough pain:
recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain
and Ireland. E J pain 2009;13;331-338
• Background Pain = constant or continuous pain of long
duration usually ≥ 12 hours / day.
Essentials of Pain Management
…Breakthrough Pain
Essentials of Pain Management
Types
Spontaneous Pain
Incidental Pain
Occurs Unexpectedly
Impacts Sleep & Mood
Maybe Unresponsive to Opioids
Related to Specific Events
Precipitated
Impacts of ADLs
Movement RelatedWt-bearing ActivitiesIdentifiable TriggersProcedures
…Breakthrough Pain
Acute onset of short duration
Peak ≈ 5-10 minutes
Duration ≈ 45-60 minutes
Intensity: moderate to severe
Essentials of Pain Management
Deandrea S, Corli O. A New Focus on Breakthrough Cancer Pain: Commentary on Davies et al. JPSM: Vol.46 No. 5, Nov 2013: 618-628
Characteristics(Cancer)
Uncontrolled
Pain
Essentials of Pain Management
Is the dose too low?
Is the interval too long?
PRN Dose administered?
Allodynia? / Hyperalgesia?
“Total Pain” Physical
Spiritual
Mental
Social
Recognize their Suffering
Consequences of Inadequate Pain Control
Impact
Function
Sleep
Psychosocial
↓ Activity↓ Appetite
DisturbanceDeprivation
DepressionAgitation & AnxietyFearIsolationMarital and Family DysfunctionIncreased demands on caregivers
Deconditioning
SUFFERING
Types of Pain & Pharmacologic Management
Essentials of Pain Management
NeuropathicNociceptive
Somatic Visceral
Intracranial
•Non-opioids-Acetaminophen
-NSAIDs
•Opioids
•Adjuvant Medication-Antispasmodics-Corticosteroids
•Opioids
• Opioids• Adjuvant
-Anticonvulsants-Antidepressants-Bisphosphonates-Corticosteroids-Local Anesthetics-NMDA Antagonist
• Non-Opioid• Adjuvant
-Steroid• Opioids
1st Line /Mild pain
2nd Line / Moderate-Severe Pain
Refractory Pain
Spinal/Epidural Opioids
± alpha-2 agonists
± local anesthetics
+ other agents
Selective nerve blocks
Neurostimulation
Neuroablation
IV Lidocaine
Subanesthetic ketamine
Palliative Sedation
Opioids
+ NSAIDs
+ AdjuvantsAcetaminophen
Aspirin/NSAIDs
± Adjuvants
Modified Pain ManagementStep Ladder
Fine PG. The evolving and important role of anesthesiology in
palliative care. Anesth Analg 2005; 100:183-188.
Approaching Pain Management
►Non-pharmacologic
• Many treatments
• Listening and acknowledging pain is one important
modality
►Pharmacologic
• Non-opioids
—Acetaminophen
—Nonsteroidal anti-inflammatory drugs
• Opioids
• Adjuvant Medications…see appendix B
Essentials of Pain Management
Non-Pharmacological Management of Pain
• Physical Therapy
• Manipulation
• Massage
• Psychotherapy
• Acupuncture
• Hypnosis
• Integrative Medicine
• Exercise
• Guided imagery
• Distraction
• Provide companionship
• Misc Therapies
Needs to be a Comprehensive Integration of Care
Listening
►Therapeutic Dialogue
• Generally safe
• Wide Therapeutic Index
• Over-dose very rare
• Non-invasive
• Low side-effect profile
• Efficacious
• Cost Effective
Essentials of Pain Management
Acknowledge the Pain….Address the Fear
…Non-pharmacologic
…Approaching Pain Management
►Pharmacologic
• Non-opioids
—Acetaminophen
—Nonsteroidal anti-inflammatory drugs
• Opioids
• Adjuvant Medications…see appendix B
Essentials of Pain Management
Non-Opioids Mild-to-Moderate Pain
Acetaminophen…relatively safe but…
• Analgesic / Antipyretic
• Liver toxicity possible if >3gm / 24 h
• Risk
—Advanced age / Hepatic Disease / Heavy Alcohol use
—Overdose leading cause of liver failure in US
—Combination Medication
NSAIDs…especially if inflammation is present
• Analgesic / Antipyretic / Anti-inflammatory
• Risk
—GI bleeding / Renal failure / Cardiovascular events
—Rate increases with longer exposure
—Multiple formulations available
Essentials of Pain Management
…Approaching Pain Management
►Pharmacologic
• Non-opioids
—Acetaminophen
—Nonsteroidal anti-inflammatory drugs
• Opioids
• Adjuvant Medications…see appendix B
Essentials of Pain Management
Choosing an Opioid: Factors Essentials of Pain Management
Past History
Hepatic Insufficiency
Patient’s Location
Hx of Addiction?
Allergies
Route of DeliveryAdvanced Age
Ease of Delivery
Familiarity
Optimal Rescue Dose
Opioid Naïve / Opioid Tolerant
Cost-Efficient?
Renal Insufficiency
Appropriate Dose
Best Cost
Already On
Dosing Interval
Side-effects
FormulationEquianalgesic Dose
Which Opioid do you Choose First?
Morphine is considered the Gold Standard
However
“The data show no important differences between morphine, oxycodone, and hydromorphone given by the oral route and permit a weak recommendation that any one of these three drugs can be used as the first choice step III opioid for moderate to severe cancer pain.”
Lancet Oncol 2012; 13: e58-68
MorphineEssentials of Pain Management
Usually 1st opioid of choice Bio-availability ≈ 35% orally Peak effect Duration ≈ 3-6 hours Route: PO / SL / PR / SC / IV Ratio: PO to SC/IV = 3 : 1 Pharmacology
Metabolism: LiverTolerated with mild-moderate hepatic impairmentMetabolites
Morphine-3-glucuronide (M3G)Morphine-6-glucuronide (M6G)
Excretion: 85% Urine Caution: Renal Insufficiency / Failure
Recommendation: reduce dose and/or frequency
• Oral ≈ q 60 min*• SC ≈ q 20 min*• IV ≈ q 10 min*
*approximation
Standard Protocol
Morphine …pharmacokineticsEssentials of Pain Management
Route
IV
SQ
PO
Onset
(minutes)
5-10
10-20
30-60
Peak
(minutes)
15-30
30-60
60-90
Duration(hours)
3-4
3-4
3-4
Titration(minutes)
10
10-20
120
McCaffery M, Pasero. Pain: Clinical Manual, pp 241-243. Mosby, Inc 1999
- PROPRIETARY AND CONFIDENTIAL -These materials are for internal purposes only.
Not for disclosure outside Gentiva except by written agreement.
Equianalgesic Dosing Chart
Essentials of Pain Management
PO/PR (mg)
• 30
• 30
• 7.5
• 20
• NA
Analgesic
• Morphine
• Hydrocodone
• Hydromorphone
• Oxycodone
• Fentanyl
SC/IV/IM (mg)
• 10
• NA
• 1.5
• NA
• 0.1
Methadone is too complex to include in this chart
(100mcg)
*based on single dose studies
Based on single dose studies
Table 4
Oral Route
Parenteral RoutesIntravenous / Subcutaneous / Intramuscular
Transdermal Route
Rectal RouteEffective Pain Management
Opioid Medication
Epidural / Intrathecal
Treatment Plan
Remember!
In the Beginning……It’s a Trial
Oral Route Preferable
Appropriate Dose
Under-treatment
Individualize Treatment
Over- treatment
Large Intra-individual Variation
Side-effects? Neurotoxicity
Around-the-Clock Dosing for Continuous Pain
Competent Caregiver? Hx of Substance Abuse?
Treatment Plan…opioid naive
Moderate-to-Severe Pain
1. Consider oral analgesic
2. Start with a short-acting opioid
• Hydrocodone/Acetaminophen 5/325mg 1 or 2 q 4 hrs as
needed for pain (has a ceiling dose)
or
• Oxycodone (with or without acetaminophen) 5mg q 4 hrs as
needed for pain
or
• Morphine 10mg q 4 hrs as needed for pain
3. Consider lower dose in the elderly
Essentials of Pain Management
- PROPRIETARY AND CONFIDENTIAL -These materials are for internal purposes only.
Not for disclosure outside Gentiva except by written agreement.
Treatment Plan…opioid naive
4. Titrate immediate release opioid to control pain
• If analgesia insufficient…increase dosage in 25-50%
increments until pain relief is adequate
• Caution with combination medication
• Short-acting opioid can be dosed every 1-2 hours
5. Consider switch to equivalent long-acting medication
when pain controlled…if appropriate
6. Initiate bowel protocol
7. Prescribe an Anti-emetic if necessary
8. Consider adjuvant medication…see Appendix B
Essentials of Pain Management
- PROPRIETARY AND CONFIDENTIAL -These materials are for internal purposes only.
Not for disclosure outside Gentiva except by written agreement.
Treatment Plan…opioid tolerant
Severe Pain
1. Determine current medication dose and frequency
2. Determine how much and what opioids were taken in the preceding 24 hours. .If necessary, calculate the total morphine equivalent dose
3. If appropriate, continue or increase extended release/long-acting opioid
Essentials of Pain Management
- PROPRIETARY AND CONFIDENTIAL -These materials are for internal purposes only.
Not for disclosure outside Gentiva except by written agreement.
Treatment Plan…opioid tolerant
Severe Pain
4. Titrate short-acting opioid to control the pain
-Prescribe 10% (5 to 15%) of the of the preceding 24 hr total dose every 1-2 hours until adequate pain control is achieved or distressing side-effects occur.…Avoid combination medications
5. Adjust or implement around-the-clock dosing*
-Combine the total equianalgesic dose of both the short-acting and long-acting opioids and administer every 8 to 12 hours around-the-clock
Essentials of Pain Management
- PROPRIETARY AND CONFIDENTIAL -These materials are for internal purposes only.
Not for disclosure outside Gentiva except by written agreement.
*Steady State PharmacokineticsWhen the rate of drug input and elimination are equivalent. It takes somewhere between 5 and 6 half-lives for a medication to reach steady state.
…Treatment Plan…opioid tolerant
6. Continually adjust / titrate the rescue dose of the short-
acting opioid to 10% (5 to 15%) of the total 24-hour
opioid dose and administer every 1-2 hours as needed
7. Monitor bowel movements…bowel protocol may need to
be adjusted
8. Consider an adjuvant medication…see Appendix B
Essentials of Pain Management
- PROPRIETARY AND CONFIDENTIAL -These materials are for internal purposes only.
Not for disclosure outside Gentiva except by written agreement.
Rescue Dosing Review
Rescue Dosing for Breakthrough Pain
► Calculate total daily dose taken
► Recommended to use same opioid
• Immediate Release
► Rescue dose is
• ~10% (5% - 15%) of the total daily dose
► May repeat after peak effect reached
► Oral ≈ q 1 h
► SC ≈ q 20 min
► IV ≈ q 10 min
Essentials of Pain Management
…Rescue Dosing Review
►If taking ≥ 3 rescue doses within 24 hours and
pain is expected to continue, re-evaluate and
increase baseline if indicated.
Essentials of Pain Management
RememberSteady State Pharmacokinetics
Opioid Titration Review
► For mild pain, a 25% increase.
► For moderate pain, 25-50% increase.
► For severe pain, 50% increase.
► For excruciating pain, 100% increase may be needed.
► Around the clock scheduled dose used within the last 24 hours + the total amount of rescue doses within 24 hours x percent increase (see above) = the new total opioid dose around the clock:
Essentials of Pain Management
24-hour Baseline Opioid
Dose
24-hour Rescue Opioid Dose
24-hour Total
Opioid Dose
+
= x
%Increase(see above)
AdditionalOpioid Dose
Required
New 24-hour Total
Opioid Dose
=
10% of this dose q 1-2 hrs
for Rescue Dosing
Opioid Adverse Effects(Usually Dose-Related and Drug-Specific)
Common
– Constipation
– Dry Mouth
– Nausea/Vomiting
– Sedation
– Sweats
47
Less Common– Respiratory Depression– CNS
• Cognitive • Bad Dreams • Hallucinations• Delirium• Myoclonus/Seizures
– Pruritus/Urticaria– Urinary Retention– Endocrine Dysfunction
Specific Characteristics
For detailed information, refer to online PI:
DailyMed at www.dailymed.nlm.nih.gov Drugs@FDA at www.fda.gov/drugsatfda
Know the opioid products you prescribe:
Drug
substanceFormulation Strength
Dosing
interval
Specific information about
product conversions, if availableSpecific drug interactions
Key
instructions
Use in opioid-
tolerant
patients
Product-
specific safety
concerns
Relative
potency to
morphine
Collaborative for REMS Education. © CO*RE 2015. www.core-rems.org
Remember
Optimal Pain Management can only be
achieved when the patient is properly assessed.
A thorough history
Appropriate physical examination
Identification of potential barriers
Efficient, Effective & Timely Communication →
Consistent and Timely Reassessment
Accurate and Comprehensive Documentation
Education…education…education
Essentials of Pain Management
SBAR
Summary
►You need to be particularly sensitive with
patients who have unstable psychiatric
disorders, a history of substance abuse, or
other flags for opioid misuse and may be at
increased risk for poorer outcomes with
chronic opioid therapy.
Essentials of Pain Management
Our Legacy
“…the alleviation of suffering is the
warrant of medicine and its test of
adequacy…it is a test that contemporary
medicine fails despite the brilliance of its
science and its awesome technological
power.”• Eric J. Cassell. N Engl J Med 1982; 306(1 l):639-45
Essentials of Pain Management
Questions?
Appendix A
Essentials of Pain Management
Morphine
First Drug of Choice
Onset…5-20 minutes
Titration…10-20 minutes
Conversion
PO to SQ/IV…..3:1
Parenteral Concentration
10mg/ml to 50mg/ml
Range of Daily Dose
Average…400-600mg
10%……..>2000mg
Rare…….20,000mg
Hydromorphone
Alternative to Morphine
Onset…same as morphine
Titration…10-20 minutes
Conversion to Hydromorphone SQ/IV
PO to SQ/IV……..…...5:1
Oral Morphine……....20:1
SQ/IV Morphine…… 5:1*
Parenteral Concentration
5mg/ml to 100mg/ml
*4-7 variable ratio
Table 2
Conversions
Morphine PO : SQ/IV 3 : 1
Hydromorphone PO : SQ/IV 5 : 1
Morphine to Hydromorphone
PO : PO 4 : 1
PO : SQ/IV 20 : 1SQ : SQ/IV 5 : 1 (4-7)
Fentanyl to Morphine
Parenteral: 0.1mg : 10mg (1 : 100)
2x Patch Strength = 24hr Oral Morphine Dose (mg)*
*Example: Fentanyl Patch 100ug/hr = Morphine 200mg/24-hrs
Table 3
Equianalgesic Dosing Chart
Essentials of Pain Management
PO/PR (mg)
• 30
• 30
• 7.5
• 20
• NA
Analgesic
• Morphine
• Hydrocodone
• Hydromorphone
• Oxycodone
• Fentanyl
SC/IV/IM (mg)
• 10
• NA
• 1.5
• NA
• 0.1
Methadone is too complex to include in this chart
(100mcg)
*based on single dose studies
Table 4
Patients considered opioid tolerant are
taking at least
– 60 mg oral morphine/day
– 25 mcg transdermal fentanyl/hr
– 30 mg oral oxycodone/day
– 8 mg oral hydromorphone/day
– 25 mg oral oxymorphone/day
– An equianalgesic dose of another opioid
Still requires caution when rotating a
patient on an IR opioid to a different
ER/LA opioid
Opioid-Tolerant Patients
The ER/LA Opioid Analgesics Risk Evaluation & Mitigation Strategy. Selected Important Safety Information. Abuse potential & risk of life-threatening respiratory depression. www.er-la-opioidrems.com/IwgUI/rems/pdf/important_safety_information.pdf. 2012.
≥ 1 Wk
Terms
► Allodynia — Pain resulting from a stimulus (such as light touch) that does
not normally elicit pain
► Analgesia — Absence of pain in response to stimulation that normally is
painful.
► Dysesthesia — An unpleasant abnormal sensation, whether spontaneous
or evoked.
► Hyperalgesia — Increased response to a stimulus that normally is painful.
Exaggerated response to noxious stimulus
► Hyperesthesia — Increased sensitivity to stimulation, excluding the special
senses. Exaggerated response to touch
► Hypesthesia — Diminished sensitivity to stimulation, excluding the special
senses.
► Hypoalgesia — Diminished response to a normally painful stimulus.
► Paresthesia — An abnormal sensation, whether spontaneous or evoked.
Essentials of Pain Management
Appendix B
Essentials of Pain Management
Adjuvant Medication
► Anti-epileptic
• Gabapentin
• Pregabalin
► Antidepressants
• TCA’s
• SSRI’s (minimally effective)
• SNRI’s
— Duloxitine (Cymbalta)
— Venlafaxine (Effexor)
• Trazadone
► Alpha-2 blockers
► Bisphosphonates
► Cannabinoid
► Corticosteroids
• Dexamethasone
• Prednisone
► NMDA antagonist
• Ketamine
• Methadone
► NSAID’s
• Cox 1
• Cox 2
► Miscellaneous
• Capsaicin
• Lidocaine
— Topical
— Patch (expensive)
— IV
Essentials of Pain Management
…Adjuvant Medication
Systemic CorticosterioidsDexamethasone (Decadron ®)
Dose: 4 to 16mg/24hrsFrequency: once or twice dailyRoute: PO / SC / IVRecommend
Consider PPI Taper if > 3 wks
AnticonvulsantsGabapentin (Neurontin ®)
Dose: 300 to 3600mg/24hrsFrequency: QD to TIDRoute: PO Onset of action ≈ 7 daysCaution
Sedation / Fatigue
Pregabalin (Lyrica ®) Dose 75 to 300mg BID
Commonly Used & Preferred
AntidepressantsNortriptyline (Pamelor ®)
Dose: 10 to 150mg/24hrsFrequency: usually at HSRoute: PO Onset of action ≈ 7 daysCaution
Anticholinergic effect
Duloxetine (Cymbalta ®)Dose: 60 QD or 60mg BIDFrequency: once or twice dailyRoute: PO Onset of action ≈ 14 days
Adjuvant Medication for….
Bone Pain
• NSAID
• Corticosteroids
• Bisphosphonates IV
• Radiation
Abdominal Colic (Obstruction)
● Anticholinergic
- Scopolamine
- Glycopyrrolate
● Corticosteroid
● Octreotide
Neuropathic Pain
Frequent UseGabapentinPregabalinNortriptylineDuloxetine
Infrequent Use BaclofenLidocaineKetamineMethadone?VenlafaxineAmitriptyline
Pain in Advanced Dementia (PAIN-AD) Scale
0 1 2
Breathing Normal Occasional labored breathing, short period of hyperventilation
Noisy labored breathing, long period of hyperventilation
Negative vocalization
None Occasional moan or groan, low-level speech with a neg. quality
Repeated calling out, loud moaning, groaning, crying
Facial Expression
Smiling or inexpressive
Sad, frightened, frowning
Facial grimacing
Body Language Relaxed Tense, distressed, pacing, fidgeting.
Rigid, fists clenched, hips flexed, pushing, pulling, striking out
Consolability No need to console Distracted or reassured by voice or touch
Unable to console, distract or reassure
Explanation in Appendix