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Pain management overview 2013 Presentation Transcript

  • 1. Y V O N A G R I F F O , M DP A I N & P A L L I A T I V E C A R E S E R V I C EM E M O R I A L S L O A N K E T T E R I N G C A N C E RC E N T E RPAIN MANAGEMENTThe following material is intended for MSKCC internal medicine housestaff teachingpurposes only. The slides were updated for the LibGuide in 2012-2013.
  • 2. 2The InternationalAssociation fortheStudy of Pain:An unpleasantsensory oremotionalexperienceassociated withactual or potentialtissue damage ordescribed in termsof such damage
  • 3. BASIC APPROACH1. ETIOLOGY of PAIN2. CLASSIFICATION of PAIN3. ASSESEMENT of PAIN4. TREATMENT of PAIN
  • 4. ETIOLOGY PAIN CAUSED BY CANCER Infiltration of Bone, Viscera, Soft tissue, Muscles Infiltration of Spinal Cord, Roots ,Plexus or PeripheralNerves Occlusion of Blood Vessels PAIN AS SEQUELAE OF CANCERTREATMENT PAIN DUE TO FRAILTY PAIN UNRELATED TO CANCER
  • 5. ETIOLOGY-Treatment relatedPOST-SURGICAL - Phantom Pain- Neuroma- Adhesions- Post-Thoracotomy, MastectomyCHEMOTHERAPY -Peripheral Neuropathy-MucositisRADIOTHERAPY -Radiation Dermatitis-Radiation Neuritis
  • 6. Mixed TypeCaused by acombination of bothprimary injury orsecondary effectsCLASSIFICATION of PAINNociceptivePainCaused by activity inneural pathways inresponse to potentiallytissue-damaging stimuliNeuropathicPainInitiated or caused byprimary lesion ordysfunction in thenervous systemPostoperativepainMechanicallow back painSickle cellcrisisArthritisPostherpeticneuralgiaNeuropathiclow back painCRPS*Sports/exerciseinjuries*Complex regional pain syndromeCentral post-stroke pain, spineTrigeminalneuralgiaDistalpolyneuropathy(eg, diabetic, HIV)
  • 7. CANCER PAIN INITIAL ASSESMENT and DIAGNOSIS ofUnderlying cause TREATMENT OF ACUTE UNDERLYING CAUSE SPECIFIC ANTI-TUMOR THERAPY-Surgery-Radiation-Chemotherapy PAIN MANAGEMENT-ANALGESICSWHO LADDER Step 1-3
  • 8. CLINICAL ASSESSMENT OF PAIN8Believe the patient’s self-report of painTake a careful history—ONSET (temporal pattern) of pain—LOCATION site of pain/widespread or localized/uni-bilateral—DURATION of pain /constant or incidental/—CHARACTER/quality and intensity of pain/—AGGRAVATING/RELIEVING factors—RESPONSE to analgesics—DEGREE of intensity and interference with patient’s life—ASSOCIATED signs and symptoms
  • 9. ASSESSMENT of PAIN INTENSITYNo Mild Moderate Severe Very Worstpain pain pain pain severe possiblepain painVerbal Pain Intensity ScaleNopainVisual Analog ScaleFaces Scale0 1 2 3 4 50–10 Numeric Pain Intensity ScaleNo Moderate Worstpain pain possible pain0 1 2 3 4 5 6 7 8 9 10Worstpossiblepain19
  • 10. WHO –3 Steps ANALGESICS LADDER For mild pain, use non-opioid first When pain persists or increases, add an opioid If pain becomes more severe, increase the opioidpotency or dose Schedule doses on around-the-clock basis, withadditional PRN doses -rescues
  • 11. ADJUVANT ANALGESICS Anticonvulsants Antidepressants Corticosteroids Neuroleptics Anxiolytics Muscle relaxants Anesthetics Antispasmodics
  • 12. BASIC PAIN MANAGEMENT Believe Pt’s self report Assess factors affecting Pt’s pain report (medical,psychological, spiritual, functional) Titrate analgesics to effectiveness and tolerance ofside effects If on ATC opioid must have PRN Treat Opioids side effects (bowel regimen)
  • 13. STEP 1- WHO ANALGESICS14NON-OPIOID ANALGESICSACETAMINOPHENNASIDS -(COX -2 INHIBITORS,ASA, SALICYLIC ACIDDERIVATIVES)Benefits:NO TOLERANCE or PHYSICAL DEPENDENCEADDITIVE ANALGESIA when COMBINDED with an OPIOIDCaution:CEILIING EFFECT for ANALGESIARISKS RELATED to PLATELET DYSFUNCTION, GASTRICULCERATION and GI BLEEDING, CARDIOVASCULAR EVENTS,HTN, RENAL INSUFFICIENCY or LIVER TOXICITY
  • 14. STEP 2- WHO ANALGESICS15WEAK OPIOIDSCODEINEHYDROCODONEOXYCODONE –(in combination with a non-opioid)TRAMADOL (mu-agonist, norepinephrineand serotonin reuptake inhibitor)TAPENTADOL (mu-agonist, norepinephrinereuptake inhibitor)
  • 15. STEP 3 – WHO ANALGESICSSTRONG OPIOIDSMORPHINEHYDROMORPHONEFENTANYLOXYCODONEMETHADONELEVORPHANOLBUPRENORPHINEOXYMORPHONEMEPERIDINE
  • 16. CHOOSING THE OPIOID ANALGESIC17Patient sensitivity and allergyPrior opioid exposureCurrent intensity of pain or pain crisisPain pathophysiology (nociceptive vs neuropathic)Available route of administrationRequirements for rescue medicationsMetabolic factorsDrug interactionsCost/availability and formulary preparationsStreet value
  • 17. ROUTES of OPIOID ADMINISTRATION ORAL -tablets, elixirs RECTAL-suppository TRANSDERMAL, TRANSBUCCAL SUBCUTANEOUS INTRAVENOUS bolus, continuous infusion, PCA EPIDURAL INTRATHECAL
  • 18. ALGORITHM for OPIOID THERAPYPatientSelectionInitial PatientAssessmentTrial of OpioidTherapyAlternatives toOpioid TherapyPatientReassessmentExit StrategyConversion toLong-actingOpioidOpioid RotationContinueOpioid Therapy Used with permission of Nathaniel P. Katz, MD7
  • 19. MONITORING OPIOID THERAPY20Continual monitoring and follow-ups areessential to good opioid analgesic therapy –during the trial and throughout chronic therapyCRITICAL OUTCOMES = “4 A’s of Pain” Analgesia Adverse effects Activities of daily living Aberrant opioid-related behaviorAdjust and Manage therapy based onoutcomesDocument critical outcomes
  • 20. 21Short acting Opioids = (immediate release preparations)– Morphine (MSIR ®, Roxanol ™, rectal suppositories– Codeine (Tylenol with codeine, Soma)– Hydrocodone (Vicodin ®, Zydone ® Lortab ®,Vicoprofen ®, Norco®)– Oxycodone (Roxicodone, Oxy IR ®, OxyFAST, Percocet®, Percodan ®, Tylox ®)– Hydromorphone (Dilaudid ®)– Oxymorphone (Opana IR)– Fentanyl (Actiq ®, Fentora ®,Onsolis)CATEGORIES OF OPIOID ANALGESICS
  • 21. CATEGORIES OF OPIOID ANALGESICSLONG – ACTING OPIOIDS – EXTENDED RELEASEPREPARATIONS Morphine sustained – release (MS Contin, Avinza, Kadian,Oramorph) Oxycodone sustained – release (OxyContin) Oxymorphone – sustained release (Opana ER) Fentanyl – transdermal patches (Duragesic) Hydromorphone –(Exalgo)LONG – HALF LIFE OPIOIDS Methadone Buprenorphine Levorphanol
  • 22. 23“GOLD STANDARD” – FOR TREATMENT ofMODERATE TO SEVERE PAIN”Full mu-receptor agonistBioavailability – 30% (PO: IV dose is 3:1)Easily available in wide range of preparations– Immediate and sustained release– Oral tablets, elixir, suspension, capsules– Rectal suppositories– Parenteral (IV, IM, SC, epidural, intrathecal)Most widely used opioid analgesicCAVEAT !!! – BID/TID medication– Active morphine metabolitesMORPHINE-6-GLUCURONIDEMORPHINE-3-GLUCURONIDEMORPHINE
  • 23. 24Semisynthetic derivative of thebaineMost utilized opioid worldwideFull mu-receptor agonist, Kappa receptor agonist ??Bioavailability – 50%Oxycodone : morphine dose ration 1: 1.5-2IR and ER preparations, oral only(tablets or elixir)Sustained release preparation OXYCONTIN has 2phase release (immediate and extended in the samepill)OXYCODONE
  • 24. FENTANYL25Full- mu receptor agonistHigh potency, short duration of action, rapid onset of actionLipophilic – ideal drug for transdermal and transmucosaladministrationbioavailability – 50%Parenteral, transdermal and transmucosal preparations25 mcg/hour transdermal Fentanyl patch = 1mg/1 hour IV MorphineTransdermal Fentanyl patch takes 12 hours to reach analgesic bloodlevels on initiation (6 – 18h)90 – 95% of transdermal Fentanyl reaches systemic circulation asunchanged FentanylConvenient to use (3 – day drug reservoir)Ideal for children and uncooperative/impaired adults
  • 25. FENTANYL PATCH24-hour Oral Morphine Initial Fentanyl dose30-59 mg 12 mcg60-134 mg 25 mcg135-224 mg 50 mcg225-314 mg 75 mcg315-404 mg 100 mcg
  • 26. ACTIQ, FENTORA, SUBSYS,ABSTRAL Transbuccal Fentanyl -No directcorrelation with TD Fentanyl dose !!! NEVER use for opioid naïve patient !!! Keep away from children, pets Restricted distribution-TIRF-REMS
  • 27. 30Semisynthetic opioid, hydrogenated ketone analog ofmorphineFull, potent – mu – receptor agonistAvailable for oral, parenteral and rectal use PO:IVdose is 5:1Oral hydromorphone : morphine dose ration is 1: 4Parenteral hydromorphone : morphine dose ratio is1:7Short duration of action : 3-4 hoursHYDROMORPHONE
  • 28. 31Synthetic opioid - mu- receptor agonist- NMDA receptor antagonist- serotonin reuptake inhibitorUnique pharmacology - variable and long half-life (8 – 80 hours)- steady-state plasma concentration up to 10 days- potency greater then expectedGood oral bioavailability – 60 – 95% PO:IV dose is 2:1Inexpensive and effective – oral( tablets or elixir) or parenteralBut requires special knowledge- how to initiate and titrate the dose- monitor for cardiac toxicity (QT prolongation )No active metabolites ! Clearance not influenced by hepatic or renalimpairmentMETHADONE
  • 29. METHADONE32ACUTE USE: 1 MG IV MORPHINE = 1 MG IVMETHADONECHRONIC USE: 10 MG IV MORPHINE = 1MG IVMETHADONE30 – 90 mg daily PO Morphine 4 : 190 – 300 mg daily PO Morphine 6-8 : 1>300 mg daily PO Morphine 10-12 : 11960-s – in single dose studies morphine and methadonedoses are equal (Raymond Houde, Equianalgesicconversion tables)
  • 30. OPIOID EQUIANALGESIC DOSESOpioid parenteral oral conversion duration(mg) (mg) (IV to PO) (hours)Morphine 10 30 3 3 - 4Methadone 10 20 2 4 - 8Hydromorphone 1.5 7.5 5 2 - 3Meperidine 75 300 4 2 - 3Levorphanol 2 4 2 4- 6Oxycodone - 20 - 3 - 5Oxymorphone 1 5 5 3 - 4Fentanyl 0.25 - 1 1- 2
  • 31. OPIOID CONVERSIONS Calculate 24 hrs IV or PO requirement Multiply by IV or ORAL conversion factor Divide in multiple dosages or hourly rate dependingon medication to be used If using SR preparation, add 10-15% of 24 hrs dosein IR form for breakthrough pain PRN
  • 32. OPIOID CONVERSION Example: Opioid equianalgesic values for:Morphine 10 mg IV= morphine 30 mg PO=hydromorphone 1.5 mg IV = hydromorphone 7.5 PO=Fentanyl 250 mcg IV = Methadone 1mg IV Example: Same drug, changed routeChange 90 mg q12 MS Contin PO to IV continuousinfusionCalculate 24-h current dose: 180 mg MS/24 hLook up equianalgesic ratio: PO/IV= 3Calculated new dose using ratios: 180/3=60 mg IV/24 hours =2.5 mg/h continuous infusion61
  • 33. 36OPIOID THERAPYASSESMENTANALGESIA+ - -ADVERSEEFFECTS - + +   -CONTINUECURRENTOPIOIDINCREASEDOSE OFOPIOIDIMPROVEMANAGEMENTOF SIDE EFFECTSOPIOIDROTATION+
  • 34. OPIOID SIDE EFFECTS37COMMON– CONSTIPATION– NAUSEA and VOMITING– COGNITIVE IMPAIRMENT• sedation• confusion• hallucinations• agitation/myoclonus– MIOSIS– RESPIRATORY DEPR.– COUGH SUPPRESSIONLESS COMMON– URINARY RETENTION– ENDOCRINEDYSFUNCTION– ITCHING (HISTAMINERELEASE)– SWEATING– HEADACHE– DELIRUM– BILIARY SPASM/GASTRIC STASIS– DRY MOUTH– SEIZURES– HYPEALGESIA/ALLODYNIA– TOLERANCE, PHYSICAL DEPENDENCE,ADDICTION
  • 35. MANAGEMENT OF OPIOIDS SIDE EFFECTS38NALOXONEANTIEMETICSLAXATIVESANTICHOLINERGICSPSYCHOSTIMULANTSANTIPSYCHOTICSPOLYPHARMACY
  • 36. NALOXONE (Narcan) Opioid Antagonist Used to reverse opioid-induced respiratorydepression May precipitate severe withdrawal symptoms andpain Onset of action 1-2 min Short duration of action- 45 min
  • 37. NALOXONE DOSAGE RESPIRATORY DEPRESSION RR < 8/min DILUTE !!! 1 ml in 9 ml normal saline 0.04 mg IV push over 15 sec every 1-3 min PRN RESPIRATORY ARREST 1 ml UNDILUTED !!! = 0.4 mg IV push over 15 sec follow by 0.4 mg every 1- 3 min PRN
  • 38. OPIOID naïve ADULTS Avoid starting long acting opioid !!! Start small doses short acting (Oxycodone 5 mg q3hprn, MSIR 15 mg q3h prn, Dilaudid 2mg q3h prn) Acute severe pain- Morphine 5-10 mg IV, Dilaudid0.5-2 mg IV, Toradol 15-30 mg IV IV-PCA- AVOID BASAL for first several hours and CAVEAT- Pts with respiratory disease, sleep apnea
  • 39. IV –PCA Patient Controlled AnalgesiaIf pain is not controlled:3 choices- increase basal hourly rate- increase rescue doses- increase both (most common approach)Mild-moderate pain- increase dose by 25%Severe pain- increase dose by 50%Or increase basal rate based on # of rescues taken inthe last 12-24 hours
  • 40. RESCUE-PRN dose IV rescue- ½ of IV hourly basal dose IV rescue can be given every 10- 15-20 min PO rescue- 10-20 % of TOTAL daily opioid dosegiven every 2-3 hours PRN
  • 41. IV- PCA Do not prescribe rescue doses in delirious patients !!! Family members can not operate PCA ! CAB= Clinician activated bolus, given by nurse/MD.Used for pain crisis, prior to tests or PT Methadone and Fentanyl require separate IV line
  • 42. SWITCH from FENTANYL PATCH toIV-PCA Determine target IV PCA setting Remove patches (in most cases) Start with 0 basal (in most cases) 6h after patch removal increase basal to 50% oftarget dose 12h after patch removal increase basal to full target
  • 43. SWITCH from IV PCA to FENTANYL PATCH Determine patch dose 6h after patch placement decrease PCA basal by 50% 12h after patch placement D/C basal and continuerescues overnight D/C PCA in AM and start oral PRN rescues
  • 44. OPIOIDS RESTRICTED to Pain Services atMSKCC Fentanyl PCA- for basal and rescues at and above 50mcg/h Dilaudid PCA- for basal and rescues at and above 0.4mg/h IV Methadone IV OxymorphoneMORPHINE PCA IS UNRESTRICTED!!!
  • 45. TAPERING OF OPIOIDS Literature- Pts can tolerate 75% decrease withoutwithdrawal symptoms Clinical experience- many Pts need slow taper- 25-50% or less every 2-3 days Educate Pts on withdrawal symptoms and how tomanage it
  • 46. PRINCIPLES OF PAIN MANAGEMENT- SUMMARY - Cancer pain can - and must be - treated Establish underlying diagnosis of pain Use analgesics AROUND THE CLOCK and PRN !!! WHO-3-step analgesic ladder approach, non-opioids and opioid mu- agonists Prophylactic bowel regimen Add adjuvant analgesics when indicated Continued supervision and dose adjustments
  • 47. Thank You