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On Pain: Taking the pain out of pain managementSuzana Makowski, MD MMM FACPPalliative CareUMassMemorial/UMassMedicalSchool
Overview• Pain assessment review• Opioid pharmacology: what I wish I had known...• Pain syndromes
•   Intensity                     Assessing pain:             •   Location                                                ...
Pain Intensity• Visual analogue scale: No pain-------------------------Worst pain• Numeric scale: 0 - 1 - 2 - 3 - 4 - 5 - ...
PAINAD Scale: for non-verbal patients withdementia
Pain Assessment: TimelineIntensity                Time
Challenges to pain assessment• Acute vs. chronic pain         • Dependence• Concerns about addiction and   • Tolerance  ab...
Barriers to Pain ManagementPhysician-Related• Limited knowledge of pain pathophysiology and assessment skills• Biases agai...
Racial & Ethnic Barriers• Language or cultural differences make pain assessment more difficult• Physiciansʼ perceptions an...
Untreated pain can lead to worsening chronic pain• In chronic pain, the nervous system remodels continuously in  response ...
Chronic Pain Syndromes: Cancer, Chronic Low Back Pain, Osteoarthritis,Fibromyalgia
Cancer painHighly prevalent:• 30-50% in active treatment• 75-90% in advanced illnessPrinciples of AssessmentPain History  ...
Cancer Pain Treatment considerations   Identify the cause of the pain• Primary treatment if indicated• WHO ladder combined...
WHO guidelines• Step 3: Opioid for moderate  to severe pain  +/- adjunctive treatment  +/- non-opioid                     ...
Chronic Low Back Pain• 60-85% lifetime prevalenceClinical Characteristics• Preoccupation with pain• Consistently disabled ...
Low-Back Pain Treatment Considerations• Analgesic Medications• Adjuvant Analgesics• Physical Therapy Approaches• Neural St...
Osteoarthritis• Affects over 80% of people over 55• 23% have limitation of activityDiagnosis• History: age, functionality,...
Osteoarthritis Treatment Considerations• After comprehensive assessment of function and pain        Mild to moderate pain ...
Pain treatment• Pharmacotherapy• Rehabilitative Approaches• Psychologic Interventions• Anesthesia/Interventional Pain Appr...
Opioids• Pure (Full) Agonists: Preferred for Chronic Pain   • Bind to opioid receptor(s)   • No antagonist activity   • No...
Oral Opioids        Short-acting                   Long-acting     Hydrocodone/APAP                                   Tran...
Opioid pharmacology• Conjugated in liver• First pass metabolism• Excreted by kidney (90-95%)• First order kinetics
First order kinetics of opioids       6-7 min   15-20 min   45-60 min
Opioid pharmacology• Conjugated by liver• 90-95% excreted in urine• Dehydration, renal failure, severe hepatic failure  • ...
Delivery of opioidsWhat is the half life (range) for opioids?   2-4 hoursHow many half lives to get to steady state?   4-5...
Scheduling oral short-acting opioids• Scheduled dosing based on t1/2  • Q4 hours• PRN dosing based on time to Cmax  • Can ...
Scheduling long-acting opioids(except methadone)• Reason for use:  • Improve compliance, adherence• Dose q8, q12, q24 hour...
Side effects of opioids            Common                     Uncommon                                 Bad dreams/hallucin...
Opioid side effects: Constipation• Stimulant laxative:   • Senna, bisacodyl, glycerine, etc.• Stool softener   • Docusate•...
Opioid side effects: Nausea/Vomiting• Onset with start of opioids, tolerance may develop• Mechanism: dopamine receptors an...
Opioid side-effects: Sedation• Onset with start of opioids  • Distinguish from exhaustion due to pain*  • Tolerance develo...
Opioid side-effects: Neuroexcitability• Presentation  • Cognitive changes: CAM assessment             Reason to avoid “tit...
Opioid side-effects: respiratory depression• Opioid effects differ among patients  • Change in LOC occurs before respirato...
Summary• Treat pain as though it were your own:   ✴remember under/untreated acute pain can lead to severe chronic pain• Sc...
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On pain

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  • Transcript of "On pain"

    1. 1. On Pain: Taking the pain out of pain managementSuzana Makowski, MD MMM FACPPalliative CareUMassMemorial/UMassMedicalSchool
    2. 2. Overview• Pain assessment review• Opioid pharmacology: what I wish I had known...• Pain syndromes
    3. 3. • Intensity Assessing pain: • Location • Quality: Nociceptive/NeuropathicThe easiest pain to tolerate is someone else’s • Timeline • Alleviating/Exacerbating factors
    4. 4. Pain Intensity• Visual analogue scale: No pain-------------------------Worst pain• Numeric scale: 0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10• Categorial scale: mild (1-3) - moderate (4-6) - severe (7-10)• FACES scale:• PAID-AD scale:
    5. 5. PAINAD Scale: for non-verbal patients withdementia
    6. 6. Pain Assessment: TimelineIntensity Time
    7. 7. Challenges to pain assessment• Acute vs. chronic pain • Dependence• Concerns about addiction and • Tolerance abuse/misuse • Addiction• What else? • Pseudoaddiction
    8. 8. Barriers to Pain ManagementPhysician-Related• Limited knowledge of pain pathophysiology and assessment skills• Biases against opioid therapy and overestimation of risks• Fear of regulatory scrutiny/actionPatient-Related• Exaggerated fear of addiction, tolerance, side effects• Reluctance to report pain: stoicism, desire to “please” physician• Concerns about “meaning” of pain (associate increased pain with worsening disease)System-Related• Low priority given to pain and symptom control• Limits on number of Rxs filled per month & number of refills allowed• Reimbursement policies(American Pain Society, 2001; Glajchen, 2001; Lister, 1996; Portenoy RK, 1996; Weinstein et al, 2000)
    9. 9. Racial & Ethnic Barriers• Language or cultural differences make pain assessment more difficult• Physiciansʼ perceptions and misconceptions: ✴minority-group patients have fewer financial resources to pay for prescriptions ✴higher drug-abuse potential among minority groups• Patients’ lack of assertiveness in seeking treatment• Lack of treatment expertise at many sites at which minority-group patients are treated• Relative unavailability of opioids in some communities (Bonham, 2001; Glajchen, 2001)
    10. 10. Untreated pain can lead to worsening chronic pain• In chronic pain, the nervous system remodels continuously in response to repeated pain signals • nerves become hypersensitive to pain • nerves become resistant to antinociceptive system• If untreated, pain signals will continue even after injury resolves• Chronic pain signals become embedded in the central nervous system
    11. 11. Chronic Pain Syndromes: Cancer, Chronic Low Back Pain, Osteoarthritis,Fibromyalgia
    12. 12. Cancer painHighly prevalent:• 30-50% in active treatment• 75-90% in advanced illnessPrinciples of AssessmentPain History • chronicity • intensity and severity • pathophysiology and mechanism • tumor type and stage of disease • pattern of pain and syndrome Physical and Neurologic Examination Radiographic Findings
    13. 13. Cancer Pain Treatment considerations Identify the cause of the pain• Primary treatment if indicated• WHO ladder combined with etiology-specific therapies for syndromes ✴pharmacologic and nonpharmacologic interventions ✴long-acting + short-acting opioids ✴adjuvant medications for neuropathic pain ✴NSAIDs and steroids can be helpful when there is an inflammatory component to pain
    14. 14. WHO guidelines• Step 3: Opioid for moderate to severe pain +/- adjunctive treatment +/- non-opioid Pain Persists• Step 2: Opioids for mild to moderate pain +/- adjunctive treatment +/- non-opioid Pain Persists• Step 1: Non-opioid +/- adjunctive treatment (Adapted from Portenoy et al, 1997)
    15. 15. Chronic Low Back Pain• 60-85% lifetime prevalenceClinical Characteristics• Preoccupation with pain• Consistently disabled from pain• Depression and anxiety are common• High incidence of psychiatric diagnoses• Drug misuse is common, but addiction relatively rare
    16. 16. Low-Back Pain Treatment Considerations• Analgesic Medications• Adjuvant Analgesics• Physical Therapy Approaches• Neural Stimulation• Psychologic Management• Multidisciplinary Pain Centers
    17. 17. Osteoarthritis• Affects over 80% of people over 55• 23% have limitation of activityDiagnosis• History: age, functionality, degree of pain, stiffness, time of occurrence (e.g., morning, at rest, during activity)• Physical examination: range of motion, tenderness, bony enlargement of joint• Laboratory findings: radiograph, CBC, synovial fluid analysis
    18. 18. Osteoarthritis Treatment Considerations• After comprehensive assessment of function and pain Mild to moderate pain Acetaminophen Moderate to severe pain COX-2 and NSAIDs Severe arthritic pain (unresponsive to non-opioid, or for elderly at risk Opioids for renal insufficiency) Drug therapy ineffective or Surgery debilitating pain/function
    19. 19. Pain treatment• Pharmacotherapy• Rehabilitative Approaches• Psychologic Interventions• Anesthesia/Interventional Pain Approaches• Neurostimulatory Techniques• Radiotherapy• Surgery• Complementary/Alternative Approaches• Lifestyle Changes
    20. 20. Opioids• Pure (Full) Agonists: Preferred for Chronic Pain • Bind to opioid receptor(s) • No antagonist activity • No ceiling effect• Agonist-Antagonists • Ceiling effect for analgesia • Can reverse effects of pure agonists ✴ mixed agonist-antagonists (butorphanol, ✴ nalbuphine, pentazocine, dezocine) ✴ partial agonists (buprenorphine)• Antagonists • Reverse or block agonist effects of pure opioids • Naloxone has been used to treat opioid overdose, addiction
    21. 21. Oral Opioids Short-acting Long-acting Hydrocodone/APAP Transdermal fentanyl Oxycodone +/- APAP methadone Morphine morphine ER Hydromorphone oxycodone ER Oral transmucosal fentanyl Cmax ~ 45 min Cmax and T1/2 vary based on T1/2 ~ 4 hours formulation and drug Except fentanyl
    22. 22. Opioid pharmacology• Conjugated in liver• First pass metabolism• Excreted by kidney (90-95%)• First order kinetics
    23. 23. First order kinetics of opioids 6-7 min 15-20 min 45-60 min
    24. 24. Opioid pharmacology• Conjugated by liver• 90-95% excreted in urine• Dehydration, renal failure, severe hepatic failure • Decrease interval/dosing size • If oliguria/anuria • STOP routine dosing (basal rate) of morphine • Use ONLY PRN
    25. 25. Delivery of opioidsWhat is the half life (range) for opioids? 2-4 hoursHow many half lives to get to steady state? 4-5What do you base your scheduled dosing on: Cmax or T1/2? T1/2What do you base your breakthrough dosing on: Cmax or T1/2? Cmax
    26. 26. Scheduling oral short-acting opioids• Scheduled dosing based on t1/2 • Q4 hours• PRN dosing based on time to Cmax • Can be as frequent as Q1 hour PRN• Adjust scheduled dose daily based on prn use
    27. 27. Scheduling long-acting opioids(except methadone)• Reason for use: • Improve compliance, adherence• Dose q8, q12, q24 hours (depending on product) • Don’t crush or chew • May use time-release granules (Kadian)• Adjust dose every 2-4 days (once steady state is reached.)
    28. 28. Side effects of opioids Common Uncommon Bad dreams/hallucinations Constipation* Delirium Dry mouth Myoclonus Nausea/Vomiting Seizures Sedation Pruritus, urticaria Sweats Respiratory suppression Urinary retention *No development of tolerance
    29. 29. Opioid side effects: Constipation• Stimulant laxative: • Senna, bisacodyl, glycerine, etc.• Stool softener • Docusate• Prokinetic agent • Metoclopramide• Osmotic laxative (from above or below)• Specific to peripheral opioid receptors • methylnatrexone
    30. 30. Opioid side effects: Nausea/Vomiting• Onset with start of opioids, tolerance may develop• Mechanism: dopamine receptors and decreased motility• Prevent or treat with dopamine-blocking anti-emetics (avoid with long-QT): • Haloperidol 0.5-1mg every 6 hours • Droperidol 0.625 mg (PACU order set) • Metoclopramide 10mg every 6 hours• Alternative opioid if refractory
    31. 31. Opioid side-effects: Sedation• Onset with start of opioids • Distinguish from exhaustion due to pain* • Tolerance develops within days• Complex assessment in advanced disease• If persistent, may consider alternative opioid or route of administration• Psychostimulants may play a role as well • Methylphenidate 5mg qAM and 1 noon
    32. 32. Opioid side-effects: Neuroexcitability• Presentation • Cognitive changes: CAM assessment Reason to avoid “titrate to comfort” order at end- • acute onset or fluctuating course, of-life • inattention, • disorganized thinking/altered level of consciousness • Restlessness, agitation • Can cause hyperalgesia • Myoclonic jerks, seizures (may be repressed if on benzodiazepines) • More common in renal failure• Mechanism: • Morphine/hydromorphone 6-glucoronide build-up• Management: • Benzodiazepines, fluids, and perhaps dialysis - antipsychotics exacerbate symptoms
    33. 33. Opioid side-effects: respiratory depression• Opioid effects differ among patients • Change in LOC occurs before respiratory suppression • Pharmacologic tolerance develops rapidly • Most studies of respiratory depression in opioids looked at patients with drug overdose• Management: • Identify and treat contributing causes • Reduce opioid dose and observe • If unstable vital signs: • Naloxone 0.1-0.2 mg IV q 1-2 min
    34. 34. Summary• Treat pain as though it were your own: ✴remember under/untreated acute pain can lead to severe chronic pain• Schedule routine opioids based on half-life• Consider offering prns based on Cmax: ✴IV=6-12 min; ✴SQ=20-30min; ✴PO=45-1hour• When ordering opioids, always order bowel regimen to avoid constipation• Watch for neurotoxicity in renal insufficiency - especially at end-of-life
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