This document discusses chronic pain in older adults. It notes that chronic pain is common in older populations, affecting 25-50% of community-dwelling elders and 45-50% of nursing home residents. The pathophysiology of chronic pain can involve nerve sensitization, nerve damage, and inflammatory mediators. Treatment of chronic pain in older adults requires special considerations due to age-related changes in pharmacokinetics and pharmacodynamics. Non-pharmacological therapies and non-opioid medications are preferred, with opioids used cautiously at lower doses. Proper evaluation, treatment planning, and monitoring are important for safe and effective management of chronic pain in older patients.
Different descriptions of Pain, Pain Pathways, Specific Types of pains and their management, Pharmacological treatment of pain and non-pharmacological maneuvers to relieve pain, WHO ladder of pain, Chronic Pain management Goals
Pain definition, Pain pathways, pain modulation, the endorphin system, Types of Pain, current trend of Drugs used for pain management. New Drugs for pain
Different descriptions of Pain, Pain Pathways, Specific Types of pains and their management, Pharmacological treatment of pain and non-pharmacological maneuvers to relieve pain, WHO ladder of pain, Chronic Pain management Goals
Pain definition, Pain pathways, pain modulation, the endorphin system, Types of Pain, current trend of Drugs used for pain management. New Drugs for pain
CHRONIC PAIN AND DEPRESSION: Cause or Effect or Linked?Sudhir Kumar
Chronic pain and depression are both common conditions, and in many patients, they co-exist. This presentation looks at the link between chronic pain and depression. Various drugs that can be used to treat chronic pain/depression have been discussed, with a special emphasis on tricyclic antidepressants.
a detailed description of pain and therpaeutic options available and clinical assessment of pain, approach to the patient with pain, assessment of intensity of pain, nsaids and opioids, tca. WHO pain ladder, chronic opioid therapy
Conclusions:
74% of patients discharge home with moderate to severe pain --> with or without treatment before
ED patients should receive proper pain management, avoiding delays such as those related to diagnostic testing or consultation
In order to further improve patient care we must now apply our knowledge regarding acute and chronic pain treatment base on pharmacology of the drugs
Ongoing research in the area of ED patient pain management conducted and an algorythm or clinical guidelines in this area should be developed
Effective physician and patient educational strategies should be developed regarding pain management, including the use of pain therapy adjuncts and how to minimize pain after disposition from the ED
CHRONIC PAIN AND DEPRESSION: Cause or Effect or Linked?Sudhir Kumar
Chronic pain and depression are both common conditions, and in many patients, they co-exist. This presentation looks at the link between chronic pain and depression. Various drugs that can be used to treat chronic pain/depression have been discussed, with a special emphasis on tricyclic antidepressants.
a detailed description of pain and therpaeutic options available and clinical assessment of pain, approach to the patient with pain, assessment of intensity of pain, nsaids and opioids, tca. WHO pain ladder, chronic opioid therapy
Conclusions:
74% of patients discharge home with moderate to severe pain --> with or without treatment before
ED patients should receive proper pain management, avoiding delays such as those related to diagnostic testing or consultation
In order to further improve patient care we must now apply our knowledge regarding acute and chronic pain treatment base on pharmacology of the drugs
Ongoing research in the area of ED patient pain management conducted and an algorythm or clinical guidelines in this area should be developed
Effective physician and patient educational strategies should be developed regarding pain management, including the use of pain therapy adjuncts and how to minimize pain after disposition from the ED
How to set realistic goals when you have chronic painJeannette Pforr
In this lesson, you will:
- Understand the trade-offs between getting good pain relief, and being able to reach your activity goals
- Learn the value of having a "pain action plan"
- Learn how to set up your own action plan
- Learn how to track your action plan
Evidence-based Back Pain Management (EBM in general)Sohail Bajammal
A generic introductory presentation on using evidence-based medicine (EBM) principles to answer clinical questions. Back pain was used as an example to introduce the concept. The presentation does not address the treatment of back pain. The presentation was given in May 2010.
CONTEMPORARY PRINCIPLES OF PAIN MANAGEMENT.
Bruce CLEMINSON, Macmillan Palliative Care Education Facilitator, Fellow of the Royal College of General Practitioners & Member, European Association for Palliative Care, Shetland, United Kingdom
- - -
СОВРЕМЕННЫЕ ПРИНЦИПЫ ОБЕЗБОЛИВАНИЯ.
Брюс КЛЕМИНСОН, Координатор образовательных программ по паллиативной помощи центра Мак Миллан, член Королевской коллегии врачей общей практики, Шетландские острова, Великобритания
Pain management strategies & effects on wellbeingmiranda olding
Overview of pain, common pain management strategies and their effects on wellbeing. Side effects, effects on wellbeing, Covers Pain cycle, Persistent or chronic pain, pain gate theory, pharmaceutical and non-pharmaceutical or pain treatments, including complementary therapies, electrotherapies, psychological therapies for pain.
Written for student OT conference 'Perspectives on Wellbeing' Feb 2016
We live in an era of medication, but what else can we do to improve mental health? Are we excessively prescribing, can we approach medicine in a more holistic way?
With vision loss comes increased chance of trauma and falls. How can one prevent such injuries from occurring and are their preventative measures one can take?
What is the correlation between CNS active medication and fall risk for the geriatric community and how should one best prevent fall injuries from occurring for those taking such medication?
Dementia care world's great healthcare economic challenge for 21st cent ap...SDGWEP
Dementia is currently the fastest growing cause of death in America. How do you care for those suffering from Dementia and what are the typical signs of this mental disability
Geriatric Telehealth modalities are presented including Store & Forward Telehealth, Clinical Video (Real-Time) Telehealth, Home (Remote Monitoring) Telehealth and SCAN (Specialty Care Access Network) for inter-professional TeleWound Care across the healthcare continuum.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
2. The International Association for the Study of
Pain (IASP) defines pain as “an unpleasant
sensory and emotional experience associated
with actual or potential tissue damage”
Pain is the single most common reason for
patients to seek medical attention
3.
4.
5.
6.
7.
8. 2000 – 13.1% of population over 65
2030 – 20% of population over 65
25-50% of community elders suffer chronic
pain of some kind
45-50% of Nursing home residents suffer
chronic pain
9. Chronic pain effects approx. 100 million
Americans
Roughly cost $635 billions annually
Incidence greater than Diabetes, heart disease
and cancer combined.
10. - sensitization of nociceptors
- Nerve damage
- Release of sensitizing humoral mediators
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24. In some conditions, nociception due to tissue
damage may occur, but the patient may not
perceive, or feel it
i.e., diabetic peripheral neuropathy
Conversely, the patient may perceive severe
pain with no demonstrable evidence of tissue
damage
i.e., trigeminal neuralgia
30. The process by which afferent nerve endings
participate in translating noxious stimuli (e.g.,
a pinprick) into nociceptive impulses
Noxious stimulation is first carried by the
faster A-delta fibers and then by the slower C
fibers
Local injury can cause nociceptors to become
hypersensitive to noxious stimuli, thereby
creating a condition called sensitization
31. • The process by which impulses are
sent to the dorsal horn of the spinal
cord and the brain
• Noxious stimulation is first carried
by the faster A-delta fibers and then
by the slower C fibers
32. • The process of dampening or amplifying pain-
related neural signals
• A variety of modalities can modulate these
pathways”, including:
• Systemic or neuro-axial injection of opioids
• Electric stimulation, TENS, Acupuncture, Massage.
• TCA’S, AED’s
• Stress, Anxiety
• Depression
33. Refers to the subjective experience of pain
Results from the interaction of transduction,
transmission, modulation
Dependent on the psychological aspects of the
individual
34.
35. Neuropathic pain is pain due to damaged or
dysfunctional nerves
The pathophysiology of neuropathic pain can have
both peripheral and central mechanisms
it is doubtful that a single mechanism can account
for all cases
The end result is pain that is experienced without
evidence of noxious stimulus
36. - Enhanced pain intensity
- Enlargement of pain areas
- Widespread hyperalgesia
- Enhanced disability
37.
38. - sensitization of central neural structures
- Dysfunction of endogenous pain modulation
39. - Psychophysical Assessments
- Objective Assessments
- Measuring spread of pain and referred pain
areas
- Measurement of endogenous modulation
- Measurement of Temporal Summation
40.
41.
42.
43.
44.
45.
46.
47.
48. Can be classified mostly into 3 broad groups:
- Curative/Disease modifying
- Rehabilitative
- Palliative
49. Simplest and preferred when the identifiable
pathophysiological process is present and
becomes the target of treatment.
Typically pain should resolve once the
underlying process resolves
Examples – ORIF, Appendectomy, Angioplasty
for ischemia
Difficult to treat ‘upstream’ pathophysiologic
process
50. Appropriate when 2 conditions apply
- the curative model is not appropriate
- major goal of treatment is improving patient’s
ability to function
- Examples – multidisciplinary pain rehabilitation
(PT, OT, counselling, biofeedback, CAM,
vocational rehab, etc.,)
51. Combination of Medication management to
control pain
And/or
Less demanding rehabilitative therapies
52. Low levels of pain can cause high functional
impact, depression
Although pain threshold increases with age,
tolerance for pain decreases.
53.
54.
55. Multiple pain complaints, multiple medical
problems, poor communication/under-
reporting
Cognitive decline, depression, anxiety,
insomnia, fatigue
Poor nutrition, poor tolerance to tests and
procedures.
56. Can be more reliable than just pain reporting,
especially in low cognitive patients.
Facial expressions
Verbalizations
Body movements
57. Changes in interpersonal interactions
Changes in activity patterns or routine
Mental status changes
58. Decreased renal function (decrease in
glomeruli, decrease in renal excretion, low
GFR, higher serum drug levels)
Decreased hepatic function (decreased
Cyt.P450 oxidation causing higher serum drug
levels
Decreased serum protein, decreased functional
binding to proteins – Less unbound drug,
increased CNS effect.
59. Two metabolites – M3G, M6G (6 is more active
and leads to sedation, as this is renally
excreted)
Elimination by hepatic metabolism to
glucuronides
T1/2 is 2-4 hrs. may be elevated in elderly up
to 15 hrs.
60. Metabolized to normeperidine
Not reversible by naloxone
This leads to respiratory depression and
excitatory neurotoxicity, anti-cholinergic
effects, urinary retention
Blocks reuptake of NE and HT, can cause fatal
reaction with concomitant SSRI (Fluoxetine)
61. Decreased nerve conduction velocity (loss of
myelin on axons, decrease axonal synapses)
Elderly adults rely on C-fiber input when
reporting pain ; whereas, younger patients use
C and A-delta.
62. TENS, heat, acupuncture, relaxation
techniques.
Exercise – targeted therapies with realistic
achievable goals, should be integrated into
daily routine and ADL’s, progress slowly as
function and strength improve.
PT / OT , custom adaptive equipment as
needed to decrease pain and improve function.
64. NSAIDS – exercise caution due to renal, GI and
CV risks
Anti-depressants and Anti-convulsants -
adjunctive role in chronic pain especially
neuropathic pain states. Dosing limited by side
effects
Topical anesthetic / NSAID patches – limited
penetration into the tissues, effective only at
superficial targets
65.
66.
67. Equalizing the ‘Pain Pendulum’
‘Balance’ pain relief with risks associated with
opioids.
(Not too much…not too little…just enough !!)
68. Always administer tools for risk assessment
(COMM, DIRE, ORT, SOAPP, SOAPP-R)
Have a clear written agreements / documentation
/ ‘opioid contract’
All opioid contracts should be simple and written
at ‘6th or 7th’ grade level or even lower !
Written consent from patient that ‘contract’ was
read and clearly understood by the patient.
69. Opioid contract/Agreement sets precedence to
‘Rules/responsibilities on patients and reviews
risks involved. Not a binding agreement but a
good practice for every provider.
Templates of medication agreements can be downloaded from www.SanDiego-
SafePrescribing.org
Create function based treatment plans with
goals, e.g, begin PT, document improvement in
ADL’s and daily routine. Review partner or
care-giver input apart from patients self report.
Review therapy notes.
70. Must have a good collaboration between
patient and clinician
Apart from pain scores, goals should be
realistic, meaningful and verifiable.
Treatment plan should be periodically re-
assessed, modified based on goals and
functional outcomes
Always have a ‘Exit strategy’ or plan
termination that is mutually agreed upon by
the patient.
71. works on 3 receptors- mu, kappa, delta.
Exerts 3 actions – 1.inhibits transmission of
nociceptive input from the periphery to the
spinal cord, 2.activation of descending
inhibitory pathways that modulate
transmission in the spinal cord (pain
“dampening”), 3. Alteration of limbic system
activity.
Thus, opioids modify sensory and affective
aspects of pain.
72. Start at lowest possible dose for opioid –naïve
patients – ‘start low go slow’
Opioid tolerant patients – select dose and
medication on case by case basis. When
converting from other opioid start at 50%
equianalgesic dose and titrate per response.
May use ER/LA therapy alone, SA only, or a
combination of ER/LA with a SA opioid.
Recommend not to use more than one SA
concurrently.
73. SA opioids typically have rapid onset (10-60 min)
and relatively short duration (2-4 hrs)
ER/LA opioids have relatively slow onset
(between 30 to 90 min) and relatively long
duration of action (4 to 72 hrs)
Combination with non-opioid adjunctives can be
beneficial and can have opioid sparing effects. But
monitor for non-opioid drug toxicity.
No ‘ceiling’ effect for opioid analgesic dosing.
Selecting ‘Abuse-Deterrent’ formulations may
minimize the opioid abuse.
77. Morphine dose is used as a ‘standard’ for dose
comparison of other opioids. Morphine
equivalent daily dose (MEDD)
Recommend not to exceed >100 mg/day
MEDD
exercise caution with morphine and Demerol
use in renal insufficiency patients. Most other
opioids eliminated by hepatic metabolism.
Codeine is a prodrug and not all patients
convert it to an active form.
78.
79. When treating chronic pain with opioids, also
be prepared to proactively treat side effects.
Common side effects include respiratory
depression, sedation, mental clouding or
confusion, nausea, vomiting, constipation,
pruritus and urinary retention.
Side effects tend to subside with time with the
“exception” of Constipation.
80. Periodic urine drug screens (should be performed
for the duration of COT)
244 un-intentional Rx drug related deaths in San Diego county in 2014, 5723 ER
discharges related to pain killers in 2013
Utilizing ‘CURES’/PDMP system for monitoring
and surveillance (CONTROLLED SUBSTANCE UTILIZATION REVIEW AND
EVALUATION SYSTEM). Register by Jan 1st, 2016.
Can complete registration online at https://pmp.doj.ca.gov/pmpreg
Perform Pill counts at each visit, especially in high
risk patients.
81. July 2012, FDA released ‘final’ guidelines to
REMS for ER/LA formulations.
2014-2015 – Government move to initiate an
action plan to formulate ‘National Pain
Strategy’(NPS)
82. Urine drug screens typically done every 1-3
months.
More frequently done in high risk patients, e.g,
Prior history of addiction, past abuse, aberrant behavior, occupations demanding
mental acuity, elderly, unstable or dysfunctional social environment, comorbid
psychiatric or medical conditions
Sometimes daily or weekly monitoring may be necessary for patients at very high
risk of adverse outcomes.
Urine specimens can be adulterated and should be aware.
Oral swab tests more easy to administer and can be more valuable than urine drug
screens.
84. Screen for hypogonadism in patients on COT,
especially with signs and symptoms of fatigue, mood changes, decreased libido,
loss of muscle mass and osteoporosis.
Perform opioid rotation if lack of efficacy, side-
effects of one opioid class, altered pharmaco-
kinetics, changes in absorption.
85. CHRONIC PAIN PATIENT ADDICTED PATIENT
Medication use is not out of control
Medication use improves quality of life
Wants to decrease medication if adverse effects
develop
Is concerned about the physical problem being
treated with the drug
Follows the practitioner-patient agreement for
use of the opioid.
May have left over medication
medication use is out of control
Medication use impairs quality of life
Medication use continues or increases despite
adverse effects
Unaware of or in denial about any problems that
develop as a result of drug treatment
Does not follow opioid agreement
Does not have left over medication. Loses
prescriptions. Always has a story about why
more drug is needed.
86. Tolerance – decreased efficacy over time
Dependence – tolerance +withdrawal
symptoms
Addiction – ‘neurobiological disease’. Strong
genetic influence. Preoccupied with continued
use despite harm
Pseudoaddiction – happens when pain is
undertreated. “drug seeking” or “clock
watching”. Usually resolves with effective pain
management.
92. Reasons to terminate may include (healing or recovery
from the treatment condition, intolerable side-effects, lack of response, discovery of
abuse or misuse or addiction)
Typically 10% dose reduction per week. Slower
taper will minimize unpleasant withdrawal
symptoms.
Clonidine can be used. 0.1 – 0.2mg PO every 6
hrs daily or patch at 0.1mg/24 hours.
Drug rehab - Methadone
93. Respiratory depression usually preceded by
warning signs and can be prevented with
careful monitoring
Take home Naloxone Rx for patients with high
risk for overdose
. In 2014 FDA approved hand held auto-
injector (Evzio) and can be used at home by
family members or caregivers.
94. Mu-1 agonist and NMDA antagonist
Analgesic duration of 4-6 hrs
Elimination t1/2 15-60 hrs
Can cause QT prolongation, Torsade de pointes
95. Has been long used to treat addiction.
Long plasma elimination half life, relatively
short analgesic half life makes it optimal for
maintenance.
Has opioid and non-opioid receptor effects
causing varied effects – ‘Broad spectrum
opioid’
Metabolized by liver enzymes that differ from
those associated with most other opioids,
leading to drug-drug interactions.
96. Significant genetic variations in the liver
enzymes that metabolize methadone
Metabolism effected by cigarette smoking and
alcohol consumption.
Lowest possible dose titration should be
followed even for opioid tolerant patients.
97.
98.
99. 1 provider and 1 pharmacy for all controlled
substances
Use CURES/PDMP
Use medication agreements when prescribing
‘COT’
Don’t mix opioids and CNS
depressants/sedatives. Monitor polypharmacy
Implement multidisciplinary approach to treat
chronic pain.
Editor's Notes
National Overdose Deaths—Number of Deaths from Benzodiazepines. The figure above is a bar chart showing the total number of US overdose deaths involving benzodiazepines from 2001 to 2013. The chart is overlayed by a line graph showing the number of deaths by females and males. From 2001 to 2013 there was a 4-fold increase in the total number of deaths.
National Overdose Deaths—Number of Deaths from Rx Opioid Pain Relievers. The figure above is a bar chart showing the total number of US overdose deaths involving opioid pain relievers from 2001 to 2013. The chart is overlayed by a line graph showing the number of deaths by females and males. From 2001 to 2013 there was a 3-fold increase in the total number of deaths.
National Overdose Deaths—Number of Deaths from Prescription Drugs. The figure above is a bar chart showing the total number of US overdose deaths involving opioid prescription drugs from 2001 to 2013. The chart is overlayed by a line graph showing the number of deaths by females and males. From 2001 to 2013 there was a 2.5-fold increase in the total number of deaths.