Transcript Treating Chronic Pain

Contemporary Pain Assessment and
Management in Today’s Adult and
Geriatric Population
Christine Coletta-Hansen ANP-BC, ACHPN
Palliative Care Nurse Practitioner
Grand View Medical Center
Course Objectives
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At the end of this lecture participants will be
able to :
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Verbalize understanding of the holistic impact of chronic pain in
today’s adult and geriatric population (10 min.)
Verbalize at least 3 reliable/valid pain assessment tools/techniques
that can be used in the adult or cognitively impaired populations
(10 min)
Compare/contrast different opioid analgesics to assist in choosing
appropriate pharmacotherapy depending on individual patient
needs.(90 min)
Discuss co-analgesia options according to pain etiology.(30 min)
Create a plan to provide pain management to patients at risk for
addiction.(40 min)
Facts and Figures about Pain
in America
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An estimated 75-150 million Americans
suffer chronic long lasting pain
1 of 7 PCP office visits are due to pain
More than 50 million are partially
or fully disabled from the pain
Pain affects up to 80% patients with
Stage IV CHF
Pain Facts cont.
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National study of 2.2 million SNF residents
showed 41.2% complained of moderate to
severe pain 60 & 180 days post initial
assessment.(Jakobsson et al 2003)
70% of those approaching end-of-life admit
to moderate to severe pain
94% of cancer patients report experiencing
moderate to severe pain (EPIC 2007)
Definition of Pain
McCafferty: clinical definition
 Scientific definition:
Changing view per Perry Fine, MD 2006
“A condition of malfunctioning of the
PNS/CNS system as well as
dysregulation of other systems
(Immune/Neuroendocrine/Sleep/Mood)
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Pain and the Patient
Chronic Pain Alters Brain
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Functional MRI performed in people
suffering chronic pain show a state of
constant activity in areas that should be
at rest.
Frontal cortex, associated with emotion,
is constantly active causing problems
with attention, sleep and causing
depression
Growing Evidence
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Chronic pain is now believed to be a
systemic or multisystem impairment
that arises from an initial trigger or
injury to the nervous system that for
reasons that are unclear does not
recover
Peripheral and Central Pathways for
Pain
Ascending Tracts
Descending Tracts
Cortex
Thalamus
Midbrain
Pons
Medulla
Spinal Cord
Factors for Pain Assessment
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Assess pain for:
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Intensity and location
Descriptors, duration
Alleviating and aggravating factors
Accompanying symptoms
Effect on quality of life (Goal Attainment
Scale; J. Farrar)
Patient’s goal for pain control
Previous effective (non)/pharmacologic tx
Ongoing Monitoring of Chronic Pain
Patients (Passik & Weinreb, 2000)
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“4 A’s”
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Analgesia
ADL’s
Adverse effects
Aberrant drug taking behaviors
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PDAT (Passik et al 2004)
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Multidimentional assessment of pain relief, side effects,
physical and psychological function and aberrant drug
related behaviors
Chronic Pain Principles
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Treat pain by least invasive route first (IV still
takes 10 hrs to reach steady state)
Give medication around the clock (use long
acting formulations when possible)
Always have breakthrough medications
available
Give medications by the “Ladder”
Individualize the dose to meet patient
needs/goals
Utilize multidisciplinary approach
Pain Types &Drug Classes
Used to Treat Them
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Nociceptive (Bone, Muscle, Visceral,
etc.) (dull, achy, throbbing, nagging)
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Neuropathic (CNS or PNS)
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Inferred tissue damage; localized; afferent
CRPS, phantom pain=CNS
Neuropathies=PNS
Idiopathic
Psychogenic (team approach necessary)
Pain assessment tools
Pain Assessment Tools(Standardized
throughout the institution)
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MCGill Pain Inventory
Wong-Baker Faces Scale
VAS/Pain thermometer
Pediatric/Adolescent
Color Intensity Scales
Verbal Descriptor Scale
Goal Attainment Scale
Elderly Attitudes Toward Pain
Treatment
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Don’t want to bother anyone
Believe pain is a normal part of the
aging process
Don’t want to be a “bad patient”
Fear becoming overmedicated or
addicted
Fear pain means illness is worsening
Chronic Pain in the ElderlyMixed/Unspecified
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Pain may have mixed or unknown causes (also,
multiple locations)
Treatment is unpredictable and various approaches
may be needed
Some pain syndromes may be psychologically based
and traditional analgesia may not be indicated
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Polypharmacy and drug interaction risks pose
increased challenges in the elderly.
Geriatric Pain Assessment
Tools
Impaired Cognition/MMSE 12
Geriatric Pain Assessment
Tools
Pain Assessment in the Nonverbal
Patient (Herr et al, 2006)
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Make all attempts for the patient’s self-report
Search for potential causes of pain (if
needed, assume pain is present)
Observe patient behaviors
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New onset confusion or agitation
Surrogate reporting of pain behaviors/activity
changes
Attempt an analgesic trial
Pain Assessment Tools for Nonverbal or
Cognitively Impaired Adults
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ADD: Assessment of Discomfort in Dementia Protocol
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CNPI: Checklist of Nonverbal Pain Indicators
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NOPPAIN: Nursing Assistant Administered Instrument to
Assess Pain in Demented Individuals
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PACSLAC: Pain Assessment Scale for Seniors with Severe
Dementia
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PAINAD: Pain Assessment in Advanced Dementia Scale
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All are referenced in the bibliography
WHO Stepladder
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Step I (beware of combination
products)NSAIDS/Cox-2/APAP
Step II
Step III
Opioids (“the good, the bad and the ugly”):
(normerperidine/CNS toxicity); propoxyphene
(norpropoxephene/CNS/Renal toxicity; 1 IN 20 DRUG RELATED DEATHS ARE FROM THIS
Merperidine
equipotency of ASA (650 mg)/merperidine
(oral); morphine (metabolites) & renal insuff.
Adjuvants
DRUG);
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Nonopioid Analgesics
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Acetaminophen (paracetamol)
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Minimal anti-inflammatory effects
Fewer adverse effects than other nonopioid
analgesics
Adverse effects
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Renal toxicity
Risk for hepatotoxicity at high doses
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Increased risk with liver disease or chronic alcoholism
??? effect on platelet function
New recommendations as low as 2600
mg/24h
Use of NSAIDS in the Elderly
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Avoid using high dose, long term NSAIDS
GI complications up to 40%. Use PPI’s
Dehydrated patients & renal failure
Use NSAIDS PRN rather than around the
clock
Topical NSAIDS give 70x more direct joint
delivery than oral route
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Dicolfenec gel/spray; Ketoprofen
2009 NSAID formulation
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IV ibuprofen(Caldalor) infused over 30 min.
Comes in 400 mg/4ml or 800 mg in 8 ml. $13.00/dose
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Only injectable drug for fever
No 5 day limit like ketorolac
Costs 9x more than ketorolac therefore stay
with it for short term use in patients at low
risk for GI bleeding or renal dysfunction.
Consider IV ibuprofen if longer IV treatment
is needed.
NSAID patch(s)
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diclofenac epolamine topical patch 1.3%
(Flector)
 1 patch/2xday to INTACT skin
 No bathing/showering
 diclofenac (Voltaren) gel 1% measured 4 gm for
LE and 2 gm for UE
 diclofenec spray has an even faster onset of
analgesia; (Pennsaid) 1.5% 40 gtts qid
Tramadol (non-schedule
opioid)
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Blocks reuptake of seratonin and norepinepherine.
Mu-receptor agonist as well
Tramadol (Ultram) 37.5 mg effective; ER (more
somulence nausea and dizziness)
ER (100/200/300 mg available)
200-400 mg in 4 divided doses
Caution with SSRI use*******
(seizures/seratonin syndrome)
Side effects are dizziness, constipation, drowsiness,
tremor, HTN, seizures. High (up to 28%)
discontinuation rate
Seratonin syndrome
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50% is antidepressant related, especially when
combined with Tramadol or methadone.
High seizure risk
Can occur within minutes to hrs after starting
ALTERED MENTATION, HYPERACTIVITY,
AKASTHESIA, MYOCLONIS, DIAPHORESIS,
HYPERTHERMIA
Tramadol, SSRI, SSNRI,TCA’s, opiates,
antihistamines, CNS stimulants, tryptans
Tapentatol (Nucynta)
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For ACUTE PAIN
Schedule II; similar to tramadol (mu agonist
and affects NE as well.
50/75/100 mg; may take up to 600 mg/day
Dose q 4-6h
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No renal or hepatic challenge
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100 mg = Oxycodone IR 15 mg but is 2x the
cost
Equianalgesic Table
PO/PR (mg)
Analgesic
SC/IV/IM (mg)
30
Morphine
10
7.5
Hydromorphone
1.5
20
Oxycodone
20
Methadone
10
10
Oxymorphone
1
30
Hydrocodone
-
Opioid allergies
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Most reactions are “pseudoallergies”:
histamine release/puritis, etc.
For a true opioid allergy use a drug
from a different class. Patients allergic
to codeine CAN usually take fentanyl,
methadone but NOT morphine,
hydrocodone or oxycodone.
Drug conversion Hints
(McPherson 2010)
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Oral/rectal same
MSO4= 1:3 (IV to oral)
Fentanyl: 50% of TDD oral morphine (25
mcg fentanyl is 50 mg MSO4 TDD)
Hydromorphone 5:1 or 3.7:1 (M:HM)
Oxycodone 1.5:1(M:O)
Tramadol 10:1 (T:M)
Chronic Pain and Opioids
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Opioids can relieve moderate to severe pain
For occasional chronic recurrent pain not
controlled by NSAIDS, use opioids PRN
Opioids: no ceiling or maximum dose
For continuous pain—Sustained release
Use breakthrough medications (1/3 –1/2 q.
12 h. dose)
“Start low and go slow”
Remember cross tolerance/opioid rotation
(20-25% of equianalgesic dose)
Pharmacogenomics of Opioids
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Genetic polymorphisms >1% of normal
population (1 out of 10 get poor response)
Sensitivity of mouse strains to morphine
(ranges from 0-90% based on strain of mouse)
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Codeine
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Poor metabolizers
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2% Asians/African Americans
10% Caucasians
20% Middle Eastern
Chronic Pain and Opioids cont.
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10 days or longer withdrawl syndrome
will occur therefore:
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Decrease dose by 50% and give q. 6 h. x 2
days then reduce by an additional 25%
every 2 days.
Opioid Options
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(Amabile, 2006)
Morphine: IR/SR (MSContin, Avinza,
Kadian/Embeda)
Oxycodone: IR/SR(OxyContin)
Hydromorphone: IR only for now
Oxymorphone (Opana)
Methadone: (1/2 life of approx. 30 hrs)
Fentanyl: high 1st pass effect and low oral
bioavailability. Highly lipophyllic.
Opioid Induced Hyperalgesia
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(Ballantine 2006)
NMDA receptor mechanisms are involved in the
development of hyperalgesia/sensitization (as
are opioid metabolites)
NMDA receptor is also involved with opioid
tolerance (desensitization).
Dilemma: Increasing the dose of opioid can either
improve or worsen pain
Weaning at times may actually improve analgesic
effect.
Hyperalgesia: neuroplastic change in pain perception
Opioids: Compare/Contrast
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Morphine: “gold standard”.
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Avinza/Kadian/MS Contin/Embeda (sequestered
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naltrexone core; REMS. $250.00 vs $90.00 for regular
ER formulation)
Oral, rectal, parenteral
 Metabolite(morphine 3-glucuronide) can cause seizures,
myoclonis, puritis, dysphoria, headache, and hyperalgesia.
Risk is increased if low GFR!!!
 Avoid in renal failure
 Crosses Blood brain barrier in 96 min(fentanyl in 6 min)
Opioids: Compare and contrast cont.
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Hydromorphone/Dilaudid: IR only
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Synthetic opioid
Oral, rectal, parenteral, intranasal
SR recalled by FDA in 2005 due to interactions with ETOH
leading to rapid drug release
Metabolite hydromorphone-3-glucuronide causes same side
effects as MSO4 but hydromorphone is more potent
therefore requiring less dosing with less adverse outcomes.
Cautious use in renal failure
Opioids: Compare/Contast cont..
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Oxycodone: IR/SR
Oxy Contin
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Synthetic
Not renally cleared therefore may be
advantageous in dialysis patients but use
cautiously
Less nausea, vomiting
Combunox (5 mg with 400 mg Ibuprofen)
Oxycodone
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New black box warning for interactions with CYP3A4
drugs (pathway for metabolizing oxycodone)
Increasing levels with inhibitors (macrolides,
antifungals or protease inhibitors)
Decreasing levels with carbamazapine, phenytoin,
rifampin (decreases level by 50%)
To avoid, prescribe morphine, codeine,
hydromorphone or tapentadol (fentanyl, hydrocodone
tramadol and propoxyphene are also 3A4 affected.
Opioids: Compare/Contrast cont….
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Methadone (synthetic opioid)
 ½ life 20-36 hrs.
 NMDA antagonist and inhibits serotonin
and norepinephrine and therefore helpful
in neuropathic pain syndromes
 Cheap
 CLOSE MONITORING. QT prolongation a
risk as are mult. drug interactions (rare if
<50 mg/day)
Methadone cont.
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80 % oral bioavailability (bid or tid dosing basal with ½ dose q 3 hrs
prn BTP); plasma levels do NOT correlate well with drug
interactions
Lipophilic
Excretion is mostly fecal therefore utilized with renal failure
patients
Analgesic properties in 30 minutes; for approximately 4-8 hrs
50% of all deaths occur in the first 2-3 weeks of use (dosed too
quickly)
Side effects: “spacy/fuzzy” feeling, drowsiness, constipation, dry
mouth, N/V, puritis, urinary retention: 98% reaches CNS
Tablets (5/10 mg); Diskets (40 mg); Solution 5/10 mg /5ml;
powder for rectal compounding; topical gel 20 mg/ml—poor
response) and IV
Drugs that may Increase
Methadone Effects
(www.zerodeaths.org) (www.torsades.org)
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Ciprofloxacin
Diazepam
Diltiazem
Actue ETOH
Fluconazole
Haloperidol
Ketoconazole
Macrolides
SSRI’s
Benzodiazepines
Verapamil
Drugs that may decrease
Methadone Effects (Leavitt 2005)
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Barbituates
Carbamazepine
Cocaine
Dexamethasone
Chronic ETOH
Heroin
Phenytoin
Rifampin
Spironolactone
Tobacco
Lopinavir & Ritonavir
Methadone Dosing
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Opioid naiive patient
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Start 5 mg po bid
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Opioid tolerant patient
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Usually do not do equianalgesic conversions
Start 5-10 mg po tid with breakthrough available
Titrate q 3-7 days (after steady state is achieved to
avoid toxicity that can occur 20 hrs out)
DO NOT COMBINE WITH BENZOS
Caution in patients with sleep apnea, respiratory
infection
Morphine to Methadone conversion
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MDD MSO4 <1 gm/day 10:1
MDD MSO4 1-2 gm/day 20:1
MDD MSO4 >2 gm/day 30-40:1
Don’t adjust in <5-7 days
Stop methadone then 12 hrs later
switch
Methadone
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Good choice if:
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MSO4 allergy
Renal issues
Neuropathic pain
Adverse drug rxn
Refractory pain
Cost
LA preferred
Methadone
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Bad choice if:
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< 1 week to live
Drug interactions
Syncope
Cognitive impairment
Non-adherent
Opana
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oxymorphone HCl (Opana)
Extended relief (5 mg/10mg/20mg/40mg) 12
hr dosing (long ½ life: 9-11 hrs)
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IR (5mg/10 mg)
Only for non-opioid naïve patients who are not
allergic to codeine(metablolite of oxycodone)
Resp. depression is a risk in the debilitated elderly
2x oxycodone; 3x MSO4
Oxymorphone cont.
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Opana and Opana ER should be taken 1
hr. prior to meals or 2 hrs after meals
(otherwise dangerously increases blood
levels)
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Titrate by 10 mg q 12 hrs q 3-7 days to relief
Structurally RT hydromorphone
Numorphan. (Injectable oxymorphone:
10mg/ml)
Opioids: Compare/Contrast cont…
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Fentanyl: IR/SR
Lipophilic., parenteral, spinal, transdermal,
transmucosally, nebulized
 Transdermal may not be appropriate choice if
“unstable” pain, fever, diaphoresis, morbid
obesity, cachexia, ascites due to altered
absorption
“clean” drug; considered safer with dialysis
NEWER RESEARCH WITH REGARD TO
CACHEXIA (Journal of Pain; Kalso, E. 2009)
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TD Fentanyl titrations
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Increase TDF in 3 days then q 6 d as
needed
Increase by 25-50 mcg/hr but do not
exceed 100% per dose increase
20% of the population will need patch
change q 48 hrs
IV:TDF is 1:1 ratio conversion
Oral Fentanyl (Actiq)
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Recommended consumption time of “lollipop”
is 15 minutes (suck between cheek and lower
gum)
Titrate as needed (Start with 200mcg units)
Redosing may occur 30 min. after start of
last dose
Ordered for up to 4 units per day
Used for breakthrough pain in patients
already tolerant of opioid administration
Fentanyl film
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(Onsolis)
Fentanyl film for BTP in opioid tolerant
patients
Wet mouth; pink side up on finger, press and
hold to cheek for 5 sec.
Dissolves in 15-30 min
200/400/600/800/1200 mcg
200 mcg to start (may repeat in 2 hrs; MAX
4/day)
Rapid Acting Opioid
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fentanyl buccal tablet (Fentora)
100/200/400/600/800 mcg
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For breakthrough pain in opioid tolerant
patients (60 mg MSO4/day; 25 mcg
fentanyl/hr; 30 mg oxycodone/day)
Starting dose 100 mcg/onset 15 min.
Redosing may occur in 30
minutes/duration 60 min.
Mean is 400 mcg/breakthrough episode
Buccal fentanyl cont.
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200-400 mcg Actiq similar to 100mcg
Fentora
Remove from blister and place entire tablet
above rear molar between upper cheek and
gum and allow to dissolve.
DO NOT spit, suck, chew or swallow tablet
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After 30 minutes, may swallow remainder with
water
Rule of Thumb
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If >200 mg oral morphine per day
think:
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Time to add co-analgesics
Opioid rotate
?opioid non-responsive pain
Evaluate pain intensity rating: if <5/10
increase does by 25-50% and if >6/10
increase by 50-100%
Opioid Side Effects
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Well known
Constipation, sedation, confusion, puritis
(histamine release), nausea, respiratory
depression, dysphoria
With chronic use (>1 week) most side effects
subside with the exception of constipation.
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Chronic opioid use: decrease in
testosterone/bone loss
Treating Side Effects
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Prevent constipation with prophylactic bowel regimen
Encourage adequate fluid intake
Treat mild sedation(psychostimulants), severe
nausea (neuroleptics, anticholinergics
antihistamines, prokinetics, corticosteroids,
benzodiazepines, 5-HT3 antagonists), puritis
(avoid antihistamine; opioid rotate
or/paroxetine/lorazepam), and
myoclonis(clonazepam/anticonvulsants/baclofen)
Breakthrough Pain (BTP)
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(Passik, Moyer, 2006)
Defined as transient increase in intensity of moderate or severe
pain occurring in the presence of well-established baseline pain
Typically rapid in onset (3 min.) and lasting short duration (30
min.). May be visceral, somatic, neuropathic
If due to movement/activity it is referred to as “incident” pain.
May be due to inadequate dosing, idiopathic, or “end of dose”
pain.
Dose 10-20% of long acting dose q 4 hrs prn
Structured Opioid Therapy for Chronic
Pain
1.
2.
3.
4.
5.
6.
7.
8.
Pt. reports pain
Rehabilitative approach
Medication management (goal directed/carefully
monitored)
Titrate to effective dose then maintain
Provide prescriptions on a monthly basis assessing
pain/effect on well-being
? Random drug screening
Increase dose if unstable pain and monitor for side
effects
If treatment fails wean or “opioid swap”.
Summary of Evidence Supporting
Long-Term Opioid Use (Ballantyne, 2006)
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Many authors report prolonged and
satisfactory analgesia for up to 6 years using
moderate doses of opioids (195 mg MSO4 or
equivalent)
Some failed pt’s improve when taken off
opioids
Question if tolerability can be overcome in
every pt. with dose escalations
Addiction rates now reportedly range from 525%
Neuropathic Pain: Opioid
Effectiveness ( Gimbel, Richards, Portenoy, 2003)
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Many recent studies suggest that
opioids provide superior analgesic
efficacy when compared to placebo
With neuropathic pain syndromes,
higher opioid doses may be needed.
Neuropathic Pain
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Central vs Peripheral
Neuropathic Pain Scale/Pain Questionnaire
Exam
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Pinprick hyperalgesia (exaggerated pain following pinprick)
Straight leg raise (lumbar nerve root)
Myofacial trigger points
Tinnel’s sign
Adjuvant/ Co-Analgesics
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Defined as drugs with other indications
that may be analgesic in specific
circumstances
Numerous drugs in diverse classes
Sequential trials are often needed
Adjuvant Analgesics for Neuropathic
Pain
Anticonvulsants
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Gabapentin commonly used
Favorable safety profile (rare drug interactions) and
positive relief in PHN/diabetic neuropathy. Does not
always work
 Usual effective dose: 600–3600 mg/d and sometimes
higher (mean >1800 mg/day); ? Effect >900 mg
TDD
Analgesic effects established for phenytoin, carbamazepine,
valproate, clonazepam, Trileptal (does not affect bone
marrow) and lamotrigine (slow titration needed)
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Pregabalin therapeutic usually >150 mg po bid
Pregabalin
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Does not effect dopamine or seratonin
or noradreniline
PNH and fibromyalgia indications
S/E: Edema and weight gain along with
other anticholinergic s/e
Typical dose 300-600 mg/day (mean
>1800 mg qd)
Start 50 mg po qd then bid then up
to 100 mg tid
Adjuvant Analgesics for
Neuropathic Pain
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Local anesthetics(sodium channel
blockade)
Oral therapy with mexiletine, tocainide,
flecainide
IV/SQ lidocaine also useful (1 hr infusion;
results can be fast; may get q 6 weeks)
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Useful for any type of neuropathic pain
Multipurpose Adjuvant
Analgesics
Antidepressants (use also with concominant
depression; often better than anticonvulsant
co-analgesics))
Enhance the descending pain inhibitory system
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Best evidence: 30 amine TCAs (eg, amitriptyline) Can alter
cardiac conduction. OBTAIN ECG due to alpha blockade.
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20 amine TCAs (desipramine, nortriptyline) better tolerated and
also analgesic

Some evidence for SSRI/SSNRIs/atypical antidepressants (eg,
paroxetine, venlafaxine, maprotiline, bupropion, Cymbalta,
others) and these are better tolerated yet

s/e: Cant see, spit, pee, s#%t; often dose related
duloxetine (Cymbalta)





SNRI
DPN indicator
20/30/60 mg caps
60 mg qd-bid is typical dosing
s/e: insomnia, somnolence, HA,
nausea, xerostomia, constipation, liver
issues
Pharmacological Interventions





Lidoderm Patches
Emla; Emu cream
Alpha blockers (clonidine)
Ketamine gel
Capsaicin tid or qid

Qutenza :New use of 30-90 min application
for 1 treatment session with potential pain
relief for up to 3 months
Qutenza (8% capsacin patch)




For tx. neuropathic pain
In office procedure
Clean area and apply local anesthetic.
Apply patch for 60 min then remove
(may burn) and apply cooling gel. Pain
relief lasts 2-12 weeks
Proposed for foot neuropathy
Ketamine





Anesthetic; NMDA receptor
antagonist
Used as a local anesthetic for
neuropathic pain syndromes
Doses: 20 mg/cc; 50 mg/cc; 100 mg/cc
Used TID
Apply directly to pain site
Ketamine IV


Can be used for neuropathic pain
resistant to opioids as well as to
attempt to reverse tolerance of opioids
Can cause hallucinations and dysphoria
therefore most are placed on a
benzodiazepine in conjunction.
Lidoderm/Lidocaine Patch 5%
 Used for treatment of peripheral neuropathies
 Apply to skin at the site of treatment
 Up to (3) patches may be applied only once
for up to 12 hours within a 24 hour period
 May be cut smaller prior to removal of the
liner
 There is enough drug in patch to last 24 -72h
Lidocaine IV






For neuropathic pain resistant to opioids
Can be 1x dosing and repeated q 6 weeks or may be
added to IV opiate infusions
125-200 mg Lidocaine over 30 minutes
Lidocaine 75 mg/hr. cont. infusion
Lidocaine 2mg/kg IV over 30 min
Toxicity rare if <4-6 mcg/hr (dizzy, oral numbness,
myoclonis, seizures
MRI burn warning


Recent studies suggest transdermal
patches (Flector/some Fentanyl/NTG
and scopalamine) have been known to
have metallic particles in their
formulations and have been known to
cause burns during MRI procedures.
Remove and replace after MRI
Adjuvant Analgesics for Neuropathic
Pain
Miscellaneous drugs
 Calcitonin




RCTs in CRPS and phantom pain
Bone pain
Limited experience
Baclofen




RCT in trigeminal neuralgia
30–200 mg/d or higher
Taper before discontinuation
FYI: TMJ relatively unresponsive to opioids
Adjuvant Analgesics for
Cancer Pain

For bone pain


Bisphosphonates (eg, pamidronate,
clodronate), calcitonin,
radiopharmaceuticals (eg, Sr89, Sm153)
For bowel obstruction pain

Anticholinergics, octreotide
Adjuvant Analgesics for
Musculoskeletal Pain
“Muscle relaxants”
 Refers to numerous drugs, eg,
cyclobenzaprine, carisoprodol (new
documentation of WD syndromes),
orphenadrine, methocarbamol,
chlorzoxazone, metaxalone
 Centrally-acting analgesics
 Do not relax skeletal muscle
Antispasmodics

Baclofen/Lioresal



5 mg/tid
Methocarbamal/
Robaxin

1.5 mg/qid
Orphenadrine/Norflex


100 mg/bid
Carisoprodol/Soma


350 mg/ tid and hs
Cyclobenzaprine/
Flexaril

10 mg/ tid
Diazepam/Valium
2-5 mg/tid
Corticosteroids



Useful for neuropathic
pain.
Immunosuppression
and endocrine effects
limit long-term use
Proximal muscle
wasting occurs after 4-6
wks of Tx.



Dexamethasone has
least mineralcorticoid
effect due to long
duration of effect(60 hr
½ life)
Once/day dosing 8-20
mg
At times high dose rapid
taper is most effective
(up to 100 mg/day then
titrate down to 2
mg/day)
cannabis (Sativex)




Oral spray
Peak 30 min.
s/e: dizziness, dry
mouth, nausea,
fatigue
For neuropathic pain

Smoked MJ is
actually better and
may become a C2
drug soon in some
states)
Chronic PainNonpharmacologic Options







Heat/Cold
Massage
Acupuncture
TENS
Exercise
Relaxation Techniques/ CBT
Touch therapies
Interventional Medicine









Transforaminal lumbar epidural steroid injections via
fluroscopy
Epiduroscopy
Intradiscal electrothermal therapy
Kyphoplasty/Vertebroplasty
Surgeries
Radiofrequency neuroablation
Intra-articular corticosteroids
Intra-articular viscotherapy
Intrathecal Infusions
Dealing With Addiction
Pain Related terms Cont.

Addiction:

Physical Dependence:

Pseudoaddiction:

overwhelming involvement with
obtaining and using a drug for its psychic effects, not
for medical reasons. It is a CHRONIC disease
after repeated
administration of a drug, withdrawal symptoms occur
when it is not taken
Iatrogenic syndrome of
behaviors developing in direct consequence of
inadequate pain management.
UNIVERSAL PRECAUTIONS FOR ALL PATIENTS
Addiction Prevalence and REMS



Evolving
The new worldwide trend is nonmedical
use of prescription drugs (NMUPD) and
soon is projected to exceed illicit drug
use.
Common: analgesics, stimulants,
sedatives, tranquilizers
Predisposing factors



Genetic factors account for 40-50% individual risk
Further influenced by environment (availability, peer
pressures, stressors, sociocultural and legal)
Prolonged use show long-lasting changes in the
brains of those with SUD’s causing neurophysiologic
reinforcement.
APS definition of Opioid Abuse

A primary, chronic neurobiological
disease with genetic, psychosocial, and
environmental factors characterized by:




Impaired control over use
Compulsive use
Continued use despite harm
Craving
Risk Stratification

Low Risk:

Moderate Risk:

High Risk:
No personal/family history of SUD and
no comorbid psychiatric condition.
+ past history of SUD, + family
history of SUD and/or comorbid psychiatric condition
Active addiction and/or major
psychiatric disorder.
Teens/Young Adult
Teens and SUD



In one recent survey more than 2.1 mill
teens abused prescription drugs
(VICODIN, OXYCODONE, sleeping pills,
anti-anxiety, and stimulants.
50% of these teens admitted to abusing
2 or more of these drug classes along
with alcohol and MJ at the same time
PARENT MEDICINE CABINETS!!!
Addiction stats



40-60 % of all patients hospitalized due
to a trauma are substance abusers
25% of all hospitalized patients are
suspected substance abusers
Largest growing population is
prescription abusers
Statistics


An estimated 20% of patients seen in
primary care have SDA’s and yet one
recent survey noted that substance
abuse was only diagnosed in 9% of
general medicine visits (Muher 2010)
Most popular illicit drugs were
marijuana (3.9 mill), pain relievers (1.7
mill), and cocaine (1.6 mill)
Statistics cont.


In 2007 approximately 22.3 million
adults were classified as having
substance dependence or abuse
disorders.
Of these adults, 15.5 mill abused
alcohol alone and 3.2 million were
abusing alcohol and other substances.
Addiction: Evolving View



Research into genetics and neurobiology.
Relationships between exposure to drug
therapies and previously undetermined
predispositions to addiction/chemical
dependency (variability in opioid receptors
and how flexible and changeable those
receptors are over time)
New tools are being developed to aid in this
risk assessment
Opioid Therapy and Chemical
Dependency

Risk of addiction: Evolving view



Acute Pain: Unlikely
Cancer Pain: Very Unlikely
Chronic non-cancer pain:


Surveys of patients without abuse or
psychopathology show rare addiction
Surveys including patients with abuse history
show mixed results
Differential Diagnoses








Pseudoaddiction
Self-medication for depression/anxiety
Spiritual distress
Boredom
Loneliness
Personality or Psychiatric disorder
Criminal Intent
Delirium
Risk Assessment Tools





DAS-I
DIRE
SOAPP
CAGE-AID
(cut down; annoyed, guilty, eyeopener); 2 or more affirmative is + predictor)
These tools are believed to have an 83% positive
predictive value in the general population
Screening for Potential Risk:
Tools (referenced in bibliography)

SOAPP: Screening and Opioid Assessment
for Patients with Pain Tool


(24 items)
ORT: Opioid Risk Tool (5 items)
SISAP: Screening Instrument for Substance
Abuse Potential (5 items)

PMQ: Pain Medication Questionnaire (26 items)
NIDA Modified ASSIST Tool
and Interventions






Step 1: Ask
Step 2: Advise
Step 3: Assess
Step 4: Assist
Step 5: Arrange
http://www.drugabuse.gov/nidamed/scr
eening/nmassist.pdf
Pain Management in Pt’s at Risk for
Developing Addiction (Newman, 2004)


Research suggests at –risk patients do
well with controlled programs and
should not compromise pain
management attempts
Patients have decreased pain threshold,
hyperalgesia, and 72% lifetime
comorbidity between substance abuse
and psychiatric disorders.
How Do We Best Treat Pain?





Acknowledge that treatment of pain is necessary.
Admit that withholding pain medication can be quite
harmful
Begin to use chronic opioids in controlled settings for
appropriate patients
Screen for addiction potential of all patients
Keep in mind an interdisciplinary team approach may
be necessary
Conflict
Relapses


Relapses are predicted by stressors
(such as poorly treated pain, as well as
other emotional/physical stressors)
THE GOALS IS TO PREVENT RELAPSE
Monitoring Drug-Related
Behaviors
Probably less predictive of
Probably more predictive of
addiction
Selling prescription drugs
 Forging prescriptions
 Stealing or “borrowing”
drugs from another person
 Injecting oral formulation
 Obtaining prescription
drugs from nonmedical
source
“Losing” prescriptions
repeatedly

addiction
Aggressive complaining
 Drug hoarding when symptoms
are milder
 Requesting specific drugs
 Acquiring drugs from other
medical sources
 Unsanctioned dose escalation
once or twice

Monitoring Drug-Related
Behaviors (cont.)
Probably more
predictive of addiction
Concurrent abuse of related
illicit drugs
 Multiple dose escalations
despite warnings
 Repeated episodes of gross
impairment or dishevelment
Probably less
predictive of addiction

Unapproved use of the drug
to treat another symptom
 Reporting of psychic effects
not intended by the clinician
 Occasional impairment

Chronic Opioid Therapy in Substance
Abusers
Good outcome
11)



(N =
Bad outcome


Primarily alcohol

Good family support
Membership in AA or
similar groups
(N = 9)
Polysubstance
Poor family support
No membership in
support groups
Dunbar SA, Katz NP. J Pain Symptom Manage. 1996;11:163171.
Treatment Approach




Open posture
Acceptance/tolerance
Exaggerated drug use suggestions to
encourage pt’s to be more forthcoming
Current use/dosing for baseline meds.
Ethics of the Treatment
Agreement


Pain Management “contract”
Provides structure, expectations of both parties and
consequences of aberrant drug behaviors. NOT
PUNATIVE!
Treatment Agreement

Plan to also:




Prevent SUD
Identify factors suggestive of relapse
Structure to provide opioids for treatment
of chronic pain while preventing the risk of
relapse
Plan if relapse occurs and needs to be
managed
Addictions Risk: Structured
Approach to Treatment



Select and monitor patients carefully
Use multidisciplinary approach
Wean therapy when goals are not
reached through repeated, varied,
thorough attempts


S/S of withdrawal
Methadone maintenance and treatment of
pain
Treatment







1. Frequent assessment for abuse during routine
visits
2. Monitoring for and treating s/e of SAD’s
3. Education regarding side effects and treatment
options
4. Coordination with specialty services
5. Use of community supports (AA/NA)
6. Prevention of exacerbations
7. Team approach to behavioral changes
Addiction Implications for Pain
Therapies




Future research addresses hopeful outcomes that we
will be better able to predict what patients will do
better with which therapies to mitigate and manage
addiction over the long term (Fione, 2006).
Set clear guidelines
Maximize non-pharmacological therapies
Urine tox. screens and treatment agreements


If need further testing Gas Chromatography/Mass
spectrometry
Remember to order
fentanyl/methadone/oxycodone/merperidine separately (not
structurally like morphine)
Treatment of Opioid Addiction

Methadone Maintenance program/MMT (MUST BE

SEPARATE from pain treatment in order to continue in
structured addition therapy with supports)
Suboxone (Buprenorphine)/BMT
 Buprenorphine/naloxone 4:1 ratio sublingual
 Physicians must meet criteria to prescribe according to the
Drug Abuse Treatment Act of 2000 or take an 8 hr course to
become certified to prescribe (limit of 30 patients)
 Daily dosing of 0.6-1.2 mg/d (8 mg is equipotent to 30-60
mg oral methadone)
 Ceiling dose is 12 mg (no effect above that dose)
Vivitrol (IM monthly Naltrexone)

Counseling, CBT, group therapy

Non-opioid treatment




Vivitrol ( 380 mg q 4 wk IM alternating buttocks
each time) or ReVia (oral) are NALTREXONE
Blocks opioid receptors however cravings continue.
ReVia dosing is 12.5 mg day 1, 25 mg day 2, 50 mg
day 3, 100 mg day 4
Clonidine (Catapres): decrease craving

Dosing 0.1-0.3 mg po q 4 h then taper over next 10-14 days
Opioid Addiction
Treatment/OAT




The use of opioid analgesia may cause addiction
relapse. Moreover the evidence suggested that
UNRELIEVED PAIN can trigger relapse.
Remember OAT should not be used for analgesia
Aggressively treat pain with conventional opioids
using SCHEDULED doses rather than prn dosing.
For those of BMT remember that there is increased
competition for mu receptors
BMT and chronic pain
treatment options




1. Continue BMT and titrate short acting opioids to
pain relief
2. Divide BMT dose to 6-8 hr intervals
3. DC BMT, implement opioid analgesia, and restart
BMT when opioid analgesia no longer needed.
4. In the hospitalized patient, DC BMT, institute
MMT, add short acting opioids to treat pain and have
naloxone at bedside. Convert back to BMT as
approaching discharge
CMS codes for Abuse
Screening and Treatment


Refer to codes and CPT codes at
http://sbirt.samhsa.gov/coding.htm
Conclusions