Transcript Overview of Pain Management IJ 05092016x

Overview of Pain Management
Ingrid Johnston
Consultant Pharmacist
Objectives
1. To understand the different types of pain
2. To review pain assessment tools
3. To understand principles of pain management
4. To understand the different analgesic groups and
common side effects
5. To identify common treatment problems
TYPES OF PAIN
Many factors
can contribute
to pain and its
perception
Nociceptive pain
Type of Mechanism
Pain
Examples
Somatic
Activation of pain receptors Burns, wounds,
on the body surface or
malignant ulcers,
musculoskeletal tissues
muscular injury, arthritis
Visceral
Damage to internal organs
Appendicitis, gallstones,
chronic chest pain
diverticulitis and pelvic
pain
Responds Well To
Simple analgesics
Opioids
Anti-inflammatories
Non-pharmacological therapies
Neuropathic pain
Mechanism
Examples
Symptoms
Damage to
peripheral and or
central nervous
system
Diabetic neuropathy,
central stoke pain,
sciatica,
phantom limb pain,
post-herpetic
neuralgia, trigeminal
neuralgia
Burning, itching,
tingling, electric,
shooting.
Responds Well To
Adjuvant drugs
Tricyclic antidepressants
Anticonvulsants
Assessment tools
Utilise an appropriate, structured pain assessment tool
Verbal descriptor pain scales
Numerical pain scale
Visual analogue pain scale
Faces pain scale
FLACC Behavioural pain scale
Abbey Pain scale
Assessment should explore multiple factors
Involve resident or representative
Multidisciplinary
Structured procedures to identify cause
Behavioural
assessment
tool
Abbey Pain
Scale
Pain assessment in advanced dementia - PAINAD
Electronic Pain Assessment?
ePAT app
http://www.epat.com.au
Uses different domains to
provide an indication of
pain SEVERITY which is
quick, accurate, objective
and reproducible
PAIN MANAGEMENT PRINCIPLES
Patient Barriers
Unrealistic expectations
Anxiety and depression
Fear of addiction
Fear of becoming tolerant to medications
Fear of adverse effects of therapy
An inability to comply with complicated
programs
An inability to understand dosing guidelines
Communication difficulties
Common Errors
Not using regular pain relief
No analgesic available for breakthrough pain
Not anticipating or treating side effects
Inappropriate choice of medicine
Lack of clear indication and max dose on PRN orders
Lack of documentation regarding use of PRN’s
Pain Management Guidelines
Treatment Strategies
– Combine pharmacological with non-pharmacological
– Multidisciplinary approach
– Clearly establish goals
– Analgesia needs to be tailored for specific pain
diagnosis
– Side effects may be more troublesome than the pain
anticipate, treat or avoid
Pain Management Guidelines
Regular (around the clock) administration
Short acting analgesia for breakthrough pain or prior to
an activity – eg dressing changes
Consider resident’s co-existing conditions
Complementary and alternative therapies may be
helpful
ANALGESIC GROUPS
Analgesic Groups
Simple
Analgesics
Weak opioids
Antiinflammatories
Strong opioids
Analgesic
adjuvants
World Health
Organisation
Analgesic
Ladder
Which analgesic?
SIMPLE ANALGESICS
Paracetamol
Mild pain
Metabolised by the liver
Excreted by the kidneys
Toxic in overdose
– Maximum dose is 4000mg per day
Many brands
Many forms
Panadol Osteo PRN use?
Has there been any
consequences of paracetamol
being removed from the PBS?
NONSTEROIDAL
ANTI-INFLAMMATORY DRUGS
Drug name
Brand name
Aspirin
Many brands. Need > 300mg dose
Diclofenac
Clonac, Dinac, Fenac, Impflac, Voltaren,
Ibuprofen
Advil, Brufen, Nurofen, Rafen
Indomethacin
Arthrexin, Indocid
Ketoprofen
Orudis, Oruvail
Naproxen
Anaprox, Crysanal, Eazydayz, Inza, Naprogesic,
Naprosyn (SR), Proxen,
Vimovo – (naproxen with esomeprazole)
Piroxicam
Feldene, Mobilis
Sulindac
Aclin
Celecoxib
Celebrex, Celaxib, Celexi, Kudeq,
Meloxicam
Melox, Meloxiauro, Meloxibell, Meloxibindo, Mobic,
Movalis
NSAIDS adverse effects
Impair renal function
– Triple whammy when combined with ACE-inhibitor/A2
antagonist + diuretic
Fluid retention
Increase blood pressure
Increased risk of cardiovascular events
Bronchospasm
Gastrointestinal issues
NSAIDS adverse effects
Gastrointestinal irritation/bleeding
To reduce risk
–
–
–
–
Use paracetamol as an alternative
Prescribe NSAID with lower risk
Use lowest effective dose
Use a PPI or misoprostol with the NSAID
NSAIDS
Residents who develop
–
–
–
–
Swollen ankles
Difficulty in breathing
Black stools
Dark coffee-coloured vomit
Should stop the NSAID and Inform the doctor
Topical NSAIDs
Used for muscular aches and pains
Safer alternative to oral NSAIDs
Only absorbed in small amounts
Somewhat less effective
Can still cause GIT haemorrhage
OPIOIDS
Opioids
Only about 1 in 5 patients obtain effective pain relief
without major side effects
Successful response includes
– Decrease in pain severity
– Improvement in physical function
Older people are more sensitive to effects and adverse
effects
Opioid
Weak
Strong
Relative potency
Morphine 10mg im/sc
Morphine
Hydromorphone
30mg oral
* Strong opioid
of
choice 1.5–2 mg SC/IM;
6–7.5 mg oral
Codeine
200mg
Fentanyl
100-150mcg sc
Methadone
Complex
Tramadol
150mg oral
Dextropopoxyphene
Unkwown
Oxycodone
15-20mg
Opioids -Constipation
Expect this to occur
Little, if any, tolerance develops
Attention to fluid intake, diet and mobility is required
Regular laxative use (eg stimulant laxative and stool
softener) is essential as soon as chronic opioid
treatment is started
Opioids – Nausea/Vomiting
May occur initially
An antiemetic may be given prophylactically
Review use within a few days as nausea
often lessens with continued opioid
use
Opioids – Respiratory Depression
Best judged by the degree of sedation
Sedation score
0 – wide awake
1 – easy to rouse
2 – easy to rouse, but cannot stay awake
3 – difficult to rouse
Aim to keep the sedation score <2
a score of 2 represents early respiratory depression
Opioid Adverse Effects
Sedation
Commonly encountered but usually resolves
within a few days
Tolerance
Develops to the respiratory depressant effects
of morphine
Hallucinations
and confusion
Due to the high risk, the elderly should receive
lower starting doses
Clinical Features of Opioid Toxicity
Pinpoint pupils
Sedation
Slow respiration
Visible cyanosis
Myoclonic
Snoring when
e.g. lips, ears, nose
jerks
asleep
Agitation, confusion, vivid dreams, nightmares or
hallucinations
Significant variability in dose at which
toxicity occurs
Opioid induced hyperalgesia
• Associated with long term use
– Abnormal pain sensitivity
– Pain is more diffuse
– Less defined in quality
• Management
– Reduce dose of opioid
– Change to an alternative opioid.
Codeine
Pro-drug of morphine
– Metabolised by CYP2D6 to morphine
– 30mg of codeine = 4.5mg of oral morphine
– Some people are unlikely to obtain analgesia with
codeine due to a genetic lack of CYP2D6
eg 6–10% of Caucasians and 1–2% of Asians
What about CYP2D6 inhibitors?
– Paroxetine, fluoxetine are strong inhibitors
– Duloxetine moderate inhibitor
Codeine
Some people are ultra-rapid metabolisers
– achieve higher morphine concentrations, increasing their
risk of toxicity
What dose is effective?
– Lowest effective dose not well defined
– Studies suggest you need 30 mg of codeine
– No conclusive evidence
Combination analgesics containing 8–15 mg of
codeine per tablet with paracetamol, aspirin or
ibuprofen
Tramadol
Opioid and non-opioid actions
Less constipation
Less analgesia
Ceiling effect in cancer pain management
Max dose 400mg/day, in elderly 300mg/day
Can interact with antidepressants
Serotonin syndrome
Dextropropoxyphene
Doloxene® and Di-Gesic ®
Should not be used
What’s New?
Tapentadol sustained release (Palexia SR)
– Dual action
– Opioid effect
– Noradrenaline reuptake inhibitor
Practice points
– Controlled release tablets
– Do not crush
– Twice daily dose, unsuitable for
acute pain management
What’s New?
Opioid with naloxone (Targin®)
– Naloxone blocks the opioid effect in the gut to reduce
constipation
– Naloxone does not enter the brain to prevent analgesic
action
– Consider use if optimised regular laxatives for opioidinduced constipation are inadequate
Practice points
– Controlled release tablets
– Do not crush
– Twice daily dose, unsuitable for acute pain management
Targin®
Oxycodone/naloxone
Markings
5mg/2.5mg
OXN, 5
10mg/5mg
OXN, 10
20mg/10mg
OXN, 20
40mg/20mg
OXN, 40
Appearance
What’s New?
Hydromorphone (Jurnista®)
Practice points
– Once daily dose
– Morphine equivalence:
32mg hydromorphone
= 160mg oral morphine
– May appear in bowel motions
Norspan® and Durogesic® Patch Therapy
Advantages
– “Flat" steady state effect (minimal peaks/troughs)
– Fantastic if swallowing is an issue
– Convenient: apply & go...
Disadvantages
–
–
–
–
–
Limited/slow ability to titrate
Slow onset
Conversion difficulties
Skin irritation
Forgetting to take off the old patch
Onset of effect from patch
Fentanyl
– Up to 72 hours for max effect
– Steady state may not be reached until the second patch is
applied
– Start at time of last the last dose of a 12-hr CR product
– 12 hours after the last dose of a 24-hr CR product
Buprenorphine
– May require other short acting drugs for 72 hours on initiation
– No other analgesics for 24hr when discontinued.
Slow Release Analgesic Products
Many opioid preparations have slow release properties
Must not be crushed
Not for breakthrough pain due to slow onset of effect
Breakthrough analgesia
Do not forget it!
Approximately 1/10th of the regular dose
Normal dose of opioid should be taken at the regular
time - no need to wait 4 hours after the breakthrough
dose
Where possible use the same opioid for regular and
PRN use
Switching Opioids
If adverse effects become intolerable, switching opioid
may prove beneficial
Consider equianalgesic doses
May be incomplete crossover tolerance
Start with 50% of the approximate equianalgesic dose
Titrate according to response
Opioid Comparison
Tapentadol
75 – 100mg oral
Conversion Ratios
Various around
ANALGESIC ADJUVANTS
Analgesic adjuvants
Neuropathic pain commonly responds to opioids
Pain relief may be incomplete
Analgesic adjuvants may improve response & allow a
reduction in opioid dose
Neuropathic pain responds best to a combination of
opioids and a co-analgesic
Analgesic adjuvants
Analgesic adjuvants
Refractory neuropathic pain
Referral
NMDA receptor antagonist ketamine
Antiarrhythmic drug flecainide
– 50mg orally bd up to max 300mg/day
Topical capsaicin 0.025% or 0.075%
Cannabinoids
Botulinum toxin type A local injection
Intrathecal administration
– Morphine, local anaesthetics, clonidine, baclofen
Corticosteroids
Analgesic adjuvant for pain due to
Inflammation
Oedema
Local administration
intralesional, intra-articular
• Prednisolone
• Prednisone
• Dexamethasone
Systemically
Oral or parental
Beneficial for space occupying pain
brain, spinal cord, nerves, liver and soft tissues
SUMMARY
Principles
1.
2.
3.
4.
Comprehensive assessment
Multidisciplinary approach
Consider nonpharmacological therapies first
Consider drug therapy if nonpharmacological therapies are
unsuccessful or inappropriate
5. If drug therapy used – appropriate dose/frequency/duration
6. Regularly review patient
7. Provide long-term support.
Principles
1. Assume that the resident is reporting a true experience
2. Assess the pain and its impact on daily life
3. Avoid categorising pain as physical or psychological
4. Educate and involve resident in management
5. Determine primary treatment goal
6. Use a multimodal approach
7. Undertake a thorough medication history
8. Correct misconceptions
9. Manage comorbidities – sleep, depression etc
10. Develop a written pain management plan
Links to Other Resources
Organisation
Link
Arthritis Foundation
http://www.move.org.au/
Supports people with
arthritis
Australian
Rheumatology
Association
http://rheumatology.org.au/
Supports health
professionals and has
consumer information
WHO analgesic ladder
http://www.who.int/cancer/pallia
tive/painladder/en/
Care Search
http://www.caresearch.com.au/C
aresearch/Default.aspx
Palliative Care Australia http://palliativecare.org.au/
The Australian Pain
Society
Relevant evidence and
quality information to
palliative care
National peak body for
palliative care
http://www.apsoc.org.au/PDF/Pu Management strategies in
blications/Pain_in_Residential_Ag residential care
ed_Care_Facilities_Management_
Strategies.pdf
Links to Other Resources
Organisation
Link
Royal Australian
College of General
Practitioners
http://www.racgp.org.au/yourpractice/guidelines/silverbook/co
mmon-clinical-conditions/painmanagement/
p://www.move.org.au/
British Pain Society
https://www.britishpainsociety.or Downloadable booklet on
g/static/uploads/resources/files/ opioids for persistent pain
book_opioid_main.pdf
National Prescribing
Service (NPS)
http://www.nps.org.au/condition
s/nervous-systemproblems/pain/forindividuals/painconditions/chronic-pain/forhealthprofessionals/management-plan
Downloadable booklet on
Medical care of older
persons in residential aged
care facilities
Developing a management
plan for chronic pain
What quality improvement activities are you likely to implement
following this session in regards to your own work?
1. _____________________________________
_____________________________________
2. _____________________________________
_____________________________________
3. _____________________________________
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