Transcript Chronic Wounds - University of Chicago

CHAMP
Pain Control
Stacie Levine MD
University of Chicago
Why is this important to teach on
the wards?
• Pain is common in the elderly
• Pain is under-recognized and undertreated
• JCAHO, ACGME/RRC requirements
• Lack of formal education on pain
control
Why is pain control often not
optimal?
• Clinician unfamiliarity with assessment
and treatment
• Opioid misconceptions
-patients, families, and clinicians
• Fear of side effects
• Concern about addiction, regulatory
reprimands, and lawsuits
Sources of pain in the elderly
• Degenerative joint
disease
• Spinal stenosis
• Fractures
• Pressure ulcers
• Neuropathic pain
• Urinary retention
•
•
•
•
•
•
Post-stroke syndrome
Improper positioning
Fibromyalgia
Cancer pain
Contractures
Postherpetic
neuralgia
• Oral/dental
• Constipation
Consequences of unrelieved pain
• Sleep disturbance
• Functional decline
• Depression,
anxiety
• Malnutrition
• Lawsuits
• Challenging
behaviors
• Polypharmacy
• Increased
healthcare
utilization
• Prolonged LOS
Teaching Objectives
• Knowledge: Housestaff should know
-Properties of medications used for pain
-Common side effects of opioids
• Skills: Housestaff will demonstrate
-bedside pain assessment in older adults
(cognitively intact and impaired)
-use of WHO 3-step ladder
-use of opiate conversion tables
Teaching Objectives
• Attitudes: Housestaff should
-appreciate how pain assessment and
management in older adults differs and
has high degree of variability
-appreciate patients symptoms of pain or
pain-related behaviors
-express satisfaction in evaluation and
management of pain
Outline for Faculty Module
• Recognition and assessment
-Cognitive impairment
• Medication selection
• Dose selection and titration
• Opiate conversions
• Management of myths and side effects
• Discharge planning
Outline for Module
• Recognition and assessment
-Cognitive impairment
• Medication selection
• Dose selection and titration
• Opiate conversions
• Management of myths and side effects
• Discharge planning
Teaching Trigger Case
• You are rounding on an 83 y.o. NH patient
admitted with pneumonia
• She has advanced dementia, bed- bound,
limited verbalization
• PMHx: DM, HTN, Stage 3 sacral ulcer s/p
debridement day before
• Patient stopped eating and is resisting
care
Trigger Case (cont.)
• Housestaff concerned she is depressed
and started Mirtazapine
• No surrogate available, wonder if a PEG
will need to be placed
• Question: How do we teach about
recognition of pain in persons with
cognitive impairment?
Bedside Assessment
• ASK the patient about present pain
• Identify preferred pain terminology
-hurting, aching, stabbing, discomfort, soreness
• Use a pain scale that works for the
individual
-Insure understanding of its use
-Modify sensory deficits
Unidimensional Scales
Acute Pain Management Guideline Panel. Acute Pain Management in Adults:
Operative Procedures. Quick Reference Guide for Clinicians. Rockville, MD: US
Department of Health and Human Services, Public Health Service, Agency for Health
Care Policy and Research. February 1992. AHCPR Pub. No. 92-0019.
Faces Pain Scale and Pain
Thermometer
Assessing pain: Nonverbal, Moderate to
Severe Impairment
• Formal assessment tools available but not
necessarily useful in routine clinical
settings
• Unique Pain Signature
• Nonverbal Pain Indicators
Unique Pain Signature
• How does the patient usually act?
• What changes are seen when they are in
pain?
family members
nursing staff
• Communication across caregiver settings
is key!
Nonverbal Pain Indicators
• Facial expressions (grimacing)
-Less obvious: slight frown, rapid blinking,
sad/frightened, any distortion
• Vocalizations (crying, moaning, groaning)
-Less obvious: grunting, chanting, calling out,
noisy breathing, asking for help
• Body movements (guarding)
-Less obvious: rigid, tense posture, fidgeting,
pacing, rocking, limping, resistance to moving
Nonverbal Pain Indicators
• Changes in interpersonal interactions
-combative, disruptive, resisting care,
decreased social interactions, withdrawn
• Changes in mental status
-confusion, irritability, agitation, crying
• Changes in usual activity
-refusing food/appetite change, increased
wandering, change in sleep habits
Assessing pain: Nonverbal, Moderate to
Severe Impairment (AGS Panel 2002)
1) Presence of non-verbal pain behaviors?
-assess at rest and with movement
2) Timely, thorough physical exam
3) Insure basic comfort needs are being met
(e.g. hunger, toileting, loneliness, fear)
4) Rule out other causative pathologies
(e.g. urinary retention, constipation, infection)
5) Consider empiric analgesic trial
Outline
• Recognition and assessment in cognitive
impairment
• Medication selection
• Dose selection and titration
• Opiate conversions
• Management of myths and side effects
• Discharge planning
Teaching Trigger Case
• You are rounding on a 75 y.o. male s/p fall
• History of lumbar stenosis with new onset
severe sharp pain down left leg
• Xrays negative
• Subintern started prn NSAIDs
• Patient in severe pain at rounds
• Question: How do we teach about medication
and dose selection in older adults?
Multimodal Approach to Pain
Management
Pharmacotherapy
Complementary Alternative
Medicine
Physical Therapy
Treatment Approaches
Psychological Support
Exercise
Interventional
Approaches
Medication Selection
• Good pain history
• Target to the type of pain
-e.g. neuropathic, nociceptive
• Consider non-pharmacologic or nonsystemic therapies alone or as adjuvants
• Use the WHO 3-Step ladder
WHO 3-Step ladder
Source: World Health Organization. Technical Report Series No. 804, Figure 2.
Geneva: World Health Organization; 1990.
Adjuvants
• Topicals (lidocaine patch, capsaicin)
• Acetaminophen
• NSAIDS, celecoxib, steroids
• Anticonvulsants
• Antidepressants
• Non-pharmacologic (TENS, PT/OT)
Step 1(Mild): Non-opioids
• Acetaminophen
• NSAIDS
• Cox-2
• Non-systemic therapies
• Non-medication modalities
• +/- other adjuvants
Step 2 (Moderate): Mild Opioids,
Opioid-like
• Codeine (e.g. T #3®)
• Hydrocodone (e.g. Vicodin®)
• Oxycodone (e.g. Percocet®)
• Tramadol (Ultram®)
• +/- Adjuvants
Step 3 (Severe): Strong Opioids
• Morphine
• Oxycodone
• Hydromorphone (Dilaudid®)
• Fentanyl
• Oxymorphone
• Methadone
• +/- Adjuvants
Transdermal Fentanyl
• Duration 24-72 hours
• 12-24 hours to reach full analgesic effect
• Not recommended as first-line in opiate naïve
patients
• Lipophilic
• Simple Conversion rule:
-1 mg po morphine = ½ mcg fentanyl
-(60 mg morphine roughly 25 mcg patch)
Other Fentanyl
• Intravenous (equivalent to patch dose, e.g.
Duragesic 100 mcg/72 = 100 mcg/hr IV)
• Transmucosal
-Actiq®
-Fentora®
• Iontophoretic Fentanyl Patch - Ionsys ®
Methadone, a Complicated Med
• Should only be used by those with
experience!
• Mu, kappa, delta agonist
• Inhibits reuptake of serotonin and
norepinephrine
• NMDA antagonist (neuropathic pain)
• Significant inter-individual variability
• Drug interactions (coumadin-like)
Methadone (cont.)
• Initial rapid tissue distribution
• Slow elimination phase
• Long and variable half-life (13-58 hours)
• Dose interval is variable (q 6 or q 8)
• Dose usually adjusted q 4-7 days
• Minimally impacted by renal disease
• Inexpensive, less street value than other
opioids
Drugs to Avoid
• Meperidine (Demerol®)
• Mixed agonist-antagonist
-e.g. Pentazocine (Talwin®)
• Propoxyphene (Darvon ®, Darvocet ®)
Opioid Pharmacology
• Block the release of neurotransmitters in
the dorsal horn of spinal cord
• Mu, delta, kappa expressed differently,
depending on opioid medication
• Conjugated in liver
• Excreted via kidney (90%–95%)
• Exception: methadone, excreted fecally
Opioid Use in Renal Failure
• Not rec’d: meperidine, codeine,
dextropropoxyphene, morphine
• Use with caution: oxycodone,
hydromorphone
• Safest: fentanyl, methadone
• Opioid dosing
CrCl
>50 mL/min
normal
10 - 50 mL/min 75% of normal
<10 mL/min
50% of normal
Clearance Concerns
Dehydration, renal failure, severe hepatic
failure
 dosing interval (extend time) or
 dosage size
– if oliguria or anuria
• STOP around the clock dosing of opioids (like
morphine)
• use ONLY prn
Opioids for Continuous Pain
• Dose find, opioid naive:
-begin with short-acting opioid ATC
-allow breakthrough based on Cmax and
patients metabolism
• Cmax (peak) after
– po, pr  1 h
– SC, IM  30 min
– IV
 6 – 15 min
Dose-finding
To achieve quick pain relief:
(LOAD)
1. Start low dose, shortacting
2. Dose q peak
3. P.C.A. not “prn”
(Patient controls it)
4. Re-eval in 4 hrs. to
figure out what dose is
needed
Starting doses and half-life
• For thin, frail elderly suggest 2-5 mg po
MSO4 or an equivalent (e.g. 1/2-1
percocet q 4h)
• Half-life at steady state
– po / po / SC / IM / IV  3-4 h
– 4-5 half-lives to reach steady state
Opioid Dose Escalation
• Should be done on percentage increase
irrespective of starting dose
mild / moderate pain
severe / uncontrolled pain
 25%–50%
 50%–100%
• How frequent? Depends on t1/2
Short-acting single-agent
Long-acting
Fentanyl transdermal
Methadone
every 2 hrs
every 24 hours
72 hours
4-7 days
Breakthrough dosing
• Use immediate-release opioids
– 10% of 24-h dose or 1/3 of one ER dose
– offer after Cmax reached
• po / pr
• SC, IM
• IV
q1h
 q 30 min
 q 10–15 min
• Do NOT use extended-release opioids
for breakthrough
Outline
• Recognition and assessment in cognitive
impairment
• Medication selection
• Dose selection and titration
• Opiate conversions
• Management of myths and side effects
• Discharge planning
Teaching Trigger Case
• You are rounding on a 70 y.o. male ESRD on HD
admitted with pleuritic chest pain
• New pulm mass found on chest CT
• Severe pleuritic pain well-controlled on
hydromorphone 4 mg IV q 3 hours
• Intern asks for help converting him to something
he can take at home
• Question: How do you teach about proper
opiate conversions?
Equianalgesic Dosing Ratios
Opioid
Hydromorphone
Morphine
Oxycodone
Hydrocodone
Codeine
Oral/Rectal
4
15
10
15
100
IV/SC
0.75
5
NA
NA
50
Note: Equianalgesic equivalencies are merely
estimates and are based on single-dose studies.
Changing Opioids – Cross-tolerance
• Start with 50%–75% of published
equianalgesic dose
1) Example: morphine 60 mg po every 12 hours
2) Change to po oxycodone long-acting
3) Use conversion ratio m:o = 15:10
4) 120 mg/x=15/10=80 mg every 24 hours
5) Reduce by 50% = 40 mg every 24 hours
=Oxycodone LA 20 mg every 12 hours
Exception = Methadone conversion
Daily Morphine
-<100 mg
-101-300 mg
-301-600 mg
-601-800 mg
-801-1000 mg
->1000 mg
Methadone:Morphine
(1:3)
(1:5)
(1:10)
(1:12)
(1:15)
(1:20)
Note: Conversion to methadone is complicated and should
only by done by those with experience!
Outline
• Recognition and assessment in cognitive
impairment
• Medication selection
• Dose selection and titration
• Opiate conversions
• Management of myths and side effects
• Discharge planning
Teaching Trigger Case
You are rounding on a 90 year old female with
severe osteoporosis admitted for sudden severe
back pain
• New vertebral compression fracture
• Pain controlled on morphine 4 mg IV q 4 hours
• Patient very sedated, family concerned
• Question: How do you teach about treatment of
side effects of opiates?
Opioid adverse effects
Common
Uncommon
Constipation
Dry mouth
Nausea / vomiting
Sedation
Sweats
Bad dreams / hallucinations
Dysphoria / delirium
Myoclonus / seizures
Pruritus / urticaria
Respiratory depression
Urinary retention
Hypogonadism
SIADH
GI Side Effects
Constipation
-NEVER resolves
-Prevent with scheduled softeners PLUS stimulants
-Avoid bulking agents (e.g. Metamucil®)
Nausea and Vomiting
– Encourage patients to eat frequent, small meals
– Treat with promotility agents (metoclopramide),
serotonergic blocking agents (odansetron) or
dopaminergic blocking agents (haloperidol,
metoclopramide, prochlorperazine)
Sedation and Delirium
• Consider trying one of the following:
1) If pain control is adequate, decrease dose by 25%
2) Rotate to a different opioid preparation
3) Use small doses of psychostimulants (2.5 to 5 mg
methylphenidate or dextroamphetamine) for
excessive somnolence
• Use nonsedating antipsychotics (haloperidol,
risperidone) for delirium
Respiratory Depression
• Does not occur in patients on chronic opioids
• Can occur in opioid-naïve patients whose
opioid dose is rapidly escalated
• Is always preceded by slowly progressive
somnolence
• If you must treat:
-Dilute naloxone (10:1) in saline and infuse 1 mL
until breathing pattern returns to normal
Teaching Trigger Case
You are rounding on a 65 y.o. male with gout
exacerbation
• Former cocaine addict
• Severe pain in hands, elbows, knees
• Resident told intern to give tylenol and steroids
• Patient asking for something stronger for pain
• Resident advised intern to “wait it out”, afraid of
awakening a former addiction
Question: How do you teach about pain treatment
in persons with a history of addiction or those
who express concern about becoming addicted
to opiates?
Addiction
• A psychologic dependence on drugs and a
behavioral syndrome characterized by
compulsive drug use and continued use
despite harm to self and others
•Use of opioids for pain management does
NOT cause addiction in the majority of
people
Physical Dependence/Withdrawal
• Develops if chronic opioids are abruptly
discontinued or dose is rapidly decreased
• Symptoms:
-Nausea, vomiting, diarrhea, abdominal pain,
body aches
-May result in psychosis and hallucinations
-Treatment: Taper dose by 50% every 2 to 3 days
Pseudoaddiction
• Occurs in context of
-Undertreated pain
-Behavioral, family, or psychologic dysfunction
• Consists of behaviors that are reminiscent of
addiction but driven by untreated or undertreated
pain
• Disappears once pain control is adequate
Tolerance
Reduced effects of a given dose of medication over time
• Doses remain unchanged when pain stimulus is
stable
• Tolerance to unwanted side effects is observed and
is desired
• Disease progression (not tolerance), should be
suspected when increasing doses are required for
pain control
Outline
• Recognition and assessment in cognitive
impairment
• Medication selection
• Dose selection and titration
• Opiate conversions
• Management of myths and side effects
• Discharge planning
Teaching Trigger Case
• Your team is preparing to discharge a 70 y.o.
male with chronic severe Pagets disease
requiring narcotics, responded well to
hydromorphone
• Intern asks you to sign the Rx (next slide)
• Question: How do you teach about appropriate
discharge planning, including prescription
writing, in persons with pain?
Common pitfalls to avoid
• Changing meds/route on discharge
• Writing the prescription
• Medication cost
• Educating patient/family
• Appropriate follow-up
TEACHING PRACTICE:
MODIFIED ROLE PLAYS
Teaching Case #1
• You are rounding on an 83 y.o. NH patient
admitted with pneumonia
• She has advanced dementia, bed-bound,
limited verbalization
• PMHx: DM, HTN, Stage 3 sacral ulcer s/p
debridement day before
• Patient stopped eating and is resisting
care
Case #1 (cont.)
• Housestaff concerned she is depressed
and started Remeron
• No surrogates – wonder if a PEG will need
to be placed
• Teaching task:
Generate a discussion regarding the
assessment of pain in cognitively impaired
patients
Teaching Case #2
• You are rounding on a 75 y.o. male s/p
fall
• History of lumbar stenosis with new onset
severe sharp pain down left leg
• Xrays negative
• Subintern started prn NSAIDs
• Patient in severe pain at rounds
Case #2 (cont.)
• Teaching Task:
Introduce the WHO 3-step ladder as a
framework for medication selection and
titration
Teaching Case #3
• You are rounding on a 70 y.o. male ESRD
on HD admitted with pleuritic chest pain
• New pulm mass found on chest CT
• Severe pleuritic pain well-controlled on
hydromorphone 4 mg IV q 3 hours
• Intern asks for help converting him to
something he can take at home
Case # 3 (cont.)
• Teaching task:
Introduce the opiate conversion table and
teach its use in converting IV medication
to oral hydromorphone, oral morphine
sustained-release, and Fentanyl patch
Calculate doses and intervals for
breakthrough medications
Teaching Case #4
You are rounding on a 65 y.o. male with gout
exacerbation
• Former cocaine addict
• Severe pain in hands, elbows, knees
• Resident told intern to give tylenol and steroids
and “wait it out”, afraid of awakening a former
addiction
• Patient asking for something stronger for pain
Case #4 (cont.)
• Teaching task:
Teach the different myths regarding opiate
medication
Teaching Case #5
You are rounding on a 90 year old female
with severe osteoporosis admitted for
sudden severe back pain
• New vertebral compression fracture
• Pain controlled on morphine 4 mg IV q 4
hours
• Patient very sedated, family concerned
Case # 5 (cont.)
• Teaching task:
Discuss this side effect of opiates and its
treatment
Teaching Case #6
• Your team is preparing to discharge a 70 y.o.
male with chronic severe Pagets disease
requiring opioids, responded well to
hydromorphone
• Intern asks you to sign the Rx
• Teaching task:
Review the Rx with the team and teach about
appropriate prescriptions and discharge
planning
Teaching case #7
• You are rounding on a 72 year old male with
metastatic bladder cancer who is being
discharged on home hospice the next day (order
on next slide)
• Teaching task:
Review interns order to change IV to Duragesic
patch. Teach the appropriate conversion.
Teaching case #8
• You are rounding on an 85 year old
woman with advanced dementia s/p fall
with pelvic fracture
• Teaching task:
Review the MAR and teach about optimal
management of pain in persons with
cognitive impairment
Teaching case #9
• You are rounding on an 80 year old female with
dementia admitted with hematemesis and
abdominal pain
• EGD: Stomach cancer, patient is dying
• She had been on morphine sulfate long-acting 60
mg po q 12 for Pagets
• Teaching task:
Show the housestaff how to effectively convert her
to a morphine infusion
References
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References
• EPERC. End-of-life/Palliative Education Resource Center
http://www.mywhatever.com/cifwriter/library/eperc/fastfact/ff_
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