Transcript Making Sense of Those Interventional Procedures for Pain

Making Sense of
Interventional Therapies for
Pain
2/7/17
Linda Vanni, MSN, RN-BC, ACNS-BC, NP
Nurse Practitioner, Pain Management
Ascension Providence
Conflict of Interest Disclosure
• Conflict of Interest
Author: Linda Vanni
Advisory Board, Collegium
Editorial Board, DSI
Speaker Bureau-The Medicine Co.
A conflict of interest is a particular financial or non-financial circumstance that might compromise, or
appear to compromise, professional judgment. Anything that fits this should be included. Examples are
owning stock in a company whose product is being evaluated, being a consultant or employee of a
company whose product is being evaluated, etc. Taken in part from “On Being a Scientist: Responsible Conduct in
Research”. National Academies Press. 1995.
Objectives
• Describe factors influencing the need
for increased use of interventional
therapies for pain
• Identify usage of interventional
therapies for pain
How did this all happen?
• 1996 APS president’s speech about the need to
have pain assessed with the same zeal as vital
signs. Ortho third highest prescribers of opioids,
dentists
– Let’s talk about hoarding
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Management pain = prescribe opioids
Things got out of hand
76 Million opioid scripts written in 1991
219 Million opioid scripts written in 2011
The jump from legal to illicit use
Where did the hysteria come from?
• Started with illicit diversion of lawfully prescribed
medications and subsequent use by opioid-naïve
individuals or by desperate people with addictive
disease who will do anything to get as high as they
can.
• Most physicians in trouble from prescribing are in
trouble due to inadequate documentation.
“Patients with addictive disease have
the right to be treated with respect
and to receive the same quality of
pain management as all other
patients.”
Increase in Chronic Diseases
• ESRD
• COPD
• CV Disease
• DM
• OSA
• Chronic Pain
Combination Analgesics Rationale
• Multiple sites of action target multiple pain
pathways
• Complementary pharmacokinetic activity
• Potentially synergistic analgesic effect
• Reduced adverse event profile with comparable
efficacy
Raffa, RB. J Clin Pharm Ther. 2001;26:257-64.
The Shifting Paradigm
• All about multi-modal
– Scheduled acetaminophen
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Pain Management always linked to function
Opioid-sparing
The future of topicals
Integrative therapies
Anti-abuse opioids being approved by FDA
Always keeping it safe
Acute Pain
1. Blocks
- Stellate Ganglion Block
–Femoral/Adductor Block
–Popliteal
–TAP
–Intercostal
2. Local Anesthetic Infusions
3. Epidural Therapy
AAOS: Orthopaedic Surgeons Can Help
Stem Opioid Epidemic
• October 16, 2015
• Ortho surgeons third highest prescribers among
physicians in the US
• Limit the volume of opioids prescribed
• Multi-modal practice plans
• Coordinating opioid prescriber
• Restricting long acting opioids for cancer related
pain
• Refer to Pain Centers
Intraarticular
Stellate Ganglion
Brachial
Plexus
Femoral
Nerve
Block
Femoral Nerve Block
• Ropvacaine or bupivacaine 0.25%, 20 mls over femoral
nerve area. Onset of action is 10-30 minutes-duration 2-8
hours.
• Area identified utilizing nerve stimulator.
• Does not necessarily cover pain in the back of the knee.
Motor issues!
Popliteal Block
Popliteal Block
TAP Block
Intercostal Block
Local anesthetics by
infusion device or by
single block
Epidural
Therapy
VCFs
Balloon Kyphoplasty Treatment Goals
• Aimed at restoring height and stability in fractured
vertebral body
• Treating pain related to vertebral collapse
Chronic Pain
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Celiac Plexus Block
Permanent Epidural Therapy
Intrathecal Pump Therapy
Kyphoplasty
Only 5-10% of
patients require
invasive pain
management therapy
Intraspinal Analgesics-MUST be
Preservative Free
• Local anesthetics
–Lipophilic-synergistic with opioids
–Block pain impulses at sympathetic
chain ganglion outside cord
–Level of analgesia evaluated via
dermatomes
Timing
• Patients need to be considered for
referral to a pain specialist at an
earlier stage of their disease process
than current clinical practice!
Celiac Plexus Block
• Celiac Plexus innervates the liver, pancreas,
gallbladder, stomach, spleen, kidneys, intestines,
and adrenal glands
• Diagnostic and then neurolytic
• Alcohol or phenol
• Can last for weeks to months
• Usually does not need to be repeated
Intraspinal= Epidural & Intrathecal
• Epidural “space”
• Intrathecal space
• Potential space outside
the intrathecal space, • Filed with CSF that
separated by arachnoid continually circulates
around spinal cord
mater
• No fluid present
• Space is created when
fluid or air injected
Embryonic Dermatomes
Dermatomes
Epidural/Intrathecal Analgesia
• Pharmacokinetics & Pharmacodynamics
– Epidural (ED) opioid instilled
– Vascular uptake in ED space
– Diffusion through the dura
– Rostral spread (cephalad) in the CSF
– Bind at opioid receptor site at the substantia
gelatinosa in the dorsal horn
Intraspinal Analgesics
• Opioids
• Lipophilic
– Diffuse rapidly through dura
– Less rostral spread in CSF, narrow segment of
analgesia
• Hydrophilic
– Diffuse slowly through dura to CSF
– Wider rostral spread & segment of analgesia
Equianalgesic Opioid Conversion
(Mg)*
Oral
Morphine
Hydromorphone
(Dilaudid)
300
60
Parenteral
Epidural
Intrathecal
100
10
1
20
2
0.2
1,000
1
0.1
100
0.1
0.01
10
0.01
0.001
Meperidine
(Demerol)
Fentanyl
Sufentanil
3,000
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*Wallace, Mark MD., Yaksh, Tony, L. Ph.D., Long-term Spinal Analgesic Delivery: A Review of the
Preclinical and Clinical Literature, Regional Anesthesia and Pain Medicine, Vol 25, No 2
(March-April): pp 120.
Epidural/Intrathecal analgesia
• Advantages
– Pain relief with fewer sedative effects
– Less respiratory depression than IV/IM
• Disadvantages
– Dependent on placement of catheter
– Technology failure
– Education required by nurses
Types of Infusion DeviseIntraspinal Infusions
• External percutaneous catheter with
external pump
• Implanted epidural portal/tunnel
system
• Implanted infusion pump
Epidural/Intrathecal Analgesia
• Local anesthetics
– Block pain at the
sympathetic chain
ganglion outside
the spinal cord
– When used, able
to use less opioid
– Most common:
bupivacaine,
ropivacaine
Implantation of Tunneled
Epidural Catheter
 Done in operating room
 Tunneled to decrease risk of infection
 Able to run high dose marcaine
 Seen twice a week at clinic
 Antibiotic therapy
 Patient’s life expectancy less than 2
months
Intraspinal Medications:
Complications
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Post-dural puncture headache
Catheter migration
Infection
Hematoma
Risk of inadvertent injection of
neurotoxic agents
New Trial Dosing System
AP-08200
Screening Test (Pain)
• Purpose: Evaluate patient’s response
to intraspinal morphine over a short
test period
– Assess pain relief
– Evaluate side effects
• At least 50% reduction in pain is
usually considered a positive
response1
1 Hassenbusch,
50%
SJ., Stanton-Hicks, M., Covington EC. Long-term intraspinal infusions of opioids in the
treatment of neuropathic pain. JPSM. 1995: 10(5); 527-543.
Pump Placement Considerations
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Careful of possible radiation field
Ostomies, ileostomy, straight cath?
Baseline abdominal pain?
Sleeping position
Condition of skin
Optimize refilling, not too deep
Abdominal binder, nutritional status
Pump size
Where to put it?
Patient
Controlled
Intrathecal
Dosing
Randomized Clinical Trial
looking at CMM vs IDDS
Journal of Clinical Oncology,
Vol. 20, No. 19 (October 1) 2002
Smith, T.J., Staats, P.S., et al.
Smith, et al. 2002
• Presented at ASCO as abstract 2002
• Published October 2002
• Prospective, multicenter, randomized
study, participation total 200.
• Compared Comprehensive Medical
Management (CMM) with intraspinal
drug delivery systems (IDDSs)
Conclusions
Whether given as part of initial therapy
or applied after failure of CMM, IDDS
reduced pain scores, significantly relieved most toxicities
of pain control drugs, and was associated with improved
survival for the length of this 6-month trial. Even the most
refractory patients failed by CMM had a 27% reduction in
pain scores, a 50% reduction in drug toxicity, and a median
survival of 3 months after receiving IDDS.
Bibliography
•
Abrahm, J.L. (2005) A Physician’s Guide to Pain and
Symptom Management in Cancer Patients. The John
Hopkins University Press, Baltimore, MA.
• McHale, H.K. (2002) Palliative Care in Kuebler, K.K. &
Esper, P. Palliative Practices from A-Z for the Bedside
Clinician. Oncology Nursing Society, Pittsburgh, PA.
• U.S.Department of Health and Human Services,
National Cancer Institute (2007), EPEC™-O, CD-ROM.
Bibliography
• Smith, T.J., Staats, P.S., Deer, T., Stearns, L.J.,
Rauck, R.L., Boortz-Marx, R.L., Buchser, E., Catala,
E., Bryce, D.A., Coyne, P.J. & Pool, G.E. (2002).
Randomized Clinical Trial of an Implantable Drug
Delivery System compared with Comprehensive
Medical Management for Refractory Cancer Pain:
Impact on pain, drug-related toxicity, and survival.
Journal of Clinical Oncology, vol. 20, No. 19, pp
4040-4049.