Transcript Level 1 (mild to moderate pain)

Pain Management in the Elderly
Rog Kyle, MD
Medical University of South Carolina
10/7/11 rev. 9/20/13
Aging Q3 ACOVE #10
Background
• Chronic pain (cancer and non-cancer)
problematic in 25-50% of elders in the
community
• Osteoarthritis (and other musculoskeletal) is
most common cause
• Low back pain (LBP) most prevalent condition
• Cancer pain
– 80% of elderly with cancer report pain
– Probably under detected and under treated
– Deficiencies
• Under documented
• Under treated – opioids and non-opioids
• Reporting by patients
– Most feared complication of illness
– Pain is the second leading complaint in physicians’
offices
– Effects on mood, functional status, and quality of
life
– Associated with increased health resources use
• Hospitalized patients
– No randomized trials
– Prospective studies on cancer patients
• Underestimate pain
• Probably do not assess frequently enough
Challenges in the elderly
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Comparatively little data
Cognitive impairment and compliance
Underreported by patients
Drug-drug interaction and polypharmacy a
serious concern
• Reduced hepatic function, reduced renal
function
Mechanisms for pain
• Nociceptive
– Nociceptors = pain fiber sensitive to noxious
stimuli
• Somatic – injury to tissues, well localized
• Visceral – injury to organs (stretch receptors),
poorly localized
• Neuropathic
– Abnormal neural activity secondary to disease, injury, or
dysfunction (allodynia).
– Persists without ongoing injury (trigeminal neuralgia, DM
neuropathy)
– Types:
• Sympathetic – from peripheral nerve injury with
autonomic changes
– “New” term – Complex Regional Pain Syndrome
(CRPS)
• Type I = RSD
• Type II = causalgia
• Peripheral autonomic pain –
– Same but without autonomic change (PHN)
• Central Pain (spinal cord injury)
Pain pathways
• Nociceptive fibers – afferent fibers to dorsal horn
– Two types
• A-delta – sharp pain (fast)
• C polymodal – dull pain (slow)
• Nociceptive fibers – afferent fibers to dorsal horn
– Two types
• A-delta – sharp pain (fast)
• C polymodal – dull pain (slow)
• Pathways
• Central processing
– Interneurons between spinal
cord/thalamus/cortex modulate pain and may be
either excitatory of inhibitory
– endogenous systems also control pain perception
– opioid, noradrenergic (fight or flight), and
serotonergic
Mechanisms for chronic pain
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Peripheral sensitization
Central sensitization
Disinhibition
Desensitization
Ectopic excitability
Structural reorganization
Phenotypic switch of neurons
Primary sensory degeneration
Sensitization
• Main cause for hypersensitivity to pain after an injury
(nociceptive sensitizer)
• Each has it’s own proposed mechanism at the cellular
level
– Peripheral – injury/inflammation releases
cytokines, chemokines, bradykinin, histamine,
prostaglandins
– Central – amplifies info from nociceptors – NMDA
receptor upregulated (controls pain – ketamine),
GABA inhibition - disinhibition - “inhibits
inhibition”
Treatment – non drug strategies
• Exercise
– PT, OT, stretching, strengthening
– general conditioning
• Physical methods
– ice, heat, massage
• Cognitive-behavioral therapy
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Chiropracty
Acupuncture
TENS
Alternative therapies
– relaxation, imagery
– herbals
WHO Ladder (adapted for elderly)
– Level 3 (severe pain): Strong
• opioids—morphine, hydromorphone,
• fentanyl, oxycodone ±adjuvants
– Level 2 (moderate to severe pain):
• Acetaminophen plus opioid (hydrocodone,
• oxycodone, codeine); tramadol ±adjuvants,
• Propoxyphene (X)
– Level 1 (mild to moderate pain):
• Acetaminophen, aspirin (X), nonspecific NSAIDs (X),
• COX-2–specific NSAIDs±adjuvants
Figure 1. WHO ladder (adapted for the elderly).
Note: Therapies marked with an “X” are not appropriate for use in the elderly.
Non-opioid options
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Acetaminophen
Alpha-adrenergic agents
Anticonvulsants
Antidepressants
Muscle relaxants
Neuroleptic agents
NMDA-receptor antagonists
NSAIDs
Oral local anesthetics
Topical analgesics
Acetaminophen
• First line
• 4000mg max
– 2000mg recommended with etoh use, liver
disease, elderly
• Watch for other OTC’s containing
acetaminophen
Alpha-adrenergics
• Epidural clonidine for neuropathic pain (FDA)
• Tizanidine outside US
Anticonvulsants
• Neuropathic pain
• Second gen may have fewer side effects
(gabapentin, topiramate)
• Many approved for HA/pain
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Carbamazepine (trigeminal neuralgia)
Divalproex (migraine)
Gabapentin (PHN)
Pregabalin (PHN, diabetic neuropathy)
Topiramate (migraine)
Duloxetine (diabetic neuropathy, fibromyalgia, DJD)
• Off label
– Lamotrigine for HIV neuropathy (and others)
– PDN
• Carbamazepine, phenytoin, gabapentin
– Chronic musculoskeletal pain
Antidepressants
• Analgesia independent of antidepressant effects
• Tricyclics (amitriptyline) for neuropathic pain
– Nortriptyline has safer side effect profile in > 60
– Amitriptyline relatively contraindicated in elderly
(cardiac, anticholinergic)
• SNRI’s
– Duloxetine, venlafaxine
• Others
– Bupropion, venlafaxine, duloxetine (neuropathic)
• SSRI’s/SNRI’s not shown to have efficacy
comparable to tricyclics
TRICYCLIC
SSRI
Amitriptyline
Desipramine
Doxepin
Imipramine
Nortriptyline
Fluoxetine
Paroxetine
Sertraline
Fluvoxamine
Citalopram
*FDA approved for pain
OTHER
Venlafaxine
Duloxetine*
Trazodone
Bupropion
Muscle relaxants
• Cyclobenzaprine
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Similar to tricyclic's
Acute LBP (2 trials)
Anticholinergic side effects, cardiac arrhythmia
Avoid in elderly
• Carisoprodol (meprobamate precursor)
– Acute LBP
– Dependency (physical, psychological), drowsiness
• Metaxalone (Skelaxine)
– Non-sedating, watch for liver tox
• Baclofen
– GABA agonist
Neuroleptics
• Fluphenaxine (Prolixin)
– Not recommended
NMDA receptor antagonists
• Scientific promise
– Dextromethorphan
– Ketamine
– Methadone
– Memantine
– Amitriptyline
NSAIDS
• 60 million Rx’s/yr (3.6 fold higher in elders)
• Clinical efficacy of equipotent doses is similar
• Individual responses highly variable – especially toxicity
– cox-1 vs. cox-2
– naprosyn may have greatest relative cardiovascular safety profile
– diclofenac - available as a topical patch for pain due to trauma and
as a gel for treatment of painful joints
– sulindac – increased hepatoxicity
– indomethacin - GI and central nervous system adverse effects may
be more frequent or severe than with other NSAIDs
– ketorolac - Risk of gastropathy is increased when use exceeds five
days
– piroxicam – high GI toxicity
– celecoxib – no antiplatelet function. Increased CV risk above
200mg/day
• Generally indicated in mild to moderate pain
• Mostly for pain of somatic origin although has
a CNS effect as well
• Each trial should last a couple weeks
• May have an opioid sparing effect as adjunct
• Protein bound – may interfere with other
protein bound drugs (dilantin. coumadin)
• Noted variability in the response to NSAIDS between
patients
– Does not appear related to serum concentrations
– Degree of Cox inhibition doesn’t correlate with effect
– Non-prostaglandin effects may predominate in some
patients
– Switching between classes of NSAIDS may be
beneficial
Topicals
• Lidoderm
– FDA approved for PHN (intact skin)
– Often used in musculoskeletal pain
• Diclofenac patch
– Topical treatment of acute (short-term) pain due
to minor strains, sprains, and contusions (bruises)
• Capsaicin
– Neurotransmitter depletion
– PHN, musculoskeletal
Tramadol
• Mu receptor and SNRI effects
• Effective in neuropathic pain, fibromyalgia, OA
• Similar side effects to opioids
– Seizures, suicide
Benzodiazepines
• Adjuvant only
• Anxiolytic
• Limitations
– Sedation
– Addictive potential
– Respiratory depression
– Avoid in elderly
• Clonazepam
– Effective in PHN and myoclonus
Opioids
• Role in treatment of pain is well established for
acute pain, malignant pain and care of the
terminally ill
• Role in chronic non-cancer pain is more
controversial
• No specific studies have been performed in the
elderly
• Decision to begin long term opioid therapy in
chronic, non-cancer pain “must be weighed
carefully”
• Most of the literature on opioid therapy consists
of reports of surveys and uncontrolled case series
• Most find that chronic pain can be controlled
with nonescalating doses of opiates – up to 6
years of rx, 180 mg morphine
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Function is improved by pt report
Cognitive function is preserved
Ability to drive or operate machinery is preserved
High drop out due to side effects (25%)
• Establish diagnosis
• Confirm inadequacy of nonopioid and
nonmedical treatments
• Ensure that the balance of risk and benefit
favors treatment
• Explain benefits and risks and clinic’s
monitoring policies
• Establish treatment goals
• Request written consent or contract, when
necessary
Side effects
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Constipation
Nausea, vomiting
Sedation
Impaired judgment
Impaired psychomotor function
Respiratory depression
Hypotension
Myoclonus
GU
Pruritus
• Constipation
– Fluids, fiber, stool softener, cathartic
– methylnaltrexone
• Sedation
– Methylphenidate, modafinil
• Dosing – no universal agreement
– Start with lowest dose of short acting preparation
– Up titrate no more often than weekly
– Convert to sustained release formulations when
possible (25-50% of 24 hour total)
– Monitor for efficacy, side effects
Pain Management
Aging Q3 ACOVE #10
PCT ASK: Circle Yes or NO
1. Are you taking any Opioids (narcotics, pain killers) for pain?
Yes >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
NO
2.
Are you having any side effects? (e.g. constipation, sedation, nausea)
Yes >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
“Blue Sheet”
MD do:
MD Circle One:
If yes, assess if
patient is taking
any adjuvants.
Yes
If yes, assess
nature of side
effects.
CNS
GI
Urinary
Autonomic
Based on this
pain
assessment, do
you plan to
adjust the
patient’s
treatment
plan?
Yes
NO
3. How you would rate your pain now?
4. Is your pain controlled?
Yes
NO
NO
(Circle One Below)
NO
Practice Partner Template
– Is patient currently taking an opioid medication? <yes>
<no>
– If yes is clicked, then:
• Is patient taking any adjuvant pain medications? <yes>
<no>
• Does patient report side effects? <yes> <no>
• Based on pain assessment, plan to: (pick list of :)
– Increase dosage of opioid pain medication
– Decrease dosage of opioid pain medication
– Add adjuvant pain medication
– No changes planned to pain medication regimen