Treatment Planning For Different Pains

Transcription

1 Gate Control Theory of How can a shot hurt worse than being shot? Treatment Planning For Different s Paul Arnstein, RN, PhD 10/29/12 fiber activity opens gate Activity of larger fibers closes gate - + Transmission Spinal Gate Thoughts, feelings, motivation May open or close gate + Gate open + Think, feel and respond to pain + Signal Transmitter Addresses simple acute pain physiology; not complex chronic pain WHO * 3-Step Approach to Relief Physiological Categories of persists or increases persists or increases Opioids for mild to moderate pain ± Non-opioid ± Adjuvant Non-opioids for mild to moderate pain ± Adjuvant Opioids for moderate to severe pain. ± Non-opioid ± Adjuvant Adjuvant examples Drugs Gabapentin Duloxetine Interventions Nerve blocks Neuroablation Non-drug Heat or cold Distraction Coping Acupuncture (e.g. Non-drug &/or Interventional Rx) Nociceptive Somatic Visceral Neuropathic Central Peripheral Sympathetically Maintained *Originally published by the World Health Organization (1986) for cancer pain 4 Temporal Categories of Strategies Differ based on Type Transient pain Relatively brief duration Etiology known proportionate to damage ~ Transient objective signs Anxiety, anger, fear common Persistent pain Longer duration Etiology ~ unknown ~disproportionate Often no objective sign Depression is common 5 Acute, Transient Pre-emptive reduction > 50% Functional focus Persistent De-emphasis pain reduction (30%) Functioning and coping despite pain Emotional stability and QOL at the end of life 6

2 The MGH Family reduction Improved life Functioning Healing Benefits Risks Psychosocial Interactions Morbidity Toxicity Legal Multi-casualty MVA Pregnant woman delivers prematurely 4 year old girl with head trauma Former amputee with fractured femur Exacerbation of chronic pain in older man 8 30y/o Mother delivers prematurely (27 wks) Type: acute postpartum & bruises Oral medications ordered Ibuprofen 600mg Q 6 h prn Tylenol with codeine 1-2 tbs Q4h prn Percocet 5/ tabs q4h prn Best practices for her pains? American Society (2008) Principles of Analgesic Use in the Treatment of Acute and Cancer, 6 th Edition Glenview, IL Institute for Clinical Systems Improvement (2008). Assessment and Management of Acute 6 th Edition accessed online 10/22/ Concerns about Codeine Assess pain & underlying mechanism Treat with analgesics & adjuvant Base on prior experience / pharmacology Requires regular dosing for ongoing pain Avoid using problem-prone drugs Anticipate, recognize & treat side effects Monitor closely, tailor to responses Attend to psychosocial concerns Nondrug, interventional/specialty care prn mg (.5-1mg/kg) Q4H [3:1 oral parenteral] 60mg codeine = 3mg oral MS = 2 aspirin Side Effects create safety concerns ~ pro-drug morphine, hydrocodone, hydromorphone GI: anorexia, nausea, vomiting, constipation, ileus Sedation w/ respiratory depression/arrest (pediatric) Pro-drug: non-metabolizers get no relief ~10% Caucasians; 20% middle eastern descent FDA warning for breastfeeding women Don t use, pediatric overdose risk 12

3 4y/o Daughter with head injury Preschool modifiers of pain Source of underlying pain? Oral medications ordered Acetaminophen 10mg/kg (120mg) Q 6 h prn Best practices for her pains? Other discomforts? Best way to assess/manage pain? No additional EBG to guide practice Prevent and treat pediatric pain cautiously Prevent & alleviate procedural pain Local anesthetic Distraction / preparation Beginning Give brief description Choose words carefully Assign everyone a job Middle Implement age appropriate distraction (e.g. count, sing) End Reward Debrief with patient Father with R-BKA, fractured femur types: Acute pain (severe) from fracture Chronic neuropathic phantom pain PAML indicates OxyContin 120 po Q12H Gabapentin 600mg Q8H medications ordered Morphine 1mg PCA dose/ 6min lockout/ 5mg/hour Best Practices? 16 The Equianalgesic Table Drug Oral IV Morphine 30mg 10mg Hydromorphone 7.5mg 1.5mg Oxycodone 20mg - Fentanyl mg (100 mcg) 25 mcg patch= ~50 mg oral morphine Methadone 10mg 5mg Dosing differs for high dose & chronic use MassPI Pocket Tool, 2011; APS, Principle of Analgesic Use 5 th Ed., 2003 (c) Mass Initiative, 2007 Approximate minimum daily need: Convert 240mg PO oxycodone to IV morphine Can calculate based on 2:1 potency ratio or cross-multiplication formula Equianalgesic Table dose of current drug Equianalgesic Table dose of new drug 20mg oxycodone 10mg IV morphine ASPI & Mass Initiative, dose current drug = (24 dose N new drug) 240mg oxycodone/day N (mg IV morphine)

4 Solve for N (N = total 24h dose new drug) 10 x mg 10mg = 10 x 240 = 20 x N = 20 x N mg N 10 x = N 120mg = N (24 o dose oxycodone (240mg) = 120mg IV morphine(5mg/hr) = ASPI & Mass Initiative, 2007 VHA/DOD Clinical Practice Guidelines, Management of Opioid Therapy (OT) for Chronic (2010), Retrieved 10/22/12 from Chou, Fanciullo, Fine, et al. (2009) Clinical Guidelines for the Use of Chronic Opioid Therapy in Noncancer. The Journal of, 10(2): Retrieved 10/22/12 from Institute for Clinical Systems Improvement (2011). Assessment and Management of Chronic 5 th Edition accessed online 10/22/12 chronic assessment_and_management_of_14399/pain chronic assessment_and_management_of guideline_.html 20 Best Practices Chronic Opioid Therapy Assess pain & mental health/sud risk Treat with analgesics & adjuvant Base on prior experience / pharmacology Requires regular dosing for opioid dependent Limit dose (<100mg/day) & duration of opioid Rx Anticipate, recognize & treat side effects Monitor closely, tailor to responses Attend to psychosocial concerns Nondrug, interventional/specialty care prn 21 Risk stratified care Informed consent & treatment agreements Frequent re-evaluation, including adherence e.g. Urine drug screens, pill counts, State monitoring Base on prior experience / pharmacology Requires regular dosing for opioid dependent Limit dose (<100mg/day) & duration of opioid Rx Anticipate, recognize & treat side effects Tailor to bio-psychosocial needs/responses Nondrug, interventional/specialty care prn 22 70y/o Grandpa worsens chronic pain Bruised chest & abdomen Significant pre-injury comorbidity Hypertension and congestive heart failure Recently widowed, depressed Chronic unstable angina & knee arthritis medications ordered Ibuprofen 800mg po Q6H Cardio-protective Aspirin Best Practices? 23 American Geriatrics Society Panel on the Pharmacological Management of Persistent in Older Persons. (2009). Pharmacological management of persistent pain in older persons. Journal of the American Geriatrics Society, 57 (8), AGS Beers Criteria Update Expert Panel (2012) Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society : 1-16 Online 10/22/12 at Hochberg MC, Altman RD, April K, et al. American College of Rheumatology (2012) Recommendations for the use of nonpharmacologic & pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res 2012 Apr; 64(4): ACCF/AHA (2011). Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction. J Am Coll Cardiol May 10;57(19):

5 Best Practices Unstable Angina Assess pain & underlying mechanism Treat with analgesics & adjuvant Base on prior experience / pharmacology Requires regular dosing for ongoing pain Avoid using problem-prone drugs Anticipate, recognize & treat side effects Monitor closely, tailor to responses Attend to psychosocial concerns Nondrug, interventional/specialty care prn 25 ACCF/AHA (2011). Guidelines J Am Coll Cardiol May 10;57(19): Risk-based Medicine for Elderly Problem prone drugs in older adults persists or increases persists or increases Carefully selected & dosed opioid or adjuvant; Tailored for pain type / intensity, & co-morbid conditions Acetaminophen Cautious use of higher risk drugs (e.g. NSAIDs) with riskreduction strategies Assess & Co-morbid states American Geriatrics Society, 2009 Adjuvant examples Drugs Gabapentin Duloxetine Interventions Nerve blocks Neuroablation Non-drug Heat or cold Distraction Coping Acupuncture (e.g. Non-drug &/or Interventional Rx) Avoid Meperidine, Indomethacin, Ketorolac, Pentazocine Avoid long-term use of other NSAIDs Including ASA > 325mg/day Avoid adjuvants sometimes used for pain Hydroxyzine, Metoclopramide, Tertiary TCAs; Skeletal muscle relaxants, Benzodiazepines, Diphenhydramine, Avoid Tramadol in patients with seizures. AGS-Beers Criteria (2012) 28 Best Practice Knee Arthritis Tramadol for chronic pain Nondrug therapies including weight loss Acetaminophen Oral NSAID (with PPI) no CV or GI morbidity Topical NSAIDs with comorbid risks Tramadol Intra-articular injections (corticosteroid or hyaluronate) Duloxetine &/or opioids after others fail Hochberg et al. American College of Rheumatology (2012) Arthritis Care Res 2012 Apr; 64(4): Weak opioid & neurotransmitter enhancer More effective for chronic (than acute) pain Starting doses: 25 mg. q 4-6 hr Maximum doses:(400 mg/24 hours) Watch for drowsiness/dizziness Avoid combining with other opioids Caution in patients with seizure disorder Titrate dose slowly The Management of Persistent in Older Patients JAGS 2002;6:S205-S Update Arthritis & Rheumatism 2000; 9; Guideline for the Management of in OA, RA, and Juvenile Chronic Arthritis. American Society. Second Edition 2002.

6 Topical options Rubefacients Lidicaine Diclofenac Capsaicin (0.025% % and 8%) Morphine gel Compounded (ketoprofen, amitriptyline, ketamine, duloxetine, etc.) Complex Patients Standard practices & guidelines ineffective Stepped therapy fails Increasing dose concerns Side effect / toxicity burden Food, Drug, or disease interactions Unclear physiology Unverified psychosocial explanations 32 Pathophysiology of pain Inflammation of tissues and nerves Peripheral Sensitization Windup Central Sensitization Neuroplastic changes Errant nerve growth Component up-regulation /down-regulation Microglia Gain Control Model of Conceptual guide for complex pain control Dampeners Turn down the pain signal volume, facilitating activity, healing & Quality of Life Spiritual M i n d S p i n a l Tissue Social Amplifiers Turn up the pain signal volume, inhibiting activity, healing & Quality of Life Adapted from Arnstein PM (2010) Clinical Coach for Effective Management. Philadelphia; FA Davis 34 Use Multimodal Approaches Gain Control of Tissue Amplification Address multiple amplifiers/dampeners Combine active & passive approaches Integrate therapies the patient believes in Medical modalities Physical modalities Psychosocial modalities CAM modalities Pharmacological Cause-directed Inflammation NSAIDs Substance P TNF-α Na + Channel Blockers Non-drug Massage, rubbing Moist heat Application ice Positioning Braces, orthotics, compression Remove source of pain or irritation

7 Gain Control of Nerve Amplification Gain Control of Illness Amplification Pharmacological Acetaminophen Opioids Anticonvulsants Antidepressants Local anesthetics Alpha blockers Non-drug Reduce summation Excessive dermatone stimuli Activate inhibitors Regional A-β fibers Contra-lateral stimulation Proximal/distal stimulation Endorphins Treat the underlying cause Promote Good nutrition, hydration, Good oxygenation, diaphragmatic breathing Paced activities and exercise Consider Dietary supplements Acupuncture / acupressure Ways to optimize functioning Gain Control of Mind Amplification Promote Relaxation techniques Knowledge about condition/sensations Distraction (music, reading, writing) Change thinking, attitudes Reduce sadness, helplessness Reduce fear, anxiety, stress Consider Biofeedback, Counseling CBT, Coping skills training Gain Control of Spiritual Amplification Promote Prayer, Meditation, Spiritual Healing Self-reflection, re: life / pain Meaningful rituals Consider Energy work (e.g. TT, reiki) Magnetic Therapy Homeopathic remedies Gain Control of Social Amplification Promote Improved communication Caring presence Healer effect Consider Psychosocial Counseling, Family therapy Pet therapy Support groups Vocational training, Volunteering Strategies Differ based on Type Acute, Transient Pre-emptive reduction > 50% Functional focus Persistent De-emphasis pain reduction (30%) Functioning and coping despite pain Emotional stability and QOL at the end of life

8 Always consider Underlying need Type of pain by mechanism or duration Type of distress Realistic Comfort function goal Analgesic options (non-opioid, opioid, adjuvant) Non-drug ways of enhancing the plan Adjustments based on response Submitted case #1 58 year old woman who had a colectomy, Not drug seeking but oblivion seeking Many psychosocial problems Family signed off Wanted to be out of it all the time Many psychiatry & pain consults service consulted a many times each day behavior still problematic / disturbing Submitted Case case #1 (58y/o post colectomy) Each evening was progressively worse Quantity of pain medication was complicating her care Growing avoidance by the staff Always consider Underlying need Type of pain by mechanism or duration Possible amplifiers / dampeners Realistic Comfort function goal Analgesic options (non-opioid, opioid, adjuvant) Non-drug ways of enhancing the plan Adjustments based on response Pammy Otamee Submitted case #2 42y/o old health professional Admitted for pancreatectomy (Indicated for chronic inflammation or tumor) Expected it to be painless Nightly repeated Service visits Very dissatisfied with her care complicated care, slowed recovery Pancreatitis Tramadol > morphine (analgesia & GI function) IV buprenorphine > procaine for pain Fentanyl TD > IM Demerol (analgesia & LOS) Chronic pancreatitis need R/o cause Esp. if pain recurs w/ advancing diet Surgical or block procedures ~ considered Wilder-Smith et al. Dig Dis Sci. 44(6): , 1999 Jun Jacobs, Scand J Gastroenterol. 35(12): , 2000 Stevens et al, Appl Nurs Res May; 15(2):

9 Always consider Underlying need Type of pain by mechanism or duration Possible amplifiers / dampeners Realistic Comfort function goal Analgesic options (non-opioid, opioid, adjuvant) Non-drug ways of enhancing the plan Adjustments based on response Pammy Otamee Submitted case #3 ICU patient extubated, reports LBP States takes scheduled oxycodone at home Too sedated for IV / po oxycodone Wife reports pain & refutes use of oxycodone Initially refused Acetaminophen Extensive patient education, counseling Involvement in care planning Topical Lidocaine, APAP, Position, Activity -InducedSedationandRespiratoryDepression.pdf. Always consider Underlying need Type of pain by mechanism or duration Possible amplifiers / dampeners Realistic Comfort function goal Analgesic options (non-opioid, opioid, adjuvant) Non-drug ways of enhancing the plan Adjustments based on response