Objectives. What is pain? 9/27/2017. Pain: Does this Hurt? Fall 2017 Dean Fox, MD, FACP

Transcription

1 Pain: Does this Hurt? Fall 2017 Dean Fox, MD, FACP Photo credit: Objectives Consider personal goal of pain management Establish mutual goal of pain management with the patient and assess accordingly Use mutual pain goal to assess pain and establish plan for managing pain Follow logical pain management algorithm Understand equianalgesic opioid dosing Appreciate WI opioid guidelines Never only opioids What is pain? Pain is an unpleasant sensory and emotional experience, associated with actual or potential tissue damage. International Association for the Study of Pain

2 What is pain management? Managing pain may be an emotional experience, associated with an unpleasant visceral response, potential or actual ego damage, and erosion of patience and confidence. What s our reality as providers? Current pain assessment tool is lacking Unaware of relative strengths of opioids Unaware of the Wisconsin Medical Examining Board Opioid Prescribing Guideline Lack knowledge and time to address patients needs and write effective orders Need standard orders to expectantly manage pain (and other symptoms) Individualized treatment Type of pain Intensity of pain Characteristics of pain Patient characteristics It is more important to know what kind of patient has the disease than what kind of disease the patient has. Sir William Osler,

3 2015 JC pain management standard Both pharmacologic and nonpharmacologic strategies have a role in the management of pain. Strategies should reflect a patientcentered approach and consider the patient s current presentation, the health providers clinical judgment, and the risks and benefits associated with the strategies, including potential risk of dependency, addiction, and abuse. Variables to address Indication (type, severity, and characteristics) Medication Dose Route Interval Characteristics of pain Continuous Intermittent Breakthrough pain Incident pain 3

4 Pain treatment principles By mouth By the clock By the ladder Individualized treatment Minimize side effects World Health Organization,(2009). WHO s Pain Relief Ladder Keep it simple PO=SL=PR TD=SC=IV=IM Only 2 doses for any opioid-enteral and parenteral By the clock Peak concentration: Oral peaks at ~ 1 hour (hydrocodone and tramadol peak at 2 h) Subcutaneous or intramuscular peaks at ~ 30 minutes Intravenous peaks at ~ 10 minutes Breakthrough medication can be given as often as the time to peak concentration for an opioid given by any specific route. 4

5 Individualized treatment Allelic variants result in different complements of opioid receptors Subtle differences exist among the receptor-binding profiles of opioids Opioid metabolism affects the balance of efficacy and tolerability Smith, HS. Opioid Metabolism. Mayo Clin Proc July 2009;84(7): Individualized treatment continued The receptor binding of opioids is incompletely understood; hence matching individual patients with specific opioids to optimize safety and efficacy remains a trial-and-error procedure. Mercadante S, Bruera E Opioid switching: a systematic and critical review. Cancer Treat Rev Jun;32(4): , Epub 2006 Apr 2009 By the Ladder (WHO Pain) Step 1 mild pain (1-3) acetaminophen, aspirin, NSAIDs, adjuvant Step 2 moderate pain (4-7) Tramadol (low potency opioid) or low dose opioid Step 3 severe pain (8-10) higher dose opioid Cancer Pain Relief with a Guide to Opioid Availability, 2 nd ed., 1996, Geneva, Switzerland: World Health Organization 5

6 Acetaminophen Ubiquitous No significant anti-inflammatory effects Potentially hepatotoxic Onset at 30 minutes, peak at 60 minutes What about IV acetaminophen? Is it opioid sparing or not? Israel, F, et al., Lack of benefit from Paracetamol for Palliative Cancer Patients Requiring High-Dose Strong Opioids: Randomized, Double-Blind Placebo- Controlled, Crossover Trial. Journal of Pain and Symptom Management. Mar 2010 ketorolac (Toradol ) NSAID (inhibits COX-1 and -2) Max daily dose is 120 mg Limit treatment to 5 days (GIB and AKI) Onset 10 minutes, peak at 45 minutes tramadol (Ultram) Weak opioid analgesic mediated through an active metabolite Selective norepinephrine reuptake inhibitor Onset 1 hour, peak 2 hours Lowers seizure threshold Less respiratory depression at recommended doses May be beneficial for patients with neuropathic component of pain Schedule IV Leppert, W. Tramadol as an analgesic for mild to moderate cancer pain. Pharmacological Reports. 2009, p

7 Moderate Pain: Initial Doses for the Opioid Naïve Patient ~2 mg MME Child/elderly 5 mg MME Adult EVERY 4 HOURS MME: Morphine Milligram Equivalents Opioid Conversions X3 IV Morphine x3 PO Morphine oxycodone hydrocodone X20 X4 IV hydromorphone X5 PO hydromorphone Mild pain orders (1-3) Acetaminophen (APAP) 650 mg PO or 650 mg rectal (if unable to take PO) Ibuprofen admin instructions below. APAP (admin 1 st ), ibuprofen (admin if mild pain/fever not responsive to APAP). Other option admin instructions alternate APAP with ibuprofen 7

8 Moderate pain orders (4-6) Oral options (select one): Oxycodone 5 mg by mouth every 4h as needed for moderate pain (4-6) OR hydrocodone/apap 5/325mg. 1 tab by mouth every 4h as needed for moderate pain (4-6). IV options (select one): Morphine 2 mg IV every 4h as needed for moderate pain (4-6). Use if unable to take oral pain medications OR Hydromorphone 0.2 mg IV every 4h as needed for moderate pain (4-6). Use if unable to take oral pain medications Severe pain orders(7-10) Oral option: Oxycodone 10 mg by mouth every 2h as needed for severe pain (7-10) IV options (select one): Morphine 4 mg IV every 2h as needed for severe pain (7-10). Use if unable to take oral pain medications. OR Hydromorphone 0.5 mg IV every 2h as needed for severe pain (7-10). Use if unable to take oral pain medications Chronic pain or substance abuse history Should not hinder adequate pain control Likely requires higher doses Negotiate care plan and insist on compliance Methadone maintenance should not be discontinued Use non-opioid analgesics, if possible Use alternative opioids or titrate methadone No parenteral opioids 8

9 Wisconsin opioid prescribing guidelines Excludes cancer patients and palliative care and hospice patients 20Services/Other%20Resources/MEB/ME B_Guidelines_v3.pdf Wisconsin guidelines Yoga, exercise, cognitive behavioral therapy, integrative medicine, and nonopioid pharmacologic therapies for acute and chronic pain. If opioids are used, combine with the therapies listed above. Wisconsin guidelines Constantly assess and monitor to ensure benefits outweigh risks before starting or continuing opioid therapy If evidence emerges of increased risk, consider weaning or discontinuing opioid therapy. If there is risk of imminent danger or if there is diversion, stop opioid therapy and treat withdrawal 9

10 Wisconsin guidelines A practitioner s first priority is to identify and treat the cause of the pain It is critical to address to the extent possible the underlying condition as the primary objective of care, acknowledging that it is important to keep the patient comfortable during this treatment. Wisconsin guidelines Never only opioids (optimize nonpharmacologic and non-opioid pharmacologic therapies) Start low and go slow (IR opioids to start) Limit duration of treatment (often less than 3 days worth, rarely more than 5) For pain outlasting expected time of healing of acute problem, transition to nonpharmacologic/non-opioid therapy Patients unwilling to have definitive treatment for the condition causing pain should be considered questionable candidates for opioid therapy. If opioids are prescribed, clear rationale must be documented. Patients unwilling to use nonpharmacologic and non-opioid treatment should not be prescribed opioids. 10

11 Wisconsin guidelines Opioids from a single provider No refills for lost or stolen prescriptions Encourages review of Wisconsin Prescription Drug Monitoring Program (PDMP) to determine risk of overdose Requires review of PDMP as of April 2017 to prescribe more than 3 day supply of opioids (WI epdmp) Access MN PDMP Surgical patients using opioids preoperatively have higher complication rates, require more opioids postoperatively, and have lower satisfaction rates with poorer outcomes following surgery. 11

12 Wisconsin guidelines Minimize concurrent prescribing with benzodiazepines as mortality risk triples Discourage oxycodone use due to higher addiction potential Use methadone only if extensively trained or experienced Discourages opioid use among illicit drug users WI guidelines (chronic) Few, if any treatments in medicine with this poor a risk/benefit ratio No high-quality evidence to support opioid treatment longer than 6 months. No parenteral opioids for chronic pain exacerbations Additional requirements for 50 MMEs daily and more still if > 90 MMEs per day Pharmacy Assistance East market Clarification of orders per protocol Addition of hierarchy of use Nausea/vomiting Constipation Addition of ladder scales (mild, moderate, severe) for pain medications to avoid duplication Impact RPh clarifications per protocol: 5,000 throughout region Assisted with identification of duplication in order sets. 12

13 What can be better tomorrow? Minimize use of acetaminophen combination products Schedule use of acetaminophen and/or NSAIDs Schedule non-opioid and opioid analgesics as indicated One intervention per indication (mild, moderate, severe) Citations AAHPM Abstract for American Academy of Hospice and Palliative Medicine meeting AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc 2002;50(6):S Beilin B, Shavit Y, Trabekin E, et al. The Effects of Postoperative Pain Management on Immune Response to Surgery, Anesth Anal 2003;97:822-7 Bernhofer, et al. 2011, Cleveland Clinic Pain Management Education for Nursing Cancer Pain Relief with a Guide to Opioid Availability, 2 nd ed., 1996, Geneva, Switzerland: World Health Organization FAST FACTS at IInternational Association for the Study of Pain. Retrieved 1/10/14 Israel, F, et al., Lack of benefit from Paracetamol for Palliative Cancer Patients Requiring High- Dose Strong Opioids: Randomized, Double-Blind Placebo-Controlled, Crossover Trial. Journal of Pain and Symptom Management. Mar 2010 Leppert, W. Tramadol as an analgesic for mild to moderate cancer pain. Pharmacological Reports. 2009, p Mangione MP, Crowley-Matoka M. Improving pain management communication: How patient understand the terms opioids and narcotics. J Gen Int Med (9): Citations continued Mercadante S, Bruera E Opioid switching: a systematic and critical review. Cancer Treat Rev Jun;32(4): , Epub 2006 Apr 2009 Pain explained:pain pathways and medications, Canadian Pain Foundation, at painexplained.ca. Retrieved 1/10/13 Photo credit: Robinson, T. Methadone Mgmnt of Pain in Hospice Setting, 2008, PharmD5700 Sir William Osler photo and quote Smith, HS. Opioid Metabolism. Mayo Clin Proc July 2009;84(7): SUPPORT Study,1995 Toombs, Methadone Treatment for Pain States World Health Organization,(2009). WHO s Pain Relief Ladder. Wisconsin Medical Examining Board Opioid Prescribing Guideline, (2017). 13