Pain Management in the Elderly. Rachelle Bernacki, M.D., M.S. Division of Hospital Medicine, UCSF Section of Geriatrics, SFVAMC

Transcription

1 Pain Management in the Elderly Rachelle Bernacki, M.D., M.S. Division of Hospital Medicine, UCSF Section of Geriatrics, SFVAMC May 2008

2 Objectives: Systematically assess pain as a symptom Patients with dementia Nursing homes, hospital settings Describe the basic principles of opioid pharmacotherapy Non-opioid adjuvant therapy Perform simple opioid dose conversions Describe the treatment of common opioid side effects 2

3 Why is this important? Pain is common in the elderly and hospitalized patients Pain is often under-recognized and under-treated JCAHO, ACGME/RRC requirements Lack of formal education on pain control 3

4 Why is pain control often not optimal? Clinician unfamiliarity with assessment and treatment Opiate misconceptions Patients, families, and clinicians Fear of side effects Constipation Sedation Concerns about Addiction Regulatory reprimands Lawsuits 4

5 Case 1 Mrs. B is an 87 year old who presents s/p fall -mild Parkinson s -Advanced dementia (MMSE 20/30) -Overnight increasing agitation, given IM Haldol and wrist restraints -Stopped eating, wouldn t sit up in bed -Day #3 attending noted tenderness along pelvic brim 5

6 Pain assessment: History Onset Provocative or Palliative features Quality Radiation and Related symptoms Severity (intensity and effect on function) Temporal pattern 6

7 Bedside Assessment ASK the patient 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 Ferrell et al. J Pain Symptom Manage Herr and Garand. Pain Management in the Elderly 200 7

8 Pain assessment: Pain intensity scales Simple Descriptive Pain Intensity Scale 0-10 or 0-3 Numeric Pain Intensity Scale Visual Analog Scale Faces Scale 8

9 Use a standard scale to track the course of pain 9

10 Faces Pain Scale and Pain Thermometer 10

11 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 Warden et al. JAMDA Villanueva et al. JAMDA

12 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! Kovach et al. J Pain Symptom Management Feldt et al. JAGS

13 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 Herr and Garand Clinics in Geriatric Medicine

14 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 Closs SJ. J Pain and Symptom Manage. March, 2004; 27(3); Feldt K. Pain Manage Nursing. March, 2000; 1(1): Frampton M. Age and Ageing. 2003; 32(3):

15 Assessing pain: Nonverbal, Moderate to Severe Impairment 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 AGS Panel

16 Tips in the Nursing Home Setting Consider round the clock tylenol dosing Use scheduled dosing (Do not use prn!) If patient cannot swallow, consider roxanol (liquid, absorbed bucally) If pt is near end of life, consider low dose fentanyl patch (12.5 mcg) Winn PA, Dentino AN. Effective pain management in the long-term care setting. J Am Med Dir Assoc. 2004; 5(5):

17 Tips in the Hospital Setting Sources of pain include: Primary disease, ie. Cancer pain BUT ALSO: Urinary retention Constipation Improper positioning Pressure ulcers IV sites, urinary catheters, and other tethers 17

18 Addressing Pain Myths in the Elderly No evidence that elderly feel less pain Elderly are not more sensitive to analgesics Mercadante, S. and Arcuri, E. Pharmacological Management of Cancer Pain in the Elderly Drugs and Aging (9):

19 Sources of Pain in the Elderly Post-stroke syndrome Improper positioning Fibromyalgia Cancer pain Contractures Postherpetic neuralgia Oral/dental Constipation Degenerative joint disease Spinal stenosis Fractures Pressure ulcers Neuropathic pain Urinary retention Cramer et al. JAGS

20 Consequences of unrelieved pain Sleep disturbance Functional decline Depression, anxiety Malnutrition Lawsuits Challenging behaviors Polypharmacy Increased healthcare utilization Prolonged LOS 20

21 Case 2 Mrs. S. is a 65 year old woman with lung cancer and chest wall pain from tumor extension. She is taking Percocet 2 tab every 6 hours. The pain is not controlled. 21

22 What is wrong with this regimen? Are there questions you would like to ask the patient? Can you suggest a better regimen? How would you assess whether the new regimen is working? 22

23 Question 1. percocet is not the appropriate drug for this type of pain 2. risk of tylenol toxicity 3. lack of long acting pain medication for constant pain 4. all of the above 1% 1% 32% 66%

24 The initial approach to pain management: Good pain history Target to the type of pain e.g. neuropathic, nociceptive Consider non-pharmacologic or non-systemic therapies alone or as adjuvants Use the WHO 3-Step ladder 24

25 A Simple Approach to Pain Management - The WHO Analgesic Ladder Severe Pain Moderate Strong Opioid Weak Opioid Mild Non-Opioid Source: World Health Organization. Technical Report Series No. 804, Figure 2. Geneva: World Health Organization;

26 WHO 3-STEP LADDER 1 MILD 3 SEVERE 2 MODERATE A/Codeine A/Hydrocodone A/Oxycodone Tramadol +/- Adjuvants Morphine Hydromorphone Methadone Oxycodone Fentanyl +/- Adjuvants ASA/NSAIDS Acetaminophen Cox-2 +/- Adjuvants 26

27 Equianalgesic Doses of Opioid Analgesics (in mg) PO Analgesic IV 200 Codeine - 15 Hydrocodone Hydromorphone Morphine Oxycodone - - Fentanyl Levy, M. Drug Therapy: Pharmacologic treatment of cancer pain. NEJM 1996; 335 (15) Jacox, A Carr, DB et al. New clinical practice guidelines for the management of pain in patients with cancer. NEJM 1994; 330 (9):

28 Opioid Pharmacology Morphine Block the release of neurotransmitters in the spinal cord Mu, delta, kappa Conjugated in liver Excreted via kidney (90% 95%) First-order kinetics Stein, C. The control of pain in peripheral tissues by opioids. NEJM 332 (25):

29 IV Plasma Concentration Cmax max SC / IM po / pr 0 Half-life life (t 1/2 ) 1/2 ) Time From Education on Palliative and End of Life Care (EPEC), available at 29

30 Opioid pharmacology... Cmax (peak) after po, pr 1 h SC, IM 30 min IV 6 15 min half-life at steady state po / po / SC / IM / IV 3-4 h. Levy, M. Drug Therapy: Pharmacologic treatment of cancer pain. NEJM 1996; 335 (15)

31 ... Opioid pharmacology Steady state after 4 5 half-lives steady state after 1 day (24 hours) Duration of effect of immediate-release formulations (except methadone) 3 5 hours po / pr shorter with parenteral bolus (1-2 hours) Levy, M. Drug Therapy: Pharmacologic treatment of cancer pain. NEJM 1996; 335 (15)

32 Opioid management for continuous pain PRN not appropriate Dose find: -begin with short-acting opioid ATC -know if patient is opioid naïve or not -allow breakthrough based on Cmax and patients metabolism For elderly, <60 kg suggest 2-5 mg po MSO4 or an equivalent (e.g. 1/2-1 percocet q 4h) Levy, M. Drug Therapy: Pharmacologic treatment of cancer pain. NEJM 1996; 335 (15)

33 Clearance concerns Conjugated by liver 90% 95% excreted in urine Dehydration, renal failure, severe hepatic failure dosing interval (extend time) or dosage size if oliguria or anuria STOP routine dosing of morphine use ONLY prn 33

34 Breakthrough Pain Transitory exacerbations of severe pain over a baseline of moderate to mild pain Reported by 2/3 of cancer patients with controlled baseline pain Often due to: incident pain or end-of-dose failure (important to distinguish) 34

35 Opioid Rescue Doses Used for breakthrough pain. Dose: Approximately 10% of daily dose equivalent. Frequency: Oral every 1-2 hours Parenteral every minutes 35

36 Tips on Specific Medications in the Elderly NSAIDs can be used in elderly Use with caution (avoid in renal failure, watch for GI blood loss, drug-drug interactions) Beware of codeine Large inter-individual differences in metabolism due to genetic polymorphism (10% poor metabolizers) Morphine Beware of 3-morphine glucuronide in renal failure (prefer dilaudid, fentanyl, methadone) 36

37 Fentanyl Elderly have decreased lean body mass to fat ratio, and fentanyl is lipophilic (can lead to accumulation) Buprenorphine May have utility in chronic pain patients 37

38 Conversions: Examples Called by GI to evaluate a 63 yo male with pancreatic cancer, who is in severe pain. He is written for 1 mg IV dilaudid (hydromorphone) q 3hr. You see the patient and ask the wife to tell you all the medications he is taking. She tells you he is on a morphine gtt sq at home at 20mg/hr. 38

39 The appropriate dosing is: 39 none of these 1. 2mg/hr IV gtt 2. 3mg/hr IV gtt 3. the current rate 4. none of these 56% 2% 2% 40% 2mg/hr IV gtt 3mg/hr IV gtt the current rate

40 Conversions: Examples Morphine SQ 10 mg/hr = 1.5 mg/hr IV hydromorphone Morphine SQ 20 mg/hr = 3 mg/hr IV hydromorphone Pt was on 1 mg IV q3hr hydromorphone = ~0.33 mg/ hr IV Under-dosed by a factor of 9! 40

41 Conversions: Examples A 65 yo man with metastatic lung cancer has dyspnea. His dyspnea is controlled on a morphine PCA with a basal rate of 1mg/hr with a prn of 2 mg. Over the past 24 hrs, he has had 23 demands and 20 prn doses. You want to convert to a fentanyl patch with MSIR for breakthrough. What is the equivalent dose? 41

42 What is the equivalent dose? 1. fentanyl 50 mcg/hr 2. fentanyl 75 mcg/hr 3. fentanyl 100 mcg/hr 4. fentanyl is an inappropriate drug for him. 18% 33% 41% 8%

43 Converting to TD Fentanyl Parenteral Morphine Transdermal Fentanyl Equivalent

44 Conversions: Examples 1mg/hr x 24 hrs = 24mg 20 doses x 2 mg = 40 mg Total 24 mg + 40 mg = 64 mg TD Fentanyl patch 100 mcg/hr q 3days (from table) 44

45 Converting to TD Fentanyl 2:1 Rule Total 24 hr dose of oral morphine should be divided in half 64 mg IV morphine = 192 mg PO morphine 192 mg / 2 =~ 100 mcg/hr fentanyl patch 45

46 Calculating prn doses 64 mg IV morphine = 192 mg PO morphine 10% Rule 20 mg MSIR q 1hr prn 46

47 Ms. F. is reluctant to take opioids. I don t want to become an addict. What do you say? 47

48 Not one in the same Addiction Pseudo-Addiction Tolerance Dependence 48

49 Opioids and Addiction Addiction is defined as psychologic dependence on drugs and a behavioral syndrome characterized by compulsive drug use and continued use despite harm to self and others* Opioids do not cause psychologic dependence Use of opioids for pain management does not cause addiction Oxford Textbook of Palliative Medicine, 3 rd Ed Cami, J. and Farre, M. Drug Addiction. NEJM 349 (10):

50 Pseudoaddiction with Opioids Occurs in context of undertreatment of 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 50

51 Tolerance to Opioids Tolerance is defined as decreasing response to a drug as a consequence of its continued use* Tolerance to analgesic effects is rare 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 Oxford Textbook of Palliative Medicine, 3 rd Ed Ballantyne and Mao, NEJM 349(20):

52 Analgesic tolerance is rarely a problem. Opioid doses remain relatively stable in the absence of worsening pathology and increased opioid requirements after stable periods is often a signal of disease progression. 52

53 Physical Dependence on Opioids Withdrawal syndrome Develops if opioids are abruptly discontinued or dose is rapidly decreased Results from neuropsychologic changes from exogenous opioids Symptoms: -Nausea, vomiting, diarrhea, abdominal pain -Body aches -Psychosis and hallucinations Treatment: If pain stimulus lessens, reduce dose by 50% every 2 to 3 days 53

54 Opioid adverse effects Common Constipation Dry mouth Nausea / vomiting Sedation Sweats Uncommon Bad dreams / hallucinations Dysphoria / delirium Myoclonus / seizures Pruritus / urticaria Respiratory depression Urinary retention SIADH 54

55 Constipation Most common adverse effect encountered during chronic opioid therapy No tolerance developed to this side effect Multifactorial Prophylactic laxatives are indicated PREVENTION IS KEY! 55

56 Constipation: Management Softeners Docusate Cathartics Senna Biscadoyl (Dulcolox) Osmotic Laxatives Magnesium/aluminum salts Lactulose Sorbitol Enemas Fiber- usually not indicated in frail or end-of-life patients 56

57 Nausea and Vomiting Common at the start of therapy Tolerance typically develops (7-10 days) Prophylactic administration of antiemetics is not necessary Select treatment on basis of characteristics 57

58 Opioid-Induced Nausea/Vomiting Stimulation of Medullary chemoreceptor trigger zone. Peak soon after administration metoclopramide, neuroleptics Enhanced vestibular sensitivity vertigo or prominent movement induced nausea scopolamine, meclizine Increased gastric antral tone early satiety, bloating, postprandial vomiting metoclopramide 58

59 Opioid Side Effects - Sedation and Cognitive Impairment Common with initiation of therapy or dose escalation. Tolerance usually develops in days-weeks. 59

60 Side Effect: Tolerance Develops at different rates to these varying effects: respiratory depression, somnolence, nausea >> analgesia > constipation. 60

61 Management of Persistent Opioid Induced Sedation and Cognitive Impairment D/C non-essential centrally acting medications. Evaluate and treat other potential causes. If analgesia satisfactory, decrease dose by 25%. If analgesia inadequate or symptoms persist despite dose reduction: trial of psychostimulant (if sedation) or neuroleptic (if delirium). switch to an alternative opioid. trial of other invasive/non-invasive approach to decrease systemic opioid requirements. 61

62 When dose-limiting side effects occur with opioids... More aggressive treatment of adverse effect(s) Opioid-sparing strategies Analgesic adjuvants Alternate route (e.g. intraspinal) Anaesthetic/Neurolytic procedures PM&R approaches Cognitive therapy Complementary therapies e.g., acupuncture, massage, music therapy Opioid rotation 62

63 Adjuvant therapies Bone pain Radiation therapy, steroids, NSAIDs, calcitonin, radiopharmaceuticals, bisphosphonates Neuropathic pain Anticonvulsants, antidepressants, antiarrhythmics 63

64 Recommendations Keep pain in the differential Anticipate pain -Would this be painful to you? Least invasive route (po) Routine, not prn dosing Start low, go slow until reach desired effect Anticipate side effects Reassess frequently 64

65 Objectives: Systematically assess pain as a symptom Describe the basic principles of opioid pharmacotherapy Perform simple opioid dose conversions Explain opioid tolerance Describe the treatment of common opioid side effects 65

66 Ballantyne and Mao, Opioid therapy for chronic pain. NEJM 349(20): Nursing 2001; 22(2): Cami, J. and Farre, M. Drug Addiction. NEJM 349 (10): Closs SJ, Barr B, Briggs M, et al. A Comparison of Five Pain Assessment Scales for Nursing Home Residents with Varying Degrees of Cognitive Impairment. J Pain and Symptom Manage. March, 2004; 27(3); Codosh J, Ferrell Ba, Shekelle PG, et al. Quality Indicators for Pain Management in Vulnerable Elders. Ann Int Med 2001; 135: Cramer GW, Galer Bs, Mendelson MA, and Thompson GD. A Drug Use Evaluation of Selected Opioids and Nonopioid Analgesics in the Nursing Facility Setting. J Am Ger Soc 2000; 48(4): Feldt K. The Checklist of Nonverbal Pain Indicators (CNPI). Pain Manage Nursing. March, 2000; 1(1): Ferrell, B. Pain in cognitively impaired nursing home patients.- Journal of Pain and Symptom Management, 1995 (8): 1. 66

67 Frampton M. Experience assessment and management of pain in people with dementia. Age and Ageing. 2003; 32(3): Kerr, K. Garand, L. Assessment and measurement of pain in older adults. Clinics in Geriatric Medicine, 17 (3): Levy, M. Drug Therapy: Pharmacologic treatment of cancer pain. NEJM 1996; 335 (15) Jacox, A Carr, DB et al. New clinical practice guidelines for the management of pain in patients with cancer. NEJM 1994; 330 (9): Jones KR, Fink R, Pepper G, Hutt E, Vojir CP, Scott J, Clark L, Mellis K. Improving nursing home staff knowledge and attitudes about pain. Gerontologist. 2004;44(4): Kovach, C. Assessment and Treatment of Discomfort for People with Late-Stage Dementia. Journal of Pain and Symptom Management 18 (6): Mercadante, S. and Arcuri, E. Pharmacological Management of Cancer Pain in the Elderly Drugs and Aging (9):

68 Stein, C. The control of pain in peripheral tissues by opioids. NEJM 332 (25): Stevenson KM, Dahl JL, Berry PH, Beck SL, Griffie J. Institutionalizing effective pain management practices: practice change programs to improve the quality of pain management in small health care organizations. J Pain Symptom Manage. 2006;31(3): Tarzian AJ, Hoffmann DE. Barriers to managing pain in the nursing home: findings from a statewide survey. J Am Med Dir Assoc. 2005; 6(3 Suppl):S13-9. Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the PAINAD (Pain Assessment in Advanced Dementia) Scale. JAMDA 2003; 4:9-15. Winn PA, Dentino AN. Effective pain management in the long-term care setting. J Am Med Dir Assoc. 2004; 5(5): Weissman DE, Griffie, J, Muchka S and Matson S. Building an institutional commitment to pain management in long-term care facilities. J Pain Symptom Manage. 2000; 20: Villanueva MR, Smith TL, Erickson JS, Lee AC, Singer CM. Pain assessment for the dementing elderly (PADE): reliability and validity of a new measure. JAMDA 2003; 4(1):