Approach to Acute Pain Management

Transcription

1 Approach to Acute Pain Management Jeanie Youngwerth, MD University of Colorado School of Medicine Associate Professor of Medicine, Hospitalist Director, Palliative Care Service Associate Director, Colorado Palliative Medicine Fellowship Program Medical Director, Halcyon Hospice and Palliative Care Pain: Objectives Discuss principles for opioid dosing and titration for acute pain Describe adjustments for opioids in the setting of renal or liver failure Apply equianalgesic opioid conversions in acute pain management Trivia Which technique has been associated with decreased acute pain levels? 1. Submerging the effected area in ice 2. Exposing the effected area to sun 3. Using profanity during the episode 4. Squeezing someone s hand during the episode Stephens: NeuroReport 2009; Stephens: Journal of Pain 2011.

2 Bonus Trivia: True / False? Habituation related to frequency of daily swearing can decrease the effectiveness of swearing as a short-term intervention to reduce pain. Pain Case Study 38 y/o M with pain from metastatic thymus cancer Diagnosed 6 years ago, persistent pain Recent scans show disease progression Admitted for acute pain crisis NKDA Cr 2.1 Pain Case Study Pain regimen: Morphine SR 90 mg po BID Oxycodone/APAP 5 mg po q4-6 hrs prn 12 tabs/day Seen in clinic 1 day ago, started on: Fentanyl 25 mcg/hr TD q3 days Dilaudid 4 mg po q6 hrs prn

3 Pain Case Study Pain regimen: Gabapentin 900 mg po TID Duloxetine 60 mg daily Dexamethasone 8 mg po daily RFA 1 month ago Pain Case Study What do you recommend? 1. Wean off of opioids as he is developing hyperalgesia 2. Switch to Hydromorphone as Morphine is no longer effective for him 3. Begin PCA for rapid control of pain 4. Increase Fentanyl TD which is more effective for patients with end-stage cancer Acute Pain Control PCAs Improved pain control Higher patient satisfaction Negative feedback system / safety measure Ballantyne: J Clin Anesth 1993; Sidebotham: J Pain Symptom Manage 1997; Hudcova: Cochrane Reviews 2006.

4 PCA Errors #1 PCA error is: 1. Improper dose/quantity 2. Wrong administration technique 3. Wrong patient US Pharmacopeia 2004; Hicks: Am J Health Syst Pharm * Pain Pearl * Avoid mixing opioids Avoid Mixing Opioids é risk for confusion and mistakes by patients and providers SIMPLIFY Morphine SR + Morphine IR prn

5 Oral Opioid Therapy Opioid breakthrough pain dosing (prn) Dose: 10-15% of 24 hour total opioid dose Interval: time to peak effect Opioid routine dosing (scheduled) Schedule IR every 4 hours IR (t½ = 2-4 hours) Consider SR (once pain stabilizes for ~48 hrs) Choice of Opioid What is considered the gold standard opioid? Grass: Anesth Analg * Pain Pearl * Avoid Morphine in renal failure

6 Renal Failure (RF) Majority of opioids renally cleared Recommendations based on presence of active metabolites Limited studies; no RCTs No consensus on GFR to define RF dose reductions Dean: J Pain Symptom Manage 2004; King: Palliat Med Renal Failure Morphine, Codeine Potent, active metabolites cleared renally Increased risk for neurotoxicity Avoid in RF Hydromorphone, Oxycodone, Tramadol Poorly studied Cautious dosing Fentanyl Limited studies No known active renal metabolites No dose adjustment short term in RF consider decreasing dose long term Dean: J Pain Symptom Manage 2004; King: Palliat Med Liver Failure Impaired oxidation and glucuronidation Limited studies- most extrapolated from RF High prevalence & risk of RF in cirrhosis Avoid Morphine, Codeine, Tramadol Transdermal preparations Davis: Clin Pharmacokinet 2007; Rhee: J Palliat Med 2007; Chandok: Mayo Clin Proc 2010.

7 Renal and Liver Failure Summary Avoid Morphine Fentanyl safer choice Oxycodone and Hydromorphone cautious dosing Consider IR preparations Consider longer dosing intervals Pain Case Study Opioid switch from Morphine PCA IV Hydromorphone Pain Case Study Pain regimen: Morphine SR 90 mg po BID = 180 mg po Oxycodone 5 mg/apap 12 tabs/day= 60 mg Seen in clinic 1 day ago, started on: Fentanyl 25 mcg/hr TD q3 days Dilaudid 4 mg po q6 hrs prn

8 Opioid Conversions Equianalgesic Dosing 1. Calculate total 24 hour total opioid dose 2. Convert to 24 hour new opioid equivalent 3. Adjust by 50-75% for incomplete cross tolerance 4. Triple check calculations 5. Constipation prophylaxis! EPEC Module ; v1.0; NCCN: Adult Cancer Pain v Incomplete Cross Tolerance When switching from one opioid to another Tolerance developed to one opioid may not completely transfer to the new opioid Start the new opioid at 50-75% of the equianalgesic dose 60% good generalization Pasternak: Trends in Pharm Sciences 2001; Ballantyne: NEJM 2003; Mehta: Anaesth 2006; ; v1.0; NCCN: Adult Cancer Pain v

9 Opioid Conversions Equianalgesic Dosing Current Opioid Total 24 hour Current Opioid = New Opioid Total 24 hour New Opioid (X) Pain Case Study 1. Calculate total 24 hour total opioid dose Current Opioid New Opioid = Total 24 hour Current Total 24 hour New Oxycodone 20 mg po Morphine 30 mg po = Oxycodone 60 mg/day po Morphine X X = Morphine 90 mg po/day Pain Case Study Morphine SR 180 mg/d po + Oxycodone Morphine 90 mg/d po TDD = Morphine 270 mg po/d

10 Pain Case Study 2. Convert to 24 hour new opioid equivalent Current Opioid New Opioid = Total 24 hour Current Total 24 hour New Morphine 30 mg po Hydromorphone 1.5 mg IV = Morphine 270 mg po/d Hydromorphone X X = Hydromorphone 13.5 mg IV/day Pain Case Study 3. Adjust by 60% for incomplete x- tolerance Hydromorphone 13.5 mg IV/day X 0.6 = Hydromorphone 8.1 mg IV/day * Pain Pearl * Adjust for incomplete cross tolerance with equianalgesic dose conversions

11 Pain Case Study 4. Triple check calculations 5. Constipation prophylaxis! -Senna 2 tabs po BID Hawley: JPSM 2008; Librach: JPSM 2010; Tarumi: JPSM Pain Case Study Hydromorphone 8.1 mg IV/day 24 hrs = 0.3 mg/hr PCA settings? PCA Management FIRST ask yourself Opioid naïve or not??? PCA Parameters Basal Demand Lockout

12 PCA Basal Rate- Opioid Tolerant Opioid tolerant Convert 24 hour total opioid requirement to hourly rate (by equianalgesic dosing) Macintrye: Br J Anaesth 2001; Lehmann: J Pain Symptom Manage 2005; Grass: Anesth Analg PCA Basal Rate- Opioid Naïve Opioid naïve No basal rate Increased rates of respiratory depression No improvement in pain scores Sidebotham: JPSMx 1997; Macintrye: Br J Anaesth 2001; Krenn: Euro J Pain 2001; Didem: Can J Anesth 2003; Grass: Anesth Analg 2005; Herr: Iowa City Guideline Summary NGC

13 PCA Demand Dose- Opioid Tolerant Demand dose 50% of the basal rate (50-100%) Grass: Anesth Analg PCA Demand Dose- Opioid Naive Morphine 0.5, 1, 2mg 0.5 mg unable to achieve adequate analgesia 2 mg higher rates of respiratory depression 1 mg optimum starting dose Owen: Anaesth 1989; Sidebotham: J Pain Symptom Manage PCA Lockout Time Based on time to peak effect

14 Time to Peak Opioid Effect 10 min Opioid Time to Peak Effect Route of Administration Oral Time to Peak Effect 60 minutes Subcutaneous 30 minutes IV 10 minutes EPEC Module ; APS 2003; APS 2006; NCCN: Adult Cancer Pain v PCA Lockout Time Morphine 7 vs 11 minutes Fentanyl 5 vs 8 minutes No difference in pain relief, anxiety or side effects Ginsberg: Pain 1995.

15 PCA Lockout Time 10 minutes is a standard interval Ginsberg: Pain 1995; Macintrye: Br J Anaesth 2001; Walder: Acta Anaesthesiol Scand 2001; Grass: Anesth Analg PCA Nurse Initiated Bolus Not studied; Variable Twice the demand dose Grass: Anesth Analg PCA Dosing Summary Basal Rate Opioid naïve: none Opioid tolerant: Convert 24 hour total opioid requirement to hourly rate (by equianalgesic dosing) Demand Dose Opioid naïve: 1 mg IV Morphine equivalent Opioid tolerant: 50% (100%) of the basal rate Lockout Time 10 minutes Nurse Initiated Bolus 2x the demand dose

16 Pain Case Study Hydromorphone 0.3 mg/hour Basal 0.3 mg/hr Demand dose 0.2 mg Lockout time 10 min Nurse-bolus 0.4 mg Nurse calls for patient with severe pain. What is the best next step when titrating the PCA for acute pain control? 1. Increase basal rate to 0.5 mg/hr 2. Increase demand dose to 0.4 mg 3. Decrease lockout time to 6 minutes 4. Change PCA opioid to Fentanyl 5. Add Oxycodone SR 10 mg PO BID Opioid Titration Acute control: immediate release/prn Demand dose Chronic control: sustained release/scheduled Basal rate Hanks: British J Cancer 2001; Grass: Anesth Analg 2005.

17 Opioid Titration Pain Severity Increase Dose Up To Mild 25% Moderate 50% Severe 100% EPEC Module ; NCCN: Adult Cancer Pain v * Pain Pearl * Avoid increasing the dose of opioid by more than 100% at any one time! PCA Demand Dose Titration Demand dose Can change every minutes if needed Practically every 60 minutes and reevaluate

18 PCA Basal Rate Titration Basal rate 8-24 hours to achieve steady state Avoid changing more frequently than q 8 hrs Every 24 hours reasonable EPEC Module ; APS PCA Basal Rate Titration Dose based on 24 hour total opioid usage Patient pain rating Your assessment Daily trend of 24 hr requirements Opioid Titration Summary Basal rate Consider change ~ daily based on 24 hour opioid usage in opioid-tolerant Demand dose Titrate for acute pain control é 25% mild pain é 50% moderate pain é 100% severe pain Lockout time Keep at 10 min

19 PCA to Oral Opioids Once stable opioid requirements for ~2 days Use TDD from PCA to calculate equianalgesic oral dose of new opioid Remember incomplete x-tolerance Pain Case Study PCA to Oral Opioid Current Opioid Total 24 hour Current New Opioid Total 24 hour New = Hydrom 1.5 mg IV = Hydrom 10mg/day IV Oxycodone 20 mg po Oxycodone X X = Oxycodone 133 mg po/day x 0.6 = 80 mg po/day = Oxycodone SR 40 mg po BID Oxycodone IR 10 mg po q1 hr prn pain Senna 2 tab po BID Creative QI Projects PCA Safety Checklist Safe, effective, rapid pain control with a standardized, transparent approach

20 Pa$ent has confirmed PCA Safety Checklist FOR ALL STEPS: Document excep6ons to any step of the safety checklist. Address psycho- social- spiritual pain. DECISION TO START PCA PCA INITIATION PCA TITRATION cogni$ve func$on physical capability Pa$ent and family educated Document PCA indica$on Discon$nue all other opioids CALCULATIONS GUIDELINES 40% reduc$on for cross tolerance when conver$ng to another opioid For basal and demand: Is demand % of basal rate? Is RN bolus % of demand? Is demand lockout 10 minutes? Double check calcula$ons with a pallia$ve care team member PCA conversion verbally communicated to primary team and nurse Is pa$ent IPC bed status? Document conversion calcula$ons (.pccalc and.pcpca) CALCULATIONS GUIDELINES Incremental 24 hour basal rate increase not to exceed 100% of previous basal rate For basal and demand: Is demand % of basal rate? Is RN bolus % of demand? Is demand lockout 10 minutes? Double check previous 24 hour use with a pallia$ve care team member Double check $tra$on calcula$ons with a pallia$ve care team member PCA $tra$on verbally communicated to primary team and nurse Document $tra$on calcula$ons (.pcpca) PCA Safety Checklist FOR ALL STEPS: Document excep6ons to any step of the safety checklist. Address psycho- social- spiritual pain. TRANSITIONING PCA TO PO Pa$ent has confirmed GI absorp$on renal func$on appropriate for medica$on CALCULATIONS GUIDELINES Stable PCA use x 48 hours 40% reduc$on for cross tolerance when conver$ng to another opioid Is oral PRN dose 10-15% of total daily dose? Double check calcula$ons with a pallia$ve care team member Pa$ent has confirmed outpa$ent insurance coverage outpa$ent provider follow up PO conversion verbally communicated to primary team and nurse Document conversion calcula$ons (.pccalc) PCA DISCONTINUATION Discon$nue basal within 4 hours of star$ng long ac$ng po Con$nue demand as PRN for hours ayer star$ng long ac$ng po for high dose conversions WHEN TRANSITIONING TO FENTANYL PATCH Discon$nue basal 6 hours ayer patch ini$a$on UPON DISCHARGE Pain medica$on regimen on discharge communicated in wri$ng to outpa$ent provider / community pallia$ve care agency WHEN DISCHARGING WITH PCA Pa$ent has confirmed infusion company home health outpa$ent pallia$ve care outpa$ent provider to write PCA orders OR inpa$ent or home hospice agency Methadone Elderly Fentanyl TD Caveats

21 Methadone Does not follow regular opioid principles! Recommend consulting Palliative Care or Pain Service for patients in acute pain crisis who are on Methadone Bruera: JPM Methadone Does not follow regular opioid principles! Recommend consulting Palliative Care or Pain Service for patients in acute pain crisis who are on Methadone Bruera: JPM Elderly- Opioid Reduction Require less opioid than younger patients to achieve same relief Opioid sensitivity é by 50% Pain intensity ê by 10-20% each decade after age 60 Herr: Iowa City Guideline Summary NGC

22 Elderly- Opioid Reduction Initiate opioids at 25-50% lower dose than recommended for younger adults Herr: Iowa City Guideline Summary NGC Evidence Grade = B; v1.0. Fentanyl TD Lipophilic Decreased absorption in cachectic Increased absorption with heat (fevers) Chronic, stable pain in opioid-tolerant Fentanyl TD 2x po Morphine 75 mcg/hr q3days 150 mg po daily NCCN: Adult Cancer Pain v Resources REMS GuestPageExternal.aspx NCCN Adult Cancer Pain Guidelines physician_gls/f_guidelines.asp

23 * Pain Pearls * Avoid mixing opioids Avoid Morphine with renal failure Adjust for incomplete cross tolerance (60%) Avoid increasing opioid dose by >100%