5/9/2013. Children who require chronic opioids for chronic pain are at significant risk of developing opioid addiction?

Transcription

1 I have no financial relationships with a commercial entity producing heathcarerelated products and/or services relevant to the content I am presenting.. Angela C. Anderson, MD Children who require chronic opioids for chronic pain are at significant risk of developing opioid addiction? The risk of developing drug addiction from opioid administration to patients with pain is: A) 0.19% B) 1.9% C) 10.9% D) 19% Patients who ask for more pain meds within an hour or less of receiving IV opioids are most likely drug seeking? If No h/o abuse or addiction Risk of addiction or abuse = 0.19% 1

2 Pseudoaddiction Headache! Headache!!! Headache! Headache! Fibio says he s in pain Fibio has been sleeping His Vitals are normal Is Fibio fibbing? Drug Seeking? Marco. Acad Emerg Med : Painful Diagnoses: Nephrolithiasis Myocardial infarction Small bowel obstruction Fracture Burn Crush injury Stab wound Amputation Decreased pain thresholds Increased risk of chronic pain Increased vulnerability to Stress/ Anxiety disorders as adults ADHD Cell death in cortical and subcortical areas Decreased short-term and long-term memory ACADEMIC EMERGENCY MEDICINE 2006; 13: Anand et al Physiology & Behavior,(1999) 66(4) : Anand et al. Pediatric Research (2007) 62, ; 2

3 Pharmacologic Pharmacologic Non-Pharmacologic Acetaminophen Ibuprofen Pharmacologic 2 nd Line? Pierce et al. Ann Pharmacother Mar;44(3): Tylenol with codeine is Stronger than ibuprofen and Safer than morphine. Nope 3

4 Codeine (Inactive) P450 CYP 2D6 Poor Metabolizers Caucasian 6 10% Africans 2-17% Asian 2 7% Morphine Codeine (Inactive) P450 CYP 2D6 Ultra-rapid Metabolizers Ethiopians 29% African Amer. 6.5% Caucasians 6.5% Greeks 6% Morphine 3 Pediatric Deaths Normal Doses of codeine.. had genetic ability to convert codeine into life-threatening or fatal amounts of morphine in the body FDA August 15, mg/kg Acetamin - No more effective than Codeine Academic Emergency Medicine 2009; 16: Annals of Emergency Medicine 2009; 54(4): mg/kg Ibuprofen Codeine Further increases in dose No further increase in efficacy Ibuprofen vs. Acetaminophen vs. Codeine 300 patients (100 per group) Ibuprofen Group significantly greater improvement in pain scores Clark. 2007;119; 460 4

5 90 Papers In the absence of robust clinical or scientific evidence, clinicians should treat NSAIDs as a risk factor for bone healing impairment, and their administration should be avoided in highrisk patients 316 Papers No significant increase in disrupted healing Ippokratis et al. The Scientific World Journal Volume 2012, Article ID , 14 pages Kurmis et al, J Bone Joint Surg Am, 2012 May 02;94(9): Age Diabetes Peripheral Vascular Disease Smoking Alcohol Anticoagulants Antibiotics Corticosteroids MS Gaston. J Bone Joint Surg [Br] 2007;89-B: Tilly just had his tonsils out Tilly has a wicked sore throat Poor Tilly Of the Following, which is the best First Line Therapy A) Codeine B) Ibuprofen C) Acetaminophen D) A Bullet to bite on American Academy of Otolaryngology Head and Neck Surgery Foundation Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy 2005 Issue 2 Cardwell, ME, Siviter G, Smith AF Art No: CD

6 15 trials 1046 children No return to OR for bleeding Less nausea and Vomiting Placebo Controlled 102 pts. competed the study Celecoxib better analgesia E. Nikanne et al Otolaryngol Head Neck Surg. 2005;132: Cardwell et al The Cochrane Database of Systematic Reviews 2005 Issue 2; Celecoxib Fewer GI effects Platelet function sparing Twice daily dosing Capsule form only Need 4 to 5 doses (2 to 3 days) for full effect 100mg bid if > 25 kg 50 mg bid if 10 to 25kg? Capsules in ice cream E. Nikanne et al Otolaryngol Head Neck Surg. 2005;132: Only available in Fixed Dose combo s HC + (Acetaminophen or Ibuprofen) Vicodin (HC + Acetamin.) Lortab (HC + Acetamin.) Lortab (HC + acetaminophen) 7.5mg /325mg/ 15ml 7.5mg /500mg/ 15ml Dose 0.2mg/kg 6

7 20 kg child Hydrocodone Dose 0.2 mg/kg 7.5mg /325mg/ 15ml 20kg x 0.2mg/kg = 4mg HC = 8 ml Lortab 8 ml Lortab = 173mg acetaminophen Normal dose of acetaminohen: 20kg x 15mg = 300mg acetaminophen Hydrocodone Acetaminophen or Ibuprofen Increased risk of toxicity with chronic use Same efficacy as codeine Codeine Morphine Codeine Morphine (Inactive) P450 CYP 2D6 Poor Metabolizers Caucasian 6 10% Africans 2-17% Asian 2 7% (Inactive) P450 CYP 2D6 Ultra-rapid Metabolizers Ethiopians 29% African Amer. 6.5% Caucasians 6.5% Greeks 6% Morphine Oxycodone MORPHINE OXYCODONE Oral Solution 2mg/1ml 4mg/1ml 20mg/1ml Oral suspension 1mg/1ml 20 mg/ml Tablets 15mg 30mg Tablets 5mg 10mg 15mg 7

8 Oxycodone Morphine Potency ++ + Vomiting + ++ Constipation ++ + Nightmares/H - + allucinations Neuropathic Pain Morphine 0.3 mg / kg PO Oxycodone 0.2 mg / kg PO Opioid (ORAL) Morphine 0.2 to 0.3 mg/kg Oxycodone 0.05 to 0.2 mg/kg Dose <50kg > 50 kg Frequency mg Every 3-4 hours 5 10 mg Every 3-4 hours No sustained or controlled release preps Especially if opioid naïve Increased risk of OD Potentially lethal if chewed or opened Opioid (ORAL) Onset of Analgesia Peak Effect Simon falls on the playground Morphine min. 1 hour Oxycodone 30 min. 1 hour Simon breaks his arm Simon has pain 8

9 Ibuprofen PRN or Around the Clock? Around the Clock P.R.N. Patient Receives Nuttin If Around the Clock Pain is suspected. ATC dosing Opioid (ORAL) Dose <50kg > 50 kg Frequency Morphine 0.2 to 0.3 mg/kg Oxycodone 0.05 to 0.2 mg/kg mg Every 3-4 hours 5 10 mg Every 3-4 hours 9

10 When can he have more? How much more can he have? Immediate-release morphine IV: 5 to 15 minutes PO: 45 to 60 minutes MORPHINE PO (Immediate Release) Time to Peak Effect = 1hr IV/SQ Time to Peak Effect = 15 to 30 min. RESCUE 25% to 50% of the 4 hour dose Q 1 hour 25% to 50% of the 4 hour dose Q 30 min. What s the maximum dose of Morphine you can give Simon? Morphine Oxycodone Hydromorphone Fentanyl Simon Says: IV Morphine doesn t work for me Only Dilaudid does.. Is this Plausible or Not? Could Be! Compared to Morphine: IV HM is 7 X more potent than IV Morphine 1.5 mg IV HM = 10mg IV MS 0.015mg/kg IV HM = 0.1mg/kg IV MS 10

11 ? Less Nausea? Less Pruritus? Less Sedation Lower third (just past anal sphincter) No 1 st pass metabolism Goes directly into circulation Proximal 2/3 Drains Hepatic vein Liver 14 Fr Suction Catheter 2.Air 1.Medication 3.Add Tip 11

12 OUCH! A delta OUCH! A delta A beta A delta Spinal A beta ( touch, vibration, position) Recruit inhibitory neurons Causes local analgesia OUCH! A delta Holding the boo boo makes it feel better 12

13 Periaqueductal gray (PAG) and Nucleus Raphe Magnus (NRM) Periaqueductal gray (PAG) and Nucleus Raphe Magnus (NRM) But NOT to the Pain! The Journal of Neuroscience, April 1, 2002, 22(7): Imaging Attentional Modulation of Pain in the Periaqueductal Gray in Humans Painfully hot Moderate-strong pain Clearly warm, but not painful Think about it Think about something else! 13

14 OUCH! fmri signal change A delta Tracey I et al, The Journal of Neuroscience April 1, 2002, 22(7): Limbic System What you think is what you get! P. Goffaux et al. / Pain 130 (2007) Putting your hand in here will lessen the pain from the stimulator That wasn t so bad at all Putting your hand in here will worsen the pain from the stimulator Boy..that hurt 14

15 Harder Open ended / Extending This will hurt The medicine will burn The medicine will taste bad As big as (e.g. size of catheter) As long as ( duration of procedure) Softer Help confine/familiarize/imply manageability It might feel (very): sore, achy, scratchy, snug, full Some children say they feel a warm feeling The medicine may taste different than anything you ve tasted before Smaller than. For less time than it takes to As much as Less than From Kuttner A Child in Pain A. Vanhaudenhuyse et al. / NeuroImage 47 (2009) one packet or cube of sugar in 10 ml water Crying reduced by 82% Grimacing reduced by 65% Lower rise in HR - Up to 12 months 15

16 Rub it in Cover it Increased endorphin release in CSF Analgesic effect blocked by naloxone Modulate NMDA receptors Decrease opioid and benzo use w/in 48 hours Golianu,. Semin Perinatol 31: Massage Decreased: Pain Anxiety Depression Nausea/Vomiting J Pain Symptom Management 2004;28: