RELIEVING VIRGINIA S PAIN AND SUFFERING 3:45-4:45PM

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1 PROVIDING QUALITY CARE TO PAIN PATIENTS IN IOWA RELIEVING VIRGINIA S PAIN AND SUFFERING 3:45-4:45PM ACPE UAN: L05-P Activity Type: Application-Based 0.1 CEU/1.0 hr Learning Objectives for Pharmacists: Upon completion of this CPE activity participants should be able to: 1. Select and adjust opioid medications based on patient needs 2. Recognize that pain is not always a physiologic problem and other avenues may need to be pursued 3. Discuss how to prevent and manage potential adverse effects of opioids 4. Describe the role each health care team member plays in end-of-life care Speaker: John Swegle, PharmD, BCPS, graduated from Drake University in 1992 and worked for two years as a retail pharmacist in eastern and central Iowa. He then attended the University of Iowa receiving a PharmD degree in After completion of a pharmacy residency in family medicine in 1997, John joined the faculty at the University of Iowa College of Pharmacy and the Mercy Family Medicine Residency Program in Mason City. He currently is an Associate Professor (Clinical) with the University of Iowa and clinical pharmacist with the Mercy Family Medicine Residency Program. In addition, he works with Hospice of North Iowa serving as a consultant pharmacist and as a faculty member for the Mercy Medical Center North Iowa Palliative Medicine Fellowship. Speaker Disclosure: John Swegle reports no actual or potential confl icts of interest in relation to this CPE activity. Off-label use of medications will not be discussed during this presentation. FEBRUARY 7, 2014 THE MEADOWS EVENTS & CONFERENCE CENTER ALTOONA, IOWA

Pain Management End-of-Life Care JOHN SWEGLE, PHARMD, BCPS ASSOCIATE PROFESSOR (CLINICAL) UNIVERSITY OF IOWA COLLEGE OF PHARMACY MERCY FAMILY MEDICINE RESIDENCY HOSPICE OF NORTH IOWA Faculty

2 Pain Management End-of-Life Care JOHN SWEGLE, PHARMD, BCPS ASSOCIATE PROFESSOR (CLINICAL) UNIVERSITY OF IOWA COLLEGE OF PHARMACY MERCY FAMILY MEDICINE RESIDENCY HOSPICE OF NORTH IOWA Faculty Disclosure John Swegle reports he does not have actual or potential conflicts of interest associated with this presentation John Swegle has indicated that off-label use of medications will not be discussed during this presentation 1

3 Learning Objectives Upon completion of this activity participants should be able to: 1. Select and adjust opioid medications based on patient needs 2. Recognize that pain is not always a physiologic problem and may require other avenues 3. Discuss how to prevent and manage potential adverse effects 4. Describe the role each healthcare team member plays in end-of-life care Pre-Assessment Questions What changes with pain management once patients transition into end-of-life care? A B C D Higher doses of opioids are used More aggressive routes of administration are utilized Everyone is changed to morphine Not much changes 2

4 Pre-Assessment Questions Which of the following disciplines play an active role in end-of-life care? A B C D E Physicians/providers Nurses Social workers Spiritual care All of the above Pre-Assessment Questions Which one of the following agents is not typically effective in preventing opioid-induced constipation? A B C D Senna MOM Docusate Bisacodyl 3

5 Make them Comfortable What does this mean? Generally Calm/relaxed/comfortable Free of pain Zero pain may not be a realistic goal At peace Don t forget about the family/caregivers What it doesn t mean. Crank up the drugs with the end point being death General Goals Reduce suffering Many involved with this Patient, family, healthcare provider Medications not always the answer Spiritual issues Utilize spiritual care services Social issues Utilize social workers Bottom line: end-of-life care is a team-based approach 4

6 General Goals Location of patient often dictates approach to care Selection of medications Route of administration Aggressiveness of titration Need for reassessment Access to healthcare professional Communication Patients, families, caregivers What to expect Watch your terminology Futile treatment, narcotic, etc. What the medications are designed to do What is the plan from here going forward Education is involved in all these steps Be prepared to take time 5

7 Let s Talk Virginia. What do you want to do? Various Etiologies for Pain Physiologic Nociceptive (somatic/visceral) Neuropathic Emotional Anxiety, depression, anger Social Interpersonal issues (family, loneliness, financial) Spiritual Non-acceptance, abandonment, paying for previous transgressions 6

8 Things to Remember Severity of the pain Barriers to successful pain management Appropriate use of analgesics Route of administration Dosing Management of adverse events Education of patients/families/caregivers/other Selecting Opioids Nothing out there that states one opioid is superior than another one Doesn t mean you randomly select one Parameters do exist to help with selection Opioids have differences in relative affinity for each receptor Realize not all individuals respond the same way to opioids Stresses the importance of individualizing therapy Age alone is not the primary issue The Journal of Pain 2009;10:

9 Selecting Opioids Combination products Hydrocodone-containing Frequently used for breakthrough pain; may be used as scheduled agent Recommendation to change to C-II status in 2014 Oxycodone-containing Codeine-containing Limited use New limitations on acetaminophen for all opioidcontaining products Limit of 325 mg acetaminophen J Natl Compr Canc Netw 2010:8: Opioid Selection Agents commonly used: Morphine Hydromorphone Fentanyl Hydrocodone Oxycodone Methadone (maybe) Additional training required Agents which are not ideal choices Meperidine Codeine Any partial agonist or agonist/antagonist Am J Kidney Dis 2003:42: Drugs Aging 2007;24:

10 Opioids Dosing: Individualized Some do poorly on 5 mg oral morphine Some require very high doses Caution with this Determine pain needs: ongoing coverage vs. PRN use Often dictated by setting Prognosis Stable vs. actively dying patients Opioids Ongoing stable pain Best to provide around-the-clock coverage Long-acting agents should be utilized Pure agonists best suited for breakthrough coverage Combinations products are limited by acetaminophen Assess pain coverage and adjust General rules Consider the amount of PRN opioid use when calculating an increase in basal; readjust PRN opioid to reflect new basal Avoid PRN only use in nursing home patients 9

11 Initial Opioid Dosing Oral Standard morphine dosing Sustained-release: 15 mg every 8-12 hours May start with less frequent administration Typical PRN dosing mg MSIR PO/SL every 1-2 hours PRN Liquid morphine often used (Roxanol 20 mg/ml SL administration) If on basal/bolus bolus dose is ~10-15% of 24-hour dose Example: Morphine SR over 24 hours Bolus is typically 5 mg every hour PRN CNS Drugs 2003;17: Initial Opioid Dosing IV/SQ If using PCA, must determine if capable of pushing the button Initial dosing Standard morphine PCA dose is 1-2 mg every minutes PRN If on basal with PCA option PCA dose is typically % of hourly basal rate Example: Morphine 2 mg hourly infusion with 1 or 2 mg bolus every 15 minutes PRN Weissman DE. Opioid Infusion Titration Orders. 2nd Edition. Fast Facts and Concepts. July 2006; 72 10

12 Opioid Dosing Titration Includes frequent reassessments individual variation to this Based on pain level Mild-moderate pain increase scheduled dose by 25-50% Severe pain increase scheduled dose by % Based on delivery system Immediate-release products: titrate every 30 minutes 2 hours (depending on route) Sustained-release products: titrate daily/every couple of days Exception to this is methadone Transdermal products: generally titrate every hours (depends on the product) Drugs Aging 2012;29: Back to Virginia.. How is treating pain at her stage in life different than treating chronic pain in other patients? 11

13 Opioid Dosing Very pro-active in end-of-life care May appear aggressive Goal is comfort Aggressive dosing requires frequent patient assessment Do not load people up on medications without follow-up assessment Avoid pain crisis situation Follow your kinetics IV vs. SQ vs. PO/SL Look at percentage increases; not mg Opioid Dosing Maximum dose Technically, there isn t one for the pure agonists Often limited by adverse effects What is meant by high dose Some have suggested doses above 200 mg oral morphine (or equivalent) are considered high doses May lead to more adverse effects and warrant opioid rotation The Journal of Pain 2009;10:

14 Equianalgesic Table Numerous ones available General points Conversions are not complete Some variation among opioids thus dosage reductions often recommended Conversions are more of an art than a science Need to know how to use them Never convert methadone from one of these tables Conversions On-line calculators Understand they are not exact 13

15 Opioid Use - Outcomes Outcomes to consider Progress toward therapeutic goals Presence of opioid adverse effects Changes in underlying pain condition Changes in psychiatric or medical comorbidities Identification of aberrant drug-related behaviors, addiction, or diversion The Journal of Pain 2009;10: Opioid Adverse Effects Constipation CNS: sedation, confusion Nausea/vomiting Urinary retention Pruritis Respiratory depression Hyperalgesia Drugs Aging 2009;26(suppl 1):63-73 Canadian Family Physician 2007;53:

16 Opioid Adverse Effects Gastrointestinal Constipation anticipate and prevent Decreased peristalsis, reduced intestinal secretions, increased resorption of fluids Often compounded by other medications and disease states Nausea/vomiting CNS Sedation/motor function/falls Confusion/delirium Caution in those with underlying cognitive decline Best to avoid opioids with active metabolites Drugs Aging 2009;26(suppl 1):63-73 Opioid Adverse Effects Pruritis/sweating Not common but may be distressing Urinary retention Suppressed production of hypothalamic, pituitary, gonadal, and adrenal hormones Most noted is testosterone deficiency in men Respiratory depression Rare in opioid naïve patients with low starting doses and appropriate titration Often the result of a therapeutic mistake Drugs Aging 2007;24:

17 Opioid Adverse Effects Hyperalgesia Opioid-induced neurotoxicity Myoclonus is the hallmark symptom Most likely in opioids with active metabolites Dehydration, infection, other CNS medications may add to development Multiple theories for development Oxidative stress, apoptosis, etc Hyperalgesia may be interpreted as increasing pain May include delirium, agitation, restlessness Canadian Family Physician 2007;53: Brain Research Reviews 2008: FDA Issues Hydrocodone classification Recommendation to move all hydrocodone products to C-II Desire for tamper-resistant formulations FDA pushing for abuse-deterrent formulations Not a mandate.yet; proposed date is 2018 Currently only OxyContin has this technology 16

18 Electronic Transmission Controlled-substances Must adhere to DEA interim final rule (IFR) Comply with federal and state law Requirements for clinicians Identify proofing, two-factor authentication credential Requirements for e-prescribing software Access controls, linking of DEA registrants, application of twofactor authentication code, accept data Requirements for pharmacy software Must be certified by a 3 rd party as meeting all requirements of the DEA IFR USPharm 2013;8(6):HS6-HS9 The Best Guide Working with opioids is an art with some science behind them Use your clinical experience in combination with the evidence Seek help if you need it If one doesn t work, try another one Do not forget other types of pain 17

19 Conclusions Treat the patient Identify etiology of pain if possible If pain is chronic, schedule the medication Oral route is preferred Multiple options exist Weigh risk versus benefit If something fails, try something else Post-Assessment Questions What changes with pain management once patients transition into end-of-life care? A B C D Higher doses of opioids are used More aggressive routes of administration are utilized Everyone is changed to morphine Not much changes 18

20 Post-Assessment Questions Which of the following disciplines play an active role in end-of-life care? A B C D E Physicians/providers Nurses Social workers Spiritual care All of the above Pre-Assessment Questions Which one of the following agents is not typically effective as monotherapy in preventing opioidinduced constipation? A B C D Senna MOM Docusate Bisacodyl 19

21 Questions 20

BASICS OF OPIOID PRESCRIBING 10:30-11:45AM

PROVIDING QUALITY CARE TO PAIN PATIENTS IN IOWA BASICS OF OPIOID PRESCRIBING 10:30-11:45AM ACPE UAN: 107-000-14-013-L01-P Activity Type: Application-Based 0.125 CEU/1.25hr Learning Objectives for Pharmacists: