Chronic Pain Simplified Part 1: A Review of the 2017 Guidelines

Transcription

1 Chronic Pain Simplified Part 1: A Review of the 2017 Guidelines Punta Cana

2 Copyright 2017 by Sea Courses Inc All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

3 CFPC CoI Templates: Slide 1 Faculty/Presenter Disclosure Faculty: JOEL BORDMAN Relationships with commercial interests: Grants/Research Support: N/A Speakers Bureau/Honoraria: Purdue, Indivior, OCFP, MedPlan, ECHO Consulting Fees: OCFP, CMPA, CNO, ONA, Purdue, Indivior, Other:

4 CFPC CoI Templates: Slide 2 Disclosure of Commercial Support This program has received financial support from SEA COURSES in the form of Honoraria. This program has received in-kind support from Sea Courses in the form of logistical support. Potential for conflict(s) of interest: Joel Bordman has received honoraria from Purdue, Indivior [Purdue, Indivior benefits from the sale of products that will be discussed in this program: Suboxone (Buprenorphine/Naloxone), OxNeo (Oxycodone LA-resistant to crushing), HydroMorphContin (Hydormorphone LA)

5 CFPC CoI Templates: Slide 3 Mitigating Potential Bias Every effort will be made to remind audience of potential bias throughout the presentation

6 Objectives To review the 2017 opioid guidelines To explore the way to treat the Legacy patients To explore how to investigate the Inherited patients

7 Is chronic pain just pain that is lasting longer than acute pain?

8 8 Cellular Mechanisms of Acute and Chronic Pain (Brookoff, 2000) Dorsal Horn Cell

9 Lets look at the 2017 Guidelines.

10 Initiation and Dosing of Opioids in Patients with Chronic Non-cancer Pain

11 Recommendation 1: Strong When considering therapy for patients with chronic non-cancer pain We recommend optimization of non-opioid pharmacotherapy and nonpharmacological therapy, rather than a trial of opioids

12 TRIAD OF CHRONIC PAIN TREATMENT Physical / Rehabilitative Psychological Medical Pharmacological Interventional 13

13 Recommendation 2: Weak For patients with chronic non-cancer pain, without current or past substance use disorder and without other active psychiatric disorders, who have persistent problematic pain despite optimized nonopioid therapy We suggest adding a trial of opioids* rather than continued therapy without opioids.

14 By a trial of opioids, we mean initiation, titration, and monitoring of response, with discontinuation of opioids if important improvement in pain or function is not achieved. The studies that identified substance use disorder as a risk factor for adverse outcomes characterized the conditions as alcohol abuse and dependence, and narcotic abuse and dependence, and sometimes referred to ICD-9 diagnoses. The mental illnesses identified in studies as risk factors for adverse outcomes were generally anxiety and depression, including ICD-9 definitions, as well as psychiatric diagnosis, mood disorder, and post-traumatic stress disorder.

15 Webster LR, Webster RM, 2005

16 Recommendation 3: Strong For patients with chronic non-cancer pain with an active substance use disorder We recommend against the use of opioids Clinicians should facilitate treatment of the underlying substance use disorders, if not yet addressed. The studies that identified substance use disorder as a risk factor for adverse outcomes characterized the conditions as alcohol abuse and dependence, and narcotic abuse and dependence, and sometimes referred to ICD-9 diagnoses.

17 Adverse Selection Combining high risk patients with high risk medical regimens Mark Sullivan, M.D.

18 Recommendation 4: Weak For patients with chronic non-cancer pain with an active psychiatric disorder whose non-opioid therapy has been optimized, and who have persistent problematic pain We suggest stabilizing the psychiatric disorder before a trial of opioids is considered

19 In Combined pain and mental health issues, Opioid Dose Escalation occurs because... Pain is assumed to be the primary cause of the patient s suffering and disability. Chronic pain care is complicated by a host of psychological and social problems that are often unaddressed.

20 Rotation and Tapering of Opioids, for Patients with Chronic Non-cancer Pain

21 Recommendation 5: Weak For patients with chronic non-cancer pain with a history of substance use disorder, whose non-opioid therapy has been optimized, and who have persistent problematic pain We suggest continuing non-opioid therapy rather than a trial of opioids The studies that identified a history of substance use disorder as a risk factor for adverse outcomes characterized the conditions as alcohol abuse and dependence, and narcotic abuse and dependence, and sometimes referred to ICD-9 diagnoses.

22 Recommendation 6: Strong For patients with chronic non-cancer pain who are beginning long term opioid therapy We recommend restricting the prescribed dose to less 90mg morphine equivalents daily rather than no upper limit or a higher limit on dosing Some patients may gain important benefit at a dose of more than 90mg morphine equivalents daily. Referral to a colleague for a second opinion regarding the possibility of increasing the dose to more than 90mg morphine equivalents daily may therefore be warranted in some individuals.

23 Recommendation 7: Weak For patients with chronic non-cancer pain who are beginning opioid therapy, we suggest restricting the prescribed dose to less than 50mg morphine equivalents daily. The weak recommendation to restrict the prescribed dose to less than 50mg morphine equivalents daily acknowledges that there are likely to be some patients who would be ready to accept the increased risks associated with a dose higher than 50mg in order to potentially achieve improved pain control.

24 Recommendation 8: Weak For patients with chronic non-cancer pain who are currently using opioids, and have persistent problematic pain and/or problematic adverse effects We suggest rotation to other opioids rather than keeping the opioid the same Rotation in such patients may be done in parallel with, and as a way of facilitating, dose reduction

25 A New Paradigm for Opioid Rotation 1. Decrease the the total dose of the old CR opioid 10-30% while starting the new CR opioid at the lowest dose for the formulation 2. Decrease the total daily dose of the old CR opioid 10-25% per week while titrating the dose of the new CR opioid weekly by 10-20% with a goal of switching over 3-4 weeks 3. Provide adequate IR opioid to manage withdrawal or increased pain Webster and Fine. Pain Medicine April 2012

26 Recommendation 9: Weak For patients with chronic non-cancer pain who are currently using 90mg morphine equivalents of opioids per day or more We suggest tapering opioids to the lowest effective dose, potentially including discontinuation, rather than making no change in opioid therapy. Some patients are likely to experience significant increase in pain or decrease in function that persists for more than one month after a small dose reduction; tapering may be paused and potentially abandoned in such patients.

27 Tapering Opioid Therapy 1.Discuss and document (with significant other?) : Withdrawal is usually not dangerous Typical withdrawal symptoms & time course hand-out 2.Often pain is no worse or possibly even better (OIH?)

28 Tapering Opioids Fast or slow 10% per day, daily pharmacy dispensing 10% q 4 weeks Use pharmacological aids Clonidine, imodium, NSAID, nabilone, GPN, PGN

29 What to do with the legacy patient? Provide updated informed consent Complications : sleep apnea, hypogonadism, falls, early dementia with benzo s, etc Review pain diagnosis Review risk factors Have a family member come in

30 What about. Medically assisted treatment in problematic opioid use: Methadone Buprenorphine / naloxone Buprenorphine injectable (coming soon?)

31 What about an inherited opioid patient? The inherited opioid patient is essentially a NEW opioid patient, to you. You cannot necessarily rely on the previous physician to have done a comprehensive assessment. It is up to you to make sure that opioid therapy is rational. For patients receiving opioids for a prolonged period who may not have had an appropriate trial of therapy, take steps to ensure that long-term therapy is warranted and dose is optimal. - R15 of Canadian Opioid Guideline

32 Current Opioid Misuse Measure (COMM) The Current Opioid Misuse Measure (COMM) is a brief patient self-assessment to monitor chronic pain patients on opioid therapy

33 Recommendation 10: Strong For patients with chronic non-cancer pain who are using opioids and experiencing serious challenges in tapering We recommend a formal multidisciplinary program.

34 Recommendation 10: (continued) Recognizing the cost of formal multidisciplinary opioid reduction programs and their current limited availability/capacity, an alternative is a coordinated multidisciplinary collaboration that includes several health professionals whom physicians can access according to their availability (possibilities include, but are not limited to, a primary care physician, a nurse, a pharmacist, a physical therapist, a chiropractor, a kinesiologist, an occupational therapist, an addiction specialist, a psychiatrist, and a psychologist).

35 Supports Academic Detailing

36 Best Practice Statements Informed consent Monitoring Contraindications

37 Expert Guidance

38 Guidance Statement # 1 Restriction in amounts of opioids prescribed

39 41 Structured Opioid Therapy (SOT) use of opioids other than Methadone or buprenorphine/naloxone to treat CNCP with specific controls in place, including patient education, written treatment agreement, shorter dispensing intervals, and frequent monitoring Improves outcomes in patients who have exhibited Problematic opioid use

40 What to do with Snowbirds? A MMAP Discussion A risk assessment should be documented. If the risk is low and the patient is reliable, it may be reasonable to consider a prescription to cover the entirety of the trip. Document the decision making process and your discussion with the patient carefully.

41 What to do with Snowbirds? Consider blister packing, video confirmation of pill counts? Caution with : Others transporting partial fills across the border (family / courier service)

42 Guidance Statement # 2 Immediate vs Controlled Release Opioids the benefit and safety of control release or sustained-release over immediate release preparations is not clearly established

43 Guidance Statement # 3 Co-prescribing with opioids the expert perspective is that opioids and benzodiazepines should very rarely be prescribed together

44 Guidance Statement # 4 Sleep apnea. Three options: Reduce opioid dose without specific treatment for sleep apnea Provide specific treatment for sleep apnea without reducing the opioid dose Reduce opioid dose and provide specific treatment for apnea

45 Guidance Statement # 5 Hypogonadism patients should be offered opioid tapering as the initial strategy to correct hypogonadism. If opioid tapering is unsuccessful or declined, clinicians may offer testosterone supplementation therapy

46 Guidance Statement # 6: Urine Drug Screening When ordering a urine drug screen, Clinicians should ask patients about all medications/drugs recently taken, and be aware of local resources to assist them in assessing for potential false positive and false negative results.

47 Guidance Statement # 7 Treatment Agreements The benefits of treatment agreements are Limited by low quality evidence with equivocal effects on opioid misuse. However, it may be useful in structuring the process of informed consent around opioid use, clarifying expectations for both patient and physician, in providing clarity regarding the nature of an hope your trial endpoints, goals and strategy in the event of a failed trial

48 Guidance Statement # 8 Tamper resistant formulations When available and affordable, tamper-resistant formulations may be used to reduce risks of altering the intended delivery system (i.e. from oral to nasal or IV injection). They do not reduce the most common mode misuse (oral ingestion), but are less favored by people who misuse opioids by any route.

49 Guidance Statement # 9 Fentanyl Patch Exchange When prescribing fentanyl or other drugs dispensed in a transdermal patch preparation, it may be advisable to ask patients to return used patches to the pharmacy when presenting for the next dispensing In Ontario this is required by law.

50 Guidance Statement # 10 Naloxone it is possible that Naloxone prescription Will highlight the potential for serious adverse events such as overdose in death for patients and their families, leading to increased vigilance and critical consideration of the benefits of the treatment.

51 Chronic Pain Simplified Part 2: A Review of Treatment Options Punta Cana

52 Objectives To review opioid options To review non-opioid pharmaceutical options To review non-pharmaceutical options

53 Classification of Pain Acute vs Chronic 3 months? 6 months? Cancer Vs Non-Cancer Do we really mean imminently terminal pain Nociceptive vs Neuropathic

54 Nociceptive vs. Neuropathic Nociceptive Usually caused by stimuli or tissue damage Normal nervous system response Neuropathic There may or may not be visible tissue damage Damage / altered function of nervous system is the major cause Affects peripheral or central nervous systems or both

55 Algorithm for the Pharmacological Management of Neuropathic Pain Gabapentinoids TCA SNRI Tramadol Opioid Analgesics Cannabinoids Consider adding additional agents sequentially if partial but inadequate pain relief + Fourth-line Agents* *topical lidocaine (second-line for postherpetic neuralgia), methadone, lamotrigine, lacosamide, tapentadol, botulinum toxin + limited randomized controlled trial evidence to support add-on combination therapy Moulin et al, Pain Res Manag 2014

56 Tricyclic Antidepressants (TCAs) Mechanism: Reduction in action potential firing of sodium channel activity Inhibition of reuptake of norepinephrine and serotonin Common adverse events Dry mouth, constipation, daytime drowsiness, urinary retention, orthostatic hypotension, arrythmias, weight gain Caution: CVD Urinary retention Glaucoma Risk of OD

57 Tricyclic antidepressants (TCAs)* Robust evidence of efficacy 1 Inexpensive medications 1 Nortriptyline* usually is better tolerated than amitriptyline* 1 Starting dose: 10mg, at bedtime 1. Moulin et al. (2007)

58 Duloxetine Independent analgesic effect (significant pain relief) has been demonstrated within the first week Starting dose: 60 mg/day 3 (A starting dose of 30 mg may be considered for tolerability reasons, with a target dose of 60 mg/day within 1-2 weeks 1 ) Usual maintenance dose: mg/day (maximum 120 mg/day) 2,3

59 Duloxetine Treatment-Emergent Adverse Events Fibromyalgia Placebo-controlled Studies 1 Most common events which occurred in 5% of duloxetine patients and statistically significantly more frequent than placebo. * Pooled data from all patients receiving duloxetine 60 mg/day, 120 mg/day and 60 mg/twice per day in randomized placebo controlled clinical trials 1. Cymbalta Product Monograph. Eli Lilly Canada Inc. Last revised: October 6, 2010.

60 Pregabalin Action same as GPN Officially indicated for neuropathic pain (PHN, DN, Central NeP), fibromyalgia Linear absorption kinetics BID dosing Side effects similar to GPN Start 25-75mg qhs then bid x7; 150mg bid x7 300 bid x 7 Effects seen within 1 week of adequate dosing Adjust dosing in renal insufficiency

61 Pregabalin Treatment-Emergent Adverse Events Fibromyalgia Placebo-controlled Studies 1 Most common events which occurred in 5% of pregabalin patients and statistically significantly more frequent and greater than placebo. 1. Lyrica Product Monograph. Pfizer Canada Inc. Last revised: June 21, 2010.

62 Pharmaceutical Cannabinoids Nabilone 0.5, 1.0mg (0.25mg available but not covered on ODB) Nausea and vomiting of cancer chemotherapy THC / CBD spray MS neuropathic pain severe cancer pain on opioids

63 65 Topicals Lidocaine (USA) Capsaicin cream Diclofenac diethylamine gel 1.16%

64 66 Vitamin D for Chronic MSK pain According to a comprehensive review of the clinical research evidence, helping certain patients overcome chronic musculoskeletal pain and fatigue syndromes may be as simple, well tolerated, and inexpensive as a daily supplement of vitamin D. Leavitt, Pain-topics.org

65 If someone needs opioids Canadian pain guidelines Opioid manager Opioid risk assessment Brief pain inventory Opioid agreement Follow by documenting the 6 A s

66 Brief Pain Inventory - BPI Adapted from Cleeland CS, Ryan KM, 1994

67 Essential Follow-up Documentation-The 6 A s 1. Analgesia (pain relief) 2. Activities (physical and psychosocial functioning) 3. Adverse Effects (and your advice) 4. Ambiguous Drug Taking Behaviour (and your response) 5. Accurate medication record 6. Affect (mental health status)

68 Canadian Opioids NATURAL ( Extracted from opium) SEMISYNTHETIC (Derived from opium extracts) SYNTHETIC (Man made) Codeine Hydrocodone Meperidine Morphine Oxycodone Fentanyl Hydromorphone Methadone Buprenorphine Tramadol Tapentadol

69 Opioids Weak Codeine and Tramadol Medium Tapentadol and Buprenorphine Strong Morphine, Oxycodone, Hydromorphone, Methadone, Fentanyl

70 Codeine ( Weak Opioid) Canada: ~80% of oral opioids prescribed Constipating Pro-drug of morphine 10% of population cannot metabolize to the active metabolite Caffeine 15mg in #1,2,3. (not in #4)

71 Codeine ( Weak Opioid) Caution with rapid 2D6 metabolizers, children and in breastfeeding Smoking increases activation Paroxitine, etc can inhibit activation

72 Morphine Metabolites (M3G, M6G) can accumulate with side effects especially in elderly and with decreased renal function Histamine mediated itch Word origin: Latin Morpheus. Greek God of SLEEP

73 Tramadol Short acting: 37.5mg with acetominophen 50mg without acetominophen Long acting: 100, 150, 200, 300mg OD Metabolite is mu receptor agonist and 5HT, NE reuptake inhibitor Risk for serotonin syndrome, hypoglycemia, seizure

74 Serotonin Syndrome Explained 3 signs or symptoms from the following triad: Cognitive and/or behavioral changes Confusion, lethargy, agitation, coma Autonomic instability Hyperthermia (fever), diarrhea, mydriasis, tachycardia, nausea/vomiting, diaphoresis Neuromuscular changes Myoclonia, tremor, seizure, hyperreflexia, clonus, muscle rigidity, ataxia Masson et al. (2000)

75 Tapentadol Mechanisms of Action Synergistic activity of two mechanisms of action: µ-opioid receptor agonist 50 times lower affinity for the µ-opioid receptor than morphine (animal models) But only 2 3 times less potent than morphine with respect to analgesic effect (animal models) Inhibition of norepinephrine reuptake The synergistic effect is observed in experimental models of nociceptive and neuropathic pain Schröder W, et al. (2011) Bee LA, et al. (2011) NUCYNTA * CR Product Monograph. (2010) *All trademark rights used under license

76 Hydromorphone Hydrophilic with less active metabolites therefore possibly less likely to cause side effects Short acting Dilaudid 1/2/4/8 mgm q4-6 HRLY Long acting Hydromorph Contin 3/6/12/18/24/30 mgm Q12 HRLY ***Caution with dose conversions from Morphine to HM

77 Oxycodone Short Acting Acetominophen/ Oxycocet 5mg Long Acting Generic or Resistant to Crushing Requires EAP form in Ontario Word origin?

78 Oxycodone Resistant to crushing: Physical properties* Hardened Tablets Oxycodone Resistant to crushing tablets following physical manipulation. Multiple strikes of OxyNEO with a hammer deform, but do not crush tablets into powder. The tablets have been hardened through a unique process to reduce the risk of being broken, crushed or chewed. *Clinical significance has not been established. There is no evidence that OxyNEO has a reduced liability compared to other controlled-release oxycodone formulations. Results may differ based on force applied. OxyNEO (oxycodone hydrochloride controlled-release tablets) Product Monograph. Purdue Pharma. October 16, 2012.

79 Oxycodone Resistant to crushing : Physical properties* Hydrogelling Oxycodone Resistant to crushing manipulated and in 2 ml of water The tablets exhibit hydrogelling properties, so that particles or whole tablets become highly viscous (gel-like) in water *Clinical significance has not been established. There is no evidence that OxyNEO has a reduced liability compared to other controlled-release oxycodone formulations. OxyNEO (oxycodone hydrochloride controlled-release tablets) Product Monograph. Purdue Pharma. October 16, 2012.

80 Fentanyl Patch DO NOT USE IN OPIOID NAIVE PATIENTS Matrix or reservior 25/50 mcg covered on ODB (LU) Useful for compliance No dose adjustment: hepatic/renal failure Short acting opioid in long acting delivery system

81 What Is Buprenorphine? Narcotic opioid analgesic Semi-synthetic derivative of the morphine alkaloid thebaine Highly lipid-soluble High affinity for the μ-opioid receptor Potent partial agonist action Dissociates slowly from the receptor Clinical significance has not been established. Purdue Pharma Canada. BuTrans Product Monograph, July 2010.

82 Buprenorphine, Current Canadian Formulations Buprenorphine / Naloxone sublingual tablets Buprenorphine Transdermal Buprenorphine Buccal Film Coming: injectable (1 month) implant (6 month)

83 Side Effects 1. Prevent and Treat Constipation Keys to prevention mobility and fluid intake Avoid bulk forming laxatives especially if poor intake Milk of Magnesia (MOM) and lactulose are possibly best/safest laxatives Stimulant laxatives (senna), enemas and disimpaction as necessary short term.

84 Side Effects 2. Sedation/Cognitive Impairment - common on initiating opioids. Beware/minimize concomminant benzodiazepines, neuroleptics and anticholinergic drugs. (reassess opioids if on for prolonged time) 3. Nausea (usually self-limited) antiemetics/motility agents 4. Urinary retention not uncommon in males.

85 Non-pharmacologic Management: Psychological Hypnosis Stress management Psychotherapy Biofeedback Light therapy Distraction therapy Mindfullness Based CBT Physical Physiotherapy TENS Ultrasound Massage Chiropractic Acupuncture Exercise (i.e. Acquafit, walking, stretching, conditioning)

86 Non-Pharmacological Management: Pearls 1. Educate the patient: Lifestyle choices Weight reduction 2. Exercise prescription: patient centred and driven Stretching, strengthening Aerobic exercises

87 Non-Pharmacological Management: Pearls 3. Reduce Falls Risk Home OT assessment Gait Aids 4. Individualized and patient centred management Pain control strategies: nonpharmacologic/pharmacologic 5. Multi/Inter-disciplinary approach

88 Fibromyalgia simplified

89 Pain Intensity Fibromyalgia Augmented Pain Processes 14 Adapted from Gracely Fibromyalgia Subjective Pain Control Stimulus Pressure Control Stimulus Intensity (kg/cm 2 ) Stimuli and responses during pain scan SI = contralateral primary somatosensory cortex SII = secondary somatosensory cortex Arrows = significant increases in the functional magnetic resonance imaging signal Red = common regions of activation in patients with fibromyalgia Green = common regions of activation in the subjective pain control condition Yellow = overlapping activations 1. Gracely RH. Arthritis Rheum. 2002;46:

90 Chronic Widespread Pain - DDx Endocrine conditions Hypothyroidism, Hyperparathyroidism Inflammatory conditions Early stages of inflammatory arthritis (when joint swelling is minimal) Polymyalgia rheumatica (older patients) SLE, Seronegative spondyloarthropathies Hwang & Barkhuizen (2006)

91 Chronic Widespread Pain - Labwork CBC, ESR, Uric Acid CRP, ANA, RF TSH Serum Calcium and phosphate CK B12

92 Thank you!