Taking the Pain Out of Pain Management Testing

Transcription

1 Taking the Pain ut of Pain Management Testing Welcome Taking the Pain ut of Pain Management Testing ctober 5, 2010 Your Host: Karen Riba Handout available by clicking on handout icon, in upper right hand corner of your screen For technical difficulties please For questions you have during the presentation use the Q & A link at the top of your screen Questions will be answered at the end of the presentation. Welcome Speaker Information P.A.C.E. credit may be obtained by submitting your completed evaluation form at the end of the webinar CE credit may be obtained by downloading the Certificate of Completion PAML employees will be able to receive one hour of continuing education. Speaker Image David Michaelsen, MS, RP General Manager of Toxicology Manages both clinical and forensic toxicology. He has a bachelor s degree in chemistry from Eastern Washington University, a criminal justice degree from Washington State University and a master s degree in forensic chemistry from ortheastern University. He is the RP for this SAMHSA-certified laboratory. Learning bjectives Discuss the importance of monitoring patients on pain medications through laboratory testing Identify and explore different treatments of pain Describe various medication s affects on pain Explore why specificity and sensitivity are important for pain management testing Interpret pain management test results in order to determine abuse and/or compliance. 10/05/2010 1

2 Taking the Pain ut of Pain Management Testing Pain Management Assessing Pain 9 out of 10 Americans aged 18 or older suffer pain at least once a month, and 42% experience it every day. Pain is one of the most common reasons for patients to seek medical attention. Affecting Sleep? Unable to walk? Enjoyment of life? Unable to Work? Freedom From Cancer Pain Adverse Effects Flector Patch Pulse Stimulation 10/05/2010 2

3 Taking the Pain ut of Pain Management Testing Korean Hand Therapy Acupuncture Altering Pain with Medications Receptor Functionality Mu Delta Located: Brain, Spinal Cord, Intestinal Tract Supraspinal analgesia physical dependence respiratory depression euphoria Located: Brain analgesia less than mu physical dependence antidepressant effects Kappa Located: Brain, Spinal Cord, Pain eurons sedation dysphoria spinal analgesia Chronic Pain Most Challenging Condition to Manage pioids Approx 90% of PM is treated with pioids Tolerance Physical Dependence Patient Divergence Drug Side Effect Lack of Long Term Relief Abuse Potential Behavioral Changes Addiction (MSCotin) Codeine Hydromorphone xycodone(xycotin) xymorphone 10/05/2010 3

4 Taking the Pain ut of Pain Management Testing pioids pioids The Power of piates Strength in Metabolism - Di-Acetyl- Codeine Buprenorphine Buprenorphine Mu partial agonist Delta competitive antagonist Kappa competitive antagonist Suboxone naloxone HCL Subutex Buprenex (Injection) Codeine Heroin xycodone H H 3C H H 3C H3C H3C H H H 3C 6-Monoacetylmorphine Hydromorphone xymorphone H H H H H H 10/05/2010 4

5 Taking the Pain ut of Pain Management Testing Tramadol H. HCl Weak Mu Agonist Like Codeine metabolizing to, Tramadol is converted to -desmthyltramadol Advantages: Fewer Gastrointestinal Issues Tapentadol HCl Marijuana Mu Agonist Long Half-Life hrs Analgesic Activity shorter than half-life Approx 82% of deaths due to are listed as accidental Minimizes nausea and vomiting Decreases intraocular pressure Stimulates hunger Long Duration of Action - Inexpensive Marijuana THC - interferes with the brain s ability to absorb Anandamide Anandamide is believed to play a role in pain sensation, memory and sleep. THC attaches to receptors in the hippocampus and weakens short-term memory. Receptors: CB1, CB2 Partial Agonist Stores and processes memories 10/05/2010 5

6 Taking the Pain ut of Pain Management Testing Urine Drug Testing Abuse Testing Abuse prevalence from pain management has been reported as high as 41%.* Assist w/ therapeutic decisions Identify recent use of prescribed drugs Identify illicit drug use. *Edward J. Cone, Yale H. Caplan,et.al. Urine Drug Testing of Chronic Pain Patients: Licit and Illicit Drug Patterns. J. Anal. Toxicol. 32: (2008). Amphetamine Methamphetamine Barbiturates Benzodiazepines THC Cocaine PCP MDMA MDA Tramadol Propoxyphene Fentanyl Codeine Hydromorphone xycodone xymorphone Heroin Carisoprodol Meprobamate Compliance piates Propoxyphene MS Contin xy Contin xymorphone Tramadol Meperidine Fentanyl Buprenorphine Diverse group of enzymes which main function is to catalyze the oxidation of organic substances like hormones and drugs. More than 11,500 distinct CYP proteins known. 10/05/2010 6

7 Taking the Pain ut of Pain Management Testing CYP1A2 Amitriptyline Desipramine Imipramine Lidocaine ortriptyline Inhibitors Citalopram Mexiletine Inducers Carbamazepine Smoking CYP2C9 Celecoxib Ibuprofen Topiramate Inhibitors Fluoxine Inducers Carbamazepine CYP2D6 Amitriptyline Bupropion Codeine Desipramine Dextromethorphan Doxepin xycodone Tramadol Inhibitors Desipramine Haloperidol Sertraline Inducers Carbamazepine CYP3A4 Amitriptyline Bupropion Citalopram Dextromethorphan Fentanyl Imipramine Ketamine Venlafaxine Benzodiazepines Inhibitors Erythromycin Grapefruit Sertraline Inducers Carbamazepine Dexamethasone Metabolizer Status Genotype Expected Drug Effect UM (ultra-rapid) EM (extensive) IM (intermediate) PM (poor) More than two copies of active enzyme gene alleles Two copies of active enzyme gene alleles Homozygous for two reduced activity enzyme gene alleles or are heterozygous for an inactive allele and a reduced activity allele Homozygous or compound heterozygous for deficiency alleles Usual doses may not lead to therapeutic drug concentration, possible nonresponse Usual doses lead to expected drug concentrations and response Drug effects between those of Ems and PMs Usualy doses may lead to higher than expected drug concentrations and possibly adverse reactions Table assumes that the metabolite resulting from the CYP metabolism is less active or inactive in comparison with the parent drug. CYP450 2D6 Allele Caucasians 7% poor metabolizers Asians 1-2% poor metabolizers African-American 2-4% poor metabolizers Codeine,, xycodone, Potential for toxicity or lack of efficacy CYP450 2D6 Allele = 121 UM (ultrarapid metabolizers) 4.1% EM (extensive metabolizers) 75% IM (intermediate metabolizer) 17% PM (poor metabolizer) 3.3% All white patients Conclusions: Genotype arrived phenotype not significantly associated with a propensity for adverse effects to develop during treatment with metoprolol. However, the results concerning tolerability of metoprolol in PMs were inconclusive because of the small number of PMS enrolled. Clin Pharmacol Ther 2005 ct;78(4):378-87, Impact of CYP2D6 genotype on adverse effects during treatment with metoprolol: a prospective clinical study. Disclaimer: There are currently no guidelines regarding how testing for CYP450 polymorphisms, and the knowledge such testing yields about predicted phenotypes, can be incorporated into clinical practice, and little information about whether such testing produces any real benefits at all. 10/05/2010 7

8 Taking the Pain ut of Pain Management Testing Complexities xycodone xymorphone Hydromorphone Codeine Heroin 6 monoacetylmorphine Carisoprodol Meprobamate Benzodiazepines xazepam or ordiazepam 3 Patients prescribed Avinza, Urine testing Performed Patient # , Hydromorphone 70 ng/ml. Patient #2-6000, Hydromorphone 450, 600 ng/ml Patient # ng/ml. Who is compliant? 1. Patient #3 nly 2. Patient #1 and #3 3. one are compliant. A patient is tested to verify morphine use. A workplace drug test is ordered with the following result: Screen negative for drugs of abuse. Creatinine level is 18 mg/dl, specific gravity is ph is 6.8. o adulterants were found Should this patient be eliminated from the program? 10/05/2010 8

9 Taking the Pain ut of Pain Management Testing Smith, Lori F137xxxx Collected 03/05/ :25am Medications listed Results xycontin CR 60mg TID egative ot Consistent Last Dose 3/4/10 11pm Fentanyl 100 mcg Patch Fentanyl > 250 ng/ml - Consistent 3/5/10 orfentanyl > 500 ng/ml - Consistent 2080 ng/ml ot Consistent Hydromorphone 129 ng/ml ot Consistent Jones, Sara W147xxxx Medications listed: Results xycodone 80mg 2 X day egative ot Consistent 80 mg AM Metab - 17, mg afternoon ng/ml-consistent 20 mg PM Endocet PR 5 daily egative ot Consistent SMA 350 mg 4 X day Meprobamate 3.2 mcg/ml - Consistent THC 344 ng/ml ot Consistent Resources Hurley, Clare T158xxxx Collected 03/09/ :00 Medications listed Results Last Dose 3/5/10 egative Consistent Xanax 1 mg Alprazolam 741 ng/ml Last Dose 3/9/10 2pm Consistent David Michaelsen dmichael@paml.com American Academy of Pain Management, Bonica s Management of Pain, 4 th edition, ISB WebMD, Medicineet.com, ticle.htm Thank-you for Attending Thank-you for Attending P.A.C.E. credit may be obtained by submitting your completed evaluation form. You will find the form by clicking on the handouts icon in the upper right hand corner of your screen CE credit may be obtained by downloading the Certificate of Completion under the handouts icon PAML employees will be able to receive one hour of continuing education credit by submitting your attendance through CE Manager. This webinar has been recorded and will be available ctober 7 th on under the Hospital Tab/Hospital Portal/Webinars heading Look for upcoming webinar information on our website 10/05/2010 9