Easing the Pain Approaches to Managing Pain Associated with Serious Illness Christine S.Ritchie, MD, MSPH, FACP, FAAHPM Harris Fishbon Distinguished Professor Courtesy J Kutner 2 Definitions Acute pain: An unpleasant sensation and emotional response to that sensation Cut, bruise, bone fracture, tooth ache Chronic pain: Unpleasant sensation that continues for prolonged period of time beyond expected time of healing Pain on most days for more than 3 (or 6) months May or may not be associated with identified disease process 3 Pain---how common is it? Community-dwelling adults: 30-50% Nursing homes: 60-80% Among palliative care patients: 83% 25% have severe or overwhelming pain Pidgeon T, et al. BMJ Supportive & Palliative Care 2015 1
Pain-- A complex experience Bio Disease-related mechanisms Biologic mechanisms of psychiatric illness Pain A complex experience Psycho Distress Anger Fear Traumatic life events Social Environmental stressors Close personal relationships 7Gatchel, Am Psychol, 2004; Gatchel, Psychol Bull, 2007 8 Sibille et al. Pain. 2012 September ; 153(9): 1789 1793 2
Pain-- Multimodal management Cognitions Emotions Behaviors Attention Psycho Bio Social Medication Exercise Surgery Sleep Healthcare Family Work Therapeutic Strategies for Pain Pharmacotherapy Nonpharmacologic: Rehabilitative approaches Behavioral approaches Complementary and alternative approaches Lifestyle changes 9 Pharmacotherapy: WHO 3-step Ladder 1 mild ASA Acetaminophen ± Adjuvants 2 moderate A/Codeine A/Hydrocodone A/Oxycodone A/Dihydrocodeine Tramadol ± Adjuvants 3 severe Morphine Hydromorphone Methadone Fentanyl Oxycodone ±Adjuvants Acetaminophen Safest pain medication on market Max allowable dose (4 grams over 24 hours) Most individuals take considerably less Safe for those over 70 to set limit at 3gm/day Need to read labels regarding presence of acetaminophen in other products Too much acetaminophen can cause liver damage Recommended first-line therapy 3
Non-Steroidals- NSAIDS (e.g. ibuprofen, naproxen) Most popular analgesic agents on market Significant safety issues > 100, 000 hospitalizations each year > 16,000 deaths each year Can precipitate heart failure episodes, worsen blood pressure, worsen kidney function Can increase risk of stroke/heart attack Frequent monitoring required Opioids (e.g. morphine, oxycodone, hydrocodone, fentanyl patch) Many side effects (constipation, lethargy, nausea, itching) Effective at treating pain Likely underused by older adults Many barriers to use Patient Physician Treatment Considerations Benefits Associated With NSAID/Opioid Use (Effect Sizes) History and Physical and Appropriate Evaluation Analgesia Improved function Improved quality of life Adverse effects Comprehensive Benefit to Harm Evaluation Overdose Abuse/Misuse patient or contact Addiction Drug-drug and drug-disease Interactions Physical dependence and tolerance Opioids 3 Oral 1 Topical 2 Pain reduction 0.32 0.24 0.58 Physical 0.22? 0.43 functioning Sleep?? 0.87 improvement Quality of life??? Socialization??? Effect sizes: <0.50 small, 0.50-0.79 moderate, 0.80 large. Kotalik J Controlling pain and reducing misuse of opioids. Can Fam Physician 2012;58 1 Bjordal et al BMJ 2004 BMJ. 2004; 329(7478): 1317. 2 Biswal et al J Rheum 2006;33:1841-44. 3 Papaleontiou J Am Geriatr Soc 2010; 58:1353-69. 4
Risks Associated With NSAID/Opioid Use Selective Topical Opioids Renal Acute kidney injury NR CKD progression NR Cardiovascular Stroke NR Heart Attack NR Congestive heart failure NR Blood Pressure increase NR NR = not reported. O Neill et al. Am J Geriatr Pharmacother 2012;10:331-42. Solomon et al. Arch Intern Med 2010;170:1968-78. Makris et al. J Rheumatol 2010;37:1236-43. Risks Associated With NSAID/Opioid Use Nonselect. Selective Topical Opioids Falls/fractures NR GI Ulceration/bleed NR Dyspepsia Hospitalization NR NR = not reported. 1 Bjordal et al BMJ 2004 BMJ. 2004; 329(7478): 1317. 2 Biswal et al J Rheum 2006;33:1841-44. 3 Papaleontiou J Am Geriatr Soc 2010; 58:1353-69. Public Health Impact of Treatment- Related Adverse Effects Hospitalizations (GIBleeding & Acute Kidney Injury) CHF exacerbations Opioids Falls/fractures Constipation/obstipation Mental status changes/sedation Overdoses Constipation Most common adverse effect encountered during chronic opioid therapy No tolerance developed to this side effect Multifactorial Prophylactic laxatives are indicated PREVENTION IS KEY! 5
Constipation: Management Softeners Docusate Cathartics Senna Biscadoyl (Dulcolox) Osmotic Laxatives Magnesium/aluminum salts Lactulose Sorbitol Enemas Fiber- usually not indicated in frail or end-of-life patients Sedation and Cognitive Impairment Discontinue non-essential medications. Evaluate and treat other potential causes. If analgesia satisfactory, decrease dose by 25%. If analgesia inadequate or symptoms persist despite dose reduction: trial of psychostimulant (if sedation) or neuroleptic (if delirium). switch to an alternative opioid. trial of other invasive/non-invasive approach to decrease systemic opioid requirements. When dose-limiting side effects occur with opioid pharmacotherapy... More aggressive treatment of adverse effect(s) Opioid-sparing strategies Analgesic adjuvants Alternate route (e.g. intraspinal) Anaesthetic/Neurolytic procedures PM&R approaches Cognitive therapy Complementary therapies e.g., acupuncture, massage, music therapy Opioid rotation Opioid Prescribing Over Past 16 Years Olfson et al. J Clin Psych 2013;74:932-39. 6
Opioid Overdose Deaths 1999-2009 Dose and Overdose Risk 1 Percent Use Ballantyne K. J Med Toxicol 2012;8:417-23. Group Health Consort Study, 1997 2005; Dunn KM, et al. Ann Intern Med. 2010 Jan 19;152(2):85 92. Therapeutic Strategies for Pain Pharmacotherapy Nonpharmacologic: Rehabilitative approaches Behavioral approaches Complementary and alternative approaches Lifestyle changes Nonpharmacologic Approaches Physical therapy Good for preserving function Underused Passive Heat/ice packs TENS Ultrasound Active Stretching Strengthening/pain relief 7
Nonpharmacologic Approaches Behavioral Therapies Cognitive-Behavioral Therapy Replacing maladaptive cognitions, emotions, behaviors with more adaptive ones Increasing functional capacity through improved coping Other Behavioral Therapies Relaxation training Mindfulness based stress reduction Nonpharmacologic Therapies Cognitive Behavioral Therapy (CBT) Areas addressed by CBT: catastrophizing acceptance of the pain condition avoidance of activity due to unrealistic concerns about harm Your emotions Your thoughts CBT Your behaviors 30 Relaxation Training Mindfulness-based Stress Reduction 31 Deep breathing Guided imagery Progressive muscle relaxation Many tools online: http://theacpa.org/relaxati on-guide https://nccih.nih.gov/healt h/stress/relaxation.htm Awareness and thinking as different capacities. awareness balances out inflammations of thought, emotional agitations and distortions Paying attention to one s pain 32 John Kabot Zin The Mindfulness Solution to Pain; http://elishagoldstein.com/videos/page/2/ 8
Mindfulness-based Stress Reduction Complementary and Alternative Approaches Body Scan- bringing awareness to each body part. Acupuncture Herbs: Feverfew Breathing- calming your mind and grounding your breath. Butterbur. Cayenne (capsaicin) Chamomile tea. Dandelion Ginger Distractions- games, conversations, reading a book 33 John Kabot Zin The Mindfulness Solution to Pain; http://elishagoldstein.com/videos/page/2/ 34 Gingko Stinging Nettle Willow Bark. Supportive Pain Management = Team Care Symptom management Follow-up Nutrition Support Supportive Care and Counseling Intake Review Tailored Plan of Care Spiritual Care Financial and Social Support Coordination Tailored Interdisciplinary Assessment &Treatment Plan Whole Person Approach 9
Summary Pain is common in the setting of serious illness Pain is a complex experience influenced by biology, environment and one s emotions and cognitions Many effective medicines for pain also have significant side effects A holistic approach includes pharmacologic and nonpharmacologic approaches to pain with input and support from an interdisciplinary team. 37 10