Learning Objectives Effective, Safe Analgesia An Approach to Appropriate Outpatient Chronic Pain Treatment By the end of this presentation, participants will be able to: Identify multiple factors that affect the success of chronic pain treatment Compare tools to assess pain status Discuss appropriateness of different pain management options 2 Amy Kennedy, PharmD, BCACP Kerry-Ann Fuller, PharmD 1 Types of pain Today s presentation Nociceptive pain Review pathophysiology of pain Pathophysiologic pain Baseline assessment of patients Nonopioid analgesics Acute pain Adjunctive therapies Chronic pain Opioid analgesics Selecting appropriate patients for opioid therapy Modifying opioid therapy 4 3 Nociceptive Pain Nociceptive Pain Perception Response to noxious stimuli Possibly mitigated by Distraction, relaxation, meditation, guided mental imagery Often protective (skeletal or somatic) Includes Transduction Worsened by things causing Anxiety, depression, fatigue, anger, fear Transmission Perception Modulation 6 5
Pathophysiologic Pain Alteration in response to noxious stimuli or healing Nerve damage Certain diseases lead to pathophysiologic changes in pain pathway Symptoms sometimes not consistent with physical findings. Presentation Continuous pain Episodic pain Exaggerated response to noxious stimuli hyperalgesia Painful response to non-noxious stimuli - allodynia Nociceptive Pain Modulation Highly controlled system for modulating pain transmission NTs Endogenous opioids,ne, 5-HT and GABA 8 7 At Presentation Requires evaluation of baseline pain History and PE Onset Duration Palliative and provocative factors Quality Location Severity/Intensity Temporal factors Types of Pain Acute Pain Typically nociceptive If undertreated, increases likelihood of chronic pain syndromes Chronic Pain Persists for months to years Often despite healing of underlying injury May be due to changes in nerve function and transmission 10 9 Nonpharmacologic Therapy Include whenever possible At Presentation Requires evaluation of baseline pain Functionality Physical deconditioning Psychosocial functioning Changes in occupational status Psychological evaluation Pain, depression, anxiety Psychiatric disorders Coping mechanisms 12 11
Nonpharmacologic Therapy Include whenever possible Perception Possibly mitigated by Distraction, relaxation, meditation, guided mental imagery Worsened by things causing Anxiety, depression, fatigue, anger, fear Nonpharmacologic Therapy Include whenever possible Perception Possibly mitigated by Distraction, relaxation, meditation, guided mental imagery Worsened by things causing Anxiety, depression, fatigue, anger, fear 14 13 Pharmacologic Therapy APAP mild to moderate pain NSAIDs Mild to moderate pain Analgesic ceiling All similarly effective Large interpatient variability Reasonable to switch to different agent within class GI, renal and cardiac concerns Topical NSAIDs Nonpharmacologic Therapy Psychological techniques Management of psychiatric comorbidities Cognitive behavioral therapy Relaxation training Biofeedback Physical techniques Physical manipulation Application of heat or cold Acupuncture May be useful for nonspecific, noninflammatory low back pain Exercise 16 15 Pharmacologic Therapy Skeletal muscle relaxants General Cyclobenzaprine, carisoprodol, methocarbamol, diazepam Efficacy shown for acute relief <1 week of low back pain Insufficient evidence for chronic low back pain or sciatica Cyclobenzaprine studied most often Carisoprodol:metabolized to meprobamate Risks for abuse and overdose Spasticity agents Tizanidine, baclofen, dantrolene Tizanidine: efficacy for acute low back pain Limited evidence for baclofen and dantrolene Pharmacologic Therapy Anticonvulsants Typically used for neuropathic pain Include gabapentin, pregabalin and carbamazepine Antidepressants TCAs & SNRIs Effective for a variety of chronic pain etiologies SSRIs Equivocal evidence for diabetic neuropathy Anxiolytics Acute anxiety due to pain 18 17
Considerations in Opioid Therapy Patient selection and risk stratification Treating high risk patients Adjusting therapy Monitoring Adverse effects 20 Opioid Therapy 19 Pt Selection and Risk Stratification History, PE and diagnostics Patient Selection and Risk Stratification Process includes history, physical exam, diagnostic testing, evaluation of functionality risk assessment of substance abuse, misuse and addiction assessment for risk of opioid-related ADE s Physical findings may not be present Intensity of pain Type of pain Neuropathic and non-neuropathic pain can both benefit Limited evidence for conditions with strong psychosocial aspects o Chronic low back pain, fibromyalgia, daily headache Failed trial of non-opioid therapy 22 21 Risk assessment tools Pt Selection and Risk Stratification Factors associated with opioid misuse Screener and Opioid Assessment for Persons with Pain (SOAPP) Personal or family history Younger age Presence of psychiatric conditions Validated tool for risk of opioid misuse 14 questions, 5 point scale, <8 minutes to complete Number of tools available Risk of misuse Appropriateness of pt for COT Questions Emotional state Personal and family history of drug use Legal history 91% sensitivity, 69% specificity Options to choose alternate cutoffs 24 23
Risk assessment tools Risk assessment tools 26 25 Risk assessment tools Risk assessment tools Opioid Risk Tool (ORT) 10 questions Questions Personal and family history of drug use Age History of psychiatric illness History of sexual abuse Rated as low, moderate or high risk 28 27 Risk assessment tools Risk assessment tools Diagnosis, Intractability, Risk, Efficacy score (DIRE) 5-item evaluation Evaluates risk, severity of disease, likelihood of benefit Items Diagnosis: severity of disease and objective findings Intractability: Pt engagement Risk: psychological & chemical health, reliability and social support Efficacy: History of response to therapy Rates suitability of candidate for COT 30 29
Discussion Rate the following two patients as high or low-risk for opioid therapy 30 years old with fibromyalgia and recent intravenous drug abuse Discussion Rate the following two patients as high or low-risk for opioid therapy 60 years old has chronic disabling osteoarthritis pain despite nonopioid therapies no significant psychiatric comorbidities, major medical comorbidities, or personal or family history of drug abuse or addiction 32 31 Patient Selection and Risk Stratification Risk of ADEs history of constipation nausea pulmonary disease cognitive impairment Higher risk patients Care taken that risks can be adequately managed More intensive structure, monitoring, and management Small prescription supply Regular assessment of aberrant behaviors Refer to provides with expertise in addiction and pain medicine History of substance abuse or a psychiatric comorbidities May need to refer to providers in pain management addiction, mental health concerns. May need to defer opioid therapy until comorbidity adequately addressed 34 33 Initiation and titration of therapy Decisions Long-acting vs short acting As-needed or around-the-clock therapy Little data Considerations Opioid-naïve? Point in treatment timeline Likelihood of adverse effects Informed consent/pain agreement Reviewed prior to starting therapy Include side effects risks and benefits monitoring course of therapy expectations of pain relief other modes of therapy discussed periodically 36 35
Increasing doses Consider Disease progression Need for improved symptom control Possibility of abuse/misuse Evaluating ADEs What is a high dose? No consensus 200 mg/day of morphine Consider more frequent or intense monitoring Monitoring therapy Pain intensity Level of functioning Progress to therapeutic goals ADE Adherence UDS 38 37 40 Breakthrough pain Short-acting opioids May increase risk for aberrant drug-related behaviors Trial with routine follow-up reasonable If high-risk Trial with more stringent monitoring/follow-up Assess o Aberrant drug-related behaviors o Progress to therapeutic goals o Risk vs benefit ratio 39 Breakthrough pain Progression of disease New, unrelated pain Needs separate assessment Therapy Directed at cause or precipitating factor Consider nonpharmacologic, nonopioid and opioid therapies Opioid rotation Consider if intolerable adverse effects Inadequate analgesia Allow 25-50% reduction in equianalgesic dose. Planned increase in pain Needs to be treated Maintenance therapy, even at high doses, may not be sufficient Patient may have even higher requirement 42 41
Determing misuse Tools available to identify misuse History UDS Current Opioid Misuse Measure (COMM) 17-item tool, <10 minutes Questions o Functioning o Medication seeking behaviors o Psychological state 77% sensitivity, 66% specificity When to wean No progress toward therapy goals Intolerable ADEs Drug misuse or aberrant behavior Serious or repeated 44 43 Risk assessment tools Risk assessment tools 46 45 48 Weaning effectively Consider inpatient if Severe medical or psychiatric comorbidities Consider rehabilitation center if Pts unable to wean at home Needs structured environment for successful weaning Concerns for addiction Motivation to seek addiction treatment Provide addiction treatment resources Continuing nonopioid pain management 47 Weaning effectively Outpatient 10% weekly to 25 50% every few days Considering factors for rate o Medical and psychiatric comorbidities o Dose of opioid o Presence of withdrawal symptoms May wean faster at higher doses
Adverse effects Constipation N&V tolerance develops in days to weeks antiemetics are helpful Promethazine ondansetron Sedation Impaired cognition Typically tolerance develops over time Monitor at initiation and dose increases Opioid withdrawal Unpleasant Typically not life-threatening Some patients Improvement in function 50 49 Adverse effects Respiratory depression Initiation dose too high Titration too rapid Other drugs causing respiratory depression Underlying pulmonary conditions Adverse effects Hypogonadism Associated with chronic use Symptoms Decreased libido, sexual dysfunction, fatigue Pruritus Myoclonus 52 51 Summary Pain is normally short-lived Pathophysiologic changes may lead to chronic pain past acute stimulus Psychologic state affects response to pain Thorough H&P needed at presentation Nonpharmacologic therapies should be tried whenever possible Psychologic and physical state will need to be addressed Nonopioid analgesics have a number of uses in acute and chronic pain Some skeletal muscle relaxants have benefit in acute low back pain but limited data for chronic use Cautions Driving Opioids cause Sedation, impaired cognition, incoordination, impaired reflexes Greater risk at initiation, concomitant administration with CNS-affecting agents, dose increases. Little data to show an effect on driving 54 53
Questions? Summary Opioid therapy requires careful history and evaluation of physical, psychologic and psychosocial functioning There are risk factors for opioid misuse Many tools exist to help evaluate appropriateness of pt for opioid therapy Dosage adjustments of opioids require more frequent monitoring Tools are available to help assess possible misuse Weaning may require outpatient, inpatient, rehabilitation or addiction services Patients should be regularly monitored for risk/benefit of opioid use and the emergence of ADEs 56 55 References Baumann T, Herndon C, Strickland J. Chapter 44. Pain Management. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 9e. New York: McGraw-Hill; 2014. http://accesspharmacy.mhmedical.com.ezproxy2.library.arizona.edu/ content.aspx?bookid=689§ionid=45310494. Accessed February 12, 2014 Chou R, Fanciullo G, Fine P, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009.10:113-30. http://www.ampainsoc.org/pub/ cp_guidelines.htm American Society of Anesthesiologists Task Force on Chronic Pain Management; American Society of Regional Anesthesia and Pain Medicine.Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010;112(4):810-33. doi: 10.1097/ALN.0b013e3181c43103 Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2;147(7):478-91 Lipman A, ed. Pain Management for Primary Care Clinicians. Ed. New York, NY: American Society of Health Systems Pharmacists ; 2004. 57