University:
West Coast University
Course:
PHAR 835 | IPC Neurology/Psychiatry
Academic year:

2024
Views:

9

Pages:

38
Author:

Asal A.

Introduction to Pain Will Ofstad, PharmD, APh, CDCES August 28, 2024 Presentation Objectives 1. Discuss the impact of pain on patients and society in context of our roles as practitioners. 2. Assess pain and communicate findings using PQRST method. 3. Match pain presentation and patient clinical considerations to therapy (drug and nondrug) as an interprofessional team. 4. Analyze the ethical and humanistic considerations of opioid treatment. Core Values and Guiding Principles Evidence-based practice Advocacy Empathy Collaboration Ethical treatment Cultural inclusiveness Interprofessional teamwork Patient-centered care Communication Compassion Health disparities reduction Comprehensive care CORE COMPETENCIES Roadmap Core Competencies for Pain Management: Results of an Interprofessional Consensus Summit. Pain Med. 2013 Jul; 14(7): 971–981. CDC: Adolescents are at Special Risk • 20% of adolescents with currently prescribed opioid medications reporting using them intentionally to get high or increase effects of alcohol or drugs. • Use of prescribed opioid pain medication before high school graduation is associated with a 33% increase in the risk of later opioid misuse. • Misuse of opioid pain medications in adolescence strongly predicts later onset of heroin use. What happens when you tell clinicians to cut back on opioids? Fear Prescription Suffering Hopeless Diversion Heroin Addiction Death So How Well Are We Managing Pain? • Chronic pain is among the most common reasons for seeking medical attention and reported by 20 to 50% of patients seen in primary care • Currently available treatment modalities on average result in only about a 30% decrease in pain • Patients with a mental health diagnosis are twice as likely to be prescribed an opioid medication • Almost 80% of chronic pain patients report that pain disrupts their activities of daily living, and two-thirds indicate that pain has negatively impacted personal relationships • More than 65% of nursing home residents report having inadequately treated pain • Pain is the most common cause of long-term disability, with lost work days in the United States estimated at more than 50 million days per year • Untreated or undertreated pain is estimated to costs taxpayers and employers over $100 billion per year, in direct and indirect expenses as Theory burst: PQRST Pain Assessment Introduce yourself and role. “Tell me about your pain” Pair Up & Get Started P: Provoke & Palliate (What makes it better/worse? Medications? Non-drug?) Q: Quality (Describe the feeling? Sharp/dull/shooting/burning/tingly/throbbing?) R: Radiation (Where do you feel it? Where does it spread?) S: Severity (Compared to before? Ask pain scale. Determine function. Ask goals & values) T: Timing (Frequency, duration, sudden or gradual onset/offset?) Mood Others Work Function and Living Eat Focus Sleep Vocabulary • Chronic (non-cancer) pain — pain which lasts beyond the ordinary duration of time that an insult or injury to the body needs to heal. (CDC: > 3 months) • Tolerance: diminishing effect as a result of chronic exposure to the opioid, highly patient variable. • Physical dependence: withdrawal (overwhelming pain, significant sign/symptoms of pain, sympathetic activation) upon abrupt opioid discontinuation or reversal with an antagonist. ➔ Tolerance and physical dependence do not tell us anything about if a patient is addicted. • Addiction: requires loss of control, compulsive use, or continued use despite overall harm. Very negative connotation, careful in your assessment and communication with the patient and family. • Pseudo-addition: occurs when patients behave in a manner that appears to have elements of addiction, but are actually due to unrelieved pain. Nociceptive Pain Figure developed by Robert W Mier DDS, MS WHO Pain Relief Ladder ACUTE PAIN! Neuropathic and Functional Pain Neuropathic: nerve pain Functional: without evidence of a pathologic condition, pain pathways are malfunctioning May be due to underlying disease • postherpetic neuralgia (due to varicella zoster viral infection) • diabetic neuropathy (due to uncontrolled diabetes) Or inherent pain pathway dysfunction, examples • Fibromyalgia, IBS, tension headache Non-Drug Options ➔ Manage other chronic problems (particularly mood, anxiety, sleep) ← • Physical and occupational therapy • Surgery • Warm pool / hot tub • Rest / ice / compress / elevate • Weight loss / exercise • Acupuncture • TENS (transcutaneous electrical nerve stimulation) • Biofeedback / relaxation therapy / stress management • Distraction • Cognitive behavioral therapy • Meditation / guided imagery / hypnosis Thinking Changes Pain Changes Thinking Radiolab | Season 10 | Episode 3 | Loops Team Activity: How should “Thinking Changes Pain Changes Thinking” inform our interaction with and support of people with chronic pain conditions? Not all pain responds best to opioids… • Nerve/functional pain: TCAs, SNRIs, anticonvulsants • Joint/inflammation: NSAIDs, steroids • Muscle spasm: muscle relaxants, benzodiazepines • Acute treatment of migraine: NSAIDs, APAP, caffeine, vasoconstrictors (triptans, ergots) • Lower back pain: NSAIDs, APAP, TCAs • Trigeminal neuralgia: carbamazepine, oxcarbazepine • Cancer bone pain: bisphosphonates, steroids, NSAIDs Also remember: treating co-morbidities and nondrug strategies can be as effective as medication Select Menu of Medication Classes Class [prototypes] Best for Tips Caution Opioids [morphine, oxycodone, fentanyl] Acute severe pain Consider non-opioid options Sedation (caution driving, working, monitor function) Methadone is an opioid and mild SNRI and NMDA antagonist (but only used by experts) TCAs [amitriptyline, nortriptyline, desipramine] Sometime for chronic noncancer pain if function improves Always recommend with colace and senna Constipation, N/V, itching Chronic pain usually requires long acting around the clock and short acting for breakthrough pain Respiratory failure Calculate daily morphine equivalence, each breakthrough dose ~10% Avoid benzodiazepines Never give long acting to opioid naïve patient Highly effective for most neuropathic pain fibromyalgia Take before bedtime Anticholinergic especially elderly (drying, sedating, confusion, sex dys, falls) Prevent migraines May have small mood benefit (but antidepressant doses are higher than pain doses) Milder adverse effects with nortriptyline, desipramine Tolerance develops Risk diversion, addiction Long QT Serotonin syndrome in combination Select Menu of Medication Classes Class [prototypes] Best for Tips Caution SNRIs [venlafaxine, duloxetine] Effective for most neuropathic pain and fibromyalgia A good choice if mood and pain are comorbidities Generally mild Sleep changes Nausea Tramadol is an opioid and SNRI Also has mood benefit Venlafaxine: Raises BP Some SNRIs are brand and expensive Prevent migraines Serotonin syndrome in combination Anticonvulsants [gabapentin, pregabalin] Effective for most neuropathic pain Gabapentin requires up titration and TID dosing, titrate up to 600mg TID Prevent migraines Other anticonvulsants are used less often Pregabalin is expensive Carbamazepine usually only for trigeminal neuralgia, serious adverse effects Generally mild for gabapentin and pregabalin Carbamazepine: N/V, leucopenia, thrombocytopenia, somnolence, liver injury, drug interactions, SJS, life threatening rash Select Menu of Medication Classes Class [prototypes] Best for Tips Caution NSAIDs [ibuprofen, naproxen] Inflammation and nociceptive pain High doses around the clock needed for inflammation. But more risk for GI bleeding and renal effects. GI bleeding at higher doses and with other agents that cause bleeding Celecoxib has less GI bleeding, but more MI Opioid sparing in combination Frequent high doses leads to temporarily reduced renal function, increase BP and fluid retention. (APAP is not an NSAID, but also opioid sparing and fewer ADEs) If used in combo with 81mg ASA, take the ASA an hour before NSAID Acute migraine Pair Activity: Pro’s and Con’s Identify drug and non-drug treatment options for each patient below. Consider potential pro’s and con’s of using the medication classes from the menu. (1) Senior: New onset stroke patient presenting with difficulty communicating, taking ASA 81mg, with history of diabetic neuropathic pain. (2) Middle Aged: Recent fall requiring hip surgery, and pain unresolved by ibuprofen. (3) Senior: Early stage Alzheimer's Dementia with history of opioid use for chronic pain. Moves in with daughter and her two teenaged children. CORE COMPETENCIES Roadmap Core Competencies for Pain Management: Results of an Interprofessional Consensus Summit. Pain Med. 2013 Jul; 14(7): 971–981. Core Values and Guiding Principles Evidence-based practice Advocacy Empathy Collaboration Ethical treatment Cultural inclusiveness Interprofessional teamwork Patient-centered care Communication Compassion Health disparities reduction Comprehensive care IOM 2011: Relieving Pain in America • Effective pain management is a moral imperative, a professional responsibility, and the duty of people in the healing professions. • Given chronic pain’s diverse effects, interdisciplinary assessment and treatment may produce the best results for people with the most severe and persistent pain problems. • The committee recognizes the serious problem of diversion and abuse of opioid drugs and questions about their long-term usefulness; it believes, however, that when opioids are used as prescribed and are appropriately monitored, they can be safe and effective • The effectiveness of pain treatments depends greatly on the strength of the clinician–patient relationship; pain treatment is never about the clinician’s intervention alone, but about the clinician and the patient (and family) working together. Patient-Centered Care The IOM (Institute of Medicine) defines patientcentered care as: “Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.” Institute of Medicine 2001. “Crossing the Quality Chasm: A New Health System for the 21st Century” Four Competencies of Interprofessional Collaborative Practice *IPEC, CORE COMPETENCIES FOR INTERPROFESSIONAL COLLABORATIVE PRACTICE (2011, 2016) Values/Ethics for Interprofessional Practice Work together with mutual respect and shared values. Roles & Responsibilities Shared acknowledgement of each participating team member’s roles and abilities. Interprofessional Communication Communicate in a responsible manner that supports a team approach. Teams and Teamwork Apply relationship-building values and the principles of team dynamics. Communication Importance of Communication ■ Joint Commission data continues to demonstrate the importance of communication in patient safety ■ 1995 - 2005: Ineffective communication identified as root cause for nearly 66 percent of all reported sentinel events* ■ 2010 - 2013: Ineffective communication among top 3 root causes of sentinel events reported** * (JC Root Causes and Percentages for Sentinel Events (All Categories) January 1995−December 2005) ** (JC Sentinel Event Data (Root Causes by Event Type) 2004-2012) Mod 3 2.0 Page 35 TEAMSTEPPS 05.2 35 Effective Communication is ... “... the successful joint establishment of meaning wherein patients and healthcare providers exchange information, enabling patients to participate actively in their care from admission through discharge, and ensuring that the responsibilities of both patients and providers are understood” (The Joint Commission, 2010b, p. 91 ) ABC – Addictive Behaviors Checklist (≥3 flags) Addiction behaviors - since last visit Addiction behaviors - within current visit  used illicit drugs or evidences problem drinking  appears sedated or confused (eg, slurred speech, unresponsive)  has hoarded meds  expresses worries about addiction  used more narcotic than prescribed  expressed a strong preference for a specific type of analgesic or a specific route of administration  ran out of meds early  expresses concern about future availability of narcotic  has increased use of narcotics  reports worsened relationships with family  used analgesics PRN when prescription is for time contingent use  misrepresents analgesic prescription or use  received narcotics from more than one provider  bought meds on the streets  indicates she or he "needs" or "must have" analgesic meds  discussion of analgesic meds is the predominant issue of visit  exhibits lack of interest in rehab or self-management  reports minimal/inadequate relief from narcotic analgesic  indicates difficulty with using medication agreement  Significant others express concern over use of analgesics If the opposite of addiction is connection… What should we do as professionals and as human beings when we see addictive behaviors? The A’s of Opioids: Assessment, Amounts, ADEs, Alternatives, Abuse, Addiction Assessment: PQRST baseline and reassessment, function, thinking, goals Alternatives: pain type, nondrug, opioid sparing strategies ADEs: importance of bowel regimen, exercise, maintain activities of daily living Abuse: risk of harm, diversion/street drugs, CUREs software, insurance, pain contract, urine screening Addiction: connection Amounts: calculating morphine equivalence, understand ATC and breakthrough Equianalgesic? • Equianalgesic opioid dosing refers to potency, how strong is • Potency is affected by route the opioid per mg or mcg (see conversion table, tables vary) • 30mg PO morphine = 10mg IV morphine  parenteral morphine is more potent • Note: the duration of action will affect how we divide the dose in the day, but not the total equianalgesic dose. • morphine SR 90mg PO q12h = morphine 30mg PO q4h fentanyl patch 25mcg/hr (x 1 day) = 75mg PO morphine/day = morphine SR 25mg PO q8h What is incomplete cross tolerance? • • • Tolerance occurs when opioids loses potency over time, requiring higher doses • Develops within the first week of treatment • Exceptions: miosis and constipation continue to worsen at higher doses Incomplete cross tolerance (ICT): • Less tolerance to the new opioid than original opioid after long-term use • Thus, even if equal analgesic potency (per the conversion table), the new opioid dose is too strong Clinicians consider reducing new opioid dose by 25-50% • Not applicable for fentanyl patch or methadone conversions (special conversion tables) • Not typically reduced if patient is currently in pain • More common to reduce if patient is frail, elderly, or ADEs present Team Problem 34 yo M, pain controlled on morphine SR 90mg PO BID and hydromorphone 1mg SQ q3h PRN pain (uses 6 doses/day). You want to convert to fentanyl patch. Hint: 30mg PO morphine = 1.5mg SQ hydromorphone Hint: 25mcg/hr fentanyl = 75mg/day PO morphine Solution 1. Calculate MEDD: 90mg x 2 = 180mg PO morphine 1mg x 6 x (30mg PO morphine/1.5mg SQ hydromorphone) = 120mg PO morphine ----------------------------- MEDD  2. 300mg/day PO morphine Convert to fentanyl patch 300mg/day PO morphine x [(25mcg/hr fentanyl) / (75mg/day PO morphine)] total equianalgesic dose  3. = 100 mcg/hr fentanyl patch ICT and clinical considerations  ICT not used for fentanyl patch conversions, pt young, currently pain well controlled. No immediate need to titrate up/down dose. Order: fentanyl patch 100 mcg/hr, apply 1 patch q72h Solution cont. 4. Cover breakthrough pain (~10% MEDD/dose, choose frequency based on dosage form). Let’s choose morphine as our breakthrough agent (inexpensive, patient tolerates). 10% MEDD = 30mg PO morphine Order: morphine 30mg PO q4h PRN pain 5. Reassess the patient in 2-3 days, and titrate as needed.

Introduction to Pain

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