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severe chronic pain management

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severe chronic pain management

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    1. Severe & ChronicPain Management Michael Rotblatt, MD, PharmD Associate Clinical Professor of Medicine, UCLA Sepulveda VA / Olive View-UCLA Medical Center

    2. Case #1: inpatient A 59 y.o. M truck driver with a hx of IVDU is admitted for acute pancreatitis You order MS 4-6mg IM q 4-6 hrs prn pain He routinely tells you that the shots dont last 4 hrs, the nurses rarely come when called, and he is frequently in pain (pain scale 9/10)

    3. Pain is often inadequately treated Knowledge: Inaccurate estimates of effective doses/durations Exaggerated fears/misconceptions of addiction, respiratory depression, regulatory scrutiny, etc. Attitude: Bias against complainers, drug-seekers, IVDU Hassle factor: Rx refills/visits, documentation

    4. Types of Pain Somatogenic (organic/physiologic) Nociceptive - aching or pressure Neuropathic - sharp, shooting, electrical, burning ex: Post-herpetic, DM, Complex Regional Pain Syndrome (RSD --> CRPS), trigeminal neuralgia, phantom limb... Mixed Psychogenic - without organic explanation

    5. Acute vs. Chronic Pain ACUTE CHRONIC Function To warn None (destructive) Etiology Usually Clear Complex/obscure Pt. Mood Anxiety/fear Depression/anger MD impact Comforting Frustratr/draining Role of tx Control/cure Improve fxn/QOL

    6. Case #2 45 y.o. M with chronic LBP has required dosage escalation of Percocet twice in the last year At times he says his pain is 9/10 in severity, but his pulse is always 60-70 and BP is 130/75 He tried stopping his medications abruptly but he experienced mild withdrawal sxs. Is he addicted to Percocet?

    7. Misconception #1 Opiates: tolerance = dependence = addiction Tolerance = need for increasing doses with time Not typical; may require drug-holidays Physical dependence = dcing or abruptly reducing doses results in withdrawal/abstinence sxs N/V/D/cramps, insomnia/anxiety, diaphoresis/salivation/yawning Addiction (psychologic dependence) Compulsive use resulting in physical, psychological, or social harm Results in drug-seeking behavior for more than pain relief Rare in pts w/o hx of substance abuse Beware of labeling patients an addict

    8. Pseudo-addiction Fear of using opioids ---> inadequate prescribing ---> inadequate pain control ---> appropriate drug seeking behavior ---> patient labeled inappropriately as a drug- seeker ---> inadequate prescribing.

    9. Misconception #2 Pain can be measured Pain is subjective Acute pain activates the sympathetic NS --> VS changes Chronic pain does not Pain scale: 0-10 Pts description must be accepted at face value Individual tolerance is highly variable Emotional states, coping styles, belief systems, genetic differences Optimal dose and duration of analgesic varies widely

    10. Case #2: 45 y.o. M with chronic LBP - chronic pain - nl VS - dosage escalation of Percocet - withdrawal sxs when stopping Percocet Addiction? Chronic pain does not affect VS Tolerance Physical dependence ---> pseudo-addict without appropriate pain control

    11. Case #3: outpatient A 68 y.o. M has chronic low back pain from prostate CA metastases, and painful peripheral neuropathy from DM He takes 1-2 tabs of T#3 about every 6 hours, without good relief He doesnt want to take anything more powerful that will become addicting

    12. Treatment: Analgesic Sequence NSAIDS/Acetaminophen ---> +/- adjuncts Weak opioids ---> +/- adjuncts Strong opioids ---> +/- adjuncts Invasive procedures

    13. NSAIDS Relatively equal analgesia at max doses ceiling (maximum) dose Injectable = ketorolac (Toradol) IM/IV Bone pain; additive effects with opioids Adverse effects GI (dyspepsia, ulcers), renal, platelets, (allergic) Poor choice for chronic pain

    14. Acetaminophen (Tylenol) May be slightly weaker than NSAIDs Additive effects with opioids Safe Overdoses -> hepatotoxicity Higher risk in pts with hepatic disease? Max dose: 4 gm/day 325 mg tablet x 12 (2 tabs q 4 hrs) 500 mg tablets x 8 (2 tabs q 6 hrs)

    15. Opioids Bind to > 4 CNS receptors - mu receptor No ceiling for analgesic effect Maximum dose: relief of pain, side effects, (tylenol) Tolerance, dependence, addiction SEs constipation, N/V, sedation/confusion/dizzy, dry mouth, pruritus hypotension, respiratory depression Respiratory depression - rare; rapidly develop tolerance Much higher risk of undertreating pain than causing resp. depr. Increased risk: Opioid-naive, rapid IV bolus (very elderly, underlying respiratory disease, long half-life drugs, other drugs affecting respiration)

    16. Opioid Dosing Issues Maximum dose of morphine = ___mg? Initial doses of MS: IV IM SQ Scheduled vs. prn Duration of activity is variable Incomplete cross-tolerance

    17. Weak Opioids Propoxyphene (Darvon) pain relief = aspirin, tylenol, placebo Darvocette Codeine T#2 = 15mg + tylenol 300mg T#3 = 30mg + tylenol 300mg T#4 = 60mg + tylenol 300mg

    18. Stronger Opioids: Codeine congeners Hydrocodone - PO, DEA III Vicodin: 5/500mg, ES = 7.5/750mg; HP = 10/660mg Oxycodone - PO, DEA II Combinations: Percocet, Percodan, Tylox. 5/325mg (typical Percocet ) Roxicodone... 5mg OxyContin 10, 20, 40mg (CR) OxyContin abuse/black market - Oxy, Hillbilly heroin

    19. Stronger Opioids - Morphine congeners Morphine - PO, CR, IM/SQ, IV/PCA pump, PR CR: MS-Contin, Oramorph SR, Kadian (QD) 15, 30, 60, 100 mg BID (- TID) Injectable Dosing: 2-4 mg IV, 8-12 mg IM/SQ Hydromorphone (Dilaudid) - PO, IM/SQ, IV, PR No CR products Dosing: 2, 4, 8 mg tabs; 3 mg supps

    20. Stronger Opioids - Synthetics Meperidine (Demerol) - PO, IM/SQ, IV Shortest duration, most irritating, CNS toxicity (normeperidine), MAOI interaction Dose = ____ mg IM/SQ No reason to use Fentanyl - IV, patch q 72 hrs, lollypop Patch: 25, 50, 75, 100 mcg/hr Onset 12-24 hrs Methadone - long t-1/2 (24-36 hrs) --> accumulation Maintains long duration crushed, NG, SL, PR, inj

    21. Misc. Agents Opioid agonist-antagonists: Partial agonists: buprenorphine (Buprenex) dezocine (Dalgan) Mixed agonists-antagonists pentazocine (Talwin-Nx) butorphanol (nasal spray - Stadol) for migraines nalbuphine (Nubain) No reason to use Addictive potential, respiratory compromise Ceiling effects, can precipitate withdrawal, more CNS SEs (delerium) Exception: buprenorphine SL (Subutex, Suboxone)

    22. Misc. Agents Tramadol (Ultram) - 50mg tab, Ultracet (37.5/325) Not a controlled substance; less abuse potential Mech: weak opioid agonist (selective mu) norepi/serotonin reuptake inhibitor 50-100mg QID or q 4-6 hrs (400mg/day max) Ceiling effect; not as effective as strong opioids SE/Cautions Nausea, constipation Accumulates in RF, HF, elderly C/I: seizures (esp. pts taking an antidepressant, antipsychotic, MAOI) Potential drug intx: SSRI

    23. Federal DEA Schedules Schedule 1: Extremely abusable/no medical use Heroin, LSD Schedule 2: High abuse potential; triplicates Morphine, Dilaudid, Percocet, Codeine, amphetamines, ritalin, cocaine, dronabinol (THC) (11159.2 exemption) Schedule 3: Tylenol w/Codeine, Vicodin Schedule 4: Benzodiazepines, Talwin, Darvon, chloral hydrate Schedule 5: Tylenol w/Codeine elixer and codeine cough syrups, lomotil

    24. Analgesic Adjuvants Neuropathic pain Antidepressants TCAs - amitriptyline, nortriptyline/desipramine (less SEs) Start with 10-25mg qhs SSRIs - inferior to TCAs Anticonvulsants Phenytoin, carbamazepine, valproate, lamotrigine, topiramate... Gabapentin (Neurontin) less SEs, no drug intxs, no drug levels Dose: start 300mg/day ---> 3,600mg/day max

    25. Analgesic Adjuvants Pharmacologic Topical: Capsaicin cream, lidocaine Benzodiazepines - anxiolytic/muscle relaxant Muscle relaxants cyclobenzaprine (Flexeril), carsiprodal (Soma), methocarbamol (Robaxin), orphenidrine (Norflex) Dietary supplements glucosamine, chondroitin, SAMe, MSM...

    26. Analgesic Adjuvants Non-pharmacologic TENS/electrical stimulation, heat/cold Stretching/exercise, massage, swimming/aquatic Biofeedback, acupuncture, chiropractic, hypnosis, relaxation therapies Referral Psychiatry/psychology Rehab/PT Pain clinic Neurology, anesthesiology, neurosurgery

    27. Invasive Procedures Trigger point/joint injections Nerve blocks, neuroablation Intraspinal infusions Epidural blocks Intrathecal pump - morphine, clonidine, baclofen Spinal cord stimulator -->

    28. Case #1 (inpatient) 59 y.o. IVDU with acute pancreatitis not controlled on MS 4-6mg IM q 4-6 hrs prn the shots dont last 4 hours, the nurses rarely come when called, and Im frequently in pain MS 8-12mg IM/SQ q 4 hrs ATC (pt may refuse) If still not effective Talk to the nurses change the dose (10-15mg) or the frequency (q 3 hrs) Consider adjuncts (sedative, muscle relaxant, Elavil) Switch to another narcotic (dilauded, fentanyl patch)

    29. Case #3 (outpatient): 68 y.o. M with metastatic prostate CA and DM neuropathy poorly controlled on 1-2 tabs T#3 q6 hrs prn Place on MS Contin 15 mg Q12 hrs, with Dilaudid 2 mg q 4 hrs prn for breakthrough pain, and Elavil 10 mg QHS for neuropathy and sleep Pt returns in one month with better pain control but requiring Dilaudid 3-4 x/day for breakthrough Increase MS Contin to 30 mg Q12 hrs and increase Elavil to 25mg ---> pt reports much better pain relief (only rarely uses dilaudid) and better sleep *** For chronic pain, many patients wont become pain free --> goal = tolerable pain, enhance functioning/QOL

    30. Case #4 47 y.o. M new patient, walks in to clinic without an appt, presenting with chronic LBP He states he takes MS Contin 120 mg BID, 4 percocets/day, flexeril 20 mg TID, and Nortriptylline 150 mg QHS. NSAIDS --> stomach upset He requests RXs for everything

    31. Potential Substance Abusers & Drug Seekers Draining to the health care system & to the provider Pseudo-addiction ? <---> ? addiction Many substance abusers have real pain and do require strong analgesics Current legislative climate sue for under-treatment of pain > over-prescribing pain meds

    32. Signs of addiction/aberrant behavior? Frequently requesting extra/increasing doses Requesting refills from different prescribers Lost/stolen meds Manipulation or deceit Problems with family/friends, job, the law Insist on injectable or short-acting drugs Hx of abuse with other drugs (ETOH) Signs/sxs - slurred speech, abscess, needle mark

    33. What do you do? To tx or not to tx? Occasional misjudgment preferable to withholding meds from patients who are in pain Utilize consultants/specialists - Psych, Pain clin Address addiction directly Objective evidence - urine drug testing Seeking pain relief or pain medication? Enlist family members Encourage treatment (chemical dependency/detox programs)

    34. What to do?, cont... Written contract (agreement) Identifies a single primary provider to provide meds Specifies responsibilities and conditions Document (Get out of Jail Free card)

    35. Take-Home Points Pain is often inadequately treated fears and misconceptions of using opioids Pain is subjective Tolerance vs. dependence vs. addiction Pseudo-addiction Scheduled preferred over prn dosing Duration of activity is variable Tylenol maximum dose = 4 gm/day Narcotic maximum dose = pain relief or SEs

    36. Take-Home Points... Respiratory depression is rare/difficult SQ/IM; usually 2-3 x the IV dose Dont use Demerol or partial agonists/antagonists Use long acting oral agents (e.g. MS Contin) Utilize analgesic adjuncts Refer - Psych, Rehab/PT, Neuro, Anesth, Pain Substance abusers/addicted patients Confront addiction, single provider, written contract Document

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