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  1. PAIN MANAGEMENT Terry J. Baumann, Pharm.D., BCPS Clinical Pharmacy Pain Practitioner Clinical Manager Department of Pharmacy Munson Medical Center Traverse City, Michigan


  3. Geek • A performer often billed as a wild man whose act usually includes biting off the head of a live chicken or snake (Merriam Webster’s Dictionary 10th Edition)

  4. THE PROBLEM • 116 million Americans suffer chronic/persistent pain (Institute of Medicine’s Committee on Advancing Pain Research publication “Relieving Pain in America” 2011) • Direct medical costs AND loss of productivity - $560 – 635 billion per year • Conflicting problems of untreated pain AND opioid abuse ADDS to this overall cost • Morbidity secondary to pain twofold greater in patients over 60 • Seen in 40-85% of patients in long term care facilities • One month before death, 66% report pain frequently or all the time • In chronic/persistent non-cancer patients 50% respond to treatments with reduction in pain of 30% (ref #75)

  5. PAIN IN AMERICA • Phone survey-Hart Research Associates July 2003 (1,004 adults) • 76% personally/family member/friend suffer from chronic pain-57% personally • Pain types • Back pain – 28% • arthritis/joint pain – 19% • Headaches/migraines – 17% • Knee pain – 17% • Shoulder pain 7% • Every age group affected • 18-34 -- 54% • 35-49 -- 56% • 50-64 -- 63% • 65+ -- 57%

  6. PAIN IN AMERICA • 75% make life-style adjustments • 20% Disability from work, 17% change jobs, 13% help with daily living, 13% move to another home • 90% did seek professional help • Rx 69% (58% effective) • Chiropractic Tx (54% effective) • Surgery 32% (54% effective 0 • Physical therapy 48% (48% effective) • OTC medications 79% (41% effective) • Other Tx 20% (40% effective) • 72% physicians supportive, 51% of bosses supportive • 57% would be willing to pay an extra $1.00 a week in taxes to pay for more pain research

  7. DEFINITION OF PAIN Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

  8. ALTERNATIVE DEFINITION OF PAIN Pain is whatever the patient says/feels it is, existing whenever he or she says/indicates it does.

  9. TYPES OF PAIN • ACUTE • Follows injury • Generally disappears when injury heals • Well-defined temporal onset • CHRONIC • Persists beyond expected healing time • Cause may be hard to define • CANCER • Definable cause • Can be acute, recurrent, or chronic

  10. CHARACTERISTICS ACUTE PAIN CHRONIC/PERSISTENT PAIN Relief of Pain Highly Desirable Highly Desirable Dependence & Unusual Common Tolerance Physiological Usually Not Present Often a Problem Component Organic Cause Common Often Not Present Family & Environ- Small Significant ment Involvement Sleep Problems Unusual Common Treatment Goal Cure Rehabilitation & Acceptance CHARACTERISTICS OF ACUTE AND CHRONIC/PERSISTENT PAIN

  11. Trends • Acute procedural pain (surgery, labor and delivery) well addressed (ref #71) • Chronic pain continues to be inadequately addressed (40% report ineffective treatment) (ref #71) • A subpopulation exists where opioids do not help and may make overall situation worse • Analgesic ADEs and errors large problem • Recognition/perception that prescription opioids are a large part of illicit drug use problem

  12. Pendulum Swings(according to TJB) • Under-treatment of cancer pain (1960-1970’s) • Development of sustained release opioids (1980’s) • Development of devices that allowed patients to deliver own opioids (1980’s) • Better definition of addiction (1980-1990’s) • Use of opioids in chronic pain (1990-2010’s) • Guidelines for use of opioids (2001-2010) • Better defined use of opioid in non-cancer pain? 2011 - ? • ????

  13. NEWS STORIES ABOUT OPIOIDS • Survey: Illegal Drug Use, Prescription Medication Abuse Increased Among Americans (AFP 9/17/10) • Nation’s Hospitals Seeing Increase in Overdoses Related to Opioid Prescriptions (Tulsa World 7/17/11) • Growing number of Newborns have Painkiller Addiction (NPR/WUSF 2/17/11) • Deaths from Rx Painkillers Still Rising (Med page today 2/17/11) • Inappropriate Use of Prescription Pain Relievers Caused Nearly 425,000 ER Visits in 2009 (CBS affiliate KHQA-TV Hannibal MO, 8/8/12) • Drug overdoses tripled in New York City 1990-2006 and most of increase due to growing abuse of prescription pain meds (New York Times 2/12/12) • 11th straight year deaths due to drug overdoses increased – pharmaceuticals “especially, opioid analgesics, have driven increase (ABC World News 2/19/13)

  14. NEWS STORIES ABOUT OPIOIDS • CDC Director calls painkiller overdoses an epidemic (State WV Journal 11/2, The Oregonian 11/2, CBS Evening News 11/1, Los Angeles Times 11/2, NPR 11/2, HealthDay 11/2, Medscape 11/2) • “More Americans now die from overdosing on painkillers than from overdosing on heroin and cocaine combined”…”deaths linked to opioid pain relievers such as OxyContin, Vicodin, and Opana have become an epidemic…the rate of deaths has more than tripled in the past decade” CDC Director Thomas Frieden

  15. Evidence of Opioid Misuse • Misuse of Opioids Doubles Over Five-Year Period (CDC MMWR 2010;59:705-709) • ED cases involving nonmedical use of opioid analgesics increased from 144,600 (2004) to 305,900 (2008) • Patients receiving higher doses of opioids at higher risk of overdose (Ann Intern Med. 2010, 152(2): 85-92.) • Close supervision of higher risk patients warranted • Unintentional drug overdose is second leading cause of death in US with 40% due to Rx opioids (NEJM. 2010, Nov 18; 363: 1981) • Among patients receiving opioid prescriptions for pain, higher doses were associated with increased risk for over overdose death (JAMA. 2011, 305(13): 1315-1321) • Risk clear what about solution ?

  16. “Perfect Storm” of increasing pain and increasing opioid misuse, abuse and diversion (ref #74)

  17. TREATING CRONIC NONCANCER PAIN WITH OPIOIDS (ref 76) • AAPM AND APS believe Rx of opioids should be extension of good professional practice • Evaluation of patient-physical exam, pain history, pain impact on patient, review of previous diagnostic studies, drug history, coexisting diseases/conditions • Treatment plan-consideration of all aspects of treatment (behavioral, physical therapy, noninvasive techniques, physical and psychosocial support, and medication) • If opioid trial selected risks should be explained to patient and family, and informed consent OR signed agreement obtained • NO TRIAL WITHOUT COMPLETE ASSESSMENT OF PAIN COMPLAINT

  18. TREATING CHRONIC NONCANCER PAIN WITH OPIOIDS (ref #76) • AAPM AND APS believe Rx of opioids should be extension of good professional practice • Consultation as needed • Pain specialist, psychologist, pharmacist • Periodic review of treatment efficacy • Assess functionalstate of patient, continued analgesia, side effects, quality of life, indications of medication misuse, use urine drug screens • Documentation • Reason for opioid, overall treatment plan, periodic review

  19. TREATING CHRONIC NONCANCER PAIN WITH OPIOIDS • Evaluate risk factors for abuse (ref #76) • Personal history of alcohol or drug abuse • Family history of alcohol or drug abuse • Younger age and presence of psychiatric conditions • Use of screening tools • Screener and Opioid Assessment of Patients with Pain (SOAPP version 1 or SOAPP-R) • Opioid Risk Tool

  20. TREATING CHRONIC NONCANCER PAIN WITH OPIOIDS • Signs of drug seeking behavior (DEA) • Unusual behavior in waiting room • Extremes in dress (way over or under dressed) • Comes in at irregular hours (on call doc only) • Must be taken care of NOW • Reluctant or unwilling to provide reference information, no regular physician • Traveling through town, visiting relative, no permanent address • Uses child or elderly person when seeking pain medications • Pressures care giver with guilt

  21. TREATING CHRONIC NONCANCER PAIN WITH OPIOIDS • Watch for diversion (ref 54) • Patients continually trying to fill Rx early despite dose agreements • Frequent reports of lost or stolen Rx • Use multiple pharmacies and multiple prescribers • Is noncompliant with other treatments • Unusual quantity • Quantity looks altered • Reports allergies to all other drugs

  22. Risk Evaluation and Mitigation Strategies (REMS) • FDA approved class-wide REMS for long acting opioids (2012) • 1) Prescriber training (provided by manufacturer and not mandatory) • 2) NEW Medication Guides ( • 3) REMS implementation responsibility falls on pharmaceutical companies • 4) Administrative requirements

  23. Petition Letter to FDA(Pain and Palliative Care PRN, List serve, posted Richard Wheeler, 8/1/12) • 37 Physicians (Physicians for Responsible Opioid Prescribing) • Strike the term “moderate” from the indication for use of opioids in non-cancer pain • Add maximum daily dose, equivalent to 100mg of morphine for non-cancer pain • Add maximum duration of 90 days for continuous (daily) use for non-cancer pain • Response (Professionals for Rational Opioid Monitoring and Pharmacotherapy)

  24. Dr. Jeffry Fudin (posted 1/23/2013) • IT IS NOT OK TO: • Drink alcohol with opioids • Use someone else’s medication • Take more medication than instructed

  25. BALANCING NEWS STORIES ABOUT OPIOIDS • “Taking legal, FDA approved opioid medications as prescribed, under the direction of a physician for pain relief, is safe and effective, and only rarely leads to addiction. When properly used, these medications rarely give a “high”-they give relief. And, most importantly, they allow many people to resume their normal lives” Dr. James Campell, Professor of Neurosurgery at Johns Hopkins Medical Center, past president Of the American Pain Society, and Chairman of The American Pain Foundation (ref 53)


  27. ASSESSMENT OF PAIN • Careful history • Believe the patient and family • When you dislike patients, pain is taken less seriously (ref #77) • Assess the nature of the pain • Acute pain • Distinct onset, short duration, physical signs • Chronic/Persistent pain • Long duration, long-standing functional impairment • Consider neuropathic pain

  28. ASSESSMENT OF PAIN • CONSIDER ONSET, WHAT MAKES PAIN BETTER OR WORSE, LOCATION, DESCRIPTION, SEVERITY, AND DOES PAIN MOVE? • Consider multiple pain types and/or sites. • Assess psychosocial status • Emotional, Social, Cultural • Assess functional status.

  29. MEDICATION HISTORY • All medications used in the past six months • Dose • Duration of use • Frequency of use • Reason for use • Perception of efficacy • Social drug use (Do not forget alcohol) • What worked, how well they worked, what did not • Side effects • Allergies • Nonprescription drug use • Nutritional supplements • Alternative therapies

  30. PAIN TREATMENT PLAN DEVELOPMENT • Develop treatment plans using assessment tools and, whenever possible, include patient and family input. • Remember in chronic pain it is unrealistic in most cases to expect COMPLETE relief of pain. • Do systematic and ongoing reassessments with functional end points in mind. • Change the plan as needed. • Document the plan and all changes. • The process should never end.

  31. The Joint Commission Sentinel Event Alert • Issue 49 concerning the safe use of opioids in hospitals was published on August 8, 2012 • Opioid analgesics rank among drugs most frequently associated with adverse drug events (as high as 16% in one trial) • This may be due to: • Lack of knowledge about potency differences • Improper prescribing and administration of multiple opioids and modalities of administration • Inadequate monitoring The Joint Commission. Sentinel Event Alert. 2012;(49):1-5. Davies EC et al. PLoS One. 2009;4(2):e4439. .

  32. Evidence from The Joint Commission Sentinel Event Database The Joint Commission. Sentinel Event Alert. 2012;(49):1-5.

  33. Selected Risk Factors for Oversedation and Respiratory Depression • Sleep apnea or sleep disorder diagnosis • Morbid obesity • Snoring • Older age • No recent opioid use • Post-surgery status • Opioid habituation • Longer length of time receiving general anesthesia • Use of other sedating drugs • Pre-existing pulmonary or cardiac disease, dysfunction, or major organ failure • Thoracic or other surgical incisions that may impair breathing • Smoker The Joint Commission. Sentinel Event Alert. 2012;(49):1-5.

  34. Actions suggested by TJC • Monitoring Guidelines/Policies • Assessment Procedures • Standardized Order Sets • Second Level Review • Bar Code Scanning • Smart Pumps • EtCO2 monitoring • Computer Decision Support Alerts • Orientation • Newsletters • Healthstream • Encourage multi-modal adjuvant therapies • Assessment Tools • Pain Scales • Risk Assessment Tools

  35. Opioid Risk Assessment Project Total number of patients analyzed = 14. BMI: body mass index. SCr: serum creatinine. BZD: benzodiazepine.

  36. Opioid Risk Assessment Project Total number of chronic pain patients analyzed = 8. BMI: body mass index. SCr: serum creatinine. BZD: benzodiazepine.

  37. Additional Strategies to Improve Patient Care & Safety • Pain Resource Nurse • Adopted from University of Wisconsin Pain Resource Nurse Program • On-going education • Pain Committee • Ad Hoc Opioid Safety Committee • PCA Monitoring • Risk Assessment/increased monitoring • Continuous End-Tidal CO2, SPO2, monitoring • Pasero opioid-induced sedation scale

  38. Additional Strategies to Improve Patient Care & Safety • Pain Medication Order Set • Hydromorphone IV doses adjusted • Fentanyl patch – computer prompts • Patient has chronic pain? • Pain is stable in severity? • Patient has “significant” opioid use? • Methadone • DUE – Fentanyl

  39. OPIOID ANALGESICS • Pharmacologic activity depends on affinity for opiate receptors. • Agents do not eliminate pain, but decrease its unpleasantness. • Some variability in onset and duration of action. • Key to effective use is individualization and proper titration

  40. OPIOID ANALGESIC ADVERSE EFFECTS • Mood changes (minimized with careful titration) • Dysphoria (may be seen as agitation in elderly) • Euphoria or paradoxical excitement • Cognitive disturbances (minimized with careful titration) • Somnolence (minimized with careful titration) • Drowsiness • Inability to concentrate; apathy • Increase in falls

  41. OPIOID ANALGESIC ADVERSE EFFECTS • Respiratory depression (minimized with careful titration) • RARE after receiving several weeks • Nausea and vomiting (tolerance usually develops) • Increased sphincter tone • Urinary retention • Histamine release • Pruritus • Rarely, exacerbation of asthma

  42. OPIOID ANALGESIC ADVERSE EFFECTS • Decreased gastrointestinal motility and secretion • Unlike most other adverse effects that are transient or are avoided with careful titration, this IS TO BE EXPECTED! • Methylnaltrexone (Relistor) sub-q (Block receptors in GI tract) • Use an aggressive bowel regimen • Lots of fluid • Plenty of dietary fiber • Stimulants • Stool softeners • by themselves are often ineffective • Bulk-producing laxative ??

  43. OPIOID ANALGESIC ADVERSE EFFECTSConsensus statement American Academy of Pain Medicine (AAPM), American Pain Society (APS), American Society of Addiction Medicine (ASAM) Feb 2001 • Tolerance – a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time. • Always a possibility • Easily confused with change in pain status • May be minimized with regular dosing • Increase dose to achieve effective analgesia

  44. OPIOID ANALGESIC ADVERSE EFFECTSConsensus statement American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine Feb 2001 • Physical Dependence – a state of adaptation that is manifest by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. • Rarely seen with short-term use • Slow wean will prevent withdrawal symptoms • determined by length of time on therapy and why on therapy

  45. OPIOID ANALGESIC ADVERSE EFFECTSConsensus statement American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine Feb 2001 • Addiction – a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. • Inability to take meds as Rx’d, frequent lost/stolen Rx, Doc shopping, isolation, intoxication • No single event is diagnostic of addictive disorder, diagnosis is pattern of behavior over time

  46. OPIOID ANALGESIC ADVERSE EFFECTSConsensus statement American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine Feb 2001 • Addiction – a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. • Usually not seen in chronic pain, risk is unknown, exposure to drugs only one of etiologic factors • An individual’s behavior that may suggest addiction sometimes a reflection of unrelieved pain or problems unrelated to addiction (Pseudoaddiction)

  47. OPIOID ANALGESICS • Equianalgesic dosing • Can use reference guides (better tables being developed) • Use only as a guide • Individual titration and constant reassessment a must • What-How well-How long-End Point

  48. Opioid Conversion Chart • Demystifying Opioid Conversion Calculations (A guide for effective dosing) Mary Lynn McPherson – American Society of Health System Pharmacists, Bethesda, MD 2010. (Whose “slide rule” are you using????) Terry Baumann e-mail

  49. Other Opioids andConversions • Need to know • What is being treated • How is patient doing on present dose • How long has the patient been treated on this dose • What are the other drugs used to treat the patient • What is the end point