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Overview of Pain Management Ingrid Johnston Consultant Pharmacist Objectives 1. To understand the different types of pain 2. To review pain assessment tools 3. To understand principles of pain management 4. To understand the different analgesic groups and common side effects 5. To identify common treatment problems TYPES OF PAIN Many factors can contribute to pain and its perception Nociceptive pain Type of Mechanism Pain Examples Somatic Activation of pain receptors Burns, wounds, on the body surface or malignant ulcers, musculoskeletal tissues muscular injury, arthritis Visceral Damage to internal organs Appendicitis, gallstones, chronic chest pain diverticulitis and pelvic pain Responds Well To Simple analgesics Opioids Anti-inflammatories Non-pharmacological therapies Neuropathic pain Mechanism Examples Symptoms Damage to peripheral and or central nervous system Diabetic neuropathy, central stoke pain, sciatica, phantom limb pain, post-herpetic neuralgia, trigeminal neuralgia Burning, itching, tingling, electric, shooting. Responds Well To Adjuvant drugs Tricyclic antidepressants Anticonvulsants Assessment tools Utilise an appropriate, structured pain assessment tool Verbal descriptor pain scales Numerical pain scale Visual analogue pain scale Faces pain scale FLACC Behavioural pain scale Abbey Pain scale Assessment should explore multiple factors Involve resident or representative Multidisciplinary Structured procedures to identify cause Behavioural assessment tool Abbey Pain Scale Pain assessment in advanced dementia - PAINAD Electronic Pain Assessment? ePAT app http://www.epat.com.au Uses different domains to provide an indication of pain SEVERITY which is quick, accurate, objective and reproducible PAIN MANAGEMENT PRINCIPLES Patient Barriers Unrealistic expectations Anxiety and depression Fear of addiction Fear of becoming tolerant to medications Fear of adverse effects of therapy An inability to comply with complicated programs An inability to understand dosing guidelines Communication difficulties Common Errors Not using regular pain relief No analgesic available for breakthrough pain Not anticipating or treating side effects Inappropriate choice of medicine Lack of clear indication and max dose on PRN orders Lack of documentation regarding use of PRN’s Pain Management Guidelines Treatment Strategies – Combine pharmacological with non-pharmacological – Multidisciplinary approach – Clearly establish goals – Analgesia needs to be tailored for specific pain diagnosis – Side effects may be more troublesome than the pain anticipate, treat or avoid Pain Management Guidelines Regular (around the clock) administration Short acting analgesia for breakthrough pain or prior to an activity – eg dressing changes Consider resident’s co-existing conditions Complementary and alternative therapies may be helpful ANALGESIC GROUPS Analgesic Groups Simple Analgesics Weak opioids Antiinflammatories Strong opioids Analgesic adjuvants World Health Organisation Analgesic Ladder Which analgesic? SIMPLE ANALGESICS Paracetamol Mild pain Metabolised by the liver Excreted by the kidneys Toxic in overdose – Maximum dose is 4000mg per day Many brands Many forms Panadol Osteo PRN use? Has there been any consequences of paracetamol being removed from the PBS? NONSTEROIDAL ANTI-INFLAMMATORY DRUGS Drug name Brand name Aspirin Many brands. Need > 300mg dose Diclofenac Clonac, Dinac, Fenac, Impflac, Voltaren, Ibuprofen Advil, Brufen, Nurofen, Rafen Indomethacin Arthrexin, Indocid Ketoprofen Orudis, Oruvail Naproxen Anaprox, Crysanal, Eazydayz, Inza, Naprogesic, Naprosyn (SR), Proxen, Vimovo – (naproxen with esomeprazole) Piroxicam Feldene, Mobilis Sulindac Aclin Celecoxib Celebrex, Celaxib, Celexi, Kudeq, Meloxicam Melox, Meloxiauro, Meloxibell, Meloxibindo, Mobic, Movalis NSAIDS adverse effects Impair renal function – Triple whammy when combined with ACE-inhibitor/A2 antagonist + diuretic Fluid retention Increase blood pressure Increased risk of cardiovascular events Bronchospasm Gastrointestinal issues NSAIDS adverse effects Gastrointestinal irritation/bleeding To reduce risk – – – – Use paracetamol as an alternative Prescribe NSAID with lower risk Use lowest effective dose Use a PPI or misoprostol with the NSAID NSAIDS Residents who develop – – – – Swollen ankles Difficulty in breathing Black stools Dark coffee-coloured vomit Should stop the NSAID and Inform the doctor Topical NSAIDs Used for muscular aches and pains Safer alternative to oral NSAIDs Only absorbed in small amounts Somewhat less effective Can still cause GIT haemorrhage OPIOIDS Opioids Only about 1 in 5 patients obtain effective pain relief without major side effects Successful response includes – Decrease in pain severity – Improvement in physical function Older people are more sensitive to effects and adverse effects Opioid Weak Strong Relative potency Morphine 10mg im/sc Morphine Hydromorphone 30mg oral * Strong opioid of choice 1.5–2 mg SC/IM; 6–7.5 mg oral Codeine 200mg Fentanyl 100-150mcg sc Methadone Complex Tramadol 150mg oral Dextropopoxyphene Unkwown Oxycodone 15-20mg Opioids -Constipation Expect this to occur Little, if any, tolerance develops Attention to fluid intake, diet and mobility is required Regular laxative use (eg stimulant laxative and stool softener) is essential as soon as chronic opioid treatment is started Opioids – Nausea/Vomiting May occur initially An antiemetic may be given prophylactically Review use within a few days as nausea often lessens with continued opioid use Opioids – Respiratory Depression Best judged by the degree of sedation Sedation score 0 – wide awake 1 – easy to rouse 2 – easy to rouse, but cannot stay awake 3 – difficult to rouse Aim to keep the sedation score <2 a score of 2 represents early respiratory depression Opioid Adverse Effects Sedation Commonly encountered but usually resolves within a few days Tolerance Develops to the respiratory depressant effects of morphine Hallucinations and confusion Due to the high risk, the elderly should receive lower starting doses Clinical Features of Opioid Toxicity Pinpoint pupils Sedation Slow respiration Visible cyanosis Myoclonic Snoring when e.g. lips, ears, nose jerks asleep Agitation, confusion, vivid dreams, nightmares or hallucinations Significant variability in dose at which toxicity occurs Opioid induced hyperalgesia • Associated with long term use – Abnormal pain sensitivity – Pain is more diffuse – Less defined in quality • Management – Reduce dose of opioid – Change to an alternative opioid. Codeine Pro-drug of morphine – Metabolised by CYP2D6 to morphine – 30mg of codeine = 4.5mg of oral morphine – Some people are unlikely to obtain analgesia with codeine due to a genetic lack of CYP2D6 eg 6–10% of Caucasians and 1–2% of Asians What about CYP2D6 inhibitors? – Paroxetine, fluoxetine are strong inhibitors – Duloxetine moderate inhibitor Codeine Some people are ultra-rapid metabolisers – achieve higher morphine concentrations, increasing their risk of toxicity What dose is effective? – Lowest effective dose not well defined – Studies suggest you need 30 mg of codeine – No conclusive evidence Combination analgesics containing 8–15 mg of codeine per tablet with paracetamol, aspirin or ibuprofen Tramadol Opioid and non-opioid actions Less constipation Less analgesia Ceiling effect in cancer pain management Max dose 400mg/day, in elderly 300mg/day Can interact with antidepressants Serotonin syndrome Dextropropoxyphene Doloxene® and Di-Gesic ® Should not be used What’s New? Tapentadol sustained release (Palexia SR) – Dual action – Opioid effect – Noradrenaline reuptake inhibitor Practice points – Controlled release tablets – Do not crush – Twice daily dose, unsuitable for acute pain management What’s New? Opioid with naloxone (Targin®) – Naloxone blocks the opioid effect in the gut to reduce constipation – Naloxone does not enter the brain to prevent analgesic action – Consider use if optimised regular laxatives for opioidinduced constipation are inadequate Practice points – Controlled release tablets – Do not crush – Twice daily dose, unsuitable for acute pain management Targin® Oxycodone/naloxone Markings 5mg/2.5mg OXN, 5 10mg/5mg OXN, 10 20mg/10mg OXN, 20 40mg/20mg OXN, 40 Appearance What’s New? Hydromorphone (Jurnista®) Practice points – Once daily dose – Morphine equivalence: 32mg hydromorphone = 160mg oral morphine – May appear in bowel motions Norspan® and Durogesic® Patch Therapy Advantages – “Flat" steady state effect (minimal peaks/troughs) – Fantastic if swallowing is an issue – Convenient: apply & go... Disadvantages – – – – – Limited/slow ability to titrate Slow onset Conversion difficulties Skin irritation Forgetting to take off the old patch Onset of effect from patch Fentanyl – Up to 72 hours for max effect – Steady state may not be reached until the second patch is applied – Start at time of last the last dose of a 12-hr CR product – 12 hours after the last dose of a 24-hr CR product Buprenorphine – May require other short acting drugs for 72 hours on initiation – No other analgesics for 24hr when discontinued. Slow Release Analgesic Products Many opioid preparations have slow release properties Must not be crushed Not for breakthrough pain due to slow onset of effect Breakthrough analgesia Do not forget it! Approximately 1/10th of the regular dose Normal dose of opioid should be taken at the regular time - no need to wait 4 hours after the breakthrough dose Where possible use the same opioid for regular and PRN use Switching Opioids If adverse effects become intolerable, switching opioid may prove beneficial Consider equianalgesic doses May be incomplete crossover tolerance Start with 50% of the approximate equianalgesic dose Titrate according to response Opioid Comparison Tapentadol 75 – 100mg oral Conversion Ratios Various around ANALGESIC ADJUVANTS Analgesic adjuvants Neuropathic pain commonly responds to opioids Pain relief may be incomplete Analgesic adjuvants may improve response & allow a reduction in opioid dose Neuropathic pain responds best to a combination of opioids and a co-analgesic Analgesic adjuvants Analgesic adjuvants Refractory neuropathic pain Referral NMDA receptor antagonist ketamine Antiarrhythmic drug flecainide – 50mg orally bd up to max 300mg/day Topical capsaicin 0.025% or 0.075% Cannabinoids Botulinum toxin type A local injection Intrathecal administration – Morphine, local anaesthetics, clonidine, baclofen Corticosteroids Analgesic adjuvant for pain due to Inflammation Oedema Local administration intralesional, intra-articular • Prednisolone • Prednisone • Dexamethasone Systemically Oral or parental Beneficial for space occupying pain brain, spinal cord, nerves, liver and soft tissues SUMMARY Principles 1. 2. 3. 4. Comprehensive assessment Multidisciplinary approach Consider nonpharmacological therapies first Consider drug therapy if nonpharmacological therapies are unsuccessful or inappropriate 5. If drug therapy used – appropriate dose/frequency/duration 6. Regularly review patient 7. Provide long-term support. Principles 1. Assume that the resident is reporting a true experience 2. Assess the pain and its impact on daily life 3. Avoid categorising pain as physical or psychological 4. Educate and involve resident in management 5. Determine primary treatment goal 6. Use a multimodal approach 7. Undertake a thorough medication history 8. Correct misconceptions 9. Manage comorbidities – sleep, depression etc 10. Develop a written pain management plan Links to Other Resources Organisation Link Arthritis Foundation http://www.move.org.au/ Supports people with arthritis Australian Rheumatology Association http://rheumatology.org.au/ Supports health professionals and has consumer information WHO analgesic ladder http://www.who.int/cancer/pallia tive/painladder/en/ Care Search http://www.caresearch.com.au/C aresearch/Default.aspx Palliative Care Australia http://palliativecare.org.au/ The Australian Pain Society Relevant evidence and quality information to palliative care National peak body for palliative care http://www.apsoc.org.au/PDF/Pu Management strategies in blications/Pain_in_Residential_Ag residential care ed_Care_Facilities_Management_ Strategies.pdf Links to Other Resources Organisation Link Royal Australian College of General Practitioners http://www.racgp.org.au/yourpractice/guidelines/silverbook/co mmon-clinical-conditions/painmanagement/ p://www.move.org.au/ British Pain Society https://www.britishpainsociety.or Downloadable booklet on g/static/uploads/resources/files/ opioids for persistent pain book_opioid_main.pdf National Prescribing Service (NPS) http://www.nps.org.au/condition s/nervous-systemproblems/pain/forindividuals/painconditions/chronic-pain/forhealthprofessionals/management-plan Downloadable booklet on Medical care of older persons in residential aged care facilities Developing a management plan for chronic pain What quality improvement activities are you likely to implement following this session in regards to your own work? 1. _____________________________________ _____________________________________ 2. _____________________________________ _____________________________________ 3. _____________________________________ _____________________________________