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CHAMP Pain Control Stacie Levine MD University of Chicago Why is this important to teach on the wards? • Pain is common in the elderly • Pain is under-recognized and undertreated • JCAHO, ACGME/RRC requirements • Lack of formal education on pain control Why is pain control often not optimal? • Clinician unfamiliarity with assessment and treatment • Opioid misconceptions -patients, families, and clinicians • Fear of side effects • Concern about addiction, regulatory reprimands, and lawsuits Sources of pain in the elderly • Degenerative joint disease • Spinal stenosis • Fractures • Pressure ulcers • Neuropathic pain • Urinary retention • • • • • • Post-stroke syndrome Improper positioning Fibromyalgia Cancer pain Contractures Postherpetic neuralgia • Oral/dental • Constipation Consequences of unrelieved pain • Sleep disturbance • Functional decline • Depression, anxiety • Malnutrition • Lawsuits • Challenging behaviors • Polypharmacy • Increased healthcare utilization • Prolonged LOS Teaching Objectives • Knowledge: Housestaff should know -Properties of medications used for pain -Common side effects of opioids • Skills: Housestaff will demonstrate -bedside pain assessment in older adults (cognitively intact and impaired) -use of WHO 3-step ladder -use of opiate conversion tables Teaching Objectives • Attitudes: Housestaff should -appreciate how pain assessment and management in older adults differs and has high degree of variability -appreciate patients symptoms of pain or pain-related behaviors -express satisfaction in evaluation and management of pain Outline for Faculty Module • Recognition and assessment -Cognitive impairment • Medication selection • Dose selection and titration • Opiate conversions • Management of myths and side effects • Discharge planning Outline for Module • Recognition and assessment -Cognitive impairment • Medication selection • Dose selection and titration • Opiate conversions • Management of myths and side effects • Discharge planning Teaching Trigger Case • You are rounding on an 83 y.o. NH patient admitted with pneumonia • She has advanced dementia, bed- bound, limited verbalization • PMHx: DM, HTN, Stage 3 sacral ulcer s/p debridement day before • Patient stopped eating and is resisting care Trigger Case (cont.) • Housestaff concerned she is depressed and started Mirtazapine • No surrogate available, wonder if a PEG will need to be placed • Question: How do we teach about recognition of pain in persons with cognitive impairment? Bedside Assessment • ASK the patient about present pain • Identify preferred pain terminology -hurting, aching, stabbing, discomfort, soreness • Use a pain scale that works for the individual -Insure understanding of its use -Modify sensory deficits Unidimensional Scales Acute Pain Management Guideline Panel. Acute Pain Management in Adults: Operative Procedures. Quick Reference Guide for Clinicians. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. February 1992. AHCPR Pub. No. 92-0019. Faces Pain Scale and Pain Thermometer Assessing pain: Nonverbal, Moderate to Severe Impairment • Formal assessment tools available but not necessarily useful in routine clinical settings • Unique Pain Signature • Nonverbal Pain Indicators Unique Pain Signature • How does the patient usually act? • What changes are seen when they are in pain? family members nursing staff • Communication across caregiver settings is key! Nonverbal Pain Indicators • Facial expressions (grimacing) -Less obvious: slight frown, rapid blinking, sad/frightened, any distortion • Vocalizations (crying, moaning, groaning) -Less obvious: grunting, chanting, calling out, noisy breathing, asking for help • Body movements (guarding) -Less obvious: rigid, tense posture, fidgeting, pacing, rocking, limping, resistance to moving Nonverbal Pain Indicators • Changes in interpersonal interactions -combative, disruptive, resisting care, decreased social interactions, withdrawn • Changes in mental status -confusion, irritability, agitation, crying • Changes in usual activity -refusing food/appetite change, increased wandering, change in sleep habits Assessing pain: Nonverbal, Moderate to Severe Impairment (AGS Panel 2002) 1) Presence of non-verbal pain behaviors? -assess at rest and with movement 2) Timely, thorough physical exam 3) Insure basic comfort needs are being met (e.g. hunger, toileting, loneliness, fear) 4) Rule out other causative pathologies (e.g. urinary retention, constipation, infection) 5) Consider empiric analgesic trial Outline • Recognition and assessment in cognitive impairment • Medication selection • Dose selection and titration • Opiate conversions • Management of myths and side effects • Discharge planning Teaching Trigger Case • You are rounding on a 75 y.o. male s/p fall • History of lumbar stenosis with new onset severe sharp pain down left leg • Xrays negative • Subintern started prn NSAIDs • Patient in severe pain at rounds • Question: How do we teach about medication and dose selection in older adults? Multimodal Approach to Pain Management Pharmacotherapy Complementary Alternative Medicine Physical Therapy Treatment Approaches Psychological Support Exercise Interventional Approaches Medication Selection • Good pain history • Target to the type of pain -e.g. neuropathic, nociceptive • Consider non-pharmacologic or nonsystemic therapies alone or as adjuvants • Use the WHO 3-Step ladder WHO 3-Step ladder Source: World Health Organization. Technical Report Series No. 804, Figure 2. Geneva: World Health Organization; 1990. Adjuvants • Topicals (lidocaine patch, capsaicin) • Acetaminophen • NSAIDS, celecoxib, steroids • Anticonvulsants • Antidepressants • Non-pharmacologic (TENS, PT/OT) Step 1(Mild): Non-opioids • Acetaminophen • NSAIDS • Cox-2 • Non-systemic therapies • Non-medication modalities • +/- other adjuvants Step 2 (Moderate): Mild Opioids, Opioid-like • Codeine (e.g. T #3®) • Hydrocodone (e.g. Vicodin®) • Oxycodone (e.g. Percocet®) • Tramadol (Ultram®) • +/- Adjuvants Step 3 (Severe): Strong Opioids • Morphine • Oxycodone • Hydromorphone (Dilaudid®) • Fentanyl • Oxymorphone • Methadone • +/- Adjuvants Transdermal Fentanyl • Duration 24-72 hours • 12-24 hours to reach full analgesic effect • Not recommended as first-line in opiate naïve patients • Lipophilic • Simple Conversion rule: -1 mg po morphine = ½ mcg fentanyl -(60 mg morphine roughly 25 mcg patch) Other Fentanyl • Intravenous (equivalent to patch dose, e.g. Duragesic 100 mcg/72 = 100 mcg/hr IV) • Transmucosal -Actiq® -Fentora® • Iontophoretic Fentanyl Patch - Ionsys ® Methadone, a Complicated Med • Should only be used by those with experience! • Mu, kappa, delta agonist • Inhibits reuptake of serotonin and norepinephrine • NMDA antagonist (neuropathic pain) • Significant inter-individual variability • Drug interactions (coumadin-like) Methadone (cont.) • Initial rapid tissue distribution • Slow elimination phase • Long and variable half-life (13-58 hours) • Dose interval is variable (q 6 or q 8) • Dose usually adjusted q 4-7 days • Minimally impacted by renal disease • Inexpensive, less street value than other opioids Drugs to Avoid • Meperidine (Demerol®) • Mixed agonist-antagonist -e.g. Pentazocine (Talwin®) • Propoxyphene (Darvon ®, Darvocet ®) Opioid Pharmacology • Block the release of neurotransmitters in the dorsal horn of spinal cord • Mu, delta, kappa expressed differently, depending on opioid medication • Conjugated in liver • Excreted via kidney (90%–95%) • Exception: methadone, excreted fecally Opioid Use in Renal Failure • Not rec’d: meperidine, codeine, dextropropoxyphene, morphine • Use with caution: oxycodone, hydromorphone • Safest: fentanyl, methadone • Opioid dosing CrCl >50 mL/min normal 10 - 50 mL/min 75% of normal <10 mL/min 50% of normal Clearance Concerns Dehydration, renal failure, severe hepatic failure dosing interval (extend time) or dosage size – if oliguria or anuria • STOP around the clock dosing of opioids (like morphine) • use ONLY prn Opioids for Continuous Pain • Dose find, opioid naive: -begin with short-acting opioid ATC -allow breakthrough based on Cmax and patients metabolism • Cmax (peak) after – po, pr 1 h – SC, IM 30 min – IV 6 – 15 min Dose-finding To achieve quick pain relief: (LOAD) 1. Start low dose, shortacting 2. Dose q peak 3. P.C.A. not “prn” (Patient controls it) 4. Re-eval in 4 hrs. to figure out what dose is needed Starting doses and half-life • For thin, frail elderly suggest 2-5 mg po MSO4 or an equivalent (e.g. 1/2-1 percocet q 4h) • Half-life at steady state – po / po / SC / IM / IV 3-4 h – 4-5 half-lives to reach steady state Opioid Dose Escalation • Should be done on percentage increase irrespective of starting dose mild / moderate pain severe / uncontrolled pain 25%–50% 50%–100% • How frequent? Depends on t1/2 Short-acting single-agent Long-acting Fentanyl transdermal Methadone every 2 hrs every 24 hours 72 hours 4-7 days Breakthrough dosing • Use immediate-release opioids – 10% of 24-h dose or 1/3 of one ER dose – offer after Cmax reached • po / pr • SC, IM • IV q1h q 30 min q 10–15 min • Do NOT use extended-release opioids for breakthrough Outline • Recognition and assessment in cognitive impairment • Medication selection • Dose selection and titration • Opiate conversions • Management of myths and side effects • Discharge planning Teaching Trigger Case • You are rounding on a 70 y.o. male ESRD on HD admitted with pleuritic chest pain • New pulm mass found on chest CT • Severe pleuritic pain well-controlled on hydromorphone 4 mg IV q 3 hours • Intern asks for help converting him to something he can take at home • Question: How do you teach about proper opiate conversions? Equianalgesic Dosing Ratios Opioid Hydromorphone Morphine Oxycodone Hydrocodone Codeine Oral/Rectal 4 15 10 15 100 IV/SC 0.75 5 NA NA 50 Note: Equianalgesic equivalencies are merely estimates and are based on single-dose studies. Changing Opioids – Cross-tolerance • Start with 50%–75% of published equianalgesic dose 1) Example: morphine 60 mg po every 12 hours 2) Change to po oxycodone long-acting 3) Use conversion ratio m:o = 15:10 4) 120 mg/x=15/10=80 mg every 24 hours 5) Reduce by 50% = 40 mg every 24 hours =Oxycodone LA 20 mg every 12 hours Exception = Methadone conversion Daily Morphine -<100 mg -101-300 mg -301-600 mg -601-800 mg -801-1000 mg ->1000 mg Methadone:Morphine (1:3) (1:5) (1:10) (1:12) (1:15) (1:20) Note: Conversion to methadone is complicated and should only by done by those with experience! Outline • Recognition and assessment in cognitive impairment • Medication selection • Dose selection and titration • Opiate conversions • Management of myths and side effects • Discharge planning Teaching Trigger Case You are rounding on a 90 year old female with severe osteoporosis admitted for sudden severe back pain • New vertebral compression fracture • Pain controlled on morphine 4 mg IV q 4 hours • Patient very sedated, family concerned • Question: How do you teach about treatment of side effects of opiates? Opioid adverse effects Common Uncommon Constipation Dry mouth Nausea / vomiting Sedation Sweats Bad dreams / hallucinations Dysphoria / delirium Myoclonus / seizures Pruritus / urticaria Respiratory depression Urinary retention Hypogonadism SIADH GI Side Effects Constipation -NEVER resolves -Prevent with scheduled softeners PLUS stimulants -Avoid bulking agents (e.g. Metamucil®) Nausea and Vomiting – Encourage patients to eat frequent, small meals – Treat with promotility agents (metoclopramide), serotonergic blocking agents (odansetron) or dopaminergic blocking agents (haloperidol, metoclopramide, prochlorperazine) Sedation and Delirium • Consider trying one of the following: 1) If pain control is adequate, decrease dose by 25% 2) Rotate to a different opioid preparation 3) Use small doses of psychostimulants (2.5 to 5 mg methylphenidate or dextroamphetamine) for excessive somnolence • Use nonsedating antipsychotics (haloperidol, risperidone) for delirium Respiratory Depression • Does not occur in patients on chronic opioids • Can occur in opioid-naïve patients whose opioid dose is rapidly escalated • Is always preceded by slowly progressive somnolence • If you must treat: -Dilute naloxone (10:1) in saline and infuse 1 mL until breathing pattern returns to normal Teaching Trigger Case You are rounding on a 65 y.o. male with gout exacerbation • Former cocaine addict • Severe pain in hands, elbows, knees • Resident told intern to give tylenol and steroids • Patient asking for something stronger for pain • Resident advised intern to “wait it out”, afraid of awakening a former addiction Question: How do you teach about pain treatment in persons with a history of addiction or those who express concern about becoming addicted to opiates? Addiction • A psychologic dependence on drugs and a behavioral syndrome characterized by compulsive drug use and continued use despite harm to self and others •Use of opioids for pain management does NOT cause addiction in the majority of people Physical Dependence/Withdrawal • Develops if chronic opioids are abruptly discontinued or dose is rapidly decreased • Symptoms: -Nausea, vomiting, diarrhea, abdominal pain, body aches -May result in psychosis and hallucinations -Treatment: Taper dose by 50% every 2 to 3 days Pseudoaddiction • Occurs in context of -Undertreated pain -Behavioral, family, or psychologic dysfunction • Consists of behaviors that are reminiscent of addiction but driven by untreated or undertreated pain • Disappears once pain control is adequate Tolerance Reduced effects of a given dose of medication over time • Doses remain unchanged when pain stimulus is stable • Tolerance to unwanted side effects is observed and is desired • Disease progression (not tolerance), should be suspected when increasing doses are required for pain control Outline • Recognition and assessment in cognitive impairment • Medication selection • Dose selection and titration • Opiate conversions • Management of myths and side effects • Discharge planning Teaching Trigger Case • Your team is preparing to discharge a 70 y.o. male with chronic severe Pagets disease requiring narcotics, responded well to hydromorphone • Intern asks you to sign the Rx (next slide) • Question: How do you teach about appropriate discharge planning, including prescription writing, in persons with pain? Common pitfalls to avoid • Changing meds/route on discharge • Writing the prescription • Medication cost • Educating patient/family • Appropriate follow-up TEACHING PRACTICE: MODIFIED ROLE PLAYS Teaching Case #1 • You are rounding on an 83 y.o. NH patient admitted with pneumonia • She has advanced dementia, bed-bound, limited verbalization • PMHx: DM, HTN, Stage 3 sacral ulcer s/p debridement day before • Patient stopped eating and is resisting care Case #1 (cont.) • Housestaff concerned she is depressed and started Remeron • No surrogates – wonder if a PEG will need to be placed • Teaching task: Generate a discussion regarding the assessment of pain in cognitively impaired patients Teaching Case #2 • You are rounding on a 75 y.o. male s/p fall • History of lumbar stenosis with new onset severe sharp pain down left leg • Xrays negative • Subintern started prn NSAIDs • Patient in severe pain at rounds Case #2 (cont.) • Teaching Task: Introduce the WHO 3-step ladder as a framework for medication selection and titration Teaching Case #3 • You are rounding on a 70 y.o. male ESRD on HD admitted with pleuritic chest pain • New pulm mass found on chest CT • Severe pleuritic pain well-controlled on hydromorphone 4 mg IV q 3 hours • Intern asks for help converting him to something he can take at home Case # 3 (cont.) • Teaching task: Introduce the opiate conversion table and teach its use in converting IV medication to oral hydromorphone, oral morphine sustained-release, and Fentanyl patch Calculate doses and intervals for breakthrough medications Teaching Case #4 You are rounding on a 65 y.o. male with gout exacerbation • Former cocaine addict • Severe pain in hands, elbows, knees • Resident told intern to give tylenol and steroids and “wait it out”, afraid of awakening a former addiction • Patient asking for something stronger for pain Case #4 (cont.) • Teaching task: Teach the different myths regarding opiate medication Teaching Case #5 You are rounding on a 90 year old female with severe osteoporosis admitted for sudden severe back pain • New vertebral compression fracture • Pain controlled on morphine 4 mg IV q 4 hours • Patient very sedated, family concerned Case # 5 (cont.) • Teaching task: Discuss this side effect of opiates and its treatment Teaching Case #6 • Your team is preparing to discharge a 70 y.o. male with chronic severe Pagets disease requiring opioids, responded well to hydromorphone • Intern asks you to sign the Rx • Teaching task: Review the Rx with the team and teach about appropriate prescriptions and discharge planning Teaching case #7 • You are rounding on a 72 year old male with metastatic bladder cancer who is being discharged on home hospice the next day (order on next slide) • Teaching task: Review interns order to change IV to Duragesic patch. Teach the appropriate conversion. Teaching case #8 • You are rounding on an 85 year old woman with advanced dementia s/p fall with pelvic fracture • Teaching task: Review the MAR and teach about optimal management of pain in persons with cognitive impairment Teaching case #9 • You are rounding on an 80 year old female with dementia admitted with hematemesis and abdominal pain • EGD: Stomach cancer, patient is dying • She had been on morphine sulfate long-acting 60 mg po q 12 for Pagets • Teaching task: Show the housestaff how to effectively convert her to a morphine infusion References • Levy M. Drug therapy: Pharmacologic treatment of cancer pain. NEJM 1996;335(15):1124-1132. • EPEC Project, The Robert Wood Johnson Foundation, 1999. • Storey P and Knight CF. UNIPAC 3: Assessment and Treatment of Pain in the Terminally Ill. AAHPM 2003. • Gazelle. Methadone for the treatment of pain. J Pall Med. 2003;6(4):620 • AGS Panel on Persistent Pain in Older Persons. 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Palliative care of the terminally ill drug addict. Cancer Invest 2006;24:425-431. • Klaschik E, Nauck F, Ostgathe C. Constipation – modern laxative therapy. Support Care Cancer 2003;11:679-685. References • McCleane G. Topical analgesics. Med Clin N Am 2007;91:125-139. • Mercadante S and Bruera E. Opioid switching: A systematic and critical review. Cancer Treatment Reviews 2006;32:304-315. • Meuser T, Pietruck C, Radbruch L, et al. Symptoms during cancer pain treatment following WHO guidelines: a longitudinal follow-up study of symptom prevalence, severity, and etiology. Pain 2001;93:247-257. • Skaer TL. Transdermal opioids for cancer pain. Health and Quality of Life Outcomes 206;4(24):1-9. • Swegle JM and Logemann C. Management of common opioidinduced adverse effects. Am Fam Physician 2006;74:1347-1354. • WHO ladder:Cancer Pain Relief and Palliative Care. Technical Report Series 804. Geneva: World Health Organization; 1990. References • EPERC. End-of-life/Palliative Education Resource Center http://www.mywhatever.com/cifwriter/library/eperc/fastfact/ff_ index.html • http://www.amacmeonline.com/pain_mgmt/module12/index.htm • Bruera E and Sweeney C. Methadone use in cancer patients with pain: A review. J Palliat Med. 2002;5(1):127-137.