Download Introduction to Chronic Pain Medication

Katy Trinkley, PharmD
Angie Thompson, PharmD
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Opioid risks and risk prevention strategies
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Medication treatment by pain type
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Fundamental principles of opioid therapy
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Opioid prescribing is on the rise
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Benefit of opioids after 1 year
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Opioid dose is directly related to mortality
Ann Intern Med. 2015; 162:276 Arch Intern Med. 2011;171:686
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Opioid prescribing is on the rise
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Benefit of opioids after 1 year
No evidence!
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Opioid dose is directly related to mortality
Ann Intern Med. 2015; 162:276 Arch Intern Med. 2011;171:686
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Opioids
 Avoid
 Minimize
 Prolong initiation
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Only indicated when safer alternatives are
exhausted
Nat Rev Drug Discov. 2010;9:589
Nat Rev Drug Discov. 2010;9:589
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Visceral
 Highly variable by specific condition
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Neuropathic or fibromyalgia
 Many opioid alternatives
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Nociceptive
 Some opioid alternatives
Neuropathic or fibromyalgia pain
 Topicals
 Lidocaine cream/patch, capsaicin
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Gabapentin
SNRI
 Venlafaxine, duloxetine
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TCA
 Nortriptyline
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Pregabalin
Nociceptive pain
 Acetaminophen
 4 grams/d
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Topicals
 Lidocaine cream/patch, diclofenac gel, capsaicin
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SNRI for low back pain
NSAIDs
 Aspirin, naproxen
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Tramadol IR/ER
Opioids
Ann Intern Med. 2015;163:JC10. Circulation. 2007; 115:1634. BMJ. 2011;342:c7086
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Goals of therapy
Selection of opioid
Initiation
Monitoring
Titration
Breakthrough pain
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Dependent on type of pain
Discussion of patient and provider expectations
Set realistic goals
 Acute pain – rapid pain relief
 Chronic pain – improve or maintain level of day to day
functioning, overall well being, relationships, reduce drug
dependency
Route of administration
Constant pain vs. intermittent pain
Renal/hepatic function
 Previous exposure to opioids
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Short term trial
No evidence supporting one opioid over another
No evidence supporting short acting vs. long acting
 Generally considered safer to use short-acting opioids for initial
therapy
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Choice of opioid, starting dose, and titration schedule
will be very patient specific
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In general start with:
 Typical starting dose
 Immediate release formulations
 Insufficient evidence to recommend around the
clock or scheduled opioids
 Titrate up slowly
▪ Especially true for geriatric patients
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Monitor for effectiveness and adverse effects
 4 A’s
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Analgesia
Activity
Aberrant drug behavior
Adverse effects
 Assessment frequency will vary based on
patient’s pain
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Dose decreases:
 Slow titration : 10% per week
 Rapid titration: 25-50% every few days
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Dose increases:
 20-50% increases in daily dose
 Equivalent to “breakthrough” dosing needed if on sustained
release products
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Transition to equivalent dose of sustained released
product, once pain control is achieved
 Maintain immediate release product for breakthrough pain
 Goal: Maximize sustained release/minimize immediate release
Brief, transitory, exacerbation of moderate to severe pain
while on stable doses of long acting opioid therapy or around
the clock parenteral therapy
 May be due to underlying condition or new/unrelated pain
 Typically treated with as need immediate release opioid
therapy
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 10-20% of total daily opioid dose
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Rescue doses for breakthrough pain should be dosed
frequently
 Outpatient setting: Every 4-6 hours is typical
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If using rescue doses consistently, consider
titrating long acting opioids
Recalculate dose of rescue therapy every time
dose of long acting opioids is adjusted
Typically use same drug for both rescue and
long acting therapy
In theory, there is no maximum ceiling dose for
opioid therapy
 Best evidence indicates 120 mg/day of morphine or
morphine equivalent
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 Maximum studied doses in randomized controlled trials
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Higher doses may indicate substance
abuse/diversion and/or need for opioid rotation or
taper