Download Geriatric Pain Management - S-COPE

Geriatric Pain Management
Richard T. Jermyn D.O., F.A.A.P.M.R.
Associate Professor: UMDNJ:SOM
Acting Chair: Department of PM&R
Director: NMI
Disclosure
Richard Jermyn, DO
Company
Consultant and
Speaker’s Bureau
Endo Pharmaceuticals,
Alpharma Inc., and Pfizer Inc.
Grant Research
Endo Pharmaceuticals; Purdue; Merz
Objectives
 Recognize the distinctions between
neuropathic pain and nociceptive pain
 Use validated clinical questioning and
screening tools to identify patients with
neuropathic pain
 Develop evidence-based comprehensive
treatment plan for patients with chronic pain
in geriatic population
Objectives
 Develop strategies for effective patient
communication to improve health outcomes
CASE STUDY
 Patient is a 73 year old female with a 10
year history of Diabetes Mellitus. Patient
has severe pain in feet and legs VAS 9 (110) for 1 year. Patient admits to not using
her insulin and blood sugars are usually
above 200. You have no medical records.
 History of Lumbar spinal stenosis
Case Study
 Volunteers at a hospital but struggles
 Limited income
Case Study
 Patient taking Neurontin 600mg
(Gabapentin) TID
 Percocet 7.5/325 (Oxycodone HCIAcetaminophen) 5-6/day
 Never has had physical therapy but feels
gets exercise at her volunteer position
 Does this patient have pain?
 Is Neurontin (Gabapentin) appropriate?
 Is Percocet (Oxycodone HCI-Acetaminophen) appropriate?
 What other strategies can be implemented?
 How do we approach this difficult patient?
What is pain
 Pain is an unpleasant sensory or emotional
experience associated with actual or
potential tissue damage or described in
terms of such damage”
 International Association for the Study of
Pain (IASP)
Noceceptive vs. Neuropathic Pain
 Nociceptive
 Pain originating
outside of the nervous
system
 Linear to the stimulus
causing
 Resolves with healing
 Protective
 Neuropathic
 Pain originating from
injury to the nervous
system
 No stimulation required
 Dysproportionate to
the stimulus causing

Serra. Acta Neurol Scand.
1999;173(suppl):7-11
Nociceptive Pain





Musculo-skeletal injuries
Arthritis
Mechanical low back pain
Sports injuries
Post-operative
Neuropathic
 Peripheral Sensory Neuropathy
– Diabetes, HIV




Post-herpetic Neuralgia
Trigeminal Neuralgia
Lumbar/cervical radiculopathy
Thalamic Stoke Syndrome
Mixed Neuropathic Nociceptive
 Cancer Pain
 Spinal Stenosis
 Low back pain
Which of the following accurately
describes neuropathic pain?
1. When acute serves as a protective function
2. Most commonly seen post-operatively
3. Disproportionate to receptor stimulus
4. Arises from a stimulus outside the nervous
system
Answer
3. Disproportionate to receptor stimulus
Neuropathic Pain Assessment:
 The best tool to assess pain is:
– ASK THE QUESTION:
 400 per 1000 have persistent pain in
patients over 81 (Crook et al)
– Common belief in the patient population and
medical community that pain is expected in the
geriatric patient.
Pain Assessment:
– Quality: sharp shooting, numbness, burning
– Intensity: VAS (0-10)
– Duration: constant, intermittent, worse at night
– associated symptoms: bowel/bladder incont.
– Medical/Surgical History:
– opportunistic infections history: herpes, CMV,
Lymes, toxoplasmosis, HIV
– Treatments that have failed
What is the most effective tool to
access pain in the pain patient
1.Western Ontario-Master University Arthritic
Scale (WOMAC)
2. Face Scale for Pain
3. Visual Analog Scale
4. Ask the question: Do you have pain?
Answer:
 4. Ask the question: Do you have pain?
Pain Assessment
 Social History:
– Live alone or partnered
– Single or multiple story homes
– Assistive devices
– Falls
– Drive
– Hobbies
 Goals for treatment: ADL’s, sports and
recreation
Neuropathic Pain Terminology
 Allodynia: painful response to a non-painful
stimulus
 Hyperalgesia: heightened response to a
painful stimulus
 Hyperpathia: an explosive response to a
painful stimulus
Physical Exam
 Upper motor neuron vs. lower motor neuron
– Upper Motor neuron: brain and spinal cord
– Lower Motor neuron: alpha motor neuron,
dorsal and ventral roots, peripheral nerves,
neuromuscular junction and muscle.
Physical Exam
 Upper motor neuron:
– hyper-reflexia
– spasticity
– hoffmans/babinski
– frontal release signs
– ataxia, tremor, dysmetria
Physical Exam
 Lower Motor Neuron
– decreased reflexes
– weakness
The following sign is indicative of a
lower motor neuron lesion:
1.
2.
3.
4.
Hoffmans reflex
Hypo-reflexia
Babinski reflex
Ataxia
Answer: 2
 2. Hypo-reflexia
Upper Motor Neuron




Metabolic: common drug effects
Lymphoma: CNS tumors
Primary or metastatic cancer
CVA: thalamic syndrome, hand-shoulder
syndrome
 Myelopathy: stenosis: lesions above L2-3
 Infectious disease: meningitis, lymes disease, HIV
 Neurological: MS, thalamic CVA
Lower Motor Neuron




Peripheral Sensory Neuropathy (DM, ETOH)
Mononeuropathy: femoral, ulnar, CTS
Radiculopathies
myopathy: CPK
– Drug effects
 Arthropathies: OA, spondylosis
 Autoimmune: RA
 Infectious Disease: Herpes zoster
Neuropathic Pain Syndromes



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
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Fibromyalgia
Complex region pain syndrome
Chronic pelvic pain
Peripheral Sensory Neuropathy
Trigeminal Neuralgia
Post-herpetic Neuralgia
Normal Pain Pathways
TRANSMISSION
F
C
MODULATION
Cortex
SS
Key:
RVM = rostroventral medulla
PAG = periaqueductal grey
C = cingulate cortex
F = frontal cortex
SS = somatosensory cortex
A = amygdala
H = hypothalamus
Ascending pathway
Descending pathway
F
C
A
H
Thalamus
Midbrain
PAG
Medulla
RVM
Spinothalamic
Tract
Injury
Spinal Cord
Adapted with permission, from Fields. In: The Placebo Effect: An Interdisciplinary Exp
Exploration.
loration. 1997.
Supraspinal Influences on Nociceptive
Processing
Inhibition
Facilitation

Substance P

Glutamate and EAA

Serotonin (5-HT2a
and 5-HT3a receptors)

+

Descending
antinociceptive pathways

Noradrenaline–
serotonin
(5-HT1a and 5-HT1b
receptors)

Opioids
GABA
EAA=excitatory amino acids. 5-HT=serotonin.
Fields HL, et al. In: Wall PD, et al., eds. Textbook of Pain. 4th ed; 1999:309-329.
Millan MJ. Prog Neurobiol. 2002;66(6):355-474.
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What chemical can facilitate or
inhibit pain depending on the
receptor?
Serotonin
Dopamine
GABA
Substance P
Answer
 Serotonin
Cortical
Spinal

Peripheral
Nerve
Treatments for neuropathic pain
 Brain: opiates, antiseizure,
antidepressants,
neurostimulents, OMM
 Spinal Cord:
anticonvulsants, opiates,
TENS, DCS, OMM
 Peripheral: topicals,
NSAIDS, Botox, muscle
relaxers, nerve blocks,
modalities, OMM
Mechanism of Action of NSAID
 Arachidonic Acid
COX-1
Cox-2
Prostaglandin
prostaglandin
hemostasis
Protection of
Gastic mucosa
Mediate pain,
Inflammation and fever
Specificity of Agents
 Category inhibition
 Cox-2
 Cox-1
 Medications
–
–
–
–
–
–
Celecoxib
Aspirin
Diclofenac (oral, gel, patch)
Etodolac
Ibuprofen
Indomethacin
(Indomethacin-Various)
– Meloxicam
– Naprosyn (Naproxen)
Opioids
 Agonist and Agonist-antagonists
– bind to opioid receptors




sustained released and short acting agents
Oral route is most preferred
mainstay for moderate to severe pain
never dose as PRN
Opioids
 Start with the lowest possible dose possible
 titrate the drug
 place the patient on a schedule and never
PRN
 use combinations of opioids and non-opioids
 be aware of tolerence
Opioids
 Weaker Opioids analgesics:
– oxycodone, hydrocodone, codeine
– available in combinations with ASA/aceto.
 Stronger Opioid analgesics:
– Roxicodone (Oxycodone HCI) immediate
release
– Oxycontin (Oxycodone HCI) sustained release
– MSContin (Morphine Sulfate), MSIR
– Methadone
– Duragesic (Fentanyl)
Dosing of Opioids
 Long-acting agents for 24 hr. relief
 Short-acting agents for breakthru pain
– no more than 2 times daily (debated)
– Combo drugs; Percocet (Oxycodone HCI), Vicodin
(Hydrocodone Bitartrate-Acetaminophen), Lortab
(Hydrocodone Bitartrate-Acetaminophen)
– Uncombinated drugs; Oxy IR (Oxycodone HCI), Actiq
(Fentanyl Citrate)
 Treat side effects such as constipation
Methadone
 Some belief that may work on neuropathic
pain via NMDA receptors inhibition
 Long half life: 24-150hrs
 Duration of activity: 4-6hrs.
 Toxicity with overlapping half lives
 HIV meds can decrease the serum level of
methadone
– Immediate withdrawal
Methadone
 When switching to methadone to another
analgesic: decrease 75-90% equi-analgesic
dose
 Take maintance Dose decrease 20% and
divide to tid-qid.
 Short acting for withdrawal symptoms
Transdermal
 98% protein bound
– Must have protein to be absorbed
– Must have protein to be excreted
 Absorption of the drug increased as the
temperature increases.
– 101-103 degrees
Ketomine
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NMDA inhibition and opiate agonist
Effect on phantom pain L.Nikolassen Pain ‘96
Intrathecal infusions H.Takahasi Pain ’98
IV infusion Correll Pain ’04
Topical
What Opioid drug can be rapidly
absorbed with increase of body
temperature?
1. Methadone
2. Oxycodone (oxycontin)
3. Morphine Sulfate ER (Kadian)
4. Fentanyl Patch (Duragesic)
Answer:
4. Fentanyl Patches
Tramadol (Ultram)
 Centrally Acting Oral Opioid Agonist
 Serotonin and Noradrenergin
 Dizziness, Nausea and Headache
Antidepressants

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Works on serotonin and noradrenergin
tricyclics, hetero, SNRI, SSRI
potentiate the opiates
treat depression as a side effect
Antidepressants
 Effexor: SSRI
(Venlafaxine)

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
Amitriptyline: tri
Lithium
Desipramine: tri
Nortriptyline:tri
Paxil:SSRI (Paroxetine)
 Prozac: SSRI (Fluoxetine)
 Serzone (Nefazodone)
 Wellbutrin (buPROPion):
Aminoketone
 Zoloft:SSRI (Sertaline)
 Cymbalta: SNRI
(duloxetine)
Side-effects
 Urinary retention, anticholinergic, increased
or decreased blood pressure, drowsiness,
nausea, headache, sweating
Antidepressants
 Pain relief is related to serum level.
 Dose at night to allow improved sleep
 SSRI’s are believed to be not as beneficial
in pain relief until recently
 Warn patients about side effects
Anticonvulsants
 Gabapentine (Neurontin):
– works on GABA and inter-neurons in dorsal
horn.
– start at low doses and titrate upward
– check renal profiles: renal excretion
– potentiate opioids weakly
– strong mood stabilizer
Anticonvulsants
 Valproic Acid: extreme caution in liver
disease, monitor blood levels, neural tube
defects in fetus, dizziness, headache,
thrombocytopenia
 Phenytoin: nystagimus, lethary, ataxia,
gingival hyperplasia, hepatic disease
Anticonvulsants
Gabitril (Tiagabine): GABA reuptake
inhibitor, caution with liver disease,
dizziness, fatigue, rare ophthalmologic
effects
 Klonopin (Clonazepam): benzodiazepine
 Lamictal (Lamotrigine): rash (serious),
dizziness, ataxia, fatigue, blurred vision
 Tegretal: aplastic anemia, rash (SJS),
photosensitivity, dizziness
Anticonvulsants
 Topomax (Topiramate): sulfa mate: fatigue,
dizziness, ataxia, parenthesis, kidney stones,
mental cloudiness, weight loss.
 Zonegran: Somnolence, dizziness, anorexia,
headache, nausea
 Lyrica (Pregabalin): Schedule V, sedation, weight
gain
– May be less sedating than Neurontin (Gabapentin)
– Indicated for post-herpetic neuralgia, diabetic
neuropathy
Antispasmodics
 Flexeril (Cyclobenzaprine): central acting,
unknown mechanism, anticholinergic side
effects
 baclofen: central acting, drowsiness,
confusion, seizures with abrupt withdrawal
 parafon forte: central acting, GI upset,
drowsiness
Muscle Relaxants
 Robaxane: central acting, drowsiness,
dizziness, GI upset, blurred vision,
headache
 Skelaxin (Metaxalone): central acting
leukopenia, hemolytic anemia, dizziness
 SOMA: addictive, dizziness, nausea
 Tizanidine: alpha adrenergic agonist,
anticholinergic, fatigue, urinary retention
Which of the following compounds
have the potential for addiction?
1.
2.
3.
4.
Flexeril (cyclobenaprine)
SOMA
Zanaflex (tizanidine)
Robaxane
Answer:
 2. SOMA
Psycho-stimulants
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Serotonin and noradrenergic
potentiate opioids
mood stabilizer
improves appetite when wasting
improves sedation
dose in am and noon only
Topical
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
Lidoderm patch (Lidocaine)
Capsaicin (cream and patch)
Ketomine topical (compound pharm)
Flector Patch (diclofenac)
Voltaren Gel (diclofenac)
Non-pharmacologic Treatment
Options
 Physical therapy
 Psychotherapy
 Biofeedback
Interdisciplinary Pain
Management
Integrated Coordinated
Nurses
Pain Specialist
Psychiatrist
Neurologist
Spine Surgeon
Primary
Clinician
Pharmacist
Physiatrist
Psychologist
Occupational Therapist
Social Worker
Anesthesiologist
Physician Assistant
Physical Therapist
Shared Decision Making
 At least 2 parties are involved: physician
and patient
 Both parties share information
 Both parties take steps to build a consensus
on what decisions are to me made
 Both parties agree on the treatment

C.Charles, A. Gofner Soc. Sci. Med Vol.44 No. 5 pp 681-692, 1972
Summary
 Neuropathic pain can be differentiated from
nociceptive pain
 Proper pain assessment and physical exam
are essential for diagnosis
 A combination of both pharmacologic and
non-pharmacologic pain strategies should
be utilized in the geriatric patient
 A “shared decision making” approach may
have better outcomes