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Making Sense of Interventional Therapies for Pain 2/7/17 Linda Vanni, MSN, RN-BC, ACNS-BC, NP Nurse Practitioner, Pain Management Ascension Providence Conflict of Interest Disclosure • Conflict of Interest Author: Linda Vanni Advisory Board, Collegium Editorial Board, DSI Speaker Bureau-The Medicine Co. A conflict of interest is a particular financial or non-financial circumstance that might compromise, or appear to compromise, professional judgment. Anything that fits this should be included. Examples are owning stock in a company whose product is being evaluated, being a consultant or employee of a company whose product is being evaluated, etc. Taken in part from “On Being a Scientist: Responsible Conduct in Research”. National Academies Press. 1995. Objectives • Describe factors influencing the need for increased use of interventional therapies for pain • Identify usage of interventional therapies for pain How did this all happen? • 1996 APS president’s speech about the need to have pain assessed with the same zeal as vital signs. Ortho third highest prescribers of opioids, dentists – Let’s talk about hoarding • • • • • Management pain = prescribe opioids Things got out of hand 76 Million opioid scripts written in 1991 219 Million opioid scripts written in 2011 The jump from legal to illicit use Where did the hysteria come from? • Started with illicit diversion of lawfully prescribed medications and subsequent use by opioid-naïve individuals or by desperate people with addictive disease who will do anything to get as high as they can. • Most physicians in trouble from prescribing are in trouble due to inadequate documentation. “Patients with addictive disease have the right to be treated with respect and to receive the same quality of pain management as all other patients.” Increase in Chronic Diseases • ESRD • COPD • CV Disease • DM • OSA • Chronic Pain Combination Analgesics Rationale • Multiple sites of action target multiple pain pathways • Complementary pharmacokinetic activity • Potentially synergistic analgesic effect • Reduced adverse event profile with comparable efficacy Raffa, RB. J Clin Pharm Ther. 2001;26:257-64. The Shifting Paradigm • All about multi-modal – Scheduled acetaminophen • • • • • • Pain Management always linked to function Opioid-sparing The future of topicals Integrative therapies Anti-abuse opioids being approved by FDA Always keeping it safe Acute Pain 1. Blocks - Stellate Ganglion Block –Femoral/Adductor Block –Popliteal –TAP –Intercostal 2. Local Anesthetic Infusions 3. Epidural Therapy AAOS: Orthopaedic Surgeons Can Help Stem Opioid Epidemic • October 16, 2015 • Ortho surgeons third highest prescribers among physicians in the US • Limit the volume of opioids prescribed • Multi-modal practice plans • Coordinating opioid prescriber • Restricting long acting opioids for cancer related pain • Refer to Pain Centers Intraarticular Stellate Ganglion Brachial Plexus Femoral Nerve Block Femoral Nerve Block • Ropvacaine or bupivacaine 0.25%, 20 mls over femoral nerve area. Onset of action is 10-30 minutes-duration 2-8 hours. • Area identified utilizing nerve stimulator. • Does not necessarily cover pain in the back of the knee. Motor issues! Popliteal Block Popliteal Block TAP Block Intercostal Block Local anesthetics by infusion device or by single block Epidural Therapy VCFs Balloon Kyphoplasty Treatment Goals • Aimed at restoring height and stability in fractured vertebral body • Treating pain related to vertebral collapse Chronic Pain • • • • Celiac Plexus Block Permanent Epidural Therapy Intrathecal Pump Therapy Kyphoplasty Only 5-10% of patients require invasive pain management therapy Intraspinal Analgesics-MUST be Preservative Free • Local anesthetics –Lipophilic-synergistic with opioids –Block pain impulses at sympathetic chain ganglion outside cord –Level of analgesia evaluated via dermatomes Timing • Patients need to be considered for referral to a pain specialist at an earlier stage of their disease process than current clinical practice! Celiac Plexus Block • Celiac Plexus innervates the liver, pancreas, gallbladder, stomach, spleen, kidneys, intestines, and adrenal glands • Diagnostic and then neurolytic • Alcohol or phenol • Can last for weeks to months • Usually does not need to be repeated Intraspinal= Epidural & Intrathecal • Epidural “space” • Intrathecal space • Potential space outside the intrathecal space, • Filed with CSF that separated by arachnoid continually circulates around spinal cord mater • No fluid present • Space is created when fluid or air injected Embryonic Dermatomes Dermatomes Epidural/Intrathecal Analgesia • Pharmacokinetics & Pharmacodynamics – Epidural (ED) opioid instilled – Vascular uptake in ED space – Diffusion through the dura – Rostral spread (cephalad) in the CSF – Bind at opioid receptor site at the substantia gelatinosa in the dorsal horn Intraspinal Analgesics • Opioids • Lipophilic – Diffuse rapidly through dura – Less rostral spread in CSF, narrow segment of analgesia • Hydrophilic – Diffuse slowly through dura to CSF – Wider rostral spread & segment of analgesia Equianalgesic Opioid Conversion (Mg)* Oral Morphine Hydromorphone (Dilaudid) 300 60 Parenteral Epidural Intrathecal 100 10 1 20 2 0.2 1,000 1 0.1 100 0.1 0.01 10 0.01 0.001 Meperidine (Demerol) Fentanyl Sufentanil 3,000 ----- *Wallace, Mark MD., Yaksh, Tony, L. Ph.D., Long-term Spinal Analgesic Delivery: A Review of the Preclinical and Clinical Literature, Regional Anesthesia and Pain Medicine, Vol 25, No 2 (March-April): pp 120. Epidural/Intrathecal analgesia • Advantages – Pain relief with fewer sedative effects – Less respiratory depression than IV/IM • Disadvantages – Dependent on placement of catheter – Technology failure – Education required by nurses Types of Infusion DeviseIntraspinal Infusions • External percutaneous catheter with external pump • Implanted epidural portal/tunnel system • Implanted infusion pump Epidural/Intrathecal Analgesia • Local anesthetics – Block pain at the sympathetic chain ganglion outside the spinal cord – When used, able to use less opioid – Most common: bupivacaine, ropivacaine Implantation of Tunneled Epidural Catheter Done in operating room Tunneled to decrease risk of infection Able to run high dose marcaine Seen twice a week at clinic Antibiotic therapy Patient’s life expectancy less than 2 months Intraspinal Medications: Complications • • • • • Post-dural puncture headache Catheter migration Infection Hematoma Risk of inadvertent injection of neurotoxic agents New Trial Dosing System AP-08200 Screening Test (Pain) • Purpose: Evaluate patient’s response to intraspinal morphine over a short test period – Assess pain relief – Evaluate side effects • At least 50% reduction in pain is usually considered a positive response1 1 Hassenbusch, 50% SJ., Stanton-Hicks, M., Covington EC. Long-term intraspinal infusions of opioids in the treatment of neuropathic pain. JPSM. 1995: 10(5); 527-543. Pump Placement Considerations • • • • • • • • • Careful of possible radiation field Ostomies, ileostomy, straight cath? Baseline abdominal pain? Sleeping position Condition of skin Optimize refilling, not too deep Abdominal binder, nutritional status Pump size Where to put it? Patient Controlled Intrathecal Dosing Randomized Clinical Trial looking at CMM vs IDDS Journal of Clinical Oncology, Vol. 20, No. 19 (October 1) 2002 Smith, T.J., Staats, P.S., et al. Smith, et al. 2002 • Presented at ASCO as abstract 2002 • Published October 2002 • Prospective, multicenter, randomized study, participation total 200. • Compared Comprehensive Medical Management (CMM) with intraspinal drug delivery systems (IDDSs) Conclusions Whether given as part of initial therapy or applied after failure of CMM, IDDS reduced pain scores, significantly relieved most toxicities of pain control drugs, and was associated with improved survival for the length of this 6-month trial. Even the most refractory patients failed by CMM had a 27% reduction in pain scores, a 50% reduction in drug toxicity, and a median survival of 3 months after receiving IDDS. Bibliography • Abrahm, J.L. (2005) A Physician’s Guide to Pain and Symptom Management in Cancer Patients. The John Hopkins University Press, Baltimore, MA. • McHale, H.K. (2002) Palliative Care in Kuebler, K.K. & Esper, P. Palliative Practices from A-Z for the Bedside Clinician. Oncology Nursing Society, Pittsburgh, PA. • U.S.Department of Health and Human Services, National Cancer Institute (2007), EPEC™-O, CD-ROM. Bibliography • Smith, T.J., Staats, P.S., Deer, T., Stearns, L.J., Rauck, R.L., Boortz-Marx, R.L., Buchser, E., Catala, E., Bryce, D.A., Coyne, P.J. & Pool, G.E. (2002). Randomized Clinical Trial of an Implantable Drug Delivery System compared with Comprehensive Medical Management for Refractory Cancer Pain: Impact on pain, drug-related toxicity, and survival. Journal of Clinical Oncology, vol. 20, No. 19, pp 4040-4049.