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Ambulatory Pain Management Ambulatory Pain Management
Richard T. Jermyn D.O., F.A.A.P.M.R.Richard T. Jermyn D.O., F.A.A.P.M.R.Associate Professor: UMDNJ:SOMAssociate Professor: UMDNJ:SOMActing Chair: Department of PM&RActing Chair: Department of PM&RDirector: NMIDirector: NMI
DisclosureDisclosureRichard Jermyn, DORichard Jermyn, DO
CompanyCompany
Consultant and Consultant and Speaker’s BureauSpeaker’s Bureau
Endo Pharmaceuticals, Endo Pharmaceuticals, Alpharma Inc., and Pfizer Inc.Alpharma Inc., and Pfizer Inc.
Grant ResearchGrant Research Endo PharmaceuticalsEndo Pharmaceuticals
ObjectivesObjectives
Learn how to interview a pain patientLearn how to interview a pain patient Review pharmacology of pain medicationsReview pharmacology of pain medications Common treatments for the pain patientCommon treatments for the pain patient Understand the pathophysiology of painUnderstand the pathophysiology of pain
CASE STUDYCASE STUDY
Patient is a 53 year old female with a 10 year history of Patient is a 53 year old female with a 10 year history of Diabetes Mellitus. Patient has severe pain in feet and Diabetes Mellitus. Patient has severe pain in feet and legs VAS 9 (1-10) for 1 year. Patient admits to not using legs VAS 9 (1-10) for 1 year. Patient admits to not using her insulin and blood sugars are usually above 200. her insulin and blood sugars are usually above 200. You have no medical records.You have no medical records.
Diagnosed with osteoarthitis of both kneesDiagnosed with osteoarthitis of both knees History of Lumbar spinal stenosis History of Lumbar spinal stenosis
Case StudyCase Study
Works as a waitress but strugglesWorks as a waitress but struggles Limited incomeLimited income
Case StudyCase Study
Patient taking Neurontin 600mg Patient taking Neurontin 600mg (Gabapentin) TID (Gabapentin) TID
Percocet 7.5/325 (Oxycodone HCI-Percocet 7.5/325 (Oxycodone HCI-Acetaminophen) 5-6/dayAcetaminophen) 5-6/day
Never has had physical therapy but feels Never has had physical therapy but feels gets exercise at workgets exercise at work
Corticosteriod injections provided no reliefCorticosteriod injections provided no relief
Does this patient have pain?Does this patient have pain?
Is Neurontin (Gabapentin) appropriate?Is Neurontin (Gabapentin) appropriate?
Is Percocet (Oxycodone HCI-Acetaminophen) Is Percocet (Oxycodone HCI-Acetaminophen) appropriate?appropriate?
How to get started?How to get started?
Acute vs Chronic Pain States
Acute Chronic
• Associated with tissue damage
• Increased autonomic nervous activity
• Resolves with healing of injury
• Serves protective function
• Extends beyond expected period of healing
• No protective function• Degrades health and
functioning• Contributes to depressed
mood
vs
Turk, Turk, OkifujiOkifuji. In: . In: BonicaBonica’’ss Management of Pain.Management of Pain. 2001; Chapman, Stillman. In: 2001; Chapman, Stillman. In: Pain and Touch.Pain and Touch. Handbook Handbook of Perception and Cognitionof Perception and Cognition. 2nd ed.. 2nd ed. 1996; Fields. 1996; Fields. NeuropsychiatrNeuropsychiatr Neuropsychol Neuropsychol BehavBehav Neurol.Neurol. 1991;4:831991;4:83--92.92.
Nociceptive Neuropathic
Nociceptive vs Neuropathic Pain States
• Arises from stimulus outside of nervous system
• Proportionate to receptor stimulation
• When acute, serves protective function
• Arises from primary lesion or dysfunction in nervous system
• No nociceptive stimulation required
• Disproportionate to receptor stimulation
• Other evidence of nerve damage
vs
Serra. Serra. Acta Neurol Scand. Acta Neurol Scand. 19991999;173(suppl):7;173(suppl):7--1111..
Examples of Nociceptive and Neuropathic Pain
• Arthritis• Mechanical low
back pain• Sports/exercise injuries• Postoperative pain
NeuropathicNociceptive Mixed
• Painful DPN• PHN• Neuropathic low back pain• Trigeminal neuralgia• Central poststroke pain• Complex regional pain syndrome• Distal HIV polyneuropathy
Caused by lesion or dysfunction in the nervous system
Caused by tissue damage
Caused by combination of primary injury and secondary
effects
• Low back pain• Fibromyalgia• Neck pain• Cancer pain
Pain AssessmentPain Assessment
– Quality: sharp shooting, numbness, burningQuality: sharp shooting, numbness, burning– Intensity: VAS (0-10)Intensity: VAS (0-10)– Duration: constant, intermittent, worse at nightDuration: constant, intermittent, worse at night– associated symptoms: bowel/bladder incont.associated symptoms: bowel/bladder incont.– Medical/Surgical History: Medical/Surgical History: – opportunistic infections history: herpes, CMV, opportunistic infections history: herpes, CMV,
Lymes, toxoplasmosis, HIVLymes, toxoplasmosis, HIV– Treatments that have failedTreatments that have failed
Pain AssessmentPain Assessment
Social History:Social History:– Live alone or partneredLive alone or partnered– Single or multiple story homesSingle or multiple story homes– Assistive devicesAssistive devices– FallsFalls– DriveDrive– HobbiesHobbies
Goals for treatment: work, childcare, school, Goals for treatment: work, childcare, school, sportssports
Physical ExamPhysical Exam
Upper motor neuron vs. lower motor neuronUpper motor neuron vs. lower motor neuron
Physical ExamPhysical Exam
Upper motor neuron:Upper motor neuron:– hyper-reflexiahyper-reflexia– spasticityspasticity– hoffmans/babinskihoffmans/babinski– frontal release signsfrontal release signs– ataxia, tremor, dysmetriaataxia, tremor, dysmetria
Physical ExamPhysical Exam
Lower Motor NeuronLower Motor Neuron– decreased reflexesdecreased reflexes– weaknessweakness
Upper Motor NeuronUpper Motor Neuron
Metabolic: common drug effectsMetabolic: common drug effects Lymphoma: CNS tumorsLymphoma: CNS tumors Primary or metastatic cancerPrimary or metastatic cancer CVA: thalamic syndrome, hand-shoulder CVA: thalamic syndrome, hand-shoulder
syndromesyndrome Myelopathy: stenosisMyelopathy: stenosis Infectious disease: meningitis, lymes diseaseInfectious disease: meningitis, lymes disease Neurological: MSNeurological: MS DementiaDementia
Lower Motor NeuronLower Motor Neuron
Peripheral Sensory NeuropathyPeripheral Sensory Neuropathy Mononeuropathy: femoralMononeuropathy: femoral RadiculopathiesRadiculopathies myopathy: CPKmyopathy: CPK
– Drug effectsDrug effects Arthropathies: OAArthropathies: OA Autoimmune: RAAutoimmune: RA Infectious Disease: Herpes zosterInfectious Disease: Herpes zoster
Normal Pain Pathways
Adapted with permission, from Fields. In: Adapted with permission, from Fields. In: The Placebo Effect: AnThe Placebo Effect: An Interdisciplinary ExInterdisciplinary Expplorationloration. 1997.. 1997.
Key:RVM = rostroventral medullaPAG = periaqueductal grey C = cingulate cortexF = frontal cortexSS = somatosensory cortexA = amygdalaH = hypothalamus
Ascending pathwayDescending pathway
TRANSMISSION
Cortex
Thalamus
SS
Midbrain
C FC
AH
PAG
RVM
Medulla
SpinothalamicTract
Injury
Spinal Cord
MODULATIONF
Normal and Abnormal Synaptic Neurotransmission
Supraspinal Influences on Nociceptive Supraspinal Influences on Nociceptive ProcessingProcessing
FacilitationFacilitation
+
Inhibition
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.
Cortical
Spinal
Peripheral Nerve
Cortical
Spinal
Peripheral Nerve
Antidepressant
Anticonvulsants
Psychostimulents
Opiates
Tens
AnticonvulsantsNSAIDS
Epidural
Nerve Blocks
Modalities
Muscle Relax
Exercise
Pain ManagementPain Management
WHO Analgesic ladderWHO Analgesic ladder
MILD
MODERATE
SEVERE
Metabolized by C450 2D6 Metabolized by C450 2D6 isoenzymesisoenzymes
AntiarrythmicsAntiarrythmics Beta-blockersBeta-blockers OpiatesOpiates AntipsychoticsAntipsychotics
SSRI’sSSRI’s TCA’sTCA’s Anti-retroviralsAnti-retrovirals
Mechanism of Action of NSAID Mechanism of Action of NSAID
Arachidonic AcidArachidonic Acid
COX-1 Cox-2
Prostaglandinprostaglandin
Protection ofGastic mucosa
hemostasis
Mediate pain,Inflammation and fever
Specificity of AgentsSpecificity of Agents
CategoryCategory inhibitioninhibition Cox-2Cox-2
Cox-1Cox-1
MedicationsMedications– Celecoxib Celecoxib – AspirinAspirin– Diclofenac (oral, gel, patch)Diclofenac (oral, gel, patch)– EtodolacEtodolac– IbuprofenIbuprofen– Indomethacin Indomethacin
(Indomethacin-Various)(Indomethacin-Various)– MeloxicamMeloxicam– Naprosyn (Naproxen)Naprosyn (Naproxen)
OpioidsOpioids
Agonist and Agonist-antagonistsAgonist and Agonist-antagonists– bind to opioid receptorsbind to opioid receptors
sustained released and short acting agentssustained released and short acting agents Oral route is most preferredOral route is most preferred mainstay for moderate to severe painmainstay for moderate to severe pain never dose as PRNnever dose as PRN
OpioidsOpioids
Start with the lowest possible dose possibleStart with the lowest possible dose possible titrate the drugtitrate the drug place the patient on a schedule and never place the patient on a schedule and never
PRNPRN use combinations of opioids and non-opioidsuse combinations of opioids and non-opioids be aware of tolerencebe aware of tolerence
OpioidsOpioids
Weaker Opioids analgesics:Weaker Opioids analgesics:– oxycodone, hydrocodone, codeineoxycodone, hydrocodone, codeine– available in combinations with ASA/aceto.available in combinations with ASA/aceto.
Stronger Opioid analgesics:Stronger Opioid analgesics:– Roxicodone (Oxycodone HCI) immediate releaseRoxicodone (Oxycodone HCI) immediate release– Oxycontin (Oxycodone HCI) sustained releaseOxycontin (Oxycodone HCI) sustained release– MSContin (Morphine Sulfate), MSIRMSContin (Morphine Sulfate), MSIR– MethadoneMethadone– Duragesic (Fentanyl)Duragesic (Fentanyl)
Dosing of OpioidsDosing of Opioids
Long-acting agents for 24 hr. reliefLong-acting agents for 24 hr. relief
Short-acting agents for breakthru painShort-acting agents for breakthru pain– no more than 2 times daily (debated)no more than 2 times daily (debated)– Combo drugs; Percocet (Oxycodone HCI), Vicodin Combo drugs; Percocet (Oxycodone HCI), Vicodin
(Hydrocodone Bitartrate-Acetaminophen), Lortab (Hydrocodone Bitartrate-Acetaminophen), Lortab (Hydrocodone Bitartrate-Acetaminophen)(Hydrocodone Bitartrate-Acetaminophen)
– Uncombinated drugs; Oxy IR (Oxycodone HCI), Actiq Uncombinated drugs; Oxy IR (Oxycodone HCI), Actiq (Fentanyl Citrate)(Fentanyl Citrate)
Treat side effects such as constipationTreat side effects such as constipation
MethadoneMethadone
Long half life: 24-150hrsLong half life: 24-150hrs Duration of activity: 4-6hrs.Duration of activity: 4-6hrs. Toxicity with overlapping half livesToxicity with overlapping half lives HIV meds can decrease the serum level of HIV meds can decrease the serum level of
methadonemethadone– Immediate withdrawalImmediate withdrawal
MethadoneMethadone
When switching to methadone to another When switching to methadone to another analgesic: decrease 75-90% equi-analgesic analgesic: decrease 75-90% equi-analgesic dosedose
Take maintance Dose decrease 20% and Take maintance Dose decrease 20% and divide to tid-qid.divide to tid-qid.
Short acting for withdrawal symptomsShort acting for withdrawal symptoms
TransdermalTransdermal
98% protein bound98% protein bound– Must have protein to be absorbedMust have protein to be absorbed– Must have protein to be excretedMust have protein to be excreted
Absorption of the drug increased as the Absorption of the drug increased as the temperature increases.temperature increases.– 101-103 degrees101-103 degrees
Tramadol (Ultram)Tramadol (Ultram)
Centrally Acting Oral Opioid AgonistCentrally Acting Oral Opioid Agonist Serotonin and NoradrenerginSerotonin and Noradrenergin Dizziness, Nausea and HeadacheDizziness, Nausea and Headache
AntidepressantsAntidepressants
Works on serotonin and noradrenerginWorks on serotonin and noradrenergin tricyclics, hetero, SNRI, SSRItricyclics, hetero, SNRI, SSRI potentiate the opiatespotentiate the opiates treat depression as a side effecttreat depression as a side effect
AntidepressantsAntidepressants
Effexor: SSRI Effexor: SSRI (Venlafaxine)(Venlafaxine)
Amitriptyline: triAmitriptyline: tri LithiumLithium Desipramine: triDesipramine: tri Nortriptyline:triNortriptyline:tri Paxil:SSRI Paxil:SSRI (Paroxetine)(Paroxetine)
Prozac: SSRI Prozac: SSRI (Fluoxetine)(Fluoxetine)
Serzone Serzone (Nefazodone)(Nefazodone)
Wellbutrin Wellbutrin (buPROPion):(buPROPion): AminoketoneAminoketone
Zoloft:SSRI Zoloft:SSRI (Sertaline)(Sertaline)
Cymbalta: SNRI Cymbalta: SNRI (duloxetine)(duloxetine)
Most neurotransmitters are Most neurotransmitters are inhibitoryinhibitory
Side-effectsSide-effects
Urinary retention, anticholinergic, increased Urinary retention, anticholinergic, increased or decreased blood pressure, drowsiness, or decreased blood pressure, drowsiness, nausea, headache, sweatingnausea, headache, sweating
AntidepressantsAntidepressants
Pain relief is related to serum level.Pain relief is related to serum level. Dose at night to allow improved sleepDose at night to allow improved sleep SSRI’s are believed to be not as beneficial SSRI’s are believed to be not as beneficial
in pain relief until recentlyin pain relief until recently Warn patients about side effectsWarn patients about side effects
AnticonvulsantsAnticonvulsants
Gabapentine (Neurontin):Gabapentine (Neurontin):– works on GABAworks on GABA– start at low doses and titrate upwardstart at low doses and titrate upward– check renal profiles: renal excretioncheck renal profiles: renal excretion– potentiate opioids weaklypotentiate opioids weakly– strong mood stabilizerstrong mood stabilizer
AnticonvulsantsAnticonvulsants
Valproic Acid: extreme caution in liver Valproic Acid: extreme caution in liver disease, monitor blood levels, neural tube disease, monitor blood levels, neural tube defects in fetus, dizziness, headache, defects in fetus, dizziness, headache, thrombocytopeniathrombocytopenia
Phenytoin: nystagimus, lethary, ataxia, Phenytoin: nystagimus, lethary, ataxia, gingival hyperplasia, hepatic diseasegingival hyperplasia, hepatic disease
AnticonvulsantsAnticonvulsants
Gabitril (Tiagabine): GABA reuptake Gabitril (Tiagabine): GABA reuptake inhibitor, caution with liver disease, inhibitor, caution with liver disease, dizziness, fatigue, rare ophthalmologic dizziness, fatigue, rare ophthalmologic effectseffects
Klonopin (Clonazepam): benzodiazepineKlonopin (Clonazepam): benzodiazepine Lamictal (Lamotrigine): rash (serious), Lamictal (Lamotrigine): rash (serious),
dizziness, ataxia, fatigue, blurred visiondizziness, ataxia, fatigue, blurred vision Tegretal: aplastic anemia, rash (SJS), Tegretal: aplastic anemia, rash (SJS),
photosensitivity, dizziness photosensitivity, dizziness
AnticonvulsantsAnticonvulsants
Topomax (Topiramate): sulfa mate: fatigue, Topomax (Topiramate): sulfa mate: fatigue, dizziness, ataxia, parenthesis, kidney stones, dizziness, ataxia, parenthesis, kidney stones, mental cloudiness, weight loss.mental cloudiness, weight loss.
Zonegran: Somnolence, dizziness, anorexia, Zonegran: Somnolence, dizziness, anorexia, headache, nauseaheadache, nausea
Lyrica (Pregabalin): Schedule V, sedation, weight Lyrica (Pregabalin): Schedule V, sedation, weight gaingain– May be less sedating than Neurontin (Gabapentin)May be less sedating than Neurontin (Gabapentin)– Indicated for post-herpetic neuralgia, diabetic Indicated for post-herpetic neuralgia, diabetic
neuropathyneuropathy
AntispasmodicsAntispasmodics
Flexeril (Cyclobenzaprine): central acting, Flexeril (Cyclobenzaprine): central acting, unknown mechanism, anticholinergic side unknown mechanism, anticholinergic side effectseffects
baclofen: central acting, drowsiness, baclofen: central acting, drowsiness, confusion, seizures with abrupt withdrawalconfusion, seizures with abrupt withdrawal
parafon forte: central acting, GI upset, parafon forte: central acting, GI upset, drowsinessdrowsiness
Muscle RelaxantsMuscle Relaxants
Robaxane: central acting, drowsiness, Robaxane: central acting, drowsiness, dizziness, GI upset, blurred vision, dizziness, GI upset, blurred vision, headacheheadache
Skelaxin (Metaxalone): central acting Skelaxin (Metaxalone): central acting leukopenia, hemolytic anemia, dizziness leukopenia, hemolytic anemia, dizziness
SOMA: addictive, dizziness, nauseaSOMA: addictive, dizziness, nausea Tizanidine: alpha adrenergic agonist, Tizanidine: alpha adrenergic agonist,
anticholinergic, fatigue, urinary retention anticholinergic, fatigue, urinary retention
Psycho-stimulantsPsycho-stimulants
Serotonin and noradrenergicSerotonin and noradrenergic potentiate opioidspotentiate opioids powerful mood stabilizerpowerful mood stabilizer improves appetite when wastingimproves appetite when wasting improves sedationimproves sedation dose in am and noon onlydose in am and noon only
TopicalTopical
Lidoderm patch (Lidocaine)Lidoderm patch (Lidocaine) CapsaicinCapsaicin Ketomine topical (compound pharm)Ketomine topical (compound pharm) Flector Patch (diclofenac)Flector Patch (diclofenac) Voltaren Gel (diclofenac)Voltaren Gel (diclofenac)
Drug Abuse and OpioidsDrug Abuse and Opioids
Not as common in the elderlyNot as common in the elderly Place patient in a drug agreementPlace patient in a drug agreement
– monthly visitmonthly visit– one pharmacy onlyone pharmacy only– can not use, sell, trade drugscan not use, sell, trade drugs– take as specified - no renewalstake as specified - no renewals
Detox when appropriate - not when sickDetox when appropriate - not when sick Treat other symptoms: depressionTreat other symptoms: depression