5/30/2011 1 By: Traci Brooks, PharmD Clinical Pharmacist Womack Army Medical Center [email protected]The views expressed herein are those of the author and do not reflect the official policy of the Department of the Army, Department of Defense, or the U.S. Government. Author of this presentation does not have discloses concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation. Conducting a Pain Assessment What to do when starting chronic opioid therapy Review of Narcotic Analgesics ◦ As needed medications ◦ Around the clock medications Review of Odds and Ends Urine Drug Screen information Touch on Treating the Addicted Patient
The views expressed herein are those of theauthor and do not reflect the official policyof the Department of the Army, Departmentof Defense, or the U.S. Government.
Author of this presentation does not havediscloses concerning possible financial orpersonal relationships with commercialentities that may have a direct or indirectinterest in the subject matter of thispresentation.
Conducting a Pain Assessment
What to do when starting chronic opioidtherapy
Review of Narcotic Analgesics◦ As needed medications
◦ Around the clock medications
Review of Odds and Ends
Urine Drug Screen information
Touch on Treating the Addicted Patient
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Chronic, painful conditions – 80 millionpeople in US◦ Millions undergo surgery or suffer a painful injury
1999 Gallup survey – 9 out of 10 Americansregularly suffer from pain.◦ 1 in 4 receive adequate pain treatment
2001 study – Geriatric patients frequentlyreceive inadequate pain therapy
February 1999 – VHA adds pain as a fifth vitalsign◦ JAMA 1995 article noted almost half of 10,000
dying patients included in this study died in severepain
The New York Times – December 9, 2008◦ “The Pain May Be Real, but the Scan Is Deceiving”
◦ Scans are useful prior to surgical interventions.
◦ What you see on the scan may not be what iscausing the pain.
◦ What is causing the pain may correct itself withoutsurgical interventions.
History◦ Where is the pain?
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History◦ Where is the pain?
◦ How did the pain begin?
History◦ Where is the pain?
◦ How did the pain begin?
◦ How long have you had the pain?
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Identify Acute or Chronic Pain
Chronic Pain◦ behavioral-psychological changes
◦ physiological changes within the nervous system
allodynia
hyperalgesia
History◦ Where is the pain?
◦ How did the pain begin?
◦ How long have you had the pain?
◦ Describe the pain.
Nocioceptive – localized, usually caused by aninjury
Neuropathic – more general area of pain◦ Central – phantom limb pain
◦ Peripheral – burning, tingling, numbness
Shooting
Prick
Ache
Burn
Throb
Pull
Sharp
Dull
Pattern of Pain Intermittent Constant
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History◦ Where is the pain?
◦ How did the pain begin?
◦ How long have you had the pain?
◦ Describe the pain.
◦ What is the pain intensity?
Advanced dementia
Intubated/unconscious patients
Infant and preverbal toddlers
Self reporting
Search for potential causes ofpain/discomfort
Observation of patient behavior
Surrogate reporting of pain
Attempt an analgesic trial
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Total scores range from 0 to 10 (based on a scale of 0 to 2 for five items),with a higher score indicating more severe pain (0=”no pain" to 10=”severepain”).
History◦ Where is the pain?
◦ How did the pain begin?
◦ How long have you had the pain?
◦ Describe the pain.
◦ What is the pain intensity?
◦ What improves the pain?
Medication
Eating
Rest
Sleep
Repositioning
Heat
Cold
Exercise
Relaxation
Massage
History◦ Where is the pain?
◦ How did the pain begin?
◦ How long have you had the pain?
◦ Describe the pain.
◦ What is the pain intensity?
◦ What improves the pain?
◦ Any relevant PMH?
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myocardial ischemia
neoplasm
expanding aortic aneurysm
diabetic neuropathy
AIDS
peripheral vascular disease
stroke
History◦ Where is the pain?
◦ How did the pain begin?
◦ How long have you had the pain?
◦ Describe the pain.
◦ What is the pain intensity?
◦ What improves the pain?
◦ Any relevant PMH?
◦ How does the pain impact your life?
Sleep
Mood
Activity
Nutrition
Elimination
Social Interactions
Self Image
Sexuality
History◦ Where is the pain?
◦ How did the pain begin?
◦ How long have you had the pain?
◦ Describe the pain.
◦ What is the pain intensity?
◦ What improves the pain?
◦ Any relevant PMH?
◦ How does the pain impact your life?
◦ What have you tried in the past?
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Medications◦ What medications have you taken?
◦ How did they work?
◦ Why did you stop taking it?
Surgical
Non-pharmacologic◦ Over-the-counter
◦ Alternative medicine
How do you prefer to take your painmedication?◦ Scheduled or PRN or Do not like taking medication
Do you feel you need a stronger painmedication?
Do you feel you need to take more of the painmedication than prescribed?
Are you concerned that you use too muchpain medication?
Waiting room
Rising from chair in waiting room
Gait walking to exam room
Pain behaviors throughout exam
General appearance
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Evaluated in person prior to initiation oftherapy◦ Including appropriate H&P
Assess risk factors for addiction/abuse◦ Family history of substance abuse, pending
legal/disciplinary actions related to controlledsubstances, certain psychiatric comorbidites, hx ofnoncompliance
Provide patient with risks/benefits/sideeffects associated with opioid use
Reassess at regular intervals
5 Questions to ask:◦ Is there a clear diagnosis?
◦ Is there documentation of adequate work-up?
◦ Is there functional impairment?
◦ Has non-opioid multi-modality treatment failed?
◦ Are there contraindications to opioid therapy?
Diagnosis◦ 1=benign chronic condition w/ min objective findings or
no definite medical diagnosis◦ 2=slowly progressive condition concordant w/ moderate
pain, or fixed condition w/ moderate objective findings◦ 3=advanced condition concordant w/ severe pain w/
objective findings
Intractability◦ 1=few therapies have been tried and the patient takes a
passive role in his/her pain management process◦ 2=most customary treatments have been tried but the
patient is not fully engaged, or barriers present◦ 3=patient fully engaged in a spectrum of appropriate
treatments but with inadequate response
Risk (R=total of P+C+R+S below)◦ Psychological
1=serious personality dysfunction or mental illnessinterfering with care
2=personality or mental health interferes moderately
3=good communication with clinic. No significantpersonality dysfunction
◦ Chemical Health
1=active or very recent use of illicit drugs, excessivealcohol, or prescription drug abuse
2=chemical coper or history of
3=Not drug-focused or chemically reliant
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Risk – continued◦ Reliability 1=history of numerous problems: medication misuse,
missed appts, rare follow through 2=occasional difficulties w/ compliance, generally reliable 3=highly reliable
◦ Social Support 1=life in chaos 2=reduction in some relationships, life roles 3=supportive family/close relationships
Efficacy score 1=poor function or minimal pain relief despite moderate to
high doses 2=moderate benefit w/ function improved 3=good improvement in pain, function and quality of life
Total score = D + I + R + E
Score 7-13: Not a suitable candidate forlong-term opioid analgesia
Score 14-21: Good candidate for long-termopioid analgesia
Meet with prescribing provider at least every60 to 90 days◦ High risk patients may warrant shorter intervals for
follow up
Agreement rather than contract
Clarifies expectations and responsibilities ofpatient and provider
Identify patient’s support system that arepermitted to discuss issues associated withpain management
Address sole provider prescribing,random/regular lab screenings, contingenciesfor non-compliance
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Random pill counts
Urine or blood screening
Discussion with family members
Per agreement – non-compliance may resultin transition to non-opioid treatment model
May include case management, clinicalpharmacy, pain management, primary care,behavioral health, physical therapy, socialwork, other specialists as needed(neurologist, oncologist)
North Carolina Controlled SubstancesRegistery
http://www.who.int/topics/en/
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Cancer pain
Terminally ill patients
Not Chronic Non-malignant Pain◦ Only when all conservative methods have been
exhausted
Safety◦ Respiratory depression
Tolerability◦ Itching, constipation, addiction
Efficacy◦ Reduction in pain score
Price
Simplicity
Phenanthrene
codeine
morphine
hydromorphone
oxymorphone
hydrocodone
oxycodone
Phenylpiperidines
◦ meperidine
◦ fentanyl
◦ sufentail
Diphenylheptanes◦ methadone
◦ propoxyphene
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Supraspinal analgesia
Respiratory depression
Euphoria
Physical Dependence
Decreased GI motility
Increased prolactinrelease
Miosis
Bradycardia
Spinal analgesia
Increased GH release
Inhibits Ach release
Spinal analgesia
Sedation
Disorientation,hallucinations
Depersonalization
Less miosis
Dysphoria
ADH release (diuresis)
Supraspinal analgesia
Positive reinforcement of supraspinalanalgesia
Suppresses noxious thermal stimuli atspinal cord
Enhances m agonists.
Hypersensitivity Severe respiratory depression Acute or severe asthma
Known or suspected paralytic ileus Head injury or carniotomy Acute pancreatitis Acute alcohol intoxication Hypovolemic shock – use IV
Half-life:◦ Buccal film – 14hours◦ Buccal tablet 100-200mcg – 3-4hours
400-800mcg – 11-12hours
◦ Lozenge – 7hours
T #2 – 15mg of Codeine, 300mg Acetaminophen
T #3 – 30mg of Codeine, 300mg Acetaminophen
T #4 – 60mg of Codeine, 300mg Acetaminophen
Codeine is metabolized hepatically tomorphine via CYP2D6◦ Approximately 10% of Europeans and Caucasian
lack this ability
Opioid naïve – base off the codeinecomponent◦ 1-2 q4h PRN
Time to onset: 0.5 to 1 hour
Half-life: 2.5-3.5 hours
Derivative of codeine Many formulations with adjuvants◦ Lorcet – 10mg hydrocodone/650mg acetaminophen◦ Lorcet HD/Vicodin – 5mg/500mg◦ Lorcet Plus – 7.5mg/650mg◦ Lortab – 2.5mg/500mg, 5mg/500mg, 7.5mg/500mg,
10mg/500mg◦ Lortab elixir – 2.5mg/167mg per 5mL◦ Norco – 5/325mg, 7.5/325mg, 10/325mg◦ Vicodin ES – 7.5/750mg◦ Vicodin HP – 10/660mg
◦ Vicoprofen – 7.5mg hydrocodone/200mg ibuprofen
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Opioid naïve – 5-10mg four times daily ofhydrocodone◦ Limit acetaminophen consumption not to exceed
4000mg/day
Time to onset: 10-20 minutes
Half-life: 3.3-4.4 hours
18 times less potent than morphine in binding tomu-opioid receptors; 2-3 times less analgesiceffect
Binds to mu-opioid receptors, inhibits reuptakeof norepinephrine
Only oral route Drug/drug interaction with risk of serotonin
syndrome
Approved for acute pain not chronic use
Products:◦ Nucynta 50mg, 75mg, and 100mg◦ CII
Initial dose (acute mod/sev pain): 50-100mgq4-6h PRN (may administer 2nd dose morethan 1 hour after initial dose on day one only(maximum daily dose day 1=700mg;thereafter=600mg)
Half-life: 4 hours
Metabolized to norpropoxyphene (activemetabolite)◦ Long half-life of metabolite = accumulation
◦ Increase CNS side effects
Not recommended in geriatrics – Beer’scriteria
Naproxen has been shown to be superior toDarvocet with fewer side effects
FDA recommended to stop production anddistribution of Darvocet
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Mu receptor agonist; inhibits norepinephrineand serotonin reuptake
Drug interactions◦ SSRIs, TCAs, cyclobenzaprine, alcohol
Serotonin Syndrome
May lower seizure threshold
Regular release = 50mg
Extended release = 100mg, 200mg, 300mg
Gold Standard
Tablets:◦ MSContin: 15mg, 30mg, 60mg, 100mg, 200mg◦ Dose q8h or q12h – NEVER PRN
Capsules: May be opened and sprinkled onapplesauce◦ Kadian: 20mg, 30mg, 50mg, 60mg, 80mg, 100mg,
200mg Dose q12h or q24h
◦ Avinza: 30mg, 60mg, 90mg, 120mg Dose q24h
New sustainedrelease product
Dosing: Daily Doses: 8mg, 12mg,
16mg Half-life: ~11 hours Titrate no sooner
than every 3 days Administer no more
frequently thenevery 24 hours
Hydromorphone (Exalgo(ExalgoTMTM))
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Only if Morphine Sustained-Release fails◦ Exception – allergy to morphine, cancer pain
