Easing the Pain Approaches to Managing Pain Associated with 2015. 6. 17.¢  Pharmacotherapy: WHO 3-step

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  • [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

    6/16/20151

    Easing the Pain… Approaches to Managing Pain Associated with Serious Illness

    6/16/2015

    Christine S.Ritchie, MD, MSPH, FACP, FAAHPM Harris Fishbon Distinguished Professor

    6/16/20152

    Courtesy J Kutner

    Definitions Acute pain:

    • “An unpleasant sensation and emotional response to that sensation”

    • Cut, bruise, bone fracture, tooth ache

    Chronic pain:

    • Unpleasant sensation that continues for prolonged period of time “beyond expected time of healing”

    ‒ Pain on most days for more than 3 (or 6) months

    ‒ May or may not be associated with identified disease process

    3

    Pain---how common is it?

    Community-dwelling adults: 30-50%

    Nursing homes: 60-80%

    Among palliative care patients: 83%

    • 25% have severe or overwhelming pain

    Pidgeon T, et al. BMJ Supportive & Palliative Care 2015

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    6/16/20152

    Pain-- A complex experience

    7

    Bio

    SocialPsycho

    Environmental stressors Close personal relationships

    Distress Anger Fear Traumatic life events

    Disease-related mechanisms Biologic mechanisms of psychiatric illness

    Gatchel, Am Psychol, 2004; Gatchel, Psychol Bull, 2007

    Pain A complex experience

    8 Sibille et al. Pain. 2012 September ; 153(9): 1789–1793

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    6/16/20153

    Pain-- Multimodal management

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    Bio

    SocialPsycho Healthcare Family Work

    Cognitions Emotions Behaviors Attention

    Medication Exercise Surgery Sleep

    Therapeutic Strategies for Pain • Pharmacotherapy

    • Nonpharmacologic: ‒Rehabilitative approaches ‒Behavioral approaches ‒Complementary and

    alternative approaches ‒Lifestyle changes

    Pharmacotherapy: WHO 3-step Ladder

    1 mild1 mild

    2 moderate2 moderate

    3 severe3 severe Morphine

    Hydromorphone

    Methadone

    Fentanyl

    Oxycodone

    ± Adjuvants

    A/Codeine

    A/Hydrocodone

    A/Oxycodone

    A/Dihydrocodeine

    Tramadol

    ± Adjuvants

    ASA

    Acetaminophen

    NSAIDs

    ± Adjuvants

    Acetaminophen

    Safest pain medication on market Max allowable dose (4 grams over 24 hours)

    • Most individuals take considerably less • Safe for those over 70 to set limit at 3gm/day • Need to read labels regarding presence of

    acetaminophen in other products • Too much acetaminophen can cause liver

    damage Recommended first-line therapy

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    6/16/20154

    Non-Steroidals- NSAIDS (e.g. ibuprofen, naproxen)

    Most popular analgesic agents on market Significant safety issues

    • > 100, 000 hospitalizations each year • > 16,000 deaths each year Can precipitate heart failure episodes, worsen blood pressure, worsen kidney function Can increase risk of stroke/heart attack Frequent monitoring required

    Opioids (e.g. morphine, oxycodone, hydrocodone, fentanyl patch)

    Many side effects (constipation, lethargy, nausea, itching)

    Effective at treating pain • Likely underused by older adults

    Many barriers to use • Patient • Physician

    Treatment Considerations

    Overdose

    Abuse/Misuse patient or contact

    Addiction

    Drug-drug and drug-disease Interactions

    Physical dependence and tolerance

    Analgesia

    Improved function

    Improved quality of life

    Adverse effects

    Comprehensive Benefit to Harm Evaluation

    Kotalik J Controlling pain and reducing misuse of opioids. Can Fam Physician 2012;58

    History and Physical and Appropriate Evaluation

    Benefits Associated With NSAID/Opioid Use (Effect Sizes)

    Oral NSAIDs1 Topical NSAIDs2

    Opioids3

    Pain reduction 0.32 0.24 0.58

    Physical functioning

    0.22 ? 0.43

    Sleep improvement

    ? ? 0.87

    Quality of life ? ? ?

    Socialization ? ? ? Effect sizes:

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    6/16/20155

    Risks Associated With NSAID/Opioid Use

    Selective NSAIDs

    Topical NSAIDs

    Opioids

    Renal

    Acute kidney injury  NR 

    CKD progression  NR 

    Cardiovascular

    Stroke  NR 

    Heart Attack  NR 

    Congestive heart failure  NR 

    Blood Pressure increase  NR 

    O’Neill et al. Am J Geriatr Pharmacother 2012;10:331-42. Solomon et al. Arch Intern Med 2010;170:1968-78. Makris et al. J Rheumatol 2010;37:1236-43.

    NR = not reported.

    Risks Associated With NSAID/Opioid Use

    Nonselect. NSAIDs

    Selective NSAIDs

    Topical NSAIDs

    Opioids

    Falls/fractures   NR 

    GI

    Ulceration/bleed   NR 

    Dyspepsia    

    Hospitalization   NR 

    1 Bjordal et al BMJ 2004 BMJ. 2004; 329(7478): 1317. 2Biswal et al J Rheum 2006;33:1841-44. 3Papaleontiou J Am Geriatr Soc 2010; 58:1353-69.

    NR = not reported.

    Public Health Impact of Treatment- Related Adverse Effects

    NSAIDs • Hospitalizations (GIBleeding & Acute

    Kidney Injury) • CHF exacerbations Opioids

    • Falls/fractures • Constipation/obstipation • Mental status changes/Sedation • Overdoses

    Constipation

    Most common adverse effect encountered during chronic opioid therapy No tolerance developed to this side effect Multifactorial Prophylactic laxatives are indicated PREVENTION IS KEY!

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    6/16/20156

    Constipation: Management

    Softeners • Docusate

    Cathartics • Senna

    • Biscadoyl (Dulcolox)

    Osmotic Laxatives • Magnesium/aluminum salts

    • Lactulose

    • Sorbitol

    Enemas

    Fiber- usually not indicated in frail or end-of-life patients

    Sedation and Cognitive Impairment

    Discontinue non-essential medications. Evaluate and treat other potential causes. If analgesia satisfactory, decrease dose by 25%. If analgesia inadequate or symptoms persist despite dose reduction: • trial of psychostimulant (if sedation) or

    neuroleptic (if delirium). • switch to an alternative opioid. • trial of other invasive/non-invasive approach to

    decrease systemic opioid requirements.

    When dose-limiting side effects occur with opioid pharmacotherapy...

    More aggressive treatment of adverse effect(s) Opioid-sparing strategies

    • Analgesic adjuvants

    • Alternate route (e.g. intraspinal) • Anaesthetic/Neurolytic procedures

    • PM&R approaches

    • Cognitive therapy • Complementary therapies ‒ e.g., acupuncture, massage, music therapy

    Opioid rotation

    Opioid Prescribing Over Past 16 Years

    Olfson et al. J Clin Psych 2013;74:932-39.

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    6/16/20157

    Opioid Overdose Deaths 1999-2009

    Ballantyne K. J Med Toxicol 2012;8:417-23.

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    Group Health Consort Study, 1997‐2005; Dunn KM, et al. Ann Intern Med. 2010 Jan 19;152(2):85‐92.

    Percent  Use

    Dose and Overdose Risk

    Therapeutic Strategies for Pain

    • Pharmacotherapy • Nonpharmacologic: ‒Rehabilitative

    approaches ‒Behavioral

    approaches ‒Complementary

    and alternative approaches

    ‒Lifestyle changes

    Nonpharmacologic Approaches

    • Good for preserving function • Underused • Passive ‒Heat/ice packs ‒TENS ‒Ultrasound

    • Active ‒Stretching ‒Strengthening/pain relief

    Physical therapy

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    6/16/20158

    Cognitive-Behavioral Therapy • Replacing maladaptive cognitions,

    emotions, behaviors with more adaptive ones

    • Increasing functional capacity through improved coping

    Other Behavioral Therapies • Relaxation training • Mindfulness based stress reduction

    Nonpharmacologic Approaches Behavioral Therapies

    Nonpharmacologic Therapies

    Areas addressed by CBT: • catastrophizing • acceptance of the

    pain condition • avoidance of activity

    due to unrealistic concerns about harm

    Cognitive Behavioral Therapy (CBT)

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    CBT

    Your thoughts

    Your behaviors

    Your emotions

    Relaxation Training

    Deep breathing Guided imagery Progressive muscle relaxation

    Many tools online: http://theacpa.org/Relaxati on-Guide https://nccih.nih.gov/healt h/stress/relaxation.htm

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    Mindfulness-based Stress Reduction

    Awareness and thinking as different capacities.

    • aware

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