Download pdf - Easing the Pain… Approaches to Managing Pain Associated with …ucsfcme.com/minimedicalschool/syllabus/spring2015/Ritchie... · 2015. 6. 17. · Pharmacotherapy: WHO 3-step Ladder

[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, FAAHPMHarris Fishbon Distinguished Professor

6/16/20152

Courtesy J Kutner

DefinitionsAcute 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


6/16/20152

Pain--A complex experience

7

Bio

SocialPsycho

Environmental stressorsClose personal relationships

DistressAngerFearTraumatic life events

Disease-related mechanismsBiologic mechanisms of psychiatric illness

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

PainA complex experience

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


6/16/20153

Pain--Multimodal management

9

Bio

SocialPsychoHealthcareFamilyWork

CognitionsEmotionsBehaviorsAttention

MedicationExerciseSurgerySleep

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


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 TopicalNSAIDs2

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: <0.50 small, 0.50-0.79 moderate, ≥ 0.80 large.

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.


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!


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.


6/16/20157

Opioid Overdose Deaths 1999-2009

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

1

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


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 ApproachesBehavioral 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)

30

CBT

Your thoughts

Your behaviors

Your emotions

Relaxation Training

Deep breathing

Guided imagery

Progressive muscle relaxation

Many tools online:

http://theacpa.org/Relaxation-Guide

https://nccih.nih.gov/health/stress/relaxation.htm

31

Mindfulness-based Stress Reduction

Awareness and thinking as different capacities.

• awareness balances out inflammations of thought, emotional agitations and distortions

• Paying attention to one’s pain

6/16/201532John Kabot Zin The Mindfulness Solution to Pain; http://elishagoldstein.com/videos/page/2/


6/16/20159

Mindfulness-based Stress Reduction

Body Scan- bringing awareness to each body part.

Breathing- “calming your mind and grounding your breath.”

Distractions- games, conversations, reading a book

6/16/201533John Kabot Zin The Mindfulness Solution to Pain; http://elishagoldstein.com/videos/page/2/

Complementary and Alternative Approaches

Acupuncture

Herbs:

• Feverfew

• Butterbur .

• Cayenne (capsaicin)

• Chamomile tea .

• Dandelion

• Ginger

• Gingko

• Stinging Nettle

• Willow Bark.

6/16/201534

Tailored Interdisciplinary Assessment &Treatment Plan

Intake ReviewTailored Plan of Care

Symptommanagement

Coordination

SupportiveCare and

CounselingNutrition Support Spiritual CareFinancial and Social Support

Whole Person Approach

Follow-up

Supportive Pain Management = Team Care


6/16/201510

Summary

Pain is common in the setting of serious illness

Pain is a complex experience influenced by biology, environment and one’s emotions and cognitions

Many effective medicines for pain also have significant side effects

A holistic approach includes pharmacologic and nonpharmacologic approaches to pain with input and support from an interdisciplinary team.

6/16/201537