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Pain management overview 2013

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Pain management overview 2013

  1. 1. Y V O N A G R I F F O , M D P A I N & P A L L I A T I V E C A R E S E R V I C E M E M O R I A L S L O A N K E T T E R I N G C A N C E R C E N T E R PAIN MANAGEMENT The following material is intended for MSKCC internal medicine housestaff teaching purposes only. The slides were updated for the LibGuide in 2012-2013.
  2. 2. 2 The International Association for the Study of Pain: An unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage
  3. 3. BASIC APPROACH 1. ETIOLOGY of PAIN 2. CLASSIFICATION of PAIN 3. ASSESEMENT of PAIN 4. TREATMENT of PAIN
  4. 4. ETIOLOGY  PAIN CAUSED BY CANCER  Infiltration of Bone, Viscera, Soft tissue, Muscles  Infiltration of Spinal Cord, Roots ,Plexus or Peripheral Nerves  Occlusion of Blood Vessels  PAIN AS SEQUELAE OF CANCER TREATMENT  PAIN DUE TO FRAILTY  PAIN UNRELATED TO CANCER
  5. 5. ETIOLOGY-Treatment related POST-SURGICAL - Phantom Pain - Neuroma - Adhesions - Post-Thoracotomy, Mastectomy CHEMOTHERAPY -Peripheral Neuropathy -Mucositis RADIOTHERAPY -Radiation Dermatitis -Radiation Neuritis
  6. 6. Mixed Type Caused by a combination of both primary injury or secondary effects CLASSIFICATION of PAIN Nociceptive Pain Caused by activity in neural pathways in response to potentially tissue-damaging stimuli Neuropathic Pain Initiated or caused by primary lesion or dysfunction in the nervous system Postoperative pain Mechanical low back pain Sickle cell crisis Arthritis Postherpetic neuralgia Neuropathic low back pain CRPS* Sports/exercise injuries *Complex regional pain syndrome Central post- stroke pain, spine Trigeminal neuralgia Distal polyneuropathy (eg, diabetic, HIV)
  7. 7. CANCER PAIN  INITIAL ASSESMENT and DIAGNOSIS of Underlying cause  TREATMENT OF ACUTE UNDERLYING CAUSE  SPECIFIC ANTI-TUMOR THERAPY -Surgery -Radiation -Chemotherapy  PAIN MANAGEMENT-ANALGESICS WHO LADDER Step 1-3
  8. 8. CLINICAL ASSESSMENT OF PAIN 8 Believe the patient’s self-report of pain Take a careful history —ONSET (temporal pattern) of pain —LOCATION site of pain/widespread or localized/uni-bilateral —DURATION of pain /constant or incidental/ —CHARACTER/quality and intensity of pain/ —AGGRAVATING/RELIEVING factors —RESPONSE to analgesics —DEGREE of intensity and interference with patient’s life —ASSOCIATED signs and symptoms
  9. 9. ASSESSMENT of PAIN INTENSITY No Mild Moderate Severe Very Worst pain pain pain pain severe possible pain pain Verbal Pain Intensity Scale No pain Visual Analog Scale Faces Scale 0 1 2 3 4 5 0–10 Numeric Pain Intensity Scale No Moderate Worst pain pain possible pain 0 1 2 3 4 5 6 7 8 9 10 Worst possible pain 19
  10. 10. WHO –3 Steps ANALGESICS LADDER  For mild pain, use non-opioid first  When pain persists or increases, add an opioid  If pain becomes more severe, increase the opioid potency or dose  Schedule doses on around-the-clock basis, with additional PRN doses -rescues
  11. 11. ADJUVANT ANALGESICS  Anticonvulsants  Antidepressants  Corticosteroids  Neuroleptics  Anxiolytics  Muscle relaxants  Anesthetics  Antispasmodics
  12. 12. BASIC PAIN MANAGEMENT  Believe Pt’s self report  Assess factors affecting Pt’s pain report (medical, psychological, spiritual, functional)  Titrate analgesics to effectiveness and tolerance of side effects  If on ATC opioid must have PRN  Treat Opioids side effects (bowel regimen)
  13. 13. STEP 1- WHO ANALGESICS 14 NON-OPIOID ANALGESICS ACETAMINOPHEN NASIDS -(COX -2 INHIBITORS,ASA, SALICYLIC ACID DERIVATIVES) Benefits: NO TOLERANCE or PHYSICAL DEPENDENCE ADDITIVE ANALGESIA when COMBINDED with an OPIOID Caution: CEILIING EFFECT for ANALGESIA RISKS RELATED to PLATELET DYSFUNCTION, GASTRIC ULCERATION and GI BLEEDING, CARDIOVASCULAR EVENTS, HTN, RENAL INSUFFICIENCY or LIVER TOXICITY
  14. 14. STEP 2- WHO ANALGESICS 15 WEAK OPIOIDS CODEINE HYDROCODONE OXYCODONE –(in combination with a non- opioid) TRAMADOL (mu-agonist, norepinephrine and serotonin reuptake inhibitor) TAPENTADOL (mu-agonist, norepinephrine reuptake inhibitor)
  15. 15. STEP 3 – WHO ANALGESICS STRONG OPIOIDS MORPHINE HYDROMORPHONE FENTANYL OXYCODONE METHADONE LEVORPHANOL BUPRENORPHINE OXYMORPHONE MEPERIDINE
  16. 16. CHOOSING THE OPIOID ANALGESIC 17 Patient sensitivity and allergy Prior opioid exposure Current intensity of pain or pain crisis Pain pathophysiology (nociceptive vs neuropathic) Available route of administration Requirements for rescue medications Metabolic factors Drug interactions Cost/availability and formulary preparations Street value
  17. 17. ROUTES of OPIOID ADMINISTRATION  ORAL -tablets, elixirs  RECTAL-suppository  TRANSDERMAL, TRANSBUCCAL  SUBCUTANEOUS  INTRAVENOUS  bolus, continuous infusion, PCA  EPIDURAL  INTRATHECAL
  18. 18. ALGORITHM for OPIOID THERAPY Patient Selection Initial Patient Assessment Trial of Opioid Therapy Alternatives to Opioid Therapy Patient Reassessment Exit Strategy Conversion to Long-acting Opioid Opioid Rotation Continue Opioid Therapy Used with permission of Nathaniel P. Katz, MD 7
  19. 19. MONITORING OPIOID THERAPY 20 Continual monitoring and follow-ups are essential to good opioid analgesic therapy – during the trial and throughout chronic therapy CRITICAL OUTCOMES = “4 A’s of Pain”  Analgesia  Adverse effects  Activities of daily living  Aberrant opioid-related behavior Adjust and Manage therapy based on outcomes Document critical outcomes
  20. 20. 21 Short acting Opioids = (immediate release preparations) – Morphine (MSIR ®, Roxanol ™, rectal suppositories – Codeine (Tylenol with codeine, Soma) – Hydrocodone (Vicodin ®, Zydone ® Lortab ®, Vicoprofen ®, Norco®) – Oxycodone (Roxicodone, Oxy IR ®, OxyFAST, Percocet ®, Percodan ®, Tylox ®) – Hydromorphone (Dilaudid ®) – Oxymorphone (Opana IR) – Fentanyl (Actiq ®, Fentora ®,Onsolis) CATEGORIES OF OPIOID ANALGESICS
  21. 21. CATEGORIES OF OPIOID ANALGESICS LONG – ACTING OPIOIDS – EXTENDED RELEASE PREPARATIONS  Morphine sustained – release (MS Contin, Avinza, Kadian, Oramorph)  Oxycodone sustained – release (OxyContin)  Oxymorphone – sustained release (Opana ER)  Fentanyl – transdermal patches (Duragesic)  Hydromorphone –(Exalgo) LONG – HALF LIFE OPIOIDS  Methadone  Buprenorphine  Levorphanol
  22. 22. 23 “GOLD STANDARD” – FOR TREATMENT of MODERATE TO SEVERE PAIN” Full mu-receptor agonist Bioavailability – 30% (PO: IV dose is 3:1) Easily available in wide range of preparations – Immediate and sustained release – Oral tablets, elixir, suspension, capsules – Rectal suppositories – Parenteral (IV, IM, SC, epidural, intrathecal) Most widely used opioid analgesic CAVEAT !!! – BID/TID medication – Active morphine metabolites MORPHINE-6- GLUCURONIDE MORPHINE-3- GLUCURONIDE MORPHINE
  23. 23. 24 Semisynthetic derivative of thebaine Most utilized opioid worldwide Full mu-receptor agonist, Kappa receptor agonist ?? Bioavailability – 50% Oxycodone : morphine dose ration 1: 1.5-2 IR and ER preparations, oral only(tablets or elixir) Sustained release preparation OXYCONTIN has 2 phase release (immediate and extended in the same pill) OXYCODONE
  24. 24. FENTANYL 25 Full- mu receptor agonist High potency, short duration of action, rapid onset of action Lipophilic – ideal drug for transdermal and transmucosal administration bioavailability – 50% Parenteral, transdermal and transmucosal preparations 25 mcg/hour transdermal Fentanyl patch = 1mg/1 hour IV Morphine Transdermal Fentanyl patch takes 12 hours to reach analgesic blood levels on initiation (6 – 18h) 90 – 95% of transdermal Fentanyl reaches systemic circulation as unchanged Fentanyl Convenient to use (3 – day drug reservoir) Ideal for children and uncooperative/impaired adults
  25. 25. FENTANYL PATCH 24-hour Oral Morphine Initial Fentanyl dose 30-59 mg 12 mcg 60-134 mg 25 mcg 135-224 mg 50 mcg 225-314 mg 75 mcg 315-404 mg 100 mcg
  26. 26. ACTIQ, FENTORA, SUBSYS,ABSTRAL  Transbuccal Fentanyl -No direct correlation with TD Fentanyl dose !!!  NEVER use for opioid naïve patient !!!  Keep away from children, pets  Restricted distribution-TIRF-REMS
  27. 27. 30 Semisynthetic opioid, hydrogenated ketone analog of morphine Full, potent – mu – receptor agonist Available for oral, parenteral and rectal use PO:IV dose is 5:1 Oral hydromorphone : morphine dose ration is 1: 4 Parenteral hydromorphone : morphine dose ratio is 1:7 Short duration of action : 3-4 hours HYDROMORPHONE
  28. 28. 31 Synthetic opioid - mu- receptor agonist - NMDA receptor antagonist - serotonin reuptake inhibitor Unique pharmacology - variable and long half-life (8 – 80 hours) - steady-state plasma concentration up to 10 days - potency greater then expected Good oral bioavailability – 60 – 95% PO:IV dose is 2:1 Inexpensive and effective – oral( tablets or elixir) or parenteral But requires special knowledge - how to initiate and titrate the dose - monitor for cardiac toxicity (QT prolongation ) No active metabolites ! Clearance not influenced by hepatic or renal impairment METHADONE
  29. 29. METHADONE 32 ACUTE USE: 1 MG IV MORPHINE = 1 MG IV METHADONE CHRONIC USE: 10 MG IV MORPHINE = 1MG IV METHADONE 30 – 90 mg daily PO Morphine 4 : 1 90 – 300 mg daily PO Morphine 6-8 : 1 >300 mg daily PO Morphine 10-12 : 1 1960-s – in single dose studies morphine and methadone doses are equal (Raymond Houde, Equianalgesic conversion tables)
  30. 30. OPIOID EQUIANALGESIC DOSES Opioid parenteral oral conversion duration (mg) (mg) (IV to PO) (hours) Morphine 10 30 3 3 - 4 Methadone 10 20 2 4 - 8 Hydromorphone 1.5 7.5 5 2 - 3 Meperidine 75 300 4 2 - 3 Levorphanol 2 4 2 4- 6 Oxycodone - 20 - 3 - 5 Oxymorphone 1 5 5 3 - 4 Fentanyl 0.25 - 1 1- 2
  31. 31. OPIOID CONVERSIONS  Calculate 24 hrs IV or PO requirement  Multiply by IV or ORAL conversion factor  Divide in multiple dosages or hourly rate depending on medication to be used  If using SR preparation, add 10-15% of 24 hrs dose in IR form for breakthrough pain PRN
  32. 32. OPIOID CONVERSION  Example: Opioid equianalgesic values for: Morphine 10 mg IV= morphine 30 mg PO =hydromorphone 1.5 mg IV = hydromorphone 7.5 PO =Fentanyl 250 mcg IV = Methadone 1mg IV  Example: Same drug, changed route Change 90 mg q12 MS Contin PO to IV continuous infusion Calculate 24-h current dose: 180 mg MS/24 h Look up equianalgesic ratio: PO/IV= 3 Calculated new dose using ratios: 180/3= 60 mg IV/24 hours =2.5 mg/h continuous infusion 61
  33. 33. 36 OPIOID THERAPY ASSESMENT ANALGESI A + - - ADVERSE EFFECTS - + +     - CONTINUE CURRENT OPIOID INCREASE DOSE OF OPIOID IMPROVE MANAGEMENT OF SIDE EFFECTS OPIOID ROTATION +
  34. 34. OPIOID SIDE EFFECTS 37 COMMON – CONSTIPATION – NAUSEA and VOMITING – COGNITIVE IMPAIRMENT • sedation • confusion • hallucinations • agitation/myoclonus – MIOSIS – RESPIRATORY DEPR. – COUGH SUPPRESSION LESS COMMON – URINARY RETENTION – ENDOCRINE DYSFUNCTION – ITCHING (HISTAMINE RELEASE) – SWEATING – HEADACHE – DELIRUM – BILIARY SPASM/GASTRIC STASIS – DRY MOUTH – SEIZURES – HYPEALGESIA/ALLODYNIA – TOLERANCE, PHYSICAL DEPENDENCE, ADDICTION
  35. 35. MANAGEMENT OF OPIOIDS SIDE EFFECTS 38 NALOXONE ANTIEMETICS LAXATIVES ANTICHOLINERGICS PSYCHOSTIMULANTS ANTIPSYCHOTICS POLYPHARMACY
  36. 36. NALOXONE (Narcan)  Opioid Antagonist  Used to reverse opioid-induced respiratory depression  May precipitate severe withdrawal symptoms and pain  Onset of action 1-2 min  Short duration of action- 45 min
  37. 37. NALOXONE DOSAGE  RESPIRATORY DEPRESSION RR < 8/min  DILUTE !!! 1 ml in 9 ml normal saline  0.04 mg IV push over 15 sec every 1-3 min PRN  RESPIRATORY ARREST  1 ml UNDILUTED !!! = 0.4 mg IV push over 15 sec  follow by 0.4 mg every 1- 3 min PRN
  38. 38. OPIOID naïve ADULTS  Avoid starting long acting opioid !!!  Start small doses short acting (Oxycodone 5 mg q3h prn, MSIR 15 mg q3h prn, Dilaudid 2mg q3h prn)  Acute severe pain- Morphine 5-10 mg IV, Dilaudid 0.5-2 mg IV, Toradol 15-30 mg IV  IV-PCA- AVOID BASAL for first several hours and  CAVEAT- Pts with respiratory disease, sleep apnea
  39. 39. IV –PCA Patient Controlled Analgesia If pain is not controlled: 3 choices - increase basal hourly rate - increase rescue doses - increase both (most common approach) Mild-moderate pain- increase dose by 25% Severe pain- increase dose by 50% Or increase basal rate based on # of rescues taken in the last 12-24 hours
  40. 40. RESCUE-PRN dose  IV rescue- ½ of IV hourly basal dose  IV rescue can be given every 10- 15-20 min  PO rescue- 10-20 % of TOTAL daily opioid dose given every 2-3 hours PRN
  41. 41. IV- PCA  Do not prescribe rescue doses in delirious patients !!!  Family members can not operate PCA !  CAB= Clinician activated bolus, given by nurse/MD. Used for pain crisis, prior to tests or PT  Methadone and Fentanyl require separate IV line
  42. 42. SWITCH from FENTANYL PATCH to IV-PCA  Determine target IV PCA setting  Remove patches (in most cases)  Start with 0 basal (in most cases)  6h after patch removal increase basal to 50% of target dose  12h after patch removal increase basal to full target
  43. 43. SWITCH from IV PCA to FENTANYL PATCH  Determine patch dose  6h after patch placement decrease PCA basal by 50 %  12h after patch placement D/C basal and continue rescues overnight  D/C PCA in AM and start oral PRN rescues
  44. 44. OPIOIDS RESTRICTED to Pain Services at MSKCC  Fentanyl PCA- for basal and rescues at and above 50 mcg/h  Dilaudid PCA- for basal and rescues at and above 0.4 mg/h  IV Methadone  IV Oxymorphone MORPHINE PCA IS UNRESTRICTED!!!
  45. 45. TAPERING OF OPIOIDS  Literature- Pts can tolerate 75% decrease without withdrawal symptoms  Clinical experience- many Pts need slow taper- 25- 50% or less every 2-3 days  Educate Pts on withdrawal symptoms and how to manage it
  46. 46. PRINCIPLES OF PAIN MANAGEMENT - SUMMARY -  Cancer pain can - and must be - treated  Establish underlying diagnosis of pain  Use analgesics AROUND THE CLOCK and PRN !!!  WHO-3-step analgesic ladder approach, non- opioids and opioid mu- agonists  Prophylactic bowel regimen  Add adjuvant analgesics when indicated  Continued supervision and dose adjustments
  47. 47. Thank You

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