PDF Pain Management Pain in Primary Care in Primary Care
[Pages:13]Pain Management in Primary Care
Robert M. Taylor, MD
Associate Professor of Neurology Medical Director
Pain and Palliative Medicine Program The Ohio State University
Pain in Primary Care
? Pain was primary reason for 40% of doctor visits in a Finnish study from 2001 9 Most common reason for visiting doctor
? Not enough pain specialists to treat all the patients with chronic pain
? Primary care doctors will end up managing most pain problems
? Easier if some basic principles in mind
Pain Definition
? Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
? Pain is always subjective
Pain Mechanisms
? Traditional pain categories:
9 Nociceptive
? Somatic
? Visceral 9 Neuropathic 9 Complex Regional Pain Syndrome
(CRPS)
? Formerly Reflex Sympathetic Dystrophy (RSD)
1
Acute vs. Chronic Pain
? Acute pain
9 Well-defined, temporal pattern of onset
9 Associated with subjective and objective physical signs and with hyperactivity of the autonomic nervous system
9 Usually self-limited
9 Responds to analgesic treatment and/or treatment of underlying disease
Chronic Malignant Pain vs. Chronic Non-malignant Pain
? Pathophysiology is similar
? Difference in longevity may be important
? Malignant pain associated with diminishing function due to disease progression
? Risks of long-term opiate therapy may be more significant in benign pain 9 Emphasize non-pharmacological treatments 9 Emphasize enhancing function & QOL
Acute vs. Chronic Pain
? Chronic pain 9 Pain that lasts for longer than 3-6 months
? Or longer than normal healing process 9 Nervous system dysregulation results in
hypersensitivity to pain
? Spontaneous generation & perpetuation of pain
? Adaptation of the autonomic nervous system
? Lack of objective signs and symptoms 9 Pain becomes a problem in itself 9 Changes in personality, lifestyle, & function
Chronic Nonmalignant Pain
? Evaluate pain etiology carefully ? Use non-pharmacolgical modalities ? Assess risk factors for addiction & abuse
9 Use non-opioids if possible ? Emphasize improved function & QOL as
primary goal of therapy, NOT pain relief 9 Consider using available tools to assess 9 Involve family, work, etc. to monitor
2
Chronic Nonmalignant Pain
? Use formal pain agreement for informed consent prior to prescribing opioids 9 Include consent for UDS
? Initiate opioids as a therapeutic trial 9 Discontinue (taper or detox) if ineffective or significant aberrant behaviors noted 9 Consider referral for addiction evaluation & treatment
? Monitor function & QOL as primary goal
? Monitor UDS & OARRS reports
Understanding Addiction
? Physical dependence 9 Normal and expected phenomenon 9 Due to decrease in endogenous analogues 9 Characteristic withdrawal syndrome 9 Usually not a serious problem
? If symptoms improve, drug can be weaned
Aberrant Drug-taking Behaviors
Steven D. Passik, PhD
? Probably more predictive
9 Selling prescription drugs
9 Prescription forgery
9 Stealing or borrowing another patient's drugs
9 Injecting oral formulation
9 Obtaining prescription drugs from non-medical sources
9 Concurrent abuse of related illicit drugs
9 Multiple unsanctioned dose escalations
9 Recurrent prescription losses
? Probably less predictive
9 Aggressive complaining about need for higher doses
9 Drug hoarding during periods of reduced symptoms
9 Requesting specific drugs
9 Acquisition of similar drugs from other medical sources
9 Unsanctioned dose escalation 1-2 times
9 Unapproved use of the drug to treat another symptom
9 Reporting psychic effects not intended by the clinician
Understanding Addiction
? Addiction
9 Psychological/behavioral phenomenon 9 Compulsive use causing physical,
psychological, or social harm to the patient 9 Continued use despite such harm 9 Compulsive actions to acquire the drug 9 Rare in terminally ill patients
? Often note increased level of functioning
3
Understanding Addiction
? "Pseudo-addiction"
9 Prevalence uncertain & controversial 9 Occurs in patients
? Whose symptoms are under-treated ? Who fear medication will be arbitrarily
withheld 9 May exhibit aberrant behaviors
? Hoarding, hostility, manipulation, lying, etc.
Pain Assessment Mnemonic
? P ? provoking, palliating factors ? Q ? quality of pain ? R ? radiation (from where to where) ? S ? severity ? T ? temporal course
9 Long term, including onset & short term
Pain Assessment
Intensity of Pain
? Pain is not measurable, hence we must rely of patients subjective descriptions
? Several rating scales of intensity are available, utilizing numbers, colors, faces 9 Mild, moderate, severe, excruciating
? Can suggest objective standard
4
Summary
? Evaluation of the patient with pain should include: 9 Determination of the clinical characteristics of the pain by careful history and exam
? Define etiology if possible 9 Determination of the mechanism of the pain
? Nociceptive, neuropathic, or CRPS 9 Classification as either acute or chronic pain
? Malignant vs. non-malignant chronic pain
WHO Pain Ladder
3 Severe
1 Mild
Acetaminophen NSAIDs ? Adjuvants
2 Moderate
Acetaminophen + Codeine Acetaminophen + Oxycodone ? NSAIDs ? Adjuvants
Morphine Hydromorphone Methadone Fentanyl Oxycodone ? Acetaminophen ? NSAIDs ? Adjuvants
Pharmacologic Treatment of Pain
WHO Ladder Concepts
? By the mouth ? By the clock ? By the ladder ? For the individual ? Attention to detail
Note: Adjuvants may 1) enhance analgesia, 2) treat concurrent symptoms, or 3) provide independent analgesia for specific types of pain
5
Sensitivity to Opioids
? Type of Pain Nociceptive - Somatic - Visceral Neuropathic
Opioid Responsiveness
+ + + + + +
Clearance Considerations
? 90-95% of opioids cleared in urine
? Dehydration, renal failure, severe hepatic failure may cause decreased clearance
? Morphine has an active metabolite (M-6-G) that may accumulate in patients with renal insufficiency
9 Consider an alternate opioid in patients with renal failure, (e.g. oxycodone, hydromorphone, fentanyl)
Opioid Pharmacology
? Conjugated in liver
? Excreted via kidney (90%?95%)
? First-order kinetics
? Cmax after
9 po 1 h 9 SC, IM 30 min 9 IV 10-15 min
? Half-life at steady state
9 po / pr / SC / IM / IV 3-4 h
Opioid Adverse Effects
Common
**Constipation** Dry mouth Nausea / vomiting Sedation Sweats
Uncommon
Bad dreams / hallucinations Dysphoria / delirium Myoclonus / seizures Pruritus / urticaria Respiratory depression Urinary retention Opioid-induced neurotoxicity
6
Opioid Constipation
? Common to all opioids
9 Effects on CNS, spinal cord, myenteric plexus 9 Easier to prevent than treat 9 Diet usually insufficient 9 Bulk forming agents not recommended
Opioid-Induced Neurotoxicity (OIN)
? Neuropsychiatric syndrome ? Cognitive dysfunction ? Delirium ? Hallucinations ? Myoclonus/seizures ? Hyperalgesia/allodynia - generalized
Opioid Constipation
? Stimulant laxative
9 Senna, bisacodyl, glycerine, casanthranol, etc
? Combine with a stool softener
9 Senna + docusate sodium
? Osmotic laxative for refractory cases
9 MOM, lactulose, sorbitol, Miralax
OIN: Treatment
? Opioid rotation
9 Reduce opioid dose (?)
? Hydration ? Benzodiazepines ? Ketamine, psychostimulants ? Non-opioid therapy
7
Opioid Na?ve Patients
? Start at a low dose & titrate to pain relief
? Opioid doses can be titrated up by 30%100% or more each day for severe pain
? Until an effective baseline dose can be established, it is best to avoid sustained release or transdermal systems since they cannot be rapidly and accurately titrated.
Equianalgesic Dosing
PO/SL
30 30 30 7 N/A 300
Name
Morphine Oxycodone Hydrocodone Hydromorphone Fentanyl Meperidine*
IV/SQ/IM
10 N/A N/A 1.5 0.1 100
Fentanyl Patch 100 g/hr roughly equals Morphine 200 mg po/24hr *DO NOT USE
Routine Oral Dosing Immediate Release
Formulations
? For adults >60kg, in moderate to severe pain, start with oral morphine 5 mg equivalent
? May want to start lower for elderly, e. g. 2.5 mg oral equivalent
? Hydrocodone, morphine, hydromorphone, oxycodone oral dosing
9 Dose q 3 to 4 h
9 Adjust dose daily for severe pain
Routine Oral Dosing
Extended Release Formulations
? Improves compliance, adherence ? Dose q 8, 12, or 24 h (product specific)
9 Don't crush or chew tablets
? May adjust dose every 2?4 days
9 Once steady state reached
8
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