Maureen E. Knell Pharm.D., BCPS

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Chronic Pain Management

• Maureen E. Knell Pharm.D., BCPS
• Clinical Assistant Professor of Pharmacy - UMKC
• Saint Lukes Multispecialty Clinic

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Housekeeping Issues

• Exam info
• Brief summary
• Class Case
• Principles apply to arthritis

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• What is chronic pain?
• How does it differ from acute pain?

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Ways to Define Chronic Pain

• Time-frame
• Malignant
• Non-malignant
• Combinations
• acute chronic
• multiple types of chronic
• Syndrome of Chronic Pain
• Impact on QOL

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Major Public Health Problem

• Common - affects 50 million people
• Under treated - only 25 report adequate pain
  relief
• 37 report recurrent pain
• 8 disabling, intractable chronic pain
• Costly - 100 billion annually (direct and
  indirect costs)

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Chronic Pain

• Nociceptive
• Muscle (fibromyalgia)
• Inflammatory (RA and OA-moderate to severe)
• Mechanical/compressive (OA and low back pain)
• Neuropathic (peripheral neuropathies)
• Focus - non-malignant chronic pain
• Common
• Risk factor for under treatment of pain
• Many cancer chronic pain principles apply to
  non-malignant chronic pain

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Syndrome of Chronic Pain

• depression
• anxiety
• sleep disturbances
• anorexia
• social and physical
  dysfunction /disability

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Impact of Chronic Pain on Quality of Life

• Physical
• Functional ability
• Strength/fatigue
• Sleep and rest
• Nausea
• Appetite
• Constipation
• Social
• Caregiver burden
• Roles and relationships
• Affection/sexual function
• Appearance

• Psychological
• Anxiety
• Depression
• Enjoyment/leisure
• Pain distress
• Happiness
• Fear
• Cognition/attention
• Spiritual
• Suffering
• Meaning of pain
• Religiosity

Pain
Adapted from Ferrell et al. Oncol Nurs Forum.
19911813039.
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Pain Scales and Treatment Steps

• Rating 1 3 Mild (Step I)
• Rating 4 6 Moderate (Step II)
• Rating 6 Severe (Step III)
• (some variability - must use clinical judgment)
• nonmalignant chronic pain pain scale may not be
  best assessment tool
• ability to perform daily activities
  (independent/instrumental activities of daily
  living)
• sleep or other chronic pain syndrome symptoms
• worsening disease symptoms/clinical findings

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Treatment Approaches to Chronic Pain -
Nociceptive

• Muscle pain
• Analgesics (pain)
• TCAs (pain/sleep)
• Muscle relaxants (only short-term (4 weeks)
  efficacy proven)
• Other antidepressants (depression / /- benefit
  for pain)
• SSRI
• NESerotonin
• APAP tramadol
• Opioids last line
• Anticonvulsants (pregablin)
• Non-RX (esp. exercise and cognitive-behavior
  therapy

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Treatment Approaches to Chronic Pain - Nociceptive

• Inflammatory pain WHO Analgesic Ladder
• Acetaminophen (?)
• Depends on underlying condition
• NSAIDs, non-acetylated salicylates, COX II
  inhibitors
• Opioids/Tramadol
• Adjuvants
• TCAs (pain and sleep)
• Muscle relaxants (short-term)
• Other antidepressants (pain and depression)
• Topical products (capsaicin)
• Immunomodulators (DMARDs in RA)
• Non-RX

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Treatment Approaches to Chronic Pain - Nociceptive

• Mechanical/Compressive Pain
• NSAIDs, non-acetylated salicylates, COX II
  inhibitors
• TCAs (pain and sleep)
• Other antidepressants (depression and pain)
• Opioids/Tramadol
• Non-RX

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Treatment Approaches to Chronic Pain - Neuropathic

• Anticonvulsants
• TCAs
• Topical lidocaine
• Opioids/Tramadol
• Combinations
• Non-Rx
• 2nd line agents (see reading)

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Case 3

• WA 47 yom with back pain
• Unsuccessful back surgery 2 years ago
• Variety of physicians
• Dissatisfied with care
• Treatment modalities since surgery - generic
  Lortab and Percocet
• Pain scores over the last month Average 6-7.
  Highest 9, Lowest 5.
• Describes two types of pain back pain
  constant, dull, aching (started 4 years ago), leg
  pain frequent shooting, tingling pain from
  buttocks to toes, worse on right than left (has
  become gradually worse over the last year)
• Limited ability to perform instrumental
  activities of daily living
• PMH HTN, Dyslipidemia, Tobacco abuse, Obesity
• Current Medications Generic Percocet,
  Alprazolam, Trazadone, Bisacodyl, HCTZ,
  Lovastatin
• Cane and wears a back brace
• See additional details in syllabus

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Case 3

• Additional Information
• Problems

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Case 3 General Chronic Pain Goals

• Reduce the incidence and severity of pain
  (timeframe depends on severity of pain and
  treatment recommended)
• Set specific goal pain score with patient input
• Maintain / improve level of function (long-term)
• Minimize potential side effects
• such as constipation and risks for APAP overdose
  (now and long-term)
• Improve QOL with specific parameters
• Reduce symptoms of chronic pain syndrome (if
  present- timeframe based on tx -- and in future)
• Improve relationships and social function
  (timeframe depends on onset of treatment
  recommended)
• Treat/improve/prevent progression underlying
  condition
• Address other disease states/problems

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Case 3 - Treatment Plan

• Combination Pain Management Therapy
• Nociceptive tx
• Neuropathic tx
• Syndrome of Chronic Pain
• Non-RX tx
• Other disease states (obesity)
• UDS?

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Case 3

• Patient Education
• Monitoring
• Effectiveness
• Pain/function
• Adverse Effects/Toxicities
• Complications
• Sign/sx of chronic pain syndrome
• Other disease states

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Roles for pharmacists in the treatment of
chronic pain?
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Understand and Overcome Barriers

• Healthcare and regulatory systems
• Patients and family members
• Health care professionals (including pharmacists)

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Non-Maligant Chronic Pain Issues

• Common sense, logical, step-wise plan
• Multi-treatment approach - appropriate trials
• Non-pharmacological therapy
• Different agents within the same drug class
• Pharmacokinetic and pharmacokinetic principles
• Around the clock dosing (/- breakthrough) for
  chronic, continuous pain
• Long-acting formulations have a rationale role
• If opioids arent helping after a reasonable
  trial then dont increase the dose

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Dosing Clinical Pearls - Increasing doses

• Try to increase long-acting dose if patient using
  regular breakthrough doses
• No max dose (ceiling effect) for opioids
• Dose increase - up to 25 - 50 (use clinical
  judgement)
• When discontinuing, taper off if on more than
  30-60 mg morphine equiv.

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Dosing Clinical Pearls

• Better to use acetaminophen-free opioids for
  severe pain
• hydrocodone products limit use due to APAP
  content
• Consider use of laxatives from start (scheduled)
  and be sure to assess at each visit
• Fiber is likely not enough

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Pain Management Definitions

• Addiction
• Pseudo-addiction
• Tolerance
• Physical dependence
• Diversion

Source Definitions Related to the Use of Opioids
for the Treatment of Pain. Consensus Statement.
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Non-Maligant Chronic Pain Issues

• Balance of appropriate pain management vs.
  controlled substances police
• Moral duty to ensure all patients have access to
  the most efficacious medications for pain
  (Holmquist GL. Pharmacy Times 1999)
• Avoid unproductive attitude
• Not all scripts are fake
• Not all people on opioids are abusers/addicts
• opioidophobia
• Avoid stereotyping/profiling
• Shift focus to assessing for efficacious use

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Non-Maligant Chronic Pain Issues

• Uniformly confirm/validate prescriptions
• Consider developing/posting a policy of when you
  confirm opioid prescriptions
• Be aware of, and identify red flag
  (addictive/diversion) behaviors
• Notify State Board of Healing Arts if concerned
• Federation of State Medical Boards Model
  Guidelines
• Evaluate physicians based on the outcomes of
  their patients, not on the amount of opioids
  prescribed

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Non-Maligant Chronic Pain Issues

• Partner with physicians
• using pain agreement for chronic pain management?
• Have physician fax copy of original
• Abuse history still need treatment in
  controlled setting
• adjuvant therapy
• longer acting options (may need higher doses)
• initially dispense small amounts
• pain agreement
• management by pain/abuse/psychiatric specialist
• strict monitoring and oversight

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• Case 3B - A patient with chronic low back pain
  tells you that he has a morphine allergy. He has
  only been treated with Darvocet N-100
• What questions would you ask the patient about
  his allergy?What would you recommend?

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Dealing with Opioid Allergies

• true allergies are infrequent
• cross reactions possible within same structural
  class
• cross reaction less likely between classes

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Opioid Classes