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Maureen E. Knell Pharm.D., BCPS

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Maureen E. Knell Pharm.D., BCPS. Clinical Assistant Professor of Pharmacy - UMKC ... Pharmacy Times 1999) Avoid unproductive attitude. Not all scripts are fake ... – PowerPoint PPT presentation

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Title: Maureen E. Knell Pharm.D., BCPS


1
Chronic Pain Management
  • Maureen E. Knell Pharm.D., BCPS
  • Clinical Assistant Professor of Pharmacy - UMKC
  • Saint Lukes Multispecialty Clinic

2
Housekeeping Issues
  • Exam info
  • Brief summary
  • Class Case
  • Principles apply to arthritis

3
  • What is chronic pain?
  • How does it differ from acute pain?

4
Ways to Define Chronic Pain
  • Time-frame
  • Malignant
  • Non-malignant
  • Combinations
  • acute chronic
  • multiple types of chronic
  • Syndrome of Chronic Pain
  • Impact on QOL

5
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)

6
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

7
Syndrome of Chronic Pain
  • depression
  • anxiety
  • sleep disturbances
  • anorexia
  • social and physical
    dysfunction /disability

8
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.
9
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

10
(No Transcript)
11
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

12
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

13
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

14
Treatment Approaches to Chronic Pain - Neuropathic
  • Anticonvulsants
  • TCAs
  • Topical lidocaine
  • Opioids/Tramadol
  • Combinations
  • Non-Rx
  • 2nd line agents (see reading)

15
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

16
Case 3
  • Additional Information
  • Problems

17
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

18
Case 3 - Treatment Plan
  • Combination Pain Management Therapy
  • Nociceptive tx
  • Neuropathic tx
  • Syndrome of Chronic Pain
  • Non-RX tx
  • Other disease states (obesity)
  • UDS?

19
Case 3
  • Patient Education
  • Monitoring
  • Effectiveness
  • Pain/function
  • Adverse Effects/Toxicities
  • Complications
  • Sign/sx of chronic pain syndrome
  • Other disease states

20
Roles for pharmacists in the treatment of
chronic pain?
21
Understand and Overcome Barriers
  • Healthcare and regulatory systems
  • Patients and family members
  • Health care professionals (including pharmacists)

22
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

23
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.

24
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

25
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.
26
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

27
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

28
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

29
  • 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?

30
Dealing with Opioid Allergies
  • true allergies are infrequent
  • cross reactions possible within same structural
    class
  • cross reaction less likely between classes

31
Opioid Classes
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