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CHAMP Pain Control

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Pain is under-recognized and under-treated. JCAHO, ACGME/RRC requirements ... Tramadol (Ultram ) /- Adjuvants. Step 3 (Severe): Strong Opioids. Morphine. Oxycodone ... – PowerPoint PPT presentation

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Title: CHAMP Pain Control


1
CHAMPPain Control
  • Stacie Levine MD
  • University of Chicago

2
Why is this important to teach on the wards?
  • Pain is common in the elderly
  • Pain is under-recognized and under-treated
  • JCAHO, ACGME/RRC requirements
  • Lack of formal education on pain control

3
Why is pain control often not optimal?
  • Clinician unfamiliarity with assessment and
    treatment
  • Opioid misconceptions
  • -patients, families, and clinicians
  • Fear of side effects
  • Concern about addiction, regulatory reprimands,
    and lawsuits

4
Sources of pain in the elderly
  • Degenerative joint disease
  • Spinal stenosis
  • Fractures
  • Pressure ulcers
  • Neuropathic pain
  • Urinary retention
  • Post-stroke syndrome
  • Improper positioning
  • Fibromyalgia
  • Cancer pain
  • Contractures
  • Postherpetic neuralgia
  • Oral/dental
  • Constipation

5
Consequences of unrelieved pain
  • Sleep disturbance
  • Functional decline
  • Depression, anxiety
  • Malnutrition
  • Lawsuits
  • Challenging behaviors
  • Polypharmacy
  • Increased healthcare utilization
  • Prolonged LOS

6
Teaching Objectives
  • Knowledge Housestaff should know
  • -Properties of medications used for pain
  • -Common side effects of opioids
  • Skills Housestaff will demonstrate
  • -bedside pain assessment in older adults
    (cognitively intact and impaired)
  • -use of WHO 3-step ladder
  • -use of opiate conversion tables

7
Teaching Objectives
  • Attitudes Housestaff should
  • -appreciate how pain assessment and management in
    older adults differs and has high degree of
    variability
  • -appreciate patients symptoms of pain or
    pain-related behaviors
  • -express satisfaction in evaluation and
    management of pain

8
Outline for Faculty Module
  • Recognition and assessment
  • -Cognitive impairment
  • Medication selection
  • Dose selection and titration
  • Opiate conversions
  • Management of myths and side effects
  • Discharge planning

9
Outline for Module
  • Recognition and assessment
  • -Cognitive impairment
  • Medication selection
  • Dose selection and titration
  • Opiate conversions
  • Management of myths and side effects
  • Discharge planning

10
Teaching Trigger Case
  • You are rounding on an 83 y.o. NH patient
    admitted with pneumonia
  • She has advanced dementia, bed- bound, limited
    verbalization
  • PMHx DM, HTN, Stage 3 sacral ulcer s/p
    debridement day before
  • Patient stopped eating and is resisting care

11
Trigger Case (cont.)
  • Housestaff concerned she is depressed and started
    Mirtazapine
  • No surrogate available, wonder if a PEG will need
    to be placed
  • Question How do we teach about recognition of
    pain in persons with cognitive impairment?

12
Bedside Assessment
  • ASK the patient about present pain
  • Identify preferred pain terminology
  • -hurting, aching, stabbing, discomfort, soreness
  • Use a pain scale that works for the individual
  • -Insure understanding of its use
  • -Modify sensory deficits

13
Unidimensional Scales
Acute Pain Management Guideline Panel. Acute Pain
Management in Adults Operative Procedures. Quick
Reference Guide for Clinicians. Rockville, MD US
Department of Health and Human Services, Public
Health Service, Agency for Health Care Policy and
Research. February 1992. AHCPR Pub. No. 92-0019.
14
Faces Pain Scale and Pain Thermometer
15
Assessing pain Nonverbal, Moderate to Severe
Impairment
  • Formal assessment tools available but not
    necessarily useful in routine clinical settings
  • Unique Pain Signature
  • Nonverbal Pain Indicators

16
Unique Pain Signature
  • How does the patient usually act?
  • What changes are seen when they are in pain?
  • family members
  • nursing staff
  • Communication across caregiver settings is key!

17
Nonverbal Pain Indicators
  • Facial expressions (grimacing)
  • -Less obvious slight frown, rapid blinking,
    sad/frightened, any distortion
  • Vocalizations (crying, moaning, groaning)
  • -Less obvious grunting, chanting, calling out,
    noisy breathing, asking for help
  • Body movements (guarding)
  • -Less obvious rigid, tense posture, fidgeting,
    pacing, rocking, limping, resistance to moving

18
Nonverbal Pain Indicators
  • Changes in interpersonal interactions
  • -combative, disruptive, resisting care,
    decreased social interactions, withdrawn
  • Changes in mental status
  • -confusion, irritability, agitation, crying
  • Changes in usual activity
  • -refusing food/appetite change, increased
    wandering, change in sleep habits

19
Assessing pain Nonverbal, Moderate to Severe
Impairment (AGS Panel 2002)
  • 1) Presence of non-verbal pain behaviors?
  • -assess at rest and with movement
  • 2) Timely, thorough physical exam
  • 3) Insure basic comfort needs are being met
  • (e.g. hunger, toileting, loneliness, fear)
  • 4) Rule out other causative pathologies
  • (e.g. urinary retention, constipation,
    infection)
  • 5) Consider empiric analgesic trial

20
Outline
  • Recognition and assessment in cognitive
    impairment
  • Medication selection
  • Dose selection and titration
  • Opiate conversions
  • Management of myths and side effects
  • Discharge planning

21
Teaching Trigger Case
  • You are rounding on a 75 y.o. male s/p fall
  • History of lumbar stenosis with new onset severe
    sharp pain down left leg
  • Xrays negative
  • Subintern started prn NSAIDs
  • Patient in severe pain at rounds
  • Question How do we teach about medication and
    dose selection in older adults?

22
Multimodal Approach to Pain Management
Physical Therapy
Pharmacotherapy
Treatment Approaches
Interventional Approaches
Complementary Alternative Medicine
Psychological Support
Exercise
23
Medication Selection
  • Good pain history
  • Target to the type of pain
  • -e.g. neuropathic, nociceptive
  • Consider non-pharmacologic or non-systemic
    therapies alone or as adjuvants
  • Use the WHO 3-Step ladder

24
WHO 3-Step ladder
  • Source World Health Organization. Technical
    Report Series No. 804, Figure 2. Geneva World
    Health Organization 1990.

25
Adjuvants
  • Topicals (lidocaine patch, capsaicin)
  • Acetaminophen
  • NSAIDS, celecoxib, steroids
  • Anticonvulsants
  • Antidepressants
  • Non-pharmacologic (TENS, PT/OT)

26
Step 1(Mild) Non-opioids
  • Acetaminophen
  • NSAIDS
  • Cox-2
  • Non-systemic therapies
  • Non-medication modalities
  • /- other adjuvants

27
Step 2 (Moderate) Mild Opioids, Opioid-like
  • Codeine (e.g. T 3)
  • Hydrocodone (e.g. Vicodin)
  • Oxycodone (e.g. Percocet)
  • Tramadol (Ultram)
  • /- Adjuvants

28
Step 3 (Severe) Strong Opioids
  • Morphine
  • Oxycodone
  • Hydromorphone (Dilaudid)
  • Fentanyl
  • Oxymorphone
  • Methadone
  • /- Adjuvants

29
Transdermal Fentanyl
  • Duration 24-72 hours
  • 12-24 hours to reach full analgesic effect
  • Not recommended as first-line in opiate naïve
    patients
  • Lipophilic
  • Simple Conversion rule
  • -1 mg po morphine ½ mcg fentanyl
  • -(60 mg morphine roughly 25 mcg patch)

30
Other Fentanyl
  • Intravenous (equivalent to patch dose, e.g.
    Duragesic 100 mcg/72 100 mcg/hr IV)
  • Transmucosal
  • -Actiq
  • -Fentora
  • Iontophoretic Fentanyl Patch - Ionsys

31
Methadone, a Complicated Med
  • Should only be used by those with experience!
  • Mu, kappa, delta agonist
  • Inhibits reuptake of serotonin and norepinephrine
  • NMDA antagonist (neuropathic pain)
  • Significant inter-individual variability
  • Drug interactions (coumadin-like)

32
Methadone (cont.)
  • Initial rapid tissue distribution
  • Slow elimination phase
  • Long and variable half-life (13-58 hours)
  • Dose interval is variable (q 6 or q 8)
  • Dose usually adjusted q 4-7 days
  • Minimally impacted by renal disease
  • Inexpensive, less street value than other opioids

33
Drugs to Avoid
  • Meperidine (Demerol)
  • Mixed agonist-antagonist
  • -e.g. Pentazocine (Talwin)
  • Propoxyphene (Darvon , Darvocet )

34
Opioid Pharmacology
  • Block the release of neurotransmitters in the
    dorsal horn of spinal cord
  • Mu, delta, kappa expressed differently, depending
    on opioid medication
  • Conjugated in liver
  • Excreted via kidney (9095)
  • Exception methadone, excreted fecally

35
Opioid Use in Renal Failure
  • Not recd meperidine, codeine,
    dextropropoxyphene, morphine
  • Use with caution oxycodone, hydromorphone
  • Safest fentanyl, methadone
  • Opioid dosing
  • CrCl 50 mL/min normal
  • 10 - 50 mL/min 75 of normal

36
Clearance Concerns
  • Dehydration, renal failure, severe hepatic
    failure
  • ? dosing interval (extend time) or
  • ? dosage size
  • if oliguria or anuria
  • STOP around the clock dosing of opioids (like
    morphine)
  • use ONLY prn

37
Opioids for Continuous Pain
  • Dose find, opioid naive
  • -begin with short-acting opioid ATC
  • -allow breakthrough based on Cmax and patients
    metabolism
  • Cmax (peak) after
  • po, pr ? 1 h
  • SC, IM ? 30 min
  • IV ? 6 15 min

38
Dose-finding
  • To achieve quick pain relief (LOAD)
  • 1. Start low dose, short-acting
  • 2. Dose q peak
  • 3. P.C.A. not prn (Patient controls it)
  • 4. Re-eval in 4 hrs. to figure out what dose is
    needed

39
Starting doses and half-life
  • For thin, frail elderly suggest 2-5 mg po MSO4 or
    an equivalent (e.g. 1/2-1 percocet q 4h)
  • Half-life at steady state
  • po / po / SC / IM / IV ? 3-4 h
  • 4-5 half-lives to reach steady state

40
Opioid Dose Escalation
  • Should be done on percentage increase
    irrespective of starting dose
  • mild / moderate pain ? 2550
  • severe / uncontrolled pain ? 50100
  • How frequent? Depends on t1/2
  • Short-acting single-agent every 2 hrs
  • Long-acting every 24 hours
  • Fentanyl transdermal 72 hours
  • Methadone 4-7 days

41
Breakthrough dosing
  • Use immediate-release opioids
  • 10 of 24-h dose or 1/3 of one ER dose
  • offer after Cmax reached
  • po / pr ? q 1 h
  • SC, IM ? q 30 min
  • IV ? q 1015 min
  • Do NOT use extended-release opioids for
    breakthrough

42
Outline
  • Recognition and assessment in cognitive
    impairment
  • Medication selection
  • Dose selection and titration
  • Opiate conversions
  • Management of myths and side effects
  • Discharge planning

43
Teaching Trigger Case
  • You are rounding on a 70 y.o. male ESRD on HD
    admitted with pleuritic chest pain
  • New pulm mass found on chest CT
  • Severe pleuritic pain well-controlled on
    hydromorphone 4 mg IV q 3 hours
  • Intern asks for help converting him to something
    he can take at home
  • Question How do you teach about proper opiate
    conversions?

44
Equianalgesic Dosing Ratios
Note Equianalgesic equivalencies are merely
estimates and are based on single-dose studies.
45
Changing Opioids Cross-tolerance
  • Start with 5075 of published equianalgesic
    dose
  • 1) Example morphine 60 mg po every 12 hours
  • 2) Change to po oxycodone long-acting
  • 3) Use conversion ratio mo 1510
  • 4) 120 mg/x15/1080 mg every 24 hours
  • 5) Reduce by 50 40 mg every 24 hours
  • Oxycodone LA 20 mg every 12 hours

46
Exception Methadone conversion
  • Daily Morphine MethadoneMorphine
  • -
  • -101-300 mg (15)
  • -301-600 mg (110)
  • -601-800 mg (112)
  • -801-1000 mg (115)
  • -1000 mg (120)
  • Note Conversion to methadone is complicated and
    should only by done by those with experience!

47
Outline
  • Recognition and assessment in cognitive
    impairment
  • Medication selection
  • Dose selection and titration
  • Opiate conversions
  • Management of myths and side effects
  • Discharge planning

48
Teaching Trigger Case
  • You are rounding on a 90 year old female with
    severe osteoporosis admitted for sudden severe
    back pain
  • New vertebral compression fracture
  • Pain controlled on morphine 4 mg IV q 4 hours
  • Patient very sedated, family concerned
  • Question How do you teach about treatment of
    side effects of opiates?

49
Opioid adverse effects
  • Common Uncommon
  • Constipation Bad dreams / hallucinations
  • Dry mouth Dysphoria / delirium
  • Nausea / vomiting Myoclonus / seizures
  • Sedation Pruritus / urticaria
  • Sweats Respiratory depression
  • Urinary retention
  • Hypogonadism
  • SIADH

50
GI Side Effects
  • Constipation
  • -NEVER resolves
  • -Prevent with scheduled softeners PLUS stimulants
  • -Avoid bulking agents (e.g. Metamucil)
  • Nausea and Vomiting
  • Encourage patients to eat frequent, small meals
  • Treat with promotility agents (metoclopramide),
    serotonergic blocking agents (odansetron) or
    dopaminergic blocking agents (haloperidol,
    metoclopramide, prochlorperazine)

51
Sedation and Delirium
  • Consider trying one of the following
  • 1) If pain control is adequate, decrease dose by
    25
  • 2) Rotate to a different opioid preparation
  • 3) Use small doses of psychostimulants (2.5 to 5
    mg methylphenidate or dextroamphetamine) for
    excessive somnolence
  • Use nonsedating antipsychotics (haloperidol,
    risperidone) for delirium

52
Respiratory Depression
  • Does not occur in patients on chronic opioids
  • Can occur in opioid-naïve patients whose opioid
    dose is rapidly escalated
  • Is always preceded by slowly progressive
    somnolence
  • If you must treat
  • -Dilute naloxone (101) in saline and infuse 1 mL
    until breathing pattern returns to normal

53
Teaching Trigger Case
  • You are rounding on a 65 y.o. male with gout
    exacerbation
  • Former cocaine addict
  • Severe pain in hands, elbows, knees
  • Resident told intern to give tylenol and steroids
  • Patient asking for something stronger for pain
  • Resident advised intern to wait it out, afraid
    of awakening a former addiction
  • Question How do you teach about pain treatment
    in persons with a history of addiction or those
    who express concern about becoming addicted to
    opiates?

54
Addiction
  • A psychologic dependence on drugs and a
    behavioral syndrome characterized by compulsive
    drug use and continued use despite harm to self
    and others
  • Use of opioids for pain management does NOT cause
    addiction in the majority of people

55
Physical Dependence/Withdrawal
  • Develops if chronic opioids are abruptly
    discontinued or dose is rapidly decreased
  • Symptoms
  • -Nausea, vomiting, diarrhea, abdominal pain, body
    aches
  • -May result in psychosis and hallucinations
  • -Treatment Taper dose by 50 every 2 to 3 days

56
Pseudoaddiction
  • Occurs in context of
  • -Undertreated pain
  • -Behavioral, family, or psychologic dysfunction
  • Consists of behaviors that are reminiscent of
    addiction but driven by untreated or undertreated
    pain
  • Disappears once pain control is adequate

57
Tolerance
  • Reduced effects of a given dose of medication
    over time
  • Doses remain unchanged when pain stimulus is
    stable
  • Tolerance to unwanted side effects is observed
    and is desired
  • Disease progression (not tolerance), should be
    suspected when increasing doses are required for
    pain control

58
Outline
  • Recognition and assessment in cognitive
    impairment
  • Medication selection
  • Dose selection and titration
  • Opiate conversions
  • Management of myths and side effects
  • Discharge planning

59
Teaching Trigger Case
  • Your team is preparing to discharge a 70 y.o.
    male with chronic severe Pagets disease requiring
    narcotics, responded well to hydromorphone
  • Intern asks you to sign the Rx (next slide)
  • Question How do you teach about appropriate
    discharge planning, including prescription
    writing, in persons with pain?

60
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61
Common pitfalls to avoid
  • Changing meds/route on discharge
  • Writing the prescription
  • Medication cost
  • Educating patient/family
  • Appropriate follow-up

62
  • TEACHING PRACTICE
  • MODIFIED ROLE PLAYS

63
Teaching Case 1
  • You are rounding on an 83 y.o. NH patient
    admitted with pneumonia
  • She has advanced dementia, bed-bound, limited
    verbalization
  • PMHx DM, HTN, Stage 3 sacral ulcer s/p
    debridement day before
  • Patient stopped eating and is resisting care

64
Case 1 (cont.)
  • Housestaff concerned she is depressed and started
    Remeron
  • No surrogates wonder if a PEG will need to be
    placed
  • Teaching task
  • Generate a discussion regarding the assessment of
    pain in cognitively impaired patients

65
Teaching Case 2
  • You are rounding on a 75 y.o. male s/p fall
  • History of lumbar stenosis with new onset severe
    sharp pain down left leg
  • Xrays negative
  • Subintern started prn NSAIDs
  • Patient in severe pain at rounds

66
Case 2 (cont.)
  • Teaching Task
  • Introduce the WHO 3-step ladder as a framework
    for medication selection and titration

67
Teaching Case 3
  • You are rounding on a 70 y.o. male ESRD on HD
    admitted with pleuritic chest pain
  • New pulm mass found on chest CT
  • Severe pleuritic pain well-controlled on
    hydromorphone 4 mg IV q 3 hours
  • Intern asks for help converting him to something
    he can take at home

68
Case 3 (cont.)
  • Teaching task
  • Introduce the opiate conversion table and teach
    its use in converting IV medication to oral
    hydromorphone, oral morphine sustained-release,
    and Fentanyl patch
  • Calculate doses and intervals for breakthrough
    medications

69
Teaching Case 4
  • You are rounding on a 65 y.o. male with gout
    exacerbation
  • Former cocaine addict
  • Severe pain in hands, elbows, knees
  • Resident told intern to give tylenol and steroids
    and wait it out, afraid of awakening a former
    addiction
  • Patient asking for something stronger for pain

70
Case 4 (cont.)
  • Teaching task
  • Teach the different myths regarding opiate
    medication

71
Teaching Case 5
  • You are rounding on a 90 year old female with
    severe osteoporosis admitted for sudden severe
    back pain
  • New vertebral compression fracture
  • Pain controlled on morphine 4 mg IV q 4 hours
  • Patient very sedated, family concerned

72
Case 5 (cont.)
  • Teaching task
  • Discuss this side effect of opiates and its
    treatment

73
Teaching Case 6
  • Your team is preparing to discharge a 70 y.o.
    male with chronic severe Pagets disease requiring
    opioids, responded well to hydromorphone
  • Intern asks you to sign the Rx
  • Teaching task
  • Review the Rx with the team and teach about
    appropriate prescriptions and discharge planning

74
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75
Teaching case 7
  • You are rounding on a 72 year old male with
    metastatic bladder cancer who is being discharged
    on home hospice the next day (order on next
    slide)
  • Teaching task
  • Review interns order to change IV to Duragesic
    patch. Teach the appropriate conversion.

76
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77
Teaching case 8
  • You are rounding on an 85 year old woman with
    advanced dementia s/p fall with pelvic fracture
  • Teaching task
  • Review the MAR and teach about optimal management
    of pain in persons with cognitive impairment

78
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79
Teaching case 9
  • You are rounding on an 80 year old female with
    dementia admitted with hematemesis and abdominal
    pain
  • EGD Stomach cancer, patient is dying
  • She had been on morphine sulfate long-acting 60
    mg po q 12 for Pagets
  • Teaching task
  • Show the housestaff how to effectively convert
    her to a morphine infusion

80
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