Managing chronic pain l.jpg
This presentation is the property of its rightful owner.
Sponsored Links
1 / 28

Managing Chronic Pain PowerPoint PPT Presentation


  • 155 Views
  • Uploaded on
  • Presentation posted in: General

Managing Chronic Pain. Palliative Care Institute of Southeast Louisiana Hospice of St. Tammany Covington, LA. Introduction. 50 million people suffer from chronic pain Treatment with opioids is safe and effective

Download Presentation

Managing Chronic Pain

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Managing chronic pain l.jpg

Managing Chronic Pain

Palliative Care Institute of

Southeast Louisiana

Hospice of St. Tammany

Covington, LA


Introduction l.jpg

Introduction

  • 50 million people suffer from chronic pain

  • Treatment with opioids is safe and effective

  • New understanding of CNS changes in chronic pain provides rationale for treatment

  • Relief from suffering is our goal


How to manage pain effectively and efficiently l.jpg

How to Manage Pain Effectively and Efficiently

  • Assessing Pain

  • Difference between Acute and Chronic

  • Treatment of Pain

  • Specific Opioids

  • Adjuvants for Pain

  • Side-effects

  • Importance of Teamwork


Assessing pain l.jpg

Assessing Pain

  • Detailed description of pain

  • What makes it better or worse

  • Effect on emotional, social status

  • Do a physical assessment

  • Review diagnostic and lab data

  • Reassess often to adjust treatment


Acute pain l.jpg

Acute Pain

  • Pathway for acute pain perception is conventional

  • Duration is short

  • Endorphins and enkephalins are released by CNS to block pain perception

  • Opioids are effective for acute pain


Chronic pain l.jpg

Chronic Pain

  • Prolonged pain impulses cause “burn-out” of the AMPA receptors involved in pain transmission in the spinal cord

  • Endorphins become less effective

  • NMDA receptors, normally quiescient, are activated, causing changes in pain transmission and behavior


Nmda effects in chronic pain l.jpg

NMDA Effects in Chronic Pain

  • Windup

  • Neural remodeling

  • Activation of NK-1 receptors

  • Afferent becomes efferent

  • Neurogenic inflammation


Treating pain with opioids l.jpg

Treating Pain with Opioids

  • Nociceptive(Somatic and Visceral) and Neuropathic Pain

  • WHO 3-step analgesic ladder

  • Step 1: Mild analgesics: APAP, Propoxyphene, NSAIDS

  • Step 2: Moderate analgesics: Codeine, Hydrocodone/APAP, Oxycodone/APAP, Tramadol

  • Step 3: Strong Opioids


Prescribing opioids for chronic pain general principles l.jpg

Prescribing Opioids for Chronic Pain- General Principles

  • Use WHO pain ladder to select analgesic

  • Around-the-clock, q. 3-4 hr.

  • Assess frequently, adjust dose

  • Add up total opioid taken q. 24hr.

  • Select long-acting opioid q. 12 hr.

  • Use short-acting opioid for breakthrough pain prn.

  • Use one short- and one long-acting

  • Reassess to titrate dose


Equianalgesic doses if morphine 10 mg p o l.jpg

Equianalgesic Doses if Morphine = 10 mg p.o.

  • Dilaudid(hydromorphone= 2mg

  • Oxycodone = 5-10 mg

  • Hydrocodone =15 mg

  • Codeine = 60mg

  • Ultram(tramadol) =50 mg

  • Demerol(merperidine) =50 mg

  • Fentanyl(duragesic)=see slide 13

  • Levorphanol = 1-2 mg


Slide11 l.jpg

Number of Analgesic Prescriptions: United States est. 2002(millions)

Step 3

WHO Stepladder

Total 13.03

Morphine 3.67

Fentanyl 4.35

Meperedine 1.78

Hydromorphone .77

Methadone 1.66

All others .08

Step 2

Total 173.32

Propoxyphene 28.94

Hydrocodone 91.83

Oxycodone 28.95

Codeine* 22.61

Dihydrocodeine 0.32

Pentazocine 0.67

Step 1

Total 135.30

COX-2 52.94

Other NSAIDs 65.98

Tramadol 16.38

*Includes Fiorinal with codeine combinations

Source: IMS Health’s National Prescription Audit (NPA) Retail Phcy., LTC & M.O.


Step 3 strong opioids l.jpg

Step 3 Strong Opioids

  • Morphine

  • Oxycodone

  • Dilaudid (Hydromorphone)

  • Fentanyl

  • Methadone

  • Levorphanol


Morphine l.jpg

Morphine

  • Usual 1st. choice for moderate, severe pain. Begin low, 15mg q 3-4 hr. Titrate ,reassess often.

  • No ceiling

  • Resp. depression rare in chronic pain patients.

  • High doses: metabolites = nausea,dysphoria, muscle jerks


Dilaudid hydromorphone l.jpg

Dilaudid- hydromorphone

  • Beginning dose 2-4 mg q 3-4 hr. Very effective, similar to MS.

  • Less nausea. No ceiling. Often used orally for breakthrough pain and i.v.

  • No sustained-release form.

  • 2 mg = 10 mg MS


Oxycodone l.jpg

Oxycodone

  • Starting oral dose 5-10 mg q 3-4 hr. Very effective

  • Less nausea, less troublesome metabolites.Combined with ASA and APAP (Percocet,etc.), limits ceiling.

  • Expensive sustained-release form (Oxycontin), no ceiling. Watch for illegal diversion. Oxycontin 10,20,40,80mg.

  • Liquid concentrate 20mg/ml useful buccally in the dying, as is MS(Roxanol).


Duragesic fentanyl l.jpg

Duragesic (Fentanyl)

  • Duragesic patch: use care in opioid- naïve patient-use 25 mcg/hr first, after pain controlled by short-acting opioid.

  • To calculate dose, convert any and all opioids to their morphine-equivalent/24 hr first.

  • 12 hr delay in onset and offset due to skin reservoir absorption.


Duragesic cont d l.jpg

Duragesic (cont’d)

  • Fever increases absorption rate. Avoid skin with scant subcut. fat.

  • 25mcg patch= 50 mg MS /24 hrs

  • 50 ‘ ‘ = 100 mg “

  • 75 “ “ = 150 mg “

  • 100 “ “ = 200mg “

  • (approx.)


Methadone and levorphanol l.jpg

Methadone and Levorphanol

  • Under-used, not marketed

  • NMDA receptor-blocking activity makes these, especially methadone, the best choice for neuropathic and complex chronic pain

  • Levorphanol is 4-8x stronger than MS: longer ½ life (q 6 hrs)


Advantages of methadone l.jpg

Advantages of Methadone

  • Long duration of action

  • Short initial distribution half-life

  • No active metabolites

  • No ceiling dose

  • NMDA receptor-blocker action in spinal cord (important in neuropathic and chronic pain)

  • Cost: approx. $20-25/month( vs. $200-500/mo. for hydromorphone,sust.act. morphine,oxycodone,fentanyl patch.


Advantages cont d l.jpg

Advantages (cont’d)

Potency at least equal to morphine

  • Oral, rectal absorption excellent

  • Low incidence of side-effects

  • Less constipating

  • Lower incidence of tolerance

  • Available for iv infusion use

  • Most important,methadone is both a mu opioid agonist and an NMDA receptor antagonist as it relates to pain relief


Disadvantages l.jpg

Disadvantages

  • Stigma and association with substance-abuse

  • Accumulation due to long and variable elimination half-life in some persons

  • Said to be hard to convert to and from other opioids

  • Fear of regulators

  • Lack of education and experience


Cost comparison of opioids 30 day supply l.jpg

Cost Comparison of Opioids ( 30 day supply)

  • Duragesic Patch 25mcg/hr $ 140

  • Duragesic Patch 100 mcg/hr $ 430

  • Oxycontin 40 mg q 12 hr $ 250

  • MS contin 60 mg q 12 hr $ 210

  • Dilaudid 4 mg q 4 hr ATC $ 118

  • Percocet 5 mg q 4 hr ATC $ 210

  • Levorphanol 2 mg q 6 hr $ 120

  • Methadone 10 mg q 8 hr $ 20


From the literature l.jpg

From the literature:

  • 108 outpatients with cancer pain on opioids

  • 103 successfully switched to methadone- oral q 8 hrs with significant reduction of pain

  • Bruera,E. et al, proceedings of the 9th World Congress on Pain,2000, p.957.


From the literature24 l.jpg

From the literature:

  • 52 prospective, consecutive patients with either uncontrolled cancer pain on opioids or intolerable side-effects switched to methadone.

  • All had significant reduction of pain and significantly less nausea, vomiting, constipation, and drowsiness.

  • Mercandante, S. et al, J. of Clinical Oncology. 2001; 19:2898-2904


Personal experience prescribing methadone 2001 2003 l.jpg

Personal experience: Prescribing Methadone 2001-2003

  • Palliative Care Consults(total) 140:

  • Methadone for Chronic pain: 88

  • Excellent relief( pain reduced from 7-10 to 0-3) : 50

  • Fair relief (pain reduced to 4-6): 18

  • No benefit or side-effects: 20

    ( Nausea 6, Sedation 12, Depression 2)


Adjuvants for pain l.jpg

Adjuvants for Pain

  • For Neuropathic pain:

    Tricyclic antidepressants-desipramine, nortriptyline preferred

    Anticonvulsants- valproic acid, gabapentin preferred

  • For bone and soft-tissue pain:

    NSAIDs,corticosteroids,palliative radiation,biphosphonates

    For visceral pain: corticosteroids,H-2 blockers,metoclopropamide


Side effects of treatment l.jpg

Side-effects of Treatment

  • Opioid adverse effects: nausea,constipation,somnolence, dysphoria, muscle jerks, itching, respiratory depression

  • Neuropathic adjuvant side-effects: dizziness ,sleepiness, low BP, liver toxicity(uncommon)

  • NSAID side-effects: nausea, GI ulcer or bleeding, edema,decreased renal function


Importance of teamwork l.jpg

Importance of Teamwork

  • Complex chronic pain, especially if caused by life-threatening disease, is best treated by a team.

  • The diverse talents of physician, nurse, social worker, chaplain, working together offers comprehensive control of physical, emotional, and spiritual pain.

  • Palliative care is for ALL patients who are suffering.


  • Login