Contemporary Pain Assessment and Management in Today’s Adult and Geriatric Population

1. Contemporary Pain Assessment and Management in Today’s Adult and Geriatric Population Christine Coletta-Hansen ANP-BC, ACHPN Palliative Care Nurse Practitioner Grand View Medical Center

4. Course Objectives • At the end of this lecture participants will be able to : • Verbalize understanding of the holistic impact of chronic pain in today’s adult and geriatric population (10 min.) • Verbalize at least 3 reliable/valid pain assessment tools/techniques that can be used in the adult or cognitively impaired populations (10 min) • Compare/contrast different opioid analgesics to assist in choosing appropriate pharmacotherapy depending on individual patient needs.(90 min) • Discuss co-analgesia options according to pain etiology.(30 min) • Create a plan to provide pain management to patients at risk for addiction.(40 min)

5. Facts and Figures about Pain in America • An estimated 75-150 million Americans suffer chronic long lasting pain • 1 of 7 PCP office visits are due to pain • More than 50 million are partially or fully disabled from the pain Pain affects up to 80% patients with Stage IV CHF

6. Pain Facts cont. • National study of 2.2 million SNF residents showed 41.2% complained of moderate to severe pain 60 & 180 days post initial assessment.(Jakobsson et al 2003) • 70% of those approaching end-of-life admit to moderate to severe pain • 94% of cancer patients report experiencing moderate to severe pain (EPIC 2007)

7. Definition of Pain • McCafferty: clinical definition • Scientific definition: Changing view per Perry Fine, MD 2006 “A condition of malfunctioning of the PNS/CNS system as well as dysregulation of other systems (Immune/Neuroendocrine/Sleep/Mood)

9. Pain and the Patient

10. Chronic Pain Alters Brain • Functional MRI performed in people suffering chronic pain show a state of constant activity in areas that should be at rest. • Frontal cortex, associated with emotion, is constantly active causing problems with attention, sleep and causing depression

12. Growing Evidence • Chronic pain is now believed to be a systemic or multisystem impairment that arises from an initial trigger or injury to the nervous system that for reasons that are unclear does not recover

13. Peripheral and Central Pathways for Pain Ascending Tracts Descending Tracts Cortex Thalamus Midbrain Pons Medulla Spinal Cord

14. Factors for Pain Assessment • Assess pain for: • Intensity and location • Descriptors, duration • Alleviating and aggravating factors • Accompanying symptoms • Effect on quality of life (Goal Attainment Scale; J. Farrar) • Patient’s goal for pain control • Previous effective (non)/pharmacologic tx

15. Ongoing Monitoring of Chronic Pain Patients (Passik & Weinreb, 2000) • “4 A’s” • Analgesia • ADL’s • Adverse effects • Aberrant drug taking behaviors • PDAT(Passik et al 2004) • Multidimentional assessment of pain relief, side effects, physical and psychological function and aberrant drug related behaviors

16. Chronic Pain Principles • Treat pain by least invasive route first (IV still takes 10 hrs to reach steady state) • Give medication around the clock (use long acting formulations when possible) • Always have breakthrough medications available • Give medications by the “Ladder” • Individualize the dose to meet patient needs/goals • Utilize multidisciplinary approach

18. Pain Types &Drug Classes Used to Treat Them • Nociceptive (Bone, Muscle, Visceral, etc.) (dull, achy, throbbing, nagging) • Inferred tissue damage; localized; afferent • Neuropathic (CNS or PNS) • CRPS, phantom pain=CNS • Neuropathies=PNS • Idiopathic • Psychogenic (team approach necessary)

20. Pain assessment tools

21. Pain Assessment Tools(Standardized throughout the institution) • MCGill Pain Inventory • Wong-Baker Faces Scale • VAS/Pain thermometer • Pediatric/Adolescent • Color Intensity Scales • Verbal Descriptor Scale • Goal Attainment Scale

23. Elderly Attitudes Toward Pain Treatment • Don’t want to bother anyone • Believe pain is a normal part of the aging process • Don’t want to be a “bad patient” • Fear becoming overmedicated or addicted • Fear pain means illness is worsening

24. Chronic Pain in the Elderly-Mixed/Unspecified • Pain may have mixed or unknown causes (also, multiple locations) • Treatment is unpredictable and various approaches may be needed • Some pain syndromes may be psychologically based and traditionalanalgesia may not be indicated • Polypharmacy and drug interaction risks pose increased challenges in the elderly.

27. Geriatric Pain Assessment Tools

28. Impaired Cognition/MMSE 12

29. Geriatric Pain Assessment Tools

30. Pain Assessment in the Nonverbal Patient(Herr et al, 2006) • Make all attempts for the patient’s self-report • Search for potential causes of pain (if needed, assume pain is present) • Observe patient behaviors • New onset confusion or agitation • Surrogate reporting of pain behaviors/activity changes • Attempt an analgesic trial

31. Pain Assessment Tools for Nonverbal or Cognitively Impaired Adults • ADD: Assessment of Discomfort in Dementia Protocol • CNPI: Checklist of Nonverbal Pain Indicators • NOPPAIN: Nursing Assistant Administered Instrument to Assess Pain in Demented Individuals • PACSLAC: Pain Assessment Scale for Seniors with Severe Dementia • PAINAD: Pain Assessment in Advanced Dementia Scale • All are referenced in the bibliography

32. WHO Stepladder • Step I (beware of combination products)NSAIDS/Cox-2/APAP • Step II • Step III • Opioids (“the good, the bad and the ugly”): Merperidine(normerperidine/CNS toxicity);propoxyphene(norpropoxephene/CNS/Renal toxicity; 1 IN 20 DRUG RELATED DEATHS ARE FROM THIS DRUG); equipotency of ASA (650 mg)/merperidine(oral); morphine(metabolites) & renal insuff. • Adjuvants

33. Nonopioid Analgesics • Acetaminophen (paracetamol) • Minimal anti-inflammatory effects • Fewer adverse effects than other nonopioid analgesics • Adverse effects • Renal toxicity • Risk for hepatotoxicity at high doses • Increased risk with liver disease or chronic alcoholism • ??? effect on platelet function • New recommendations as low as 2600 mg/24h

34. Use of NSAIDS in the Elderly • Avoid using high dose, long term NSAIDS • GI complications up to 40%. Use PPI’s • Dehydrated patients & renal failure • Use NSAIDS PRN rather than around the clock • Topical NSAIDS give 70x more direct joint delivery than oral route • Dicolfenec gel/spray; Ketoprofen

35. 2009 NSAID formulation • IV ibuprofen(Caldalor) infused over 30 min. Comes in 400 mg/4ml or 800 mg in 8 ml. $13.00/dose • Only injectable drug for fever • No 5 day limit like ketorolac • Costs 9x more than ketorolac therefore stay with it for short term use in patients at low risk for GI bleeding or renal dysfunction. • Consider IV ibuprofen if longer IV treatment is needed.

36. NSAID patch(s) • diclofenac epolamine topical patch 1.3% (Flector) • 1 patch/2xday to INTACT skin • No bathing/showering • diclofenac (Voltaren)gel 1% measured 4 gm for LE and 2 gm for UE • diclofenec spray has an even faster onset of analgesia; (Pennsaid) 1.5% 40 gtts qid

37. Tramadol (non-schedule opioid) • Blocks reuptake of seratonin and norepinepherine. Mu-receptor agonist as well • Tramadol(Ultram) 37.5 mg effective; ER (more somulence nausea and dizziness) • ER (100/200/300 mg available) • 200-400 mg in 4 divided doses • Caution with SSRI use******* (seizures/seratonin syndrome) • Side effects are dizziness, constipation, drowsiness, tremor, HTN, seizures. High (up to 28%) discontinuation rate

38. Seratonin syndrome • 50% is antidepressant related, especially when combined with Tramadol or methadone. • High seizure risk • Can occur within minutes to hrs after starting • ALTERED MENTATION, HYPERACTIVITY, AKASTHESIA, MYOCLONIS, DIAPHORESIS, HYPERTHERMIA • Tramadol, SSRI, SSNRI,TCA’s, opiates, antihistamines, CNS stimulants, tryptans

39. Tapentatol (Nucynta) • For ACUTE PAIN • Schedule II; similar to tramadol (mu agonist and affects NE as well. • 50/75/100 mg; may take up to 600 mg/day • Dose q 4-6h • No renal or hepatic challenge • 100 mg = Oxycodone IR 15 mg but is 2x the cost

40. Equianalgesic Table PO/PR (mg)AnalgesicSC/IV/IM (mg) 30 Morphine 10 7.5 Hydromorphone 1.5 20 Oxycodone - 20 Methadone 10 10 Oxymorphone 1 30 Hydrocodone -

41. Opioid allergies • Most reactions are “pseudoallergies”: histamine release/puritis, etc. • For a true opioid allergy use a drug from a different class. Patients allergic to codeine CAN usually take fentanyl, methadone but NOT morphine, hydrocodone or oxycodone.

42. Drug conversion Hints(McPherson 2010) • Oral/rectal same • MSO4= 1:3 (IV to oral) • Fentanyl: 50% of TDD oral morphine (25 mcg fentanyl is 50 mg MSO4 TDD) • Hydromorphone 5:1 or 3.7:1 (M:HM) • Oxycodone 1.5:1(M:O) • Tramadol 10:1 (T:M)

43. Chronic Pain and Opioids • Opioids can relieve moderate to severe pain • For occasional chronic recurrent pain not controlled by NSAIDS, use opioids PRN • Opioids: no ceiling or maximum dose • For continuous pain—Sustained release • Use breakthrough medications (1/3 –1/2 q. 12 h. dose) • “Start low and go slow” • Remember cross tolerance/opioid rotation (20-25% of equianalgesic dose)

44. Pharmacogenomics of Opioids • Genetic polymorphisms >1% of normal population (1 out of 10 get poor response) • Sensitivity of mouse strains to morphine (ranges from 0-90% based on strain of mouse) • Codeine • Poor metabolizers • 2% Asians/African Americans • 10% Caucasians • 20% Middle Eastern

45. Chronic Pain and Opioids cont. • 10 days or longer withdrawl syndrome will occur therefore: • Decrease dose by 50% and give q. 6 h. x 2 days then reduce by an additional 25% every 2 days.

46. Opioid Options (Amabile, 2006) • Morphine: IR/SR (MSContin, Avinza, Kadian/Embeda) • Oxycodone: IR/SR(OxyContin) • Hydromorphone: IR only for now • Oxymorphone (Opana) • Methadone: (1/2 life of approx. 30 hrs) • Fentanyl: high 1st pass effect and low oral bioavailability. Highly lipophyllic.

47. Opioid Induced Hyperalgesia(Ballantine 2006) • NMDA receptor mechanisms are involved in the development of hyperalgesia/sensitization (as are opioid metabolites) • NMDA receptor is also involved with opioid tolerance (desensitization). • Dilemma: Increasing the dose of opioid can either improve or worsen pain • Weaning at times may actually improve analgesic effect. • Hyperalgesia: neuroplastic change in pain perception

48. Opioids: Compare/Contrast • Morphine: “gold standard”. • Avinza/Kadian/MS Contin/Embeda (sequestered naltrexone core; REMS. $250.00 vs $90.00 for regular ER formulation) • Oral, rectal, parenteral • Metabolite(morphine 3-glucuronide) can cause seizures, myoclonis, puritis, dysphoria, headache, and hyperalgesia. Risk is increased if low GFR!!! • Avoid in renal failure • Crosses Blood brain barrier in 96 min(fentanyl in 6 min)

49. Opioids: Compare and contrast cont. • Hydromorphone/Dilaudid: IR only • Synthetic opioid • Oral, rectal, parenteral, intranasal • SR recalled by FDA in 2005 due to interactions with ETOH leading to rapid drug release • Metabolite hydromorphone-3-glucuronide causes same side effects as MSO4 but hydromorphone is more potent therefore requiring less dosing with less adverse outcomes. • Cautious use in renal failure

50. Opioids: Compare/Contast cont.. • Oxycodone: IR/SR • Oxy Contin • Synthetic • Not renally cleared therefore may be advantageous in dialysis patients but use cautiously • Less nausea, vomiting • Combunox (5 mg with 400 mg Ibuprofen)