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. 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 Sources of pain in the elderly

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

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 PhysicalTherapy Pharmacotherapy Treatment Approaches Interventional Approaches ComplementaryAlternative Medicine PsychologicalSupport 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 (90%–95%) • Exception: methadone, excreted fecally

35. Opioid Use in Renal Failure • Not rec’d: 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 <10 mL/min 50% 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 25%–50% severe / uncontrolled pain 50%–100% • 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 10–15 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 50%–75% of published equianalgesic dose 1) Example: morphine 60 mg po every 12 hours 2) Change to po oxycodone long-acting 3) Use conversion ratio m:o = 15:10 4) 120 mg/x=15/10=80 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 Methadone:Morphine -<100 mg (1:3) -101-300 mg (1:5) -301-600 mg (1:10) -601-800 mg (1:12) -801-1000 mg (1:15) ->1000 mg (1:20) 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 CommonUncommon 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)