Pain management in the hospitalized patient
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Joshua Vanderloo PharmD, RPh Clinical Pharmacist, University of Wisconsin Hospital and Clinics. Pain Management in the hospitalized patient. Disclosures. I have no actual or potential conflict of interest in relation to this presentation. . Objectives.

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Pain management in the hospitalized patient

Joshua Vanderloo PharmD, RPh

Clinical Pharmacist, University of Wisconsin Hospital and Clinics

Pain Management in the hospitalized patient


Disclosures

Disclosures

  • I have no actual or potential conflict of interest in relation to this presentation.


Objectives

Objectives

  • Identify importance of high quality pain management

  • Describe basic approaches and techniques for improving pain management in the hospitalized patient

  • Describe the role of non-opioid and opioid therapies in the management of pain in the hospitalized patient consistent with the WHO Pain Ladder.


Background

Background

Or: Framing the Discussion


Why is high quality pain management important

Why is high quality pain management important?

  • High cost of unmanaged pain

    • Time

    • Costs

      • $60 billion lost productivity1 and reduced patient QOL2

    • Increased length of stay3

  • HCAHPS* scores related to pain

  • Managing primary diagnosis as well as pain

*HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems

1National Institute of Neurological Disorders and Stroke. Peptides implicated in body’s response to pain.

2Postoperative pain management: a practical review, part 2. Am J Health-Syst Pharm. 2005; 62:2019-2025.

3Economic benefits of an acute interventional postoperative pain service. Anesth analg. 2007;104:S-75.


Neuroplasticity in pain processing

Neuroplasticity in Pain Processing

Neuropathic pain

Acute pain  chronic pain syndromes

Cervero F. Pain. 1996


Managing pain in the hospitalized patient

Managing Pain in the Hospitalized Patient


Pain management in the hospitalized patient

Descending Modulation

Central Sensitization

Peripheral Sensitization

Gottschalk A, Smith DS. Am Fam Physician. 2001


Inhibiting pain

Inhibiting Pain

  • Inhibitory neurotransmitters  Decrease pain transmission

    • Opioids

    • Norepinephrine

    • Serotonin

    • GABA

  • Excitatory neurotransmitters  Increase pain transmission

    • Glutamate

    • NMDA


Pain assessment

Pain Assessment

PQRST

  • Quality

  • Region/Radiation

  • Severity

  • Timing

    • Onset/Duration

  • Palliative factors

  • Previous therapies

    • Successful and nonsuccessful


Approaching pain treatment

Approaching Pain Treatment

Non-pharmacologic approaches

Pharmacologic

  • Ice

  • Heat

  • Repositioning

  • Distraction

  • Music

  • PT

  • OT

  • Continue home regimens

  • Opioids and non-opioids

  • Neuropathic pain

    • Adjuvants


Opioid and non opioid therapies

Opioid and Non-opioid Therapies


Who pain relief ladder

WHO Pain Relief Ladder

1. Initial pain: Nonopioids

2. Addition:

mild opioid or strong opioid with titration if pain inadequately managed

treatments for fear/anxiety if needed

3. Schedule medications instead of PRN – “around the clock”

Right drug, right dose, right time  80-90% effective and cost effective

World Health Organization (2009). WHO’s Pain Relief Ladder. http://www.who.int/cancer/palliative/painladder/en/


Modified who pain relief ladder

Modified WHO Pain Relief Ladder

PO preferred

Regular intervals

Analgesic chosen according to intensity

Individualization

Reassessment

Vargas-Schaffer G. Can Fam Physician. 2010.


Acetaminophen

Acetaminophen

  • Mechanism:

    • COX enzyme inhibition in CNS

    • Analgesic & antipyretic

  • Indication:

    • Mild to moderate non-inflammatory pain

    • First line for osteoarthritis

    • First line for pain control in the elderly

  • PO, IV


Acetaminophen hepatotoxicity

Acetaminophen & Hepatotoxicity

  • Risk factors

    • Alcohol

    • Liver disease

    • > 4g daily

  • Daily dose limit


Nsaids

NSAIDs

  • Inhibition of COX enzymes Prostaglandin synthesis inhibition

    • Antipyretic

    • Anti-inflammatory

  • Uses

    • Acute and chronic pain

    • Somatic pain

    • Opioid sparing


Nsaids examples

NSAIDs - Examples

  • IbuprofenPO, IV

  • Ketorolac PO, IV

  • Naproxen PO

  • Aspirin PO, PR

  • Diclofenac PO, topical

  • Indomethacin PO, PR


Nsaid adverse effects

NSAID Adverse Effects

  • Gastric, renal, cardiovascular, hematologic

  • Related to:

    • Dose

    • Length of treatment

    • Elderly

  • Role of COX-2 selective NSAIDs?

    • GI vs. cardiovascular risks

      • Decreasing GI risk

        • PPIs

        • Ibuprofen and diclofenac

ACG Guidelines. Am J Gastroenterol. 2009;104:728-738.

NSAID prescribing precautions. Am Fam Physician. 2009;80:1371-1378.


Opioids

Opioids


Delivery and formulations of opioids

Delivery and formulations of Opioids

Routes

Formulations

  • Oral

  • Intravenous

  • Intramuscular

  • Subcutaneous

  • Intrathecal

  • Transdermal

  • Immediate release

  • Extended release

  • PCA

  • Pumps

  • Patches


More advanced techniques

More advanced techniques

  • PCA

    • Dosing

      • Patient-initiated boluses

      • Clinician-initiated boluses

      • Basal rates

    • Adjusting

      • Attempts vs. deliveries

      • Sedation, end-tidal CO2

  • Epidurals

  • Intrathecal opioid ± clonidine ± local anesthetic


Opioid side effects

Opioid Side Effects

Constipation

Nausea and vomiting

CNS effects

Itching

Respiratory Depression

Less frequent: Opioid-induced Hyperalgesia, urinary retention, delirium, myoclonus


Pain management in the hospitalized patient

Trescot AM. Pain Physician. 2006.


Opioid constipation

Opioid Constipation

  • All segments of GI

    • Colon most pronounced

  • Increased transit time

    • Non-propulsive, spastic contractions

    • Electrolyte absorption?

  • Differing degrees among agents

    • PO formulations

  • Assume it will develop and will not tolerate


Exacerbating opioid constipation

Exacerbating Opioid Constipation

  • Advanced age

  • Immobility

  • Other concurrent constipating medications

  • Intraabdominal pathologies

  • Neuropathy

  • Hypercalciemia


Preventing opioid constipation

Preventing Opioid Constipation

  • Regular assessments of stooling

  • Dietary changes

  • Add preventative agents

    • Stool softener (e.g. docusate) and peristaltic stimulant/“contact cathartic”(e.g. sennosides)

    • Or osmotic laxative (e.g. lactulose or polyethylene glycol)

    • Especially for patients with consistent opioid use

  • Prophylactic management is ideal


Treating opioid constipation

Treating Opioid Constipation

  • No BM in 48 hours

    • Addition of agents

      • Lactulose, sennosides, MoM

  • No BM in 72 hours

    • Fecal impaction assessment

      • If impacted:

        • Mineral oil enema ± irritant enema ± manual disimpaction

      • Following disimpaction:

        • Prevent constipation recurrence

  • Methylnaltrexone? Oral naltrexone?


Opioid induced hyperalgesia oih

Opioid-induced Hyperalgesia (OIH)

  • Paradoxical response

    • Increased opioid exposure  pain sensitization

      • i.e. Loss of opioid efficacy

  • Suspect if

    • Opioid efficacy decreases with dose escalation

      • Especially if pain worsens or becomes more generalized


Oih management

OIH Management

  • Detoxification

  • Dose reduction

  • Opioid rotation

  • Addition of NMDA-R antagonist


  • Adjustments for organ dysfunction

    Adjustments for Organ Dysfunction

    Renal Insufficiency

    Hepatic Insufficiency


    Pain management pearls

    Pain Management Pearls

    • Multimodal approach

    • Prefer PO

      • Avoid IM

    • Schedule meds for persistent pain

    • Anticipate side effects and manage proactively

    • Avoid multiple opioids simultaneously

    • No maximum dose or analgesic ceiling

    • Continue to reassess pain and side effects


    References

    References

    • Cervero F, Laird JM. Mechanisms of touch-evoked pain (allodynia): a new model. Pain. 1996;68(1):13-23.

    • Gottschalk A, Smith DS. New concepts in acute pain therapy: preemptive analgesia. Am Fam Physician. 2001;63:1979-84.

    • Vargas-Schaffer G. Is the WHO analgesic ladder still valid? Twenty-four years of experience. Can Fam Physician. 2010;56:514-517.

    • Holmquist GL, Leon-Casasola OA, McPherson ML, Herndon CM. Patient-centered approach to pain management. ASHP Midyear Meeting. New Orleans Convention Center. New Orleans, LA. 5 Decemeber 2011. Educational programming.

    • Trescot AM, Boswell MV, Atluri SL, et al. Opioid guidelines in the management of chronic non-cancer pain. Pain Physician. 2006;9:1-39.

    • Pain: Current understanding of assessment, management, and treatments. National Pharmaceutical Council website. http://www.npcnow.org/App_Themes/Public/pdf/Issues/pub_related_research/pub_quality_care/Pain-Current-Understanding-of-Assessment-Management-and-Treatments.pdf. Accessed May 27, 2012.

    • Rhodes L, Groninger H, Malchow, R. Key concepts in pain management for the federal healthcare professional. MedIQ website. http://www.med-iq.com/index.cfm?fuseaction=courses.overview&cID=540. Accessed May 27, 2012.

    • Fine PG, Bekanich SJ. Improving acute pain management in hospitalized patients with chronic pain disorders. MedIQ website. http://www.med-iq.com/files/cme/presentation/pdfs/id_567_983.pdf. Accessed May 27, 2012.

    • Johnson SJ. Opioid safety in patients with renal or hepatic dysfunction. Pain Treatment Topics website. http://pain-topics.org/pdf/Opioids-Renal-Hepatic-Dysfunction.pdf. Accessed May 29, 2012.


    Pain management in the hospitalized patient1

    Joshua Vanderloo PharmD, RPh

    Clinical Pharmacist, University of Wisconsin Hospital and Clinics

    Pain Management in the hospitalized patient


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