pain management in the hospitalized patient
Download
Skip this Video
Download Presentation
Pain Management in the hospitalized patient

Loading in 2 Seconds...

play fullscreen
1 / 36

Pain Management in the hospitalized patient - PowerPoint PPT Presentation


  • 171 Views
  • Uploaded on

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.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Pain Management in the hospitalized patient' - xiu


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
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

slide9

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
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.

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

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

ad