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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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

  • 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

Or: Framing the Discussion


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

Neuropathic pain

Acute pain  chronic pain syndromes

Cervero F. Pain. 1996


Managing Pain in the Hospitalized Patient


Descending Modulation

Central Sensitization

Peripheral Sensitization

Gottschalk A, Smith DS. Am Fam Physician. 2001


Inhibiting Pain

  • Inhibitory neurotransmitters  Decrease pain transmission

    • Opioids

    • Norepinephrine

    • Serotonin

    • GABA

  • Excitatory neurotransmitters  Increase pain transmission

    • Glutamate

    • NMDA


Pain Assessment

PQRST

  • Quality

  • Region/Radiation

  • Severity

  • Timing

    • Onset/Duration

  • Palliative factors

  • Previous therapies

    • Successful and nonsuccessful


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


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

PO preferred

Regular intervals

Analgesic chosen according to intensity

Individualization

Reassessment

Vargas-Schaffer G. Can Fam Physician. 2010.


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

  • Risk factors

    • Alcohol

    • Liver disease

    • > 4g daily

  • Daily dose limit


NSAIDs

  • Inhibition of COX enzymes Prostaglandin synthesis inhibition

    • Antipyretic

    • Anti-inflammatory

  • Uses

    • Acute and chronic pain

    • Somatic pain

    • Opioid sparing


NSAIDs - Examples

  • IbuprofenPO, IV

  • Ketorolac PO, IV

  • Naproxen PO

  • Aspirin PO, PR

  • Diclofenac PO, topical

  • Indomethacin PO, PR


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


Delivery and formulations of Opioids

Routes

Formulations

  • Oral

  • Intravenous

  • Intramuscular

  • Subcutaneous

  • Intrathecal

  • Transdermal

  • Immediate release

  • Extended release

  • PCA

  • Pumps

  • Patches


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

Constipation

Nausea and vomiting

CNS effects

Itching

Respiratory Depression

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


Trescot AM. Pain Physician. 2006.


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

  • Advanced age

  • Immobility

  • Other concurrent constipating medications

  • Intraabdominal pathologies

  • Neuropathy

  • Hypercalciemia


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

  • 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)

  • 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

  • Detoxification

  • Dose reduction

  • Opioid rotation

  • Addition of NMDA-R antagonist


  • Adjustments for Organ Dysfunction

    Renal Insufficiency

    Hepatic Insufficiency


    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

    • 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.


    Joshua Vanderloo PharmD, RPh

    Clinical Pharmacist, University of Wisconsin Hospital and Clinics

    Pain Management in the hospitalized patient


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