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Managing Chronic Pain. Palliative Care Institute of Southeast Louisiana Hospice of St. Tammany Covington, LA. Introduction. 50 million people suffer from chronic pain Treatment with opioids is safe and effective

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managing chronic pain
Managing Chronic Pain

Palliative Care Institute of

Southeast Louisiana

Hospice of St. Tammany

Covington, LA

introduction
Introduction
  • 50 million people suffer from chronic pain
  • Treatment with opioids is safe and effective
  • New understanding of CNS changes in chronic pain provides rationale for treatment
  • Relief from suffering is our goal
how to manage pain effectively and efficiently
How to Manage Pain Effectively and Efficiently
  • Assessing Pain
  • Difference between Acute and Chronic
  • Treatment of Pain
  • Specific Opioids
  • Adjuvants for Pain
  • Side-effects
  • Importance of Teamwork
assessing pain
Assessing Pain
  • Detailed description of pain
  • What makes it better or worse
  • Effect on emotional, social status
  • Do a physical assessment
  • Review diagnostic and lab data
  • Reassess often to adjust treatment
acute pain
Acute Pain
  • Pathway for acute pain perception is conventional
  • Duration is short
  • Endorphins and enkephalins are released by CNS to block pain perception
  • Opioids are effective for acute pain
chronic pain
Chronic Pain
  • Prolonged pain impulses cause “burn-out” of the AMPA receptors involved in pain transmission in the spinal cord
  • Endorphins become less effective
  • NMDA receptors, normally quiescient, are activated, causing changes in pain transmission and behavior
nmda effects in chronic pain
NMDA Effects in Chronic Pain
  • Windup
  • Neural remodeling
  • Activation of NK-1 receptors
  • Afferent becomes efferent
  • Neurogenic inflammation
treating pain with opioids
Treating Pain with Opioids
  • Nociceptive(Somatic and Visceral) and Neuropathic Pain
  • WHO 3-step analgesic ladder
  • Step 1: Mild analgesics: APAP, Propoxyphene, NSAIDS
  • Step 2: Moderate analgesics: Codeine, Hydrocodone/APAP, Oxycodone/APAP, Tramadol
  • Step 3: Strong Opioids
prescribing opioids for chronic pain general principles
Prescribing Opioids for Chronic Pain- General Principles
  • Use WHO pain ladder to select analgesic
  • Around-the-clock, q. 3-4 hr.
  • Assess frequently, adjust dose
  • Add up total opioid taken q. 24hr.
  • Select long-acting opioid q. 12 hr.
  • Use short-acting opioid for breakthrough pain prn.
  • Use one short- and one long-acting
  • Reassess to titrate dose
equianalgesic doses if morphine 10 mg p o
Equianalgesic Doses if Morphine = 10 mg p.o.
  • Dilaudid(hydromorphone= 2mg
  • Oxycodone = 5-10 mg
  • Hydrocodone =15 mg
  • Codeine = 60mg
  • Ultram(tramadol) =50 mg
  • Demerol(merperidine) =50 mg
  • Fentanyl(duragesic)=see slide 13
  • Levorphanol = 1-2 mg
slide11
Number of Analgesic Prescriptions: United States est. 2002(millions)

Step 3

WHO Stepladder

Total 13.03

Morphine 3.67

Fentanyl 4.35

Meperedine 1.78

Hydromorphone .77

Methadone 1.66

All others .08

Step 2

Total 173.32

Propoxyphene 28.94

Hydrocodone 91.83

Oxycodone 28.95

Codeine* 22.61

Dihydrocodeine 0.32

Pentazocine 0.67

Step 1

Total 135.30

COX-2 52.94

Other NSAIDs 65.98

Tramadol 16.38

*Includes Fiorinal with codeine combinations

Source: IMS Health’s National Prescription Audit (NPA) Retail Phcy., LTC & M.O.

step 3 strong opioids
Step 3 Strong Opioids
  • Morphine
  • Oxycodone
  • Dilaudid (Hydromorphone)
  • Fentanyl
  • Methadone
  • Levorphanol
morphine
Morphine
  • Usual 1st. choice for moderate, severe pain. Begin low, 15mg q 3-4 hr. Titrate ,reassess often.
  • No ceiling
  • Resp. depression rare in chronic pain patients.
  • High doses: metabolites = nausea,dysphoria, muscle jerks
dilaudid hydromorphone
Dilaudid- hydromorphone
  • Beginning dose 2-4 mg q 3-4 hr. Very effective, similar to MS.
  • Less nausea. No ceiling. Often used orally for breakthrough pain and i.v.
  • No sustained-release form.
  • 2 mg = 10 mg MS
oxycodone
Oxycodone
  • Starting oral dose 5-10 mg q 3-4 hr. Very effective
  • Less nausea, less troublesome metabolites.Combined with ASA and APAP (Percocet,etc.), limits ceiling.
  • Expensive sustained-release form (Oxycontin), no ceiling. Watch for illegal diversion. Oxycontin 10,20,40,80mg.
  • Liquid concentrate 20mg/ml useful buccally in the dying, as is MS(Roxanol).
duragesic fentanyl
Duragesic (Fentanyl)
  • Duragesic patch: use care in opioid- naïve patient-use 25 mcg/hr first, after pain controlled by short-acting opioid.
  • To calculate dose, convert any and all opioids to their morphine-equivalent/24 hr first.
  • 12 hr delay in onset and offset due to skin reservoir absorption.
duragesic cont d
Duragesic (cont’d)
  • Fever increases absorption rate. Avoid skin with scant subcut. fat.
  • 25mcg patch= 50 mg MS /24 hrs
  • 50 ‘ ‘ = 100 mg “
  • 75 “ “ = 150 mg “
  • 100 “ “ = 200mg “
  • (approx.)
methadone and levorphanol
Methadone and Levorphanol
  • Under-used, not marketed
  • NMDA receptor-blocking activity makes these, especially methadone, the best choice for neuropathic and complex chronic pain
  • Levorphanol is 4-8x stronger than MS: longer ½ life (q 6 hrs)
advantages of methadone
Advantages of Methadone
  • Long duration of action
  • Short initial distribution half-life
  • No active metabolites
  • No ceiling dose
  • NMDA receptor-blocker action in spinal cord (important in neuropathic and chronic pain)
  • Cost: approx. $20-25/month( vs. $200-500/mo. for hydromorphone,sust.act. morphine,oxycodone,fentanyl patch.
advantages cont d
Advantages (cont’d)

Potency at least equal to morphine

  • Oral, rectal absorption excellent
  • Low incidence of side-effects
  • Less constipating
  • Lower incidence of tolerance
  • Available for iv infusion use
  • Most important,methadone is both a mu opioid agonist and an NMDA receptor antagonist as it relates to pain relief
disadvantages
Disadvantages
  • Stigma and association with substance-abuse
  • Accumulation due to long and variable elimination half-life in some persons
  • Said to be hard to convert to and from other opioids
  • Fear of regulators
  • Lack of education and experience
cost comparison of opioids 30 day supply
Cost Comparison of Opioids ( 30 day supply)
  • Duragesic Patch 25mcg/hr $ 140
  • Duragesic Patch 100 mcg/hr $ 430
  • Oxycontin 40 mg q 12 hr $ 250
  • MS contin 60 mg q 12 hr $ 210
  • Dilaudid 4 mg q 4 hr ATC $ 118
  • Percocet 5 mg q 4 hr ATC $ 210
  • Levorphanol 2 mg q 6 hr $ 120
  • Methadone 10 mg q 8 hr $ 20
from the literature
From the literature:
  • 108 outpatients with cancer pain on opioids
  • 103 successfully switched to methadone- oral q 8 hrs with significant reduction of pain
  • Bruera,E. et al, proceedings of the 9th World Congress on Pain,2000, p.957.
from the literature24
From the literature:
  • 52 prospective, consecutive patients with either uncontrolled cancer pain on opioids or intolerable side-effects switched to methadone.
  • All had significant reduction of pain and significantly less nausea, vomiting, constipation, and drowsiness.
  • Mercandante, S. et al, J. of Clinical Oncology. 2001; 19:2898-2904
personal experience prescribing methadone 2001 2003
Personal experience: Prescribing Methadone 2001-2003
  • Palliative Care Consults(total) 140:
  • Methadone for Chronic pain: 88
  • Excellent relief( pain reduced from 7-10 to 0-3) : 50
  • Fair relief (pain reduced to 4-6): 18
  • No benefit or side-effects: 20

( Nausea 6, Sedation 12, Depression 2)

adjuvants for pain
Adjuvants for Pain
  • For Neuropathic pain:

Tricyclic antidepressants-desipramine, nortriptyline preferred

Anticonvulsants- valproic acid, gabapentin preferred

  • For bone and soft-tissue pain:

NSAIDs,corticosteroids,palliative radiation,biphosphonates

For visceral pain: corticosteroids,H-2 blockers,metoclopropamide

side effects of treatment
Side-effects of Treatment
  • Opioid adverse effects: nausea,constipation,somnolence, dysphoria, muscle jerks, itching, respiratory depression
  • Neuropathic adjuvant side-effects: dizziness ,sleepiness, low BP, liver toxicity(uncommon)
  • NSAID side-effects: nausea, GI ulcer or bleeding, edema,decreased renal function
importance of teamwork
Importance of Teamwork
  • Complex chronic pain, especially if caused by life-threatening disease, is best treated by a team.
  • The diverse talents of physician, nurse, social worker, chaplain, working together offers comprehensive control of physical, emotional, and spiritual pain.
  • Palliative care is for ALL patients who are suffering.
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