General guideline for pain therapy and opioid usage

1. General guideline for pain therapy and opioid usage Kongkiat Kulkantrakorn, M.D. Associate Professor of Neurology Faculty of Medicine, Thammasat University

2. Barriers to Effective Pain Management:Cancer and Non-Cancer • Failure of: • patients to comply with medication regimens • healthcare professionals to adhere to guidelines and standards • institutions to adopt and enforce guidelines and standards

3. Healthcare ProfessionalBarriers to Effective Pain Management • Inadequate training in pain management -52% of oncologists surveyed (1994: Oregon) considered their training to be poor • Poor assessment of pain • Concern about: -regulation of controlled substances -tolerance -side effects management • Fear of addiction (AHCPR 1994,AAPM & APS 1997)

4. JCAHO Revised Standards for Pain Management • Pts. have the right to appropriate assessment and management of pain • Pts. are involved in all aspects of their care, including making care decisions about managing pain effectively…….Counseling • The goal of the pt.’s care is to provide individualized care in setting responsive to specific pt. needs

5. APS Guidelines :Treatment of Acute Pain and Cancer Pain • Individualize therapy • Administer analgesics regularly • Know your opioids • Give infant and children adequate doses • Follow patients closely • Use equianalgesic doses when switching opioids • Recognize and treat side effects

6. APS Guidelines: Treatment of Acute Pain and Cancer Pain 8. Be aware of hazards of meperidine and mixed agonist-antagonists 9. Do not use placebos to assess pain 10. Treat tolerance 11. Be aware of the development of physical dependence and prevent withdrawal 12. Do not confuse addiction with physical dependence and tolerance 13. Be alert to the psychological state of the patients

7. AAPM and APS Consensus Statement Principles of good medical practice should guide the prescribing of opioids • Evaluation of the patient • Rx plan tailored to the pt.’s needs and problems • Consultation as needed, (pain medicine, psychology) • Periodic review of Rx efficacy • Documentation to support Rx plan

8. AHCPR Guidelines: Management of Cancer Pain • Clinicians should: • reassure pts. and families → most pain can be relieved safely/effectively • assess pts./if pain is present, provide optimal relief throughout the course of illness • collaborate with pts./families, taking costs of drugs and techno. into accounts in selecting Rx strategies • educate pts/families about pain and its Rx plan • encourage pts. to be active participants in pain Mx

9. Planning of treatment in cancer pain • Explaining the disease, course of the disease and its nature to the patient and his family • Making sure his understanding • Giving correct instructions • Warning about possible side effects • Taking steps to prevent drug abuse

10. - Dr. Jules Blank Oncologist and member,Wisconsin Cancer Pain Initiative

11. ADDICTION • A PSYCHOLOGICAL AND BEHAVIOURAL DISORDER • HAS NOTHING TO DO WITH PHYSICAL DEPENDENCE • CHARACTERIZED BY • Loss of control (compulsive use) • Continuation of drug use despite adverse consequences • Preoccupation with obtaining/ using the drug despite adequate analgesia

12. Misunderstanding Addiction • Results in unnecessary withholding of opioid • Pts.may be mislabeled as an addict but real problem is that pain is not adequately treated

13. Opioid and Addiction • Risk of addiction is rare in pts. with no Hx of addiction who are prescribed opioid for the Mx of pain • Exposure to an opioid, even for prolonged periods does not produce the aberrant behaviours consistent with addiction

14. Tolerance • Tolerance: A physiologic state resulting from regular use of a drug in which an increased dosage is needed to produce the same effect or a reduced effect is observed with a constant dose. • Tolerancedoes not usually develop to the pain-relieving effects of opioids.

15. Pseudotolerance • Pseudotolerance is the need to increase dosage that is not due to tolerance ,but due to factors such as: 1.Disease progression 5.Change in Rx 2.New disease 6.Drug interaction 3.Increases physical activities 7.Addiction 4.Lack of compliance 8.Diversion

16. Approaches to Cancer pain management • Pharmacologic Management • NSAIDs/ Acetaminophen • Opioid analgesics • Adjuvant analgesics • 2.Nonpharmacologic Management • Physical modalities: Exercise/ TENS • Psychological interventions: Relaxation/ Distraction • Invasive therapies: Neuroablative / Radiation/ Anesthetic nerve blocks

17. WHO Analgesic Ladder • Developed by WHO : a guide to pharmacological Rx for cancer/ chronic pain • Drug Rx :cornerstone of cancer pain Rx • 70-90% of pts. obtain adequate pain relief from analgesic drugs alone • A further 20%will require additional interventions

18. WHO Analgesic Ladder

19. หลักการให้ยาขององค์การอนามัยโลกหลักการให้ยาขององค์การอนามัยโลก (WHO Recommendations for treatment of Cancer Pain) • ใช้รับประทาน (By the mouth) • ให้ตามกำหนดเวลา (By the clock) • ให้อย่างมีขั้นตอน (By the ladder) • ปรับยาตามรายบุคคล (For the individual) • สนใจในรายละเอียด เช่นอาการแพ้ยาฯ (With attention to detail) • WHO 1996

20. หลักการใช้ยาระงับปวดที่เหมาะสมหลักการใช้ยาระงับปวดที่เหมาะสม • รู้จักยาที่ใช้เป็นอย่างดี:กลไกการออกฤทธิ์ / ผลข้างเคียง • เลือกชนิดและขนาดยาตามพยาธิสภาพ, ความรุนแรงของความปวด • ให้ยาตามระยะเวลาการออกฤทธิ์ เพื่อป้องกันความปวด • มีคำสั่งการรักษาความปวดรุนแรงที่อาจเกิดขึ้นได้เป็นครั้งคราว (breakthrough pain) • ปรับยาตามขั้นตอนการใช้ยาแก้ปวด • ให้ยาเสริมเมื่อจำเป็น (adjuvants) • บริหารยาโดยการรับประทานถ้าทำได้ • แนะนำ ป้องกันและรักษาผลข้างเคียง • ประเมินและติดตามผลการรักษา

21. ขั้นตอนการรักษาความปวดจากมะเร็งขั้นตอนการรักษาความปวดจากมะเร็ง ประเมินความปวด - ความรุนแรง - ระยะเวลา - สาเหตุ ประเมินสภาพความแข็งแรงของผู้ป่วย - อายุ - โภชนาการ - organic disease เช่น ความดันสูง,หอบหืด, เบาหวาน, โรคตับ, โรคไต ฯลฯ

22. 3-Step ladder Step 1: Primary & Pharmacological treatment Drug therapy 1. Opioids เช่น morphine, methadone, fentanyl, tramadol, buprenorphine 2.Neuropathic medicationเช่น carbamazepine, clonazepam, sodium valproate, phenytoin, Amitriptyline, mexiletine 3.Anti-inflammatory medication เช่น NSAIDs, steroid 4.Antidepressants amitriptyline, nortriptyline 5. ยาอื่น ๆ เช่น haloperidol

23. Step 2: Alternate routes for opioid therapy Systemic Intravenous Subcutaneous infusion Transdermal

24. Step 3: Alternate Routes for Opioid therapy Celiac plexus block Splanchnic nerve block Paravertebral nerve block Superior hypogastric plexus block Stellate ganglion block T1 sympathetic ganglion block Lumbar sympathetic nerve block

25. Opioid therapy in non-malignant indication

26. Opioid Therapy in Chronic Nonmalignant Pain Undertreatment is likely because of • Barriers (patient, clinician, and system) • Published experience of multidisciplinary pain programs • Opioids associated with poor function • Opioids associated with substance use disorders and other psychiatric disorders • Opioids associated with poor outcome

27. Opioid Therapy in Chronic Nonmalignant Pain • Use of long-term opioid therapy for diverse pain syndromes is increasing • Slowly growing evidence base • Acceptance by pain specialists • Reassurance from the regulatory and law enforcement communities

28. Addiction? • Addiction • Chronic neurobiology • Impaired Control over use • Compulsive use • Continued use despite harm • Craving • Physical dependence • Specific withdrawal syndrome for each drug • Tolerance • Adaptation: diminution of drug effect over time

29. Prevalence varied from 0% up to 50% in chronic non-malignant pain patients, and from 0% to 7.7% in cancer patients depending of the subpopulation studied and the criteria used. Hojsted J, et al. Addiction to opioids in chronic pain patients: a literature review. Eur J Pain. 2007 Jul;11(5):490-518.

30. Positioning Opioid Therapy • Consider as first-line for patients with moderate-to-severe pain related to cancer, AIDS, or another life-threatening illness • Consider for all patients with moderate-to-severe noncancer pain, but weigh the influences • What is conventional practice? • Are opioids likely to work well? • Are there reasonable alternatives? • Are drug-related behaviors likely to be responsible, or problematic so as to require intensive monitoring?

31. Universal precaution in pain medicine • Diagnosis with appropriate differential dx • Psychological assessment including risk • Informed consent (written vs verbal) • Treatment agreement • Pre/Post intervention assessment of pain level and function • Appropriate trial of opioid therapy +/- adjuvants

32. Universal precaution in pain medicine 7. Reassessment of pain score and level of function 8. Regularly assess four A’s of pain medicine • Analgesia • Activity • Adverse reaction • Aberrant behaviour 9.Periodic review of pain diagnosis, co-morbid conditions and addictive disorder 10. Documentation

34. Opioid therapy for NeP • Should be titrated for efficacy vs AE • Prefer fixed dose regimen, rather than prn • Proactive management of side effects • Understand distinction among addiction, physical dependence, and tolerance • Document treatment plan and outcome with common understanding among involved parties

39. Gabapentin and opioid Gilron I, et al. N Engl J Med 2005;352:1324-34

41. J Pain Symptom Manage 2007; 34:183-9

42. Migraine and other headaches • Not the first line treatment, esp in ER • May be effective as rescue treatment, but may cause quick tolerance • Not use for long term daily treatment, lose efficacy overtime and high recurrence • For chronic headache, needs to rule out other causes, esp medication overuse

45. Others • Fibromyalgia • Weak opioid can reduce pain, along with other treatment (TCA, exercise, etc) • Musculoskeletal pain • Weak opioid as first option • For patients who failed NSAIDS or Paracetamol • Study in OA, chronic back pain: 30 mg per day • Visceral pain • Example: chronic pancreatitis, pelvic pain

47. Recommendations for using opioids inchronic non-cancer pain European Journal of Pain, 2003

49. A clear-cut diagnosis of the cause seems to improve patient outcome with opioids • Use of opioids without a clear Dx is appropriate if the pain is severe & continuous, and is responsive to opioids