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CHAMP Pain Control Stacie Levine MD University of Chicago Why is this important to teach on the wards? Pain is common in the elderly Pain is under-recognized and under-treated JCAHO, ACGME/RRC requirements Lack of formal education on pain control Why is pain control often not optimal?

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champ pain control

CHAMPPain Control

Stacie Levine MD

University of Chicago

why is this important to teach on the wards
Why is this important to teach on the wards?
  • Pain is common in the elderly
  • Pain is under-recognized and under-treated
  • JCAHO, ACGME/RRC requirements
  • Lack of formal education on pain control
why is pain control often not optimal
Why is pain control often not optimal?
  • Clinician unfamiliarity with assessment and treatment
  • Opioid misconceptions

-patients, families, and clinicians

  • Fear of side effects
  • Concern about addiction, regulatory reprimands, and lawsuits
sources of pain in the elderly
Degenerative joint disease

Spinal stenosis

Fractures

Pressure ulcers

Neuropathic pain

Urinary retention

Post-stroke syndrome

Improper positioning

Fibromyalgia

Cancer pain

Contractures

Postherpetic neuralgia

Oral/dental

Constipation

Sources of pain in the elderly
consequences of unrelieved pain
Sleep disturbance

Functional decline

Depression, anxiety

Malnutrition

Lawsuits

Challenging behaviors

Polypharmacy

Increased healthcare utilization

Prolonged LOS

Consequences of unrelieved pain
teaching objectives
Teaching Objectives
  • Knowledge: Housestaff should know

-Properties of medications used for pain

-Common side effects of opioids

  • Skills: Housestaff will demonstrate

-bedside pain assessment in older adults (cognitively intact and impaired)

-use of WHO 3-step ladder

-use of opiate conversion tables

teaching objectives7
Teaching Objectives
  • Attitudes: Housestaff should

-appreciate how pain assessment and management in older adults differs and has high degree of variability

-appreciate patients symptoms of pain or pain-related behaviors

-express satisfaction in evaluation and management of pain

outline for faculty module
Outline for Faculty Module
  • Recognition and assessment

-Cognitive impairment

  • Medication selection
  • Dose selection and titration
  • Opiate conversions
  • Management of myths and side effects
  • Discharge planning
outline for module
Outline for Module
  • Recognition and assessment

-Cognitive impairment

  • Medication selection
  • Dose selection and titration
  • Opiate conversions
  • Management of myths and side effects
  • Discharge planning
teaching trigger case
Teaching Trigger Case
  • You are rounding on an 83 y.o. NH patient admitted with pneumonia
  • She has advanced dementia, bed- bound, limited verbalization
  • PMHx: DM, HTN, Stage 3 sacral ulcer s/p debridement day before
  • Patient stopped eating and is resisting care
trigger case cont
Trigger Case (cont.)
  • Housestaff concerned she is depressed and started Mirtazapine
  • No surrogate available, wonder if a PEG will need to be placed
  • Question: How do we teach about recognition of pain in persons with cognitive impairment?
bedside assessment
Bedside Assessment
  • ASK the patient about present pain
  • Identify preferred pain terminology

-hurting, aching, stabbing, discomfort, soreness

  • Use a pain scale that works for the individual

-Insure understanding of its use

-Modify sensory deficits

unidimensional scales
Unidimensional Scales

Acute Pain Management Guideline Panel. Acute Pain Management in Adults: Operative Procedures. Quick Reference Guide for Clinicians. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. February 1992. AHCPR Pub. No. 92-0019.

assessing pain nonverbal moderate to severe impairment
Assessing pain: Nonverbal, Moderate to Severe Impairment
  • Formal assessment tools available but not necessarily useful in routine clinical settings
  • Unique Pain Signature
  • Nonverbal Pain Indicators
unique pain signature
Unique Pain Signature
  • How does the patient usually act?
  • What changes are seen when they are in pain?

family members

nursing staff

  • Communication across caregiver settings is key!
nonverbal pain indicators
Nonverbal Pain Indicators
  • Facial expressions (grimacing)

-Less obvious: slight frown, rapid blinking, sad/frightened, any distortion

  • Vocalizations (crying, moaning, groaning)

-Less obvious: grunting, chanting, calling out, noisy breathing, asking for help

  • Body movements (guarding)

-Less obvious: rigid, tense posture, fidgeting, pacing, rocking, limping, resistance to moving

nonverbal pain indicators18
Nonverbal Pain Indicators
  • Changes in interpersonal interactions

-combative, disruptive, resisting care, decreased social interactions, withdrawn

  • Changes in mental status

-confusion, irritability, agitation, crying

  • Changes in usual activity

-refusing food/appetite change, increased wandering, change in sleep habits

assessing pain nonverbal moderate to severe impairment ags panel 2002
Assessing pain: Nonverbal, Moderate to Severe Impairment (AGS Panel 2002)

1) Presence of non-verbal pain behaviors?

-assess at rest and with movement

2) Timely, thorough physical exam

3) Insure basic comfort needs are being met

(e.g. hunger, toileting, loneliness, fear)

4) Rule out other causative pathologies

(e.g. urinary retention, constipation, infection)

5) Consider empiric analgesic trial

outline
Outline
  • Recognition and assessment in cognitive impairment
  • Medication selection
  • Dose selection and titration
  • Opiate conversions
  • Management of myths and side effects
  • Discharge planning
teaching trigger case21
Teaching Trigger Case
  • You are rounding on a 75 y.o. male s/p fall
  • History of lumbar stenosis with new onset severe sharp pain down left leg
  • Xrays negative
  • Subintern started prn NSAIDs
  • Patient in severe pain at rounds
  • Question: How do we teach about medication and dose selection in older adults?
multimodal approach to pain management
Multimodal Approach to Pain Management

PhysicalTherapy

Pharmacotherapy

Treatment Approaches

Interventional

Approaches

ComplementaryAlternative

Medicine

PsychologicalSupport

Exercise

medication selection
Medication Selection
  • Good pain history
  • Target to the type of pain

-e.g. neuropathic, nociceptive

  • Consider non-pharmacologic or non-systemic therapies alone or as adjuvants
  • Use the WHO 3-Step ladder
who 3 step ladder
WHO 3-Step ladder

Source: World Health Organization. Technical Report Series No. 804, Figure 2. Geneva: World Health Organization; 1990.

adjuvants
Adjuvants
  • Topicals (lidocaine patch, capsaicin)
  • Acetaminophen
  • NSAIDS, celecoxib, steroids
  • Anticonvulsants
  • Antidepressants
  • Non-pharmacologic (TENS, PT/OT)
step 1 mild non opioids
Step 1(Mild): Non-opioids
  • Acetaminophen
  • NSAIDS
  • Cox-2
  • Non-systemic therapies
  • Non-medication modalities
  • +/- other adjuvants
step 2 moderate mild opioids opioid like
Step 2 (Moderate): Mild Opioids, Opioid-like
  • Codeine (e.g. T #3®)
  • Hydrocodone (e.g. Vicodin®)
  • Oxycodone (e.g. Percocet®)
  • Tramadol (Ultram®)
  • +/- Adjuvants
step 3 severe strong opioids
Step 3 (Severe): Strong Opioids
  • Morphine
  • Oxycodone
  • Hydromorphone (Dilaudid®)
  • Fentanyl
  • Oxymorphone
  • Methadone
  • +/- Adjuvants
transdermal fentanyl
Transdermal Fentanyl
  • Duration 24-72 hours
  • 12-24 hours to reach full analgesic effect
  • Not recommended as first-line in opiate naïve patients
  • Lipophilic
  • Simple Conversion rule:

-1 mg po morphine = ½ mcg fentanyl

-(60 mg morphine roughly 25 mcg patch)

other fentanyl
Other Fentanyl
  • Intravenous (equivalent to patch dose, e.g. Duragesic 100 mcg/72 = 100 mcg/hr IV)
  • Transmucosal

-Actiq®

-Fentora®

  • Iontophoretic Fentanyl Patch - Ionsys ®
methadone a complicated med
Methadone, a Complicated Med
  • Should only be used by those with experience!
  • Mu, kappa, delta agonist
  • Inhibits reuptake of serotonin and norepinephrine
  • NMDA antagonist (neuropathic pain)
  • Significant inter-individual variability
  • Drug interactions (coumadin-like)
methadone cont
Methadone (cont.)
  • Initial rapid tissue distribution
  • Slow elimination phase
  • Long and variable half-life (13-58 hours)
  • Dose interval is variable (q 6 or q 8)
  • Dose usually adjusted q 4-7 days
  • Minimally impacted by renal disease
  • Inexpensive, less street value than other opioids
drugs to avoid
Drugs to Avoid
  • Meperidine (Demerol®)
  • Mixed agonist-antagonist

-e.g. Pentazocine (Talwin®)

  • Propoxyphene (Darvon ®, Darvocet ®)
opioid pharmacology
Opioid Pharmacology
  • Block the release of neurotransmitters in the dorsal horn of spinal cord
  • Mu, delta, kappa expressed differently, depending on opioid medication
  • Conjugated in liver
  • Excreted via kidney (90%–95%)
  • Exception: methadone, excreted fecally
opioid use in renal failure
Opioid Use in Renal Failure
  • Not rec’d: meperidine, codeine, dextropropoxyphene, morphine
  • Use with caution: oxycodone, hydromorphone
  • Safest: fentanyl, methadone
  • Opioid dosing

CrCl >50 mL/min normal

10 - 50 mL/min 75% of normal

<10 mL/min 50% of normal

clearance concerns
Clearance Concerns

Dehydration, renal failure, severe hepatic failure

  •  dosing interval (extend time) or
  •  dosage size
  • if oliguria or anuria
    • STOP around the clock dosing of opioids (like morphine)
    • use ONLY prn
opioids for continuous pain
Opioids for Continuous Pain
  • Dose find, opioid naive:

-begin with short-acting opioid ATC

-allow breakthrough based on Cmax and patients metabolism

  • Cmax (peak) after
    • po, pr  1 h
    • SC, IM  30 min
    • IV  6 – 15 min
dose finding
Dose-finding

To achieve quick pain relief: (LOAD)

1. Start low dose, short-acting

2. Dose q peak

3. P.C.A. not “prn” (Patient controls it)

4. Re-eval in 4 hrs. to figure out what dose is needed

starting doses and half life
Starting doses and half-life
  • For thin, frail elderly suggest 2-5 mg po MSO4 or an equivalent (e.g. 1/2-1 percocet q 4h)
  • Half-life at steady state
    • po / po / SC / IM / IV  3-4 h
    • 4-5 half-lives to reach steady state
opioid dose escalation
Opioid Dose Escalation
  • Should be done on percentage increase irrespective of starting dose

mild / moderate pain 25%–50%

severe / uncontrolled pain 50%–100%

  • How frequent? Depends on t1/2

Short-acting single-agent every 2 hrs

Long-acting every 24 hours

Fentanyl transdermal 72 hours

Methadone 4-7 days

breakthrough dosing
Breakthrough dosing
  • Use immediate-release opioids
    • 10% of 24-h dose or 1/3 of one ER dose
    • offer after Cmax reached
      • po / pr  q 1 h
      • SC, IM  q 30 min
      • IV  q 10–15 min
  • Do NOT use extended-release opioids for breakthrough
outline42
Outline
  • Recognition and assessment in cognitive impairment
  • Medication selection
  • Dose selection and titration
  • Opiate conversions
  • Management of myths and side effects
  • Discharge planning
teaching trigger case43
Teaching Trigger Case
  • You are rounding on a 70 y.o. male ESRD on HD admitted with pleuritic chest pain
  • New pulm mass found on chest CT
  • Severe pleuritic pain well-controlled on hydromorphone 4 mg IV q 3 hours
  • Intern asks for help converting him to something he can take at home
  • Question: How do you teach about proper opiate conversions?
equianalgesic dosing ratios
Equianalgesic Dosing Ratios

Note: Equianalgesic equivalencies are merely estimates and are based on single-dose studies.

changing opioids cross tolerance
Changing Opioids – Cross-tolerance
  • Start with 50%–75% of published equianalgesic dose

1) Example: morphine 60 mg po every 12 hours

2) Change to po oxycodone long-acting

3) Use conversion ratio m:o = 15:10

4) 120 mg/x=15/10=80 mg every 24 hours

5) Reduce by 50% = 40 mg every 24 hours

=Oxycodone LA 20 mg every 12 hours

exception methadone conversion
Exception = Methadone conversion

Daily Morphine Methadone:Morphine

-<100 mg (1:3)

-101-300 mg (1:5)

-301-600 mg (1:10)

-601-800 mg (1:12)

-801-1000 mg (1:15)

->1000 mg (1:20)

Note: Conversion to methadone is complicated and should only by done by those with experience!

outline47
Outline
  • Recognition and assessment in cognitive impairment
  • Medication selection
  • Dose selection and titration
  • Opiate conversions
  • Management of myths and side effects
  • Discharge planning
teaching trigger case48
Teaching Trigger Case

You are rounding on a 90 year old female with severe osteoporosis admitted for sudden severe back pain

  • New vertebral compression fracture
  • Pain controlled on morphine 4 mg IV q 4 hours
  • Patient very sedated, family concerned
  • Question: How do you teach about treatment of side effects of opiates?
opioid adverse effects
Opioid adverse effects

CommonUncommon

Constipation Bad dreams / hallucinations

Dry mouth Dysphoria / delirium

Nausea / vomiting Myoclonus / seizures

Sedation Pruritus / urticaria

Sweats Respiratory depression

Urinary retention

Hypogonadism

SIADH

gi side effects
GI Side Effects

Constipation

-NEVER resolves

-Prevent with scheduled softeners PLUS stimulants

-Avoid bulking agents (e.g. Metamucil®)

Nausea and Vomiting

  • Encourage patients to eat frequent, small meals
  • Treat with promotility agents (metoclopramide), serotonergic blocking agents (odansetron) or dopaminergic blocking agents (haloperidol, metoclopramide, prochlorperazine)
sedation and delirium
Sedation and Delirium
  • Consider trying one of the following:

1) If pain control is adequate, decrease dose by 25%

2) Rotate to a different opioid preparation

3) Use small doses of psychostimulants (2.5 to 5 mg methylphenidate or dextroamphetamine) for excessive somnolence

  • Use nonsedating antipsychotics (haloperidol, risperidone) for delirium
respiratory depression
Respiratory Depression
  • Does not occur in patients on chronic opioids
  • Can occur in opioid-naïve patients whose opioid dose is rapidly escalated
  • Is always preceded by slowly progressive somnolence
  • If you must treat:

-Dilute naloxone (10:1) in saline and infuse 1 mL until breathing pattern returns to normal

teaching trigger case53
Teaching Trigger Case

You are rounding on a 65 y.o. male with gout exacerbation

  • Former cocaine addict
  • Severe pain in hands, elbows, knees
  • Resident told intern to give tylenol and steroids
  • Patient asking for something stronger for pain
  • Resident advised intern to “wait it out”, afraid of awakening a former addiction

Question: How do you teach about pain treatment in persons with a history of addiction or those who express concern about becoming addicted to opiates?

addiction
Addiction
  • A psychologic dependence on drugs and a behavioral syndrome characterized by compulsive drug use and continued use despite harm to self and others
    • Use of opioids for pain management does NOT cause addiction in the majority of people
physical dependence withdrawal
Physical Dependence/Withdrawal
  • Develops if chronic opioids are abruptly discontinued or dose is rapidly decreased
  • Symptoms:

-Nausea, vomiting, diarrhea, abdominal pain, body aches

-May result in psychosis and hallucinations

-Treatment: Taper dose by 50% every 2 to 3 days

pseudoaddiction
Pseudoaddiction
  • Occurs in context of

-Undertreated pain

-Behavioral, family, or psychologic dysfunction

  • Consists of behaviors that are reminiscent of addiction but driven by untreated or undertreated pain
  • Disappears once pain control is adequate
tolerance
Tolerance

Reduced effects of a given dose of medication over time

  • Doses remain unchanged when pain stimulus is stable
  • Tolerance to unwanted side effects is observed and is desired
  • Disease progression (not tolerance), should be suspected when increasing doses are required for pain control
outline58
Outline
  • Recognition and assessment in cognitive impairment
  • Medication selection
  • Dose selection and titration
  • Opiate conversions
  • Management of myths and side effects
  • Discharge planning
teaching trigger case59
Teaching Trigger Case
  • Your team is preparing to discharge a 70 y.o. male with chronic severe Pagets disease requiring narcotics, responded well to hydromorphone
  • Intern asks you to sign the Rx (next slide)
  • Question: How do you teach about appropriate discharge planning, including prescription writing, in persons with pain?
common pitfalls to avoid
Common pitfalls to avoid
  • Changing meds/route on discharge
  • Writing the prescription
  • Medication cost
  • Educating patient/family
  • Appropriate follow-up
slide62
TEACHING PRACTICE:

MODIFIED ROLE PLAYS

teaching case 1
Teaching Case #1
  • You are rounding on an 83 y.o. NH patient admitted with pneumonia
  • She has advanced dementia, bed-bound, limited verbalization
  • PMHx: DM, HTN, Stage 3 sacral ulcer s/p debridement day before
  • Patient stopped eating and is resisting care
case 1 cont
Case #1 (cont.)
  • Housestaff concerned she is depressed and started Remeron
  • No surrogates – wonder if a PEG will need to be placed
  • Teaching task:

Generate a discussion regarding the assessment of pain in cognitively impaired patients

teaching case 2
Teaching Case #2
  • You are rounding on a 75 y.o. male s/p fall
  • History of lumbar stenosis with new onset severe sharp pain down left leg
  • Xrays negative
  • Subintern started prn NSAIDs
  • Patient in severe pain at rounds
case 2 cont
Case #2 (cont.)
  • Teaching Task:

Introduce the WHO 3-step ladder as a framework for medication selection and titration

teaching case 3
Teaching Case #3
  • You are rounding on a 70 y.o. male ESRD on HD admitted with pleuritic chest pain
  • New pulm mass found on chest CT
  • Severe pleuritic pain well-controlled on hydromorphone 4 mg IV q 3 hours
  • Intern asks for help converting him to something he can take at home
case 3 cont
Case # 3 (cont.)
  • Teaching task:

Introduce the opiate conversion table and teach its use in converting IV medication to oral hydromorphone, oral morphine sustained-release, and Fentanyl patch

Calculate doses and intervals for breakthrough medications

teaching case 4
Teaching Case #4

You are rounding on a 65 y.o. male with gout exacerbation

  • Former cocaine addict
  • Severe pain in hands, elbows, knees
  • Resident told intern to give tylenol and steroids and “wait it out”, afraid of awakening a former addiction
  • Patient asking for something stronger for pain
case 4 cont
Case #4 (cont.)
  • Teaching task:

Teach the different myths regarding opiate medication

teaching case 5
Teaching Case #5

You are rounding on a 90 year old female with severe osteoporosis admitted for sudden severe back pain

  • New vertebral compression fracture
  • Pain controlled on morphine 4 mg IV q 4 hours
  • Patient very sedated, family concerned
case 5 cont
Case # 5 (cont.)
  • Teaching task:

Discuss this side effect of opiates and its treatment

teaching case 6
Teaching Case #6
  • Your team is preparing to discharge a 70 y.o. male with chronic severe Pagets disease requiring opioids, responded well to hydromorphone
  • Intern asks you to sign the Rx
  • Teaching task:

Review the Rx with the team and teach about appropriate prescriptions and discharge planning

teaching case 7
Teaching case #7
  • You are rounding on a 72 year old male with metastatic bladder cancer who is being discharged on home hospice the next day (order on next slide)
  • Teaching task:

Review interns order to change IV to Duragesic patch. Teach the appropriate conversion.

teaching case 8
Teaching case #8
  • You are rounding on an 85 year old woman with advanced dementia s/p fall with pelvic fracture
  • Teaching task:

Review the MAR and teach about optimal management of pain in persons with cognitive impairment

teaching case 9
Teaching case #9
  • You are rounding on an 80 year old female with dementia admitted with hematemesis and abdominal pain
  • EGD: Stomach cancer, patient is dying
  • She had been on morphine sulfate long-acting 60 mg po q 12 for Pagets
  • Teaching task:

Show the housestaff how to effectively convert her to a morphine infusion

references
References
  • Levy M. Drug therapy: Pharmacologic treatment of cancer pain. NEJM 1996;335(15):1124-1132.
  • EPEC Project, The Robert Wood Johnson Foundation, 1999.
  • Storey P and Knight CF. UNIPAC 3: Assessment and Treatment of Pain in the Terminally Ill. AAHPM 2003.
  • Gazelle. Methadone for the treatment of pain. J Pall Med. 2003;6(4):620
  • AGS Panel on Persistent Pain in Older Persons. JAGS. 2002;50:S205-S224.
  • American Pain Society. APS Glossary of Pain Terminology. http://www.ampainsoc.org/links/pain_glossary.htm.
  • Bruera E and Portenoy R. Cancer Pain Assessment and Management. Cambridge University Press, 2003.
  • Cherny N, Ripamonti C, Pereira J, et al. Strategies to manage the adverse effects of oral morphine: an evidence-based report. J Cli Oncol. 2001;19:2542-2554.
references81
References
  • Dean M. Opioids in renal failure and dialysis patients. J Pian Symptom Manage 2004;28(5):497-504.
  • Gordon DB, Stevenson KK, Griffie J, et al. Opioid equianalgesic calculations. J Palliat Med. 1999;2(2):209-218.
  • Herr K, Bjoro K, Decker S. Tools for assessment of pain in nonverbal older adults with dementia: A state-of-the-science review. J Pain Symptom Manage 2006;31(2):170-192.
  • Hewitt DJ, Portenoy RK. Adjuvant drugs for neuropathic cancer pain. Topics in Palliative Care. New York: Oxford University Press 1998:31-62.
  • Kirsh KL, Passik SD. Palliative care of the terminally ill drug addict. Cancer Invest 2006;24:425-431.
  • Klaschik E, Nauck F, Ostgathe C. Constipation – modern laxative therapy. Support Care Cancer 2003;11:679-685.
references82
References
  • McCleane G. Topical analgesics. Med Clin N Am 2007;91:125-139.
  • Mercadante S and Bruera E. Opioid switching: A systematic and critical review. Cancer Treatment Reviews 2006;32:304-315.
  • Meuser T, Pietruck C, Radbruch L, et al. Symptoms during cancer pain treatment following WHO guidelines: a longitudinal follow-up study of symptom prevalence, severity, and etiology. Pain 2001;93:247-257.
  • Skaer TL. Transdermal opioids for cancer pain. Health and Quality of Life Outcomes 206;4(24):1-9.
  • Swegle JM and Logemann C. Management of common opioid-induced adverse effects. Am Fam Physician 2006;74:1347-1354.
  • WHO ladder:Cancer Pain Relief and Palliative Care. Technical Report Series 804. Geneva: World Health Organization; 1990.
references83
References
  • EPERC. End-of-life/Palliative Education Resource Center http://www.mywhatever.com/cifwriter/library/eperc/fastfact/ff_index.html
  • http://www.ama-cmeonline.com/pain_mgmt/module12/index.htm
  • Bruera E and Sweeney C. Methadone use in cancer patients with pain: A review. J Palliat Med. 2002;5(1):127-137.