This document discusses effective pain management and the challenges of treating chronic pain with opioids. It provides an overview of pain management principles, the risks of addiction, and approaches to assessing patients and monitoring opioid treatment. While opioids can help treat pain in some cases, providers must consider the risks and benefits for each patient due to the potential for abuse, addiction and undertreatment of pain.
2. Declarations There has been no commercial sponsorship or support for this program. The planners and presenters have declared that no conflict of interest exists. The MARN CE Committee does not endorse any products in conjunction with any educational activity.
4. Objectives Participants will: Gain an understanding of the principles of effective pain management Have the knowledge and/or resources to assist in indentifying patients at high risk for substance abuse, and Gain an awareness of the importance of counseling patients about the side effects, addictive nature and proper storage and disposal of prescription medications.
5. The challenge It is true that untreated and undertreated pain is a major public health issue, so is addiction.
6. Approach Pain Policy #2012 Ask (screen) Assess (comprehensively) Manage (treat) Re-assess (modify plan prn) Educate (patient/family) Educate (clinicians) Monitor (effectiveness) Pain Web Site (OurNet) PAIN
7. Case Presentation 59 y.o. man presents to his primary care physician for chronic foot pain
9. Pain It is common It is often undertreated There are many barriers to treating pain Clinical, Patient-related System-related Racial and ethnic barriers exist Language Perceptions
14. Opioid pharmacology Conjugated by liver 90-95% excreted in urine Dehydration, renal failure, severe hepatic failure Decrease interval/dosing size If oliguria/anuria STOP routine dosing (basal rate) of morphine Use ONLY PRN
15. Opioid Pharmacology What is the half life (range) for opioids? 2-4 hours How many half lives to get to steady state? 4-5 What do you base your scheduled dosing on: Cmax or T1/2? T1/2 What do you base your breakthrough dosing on: Cmaxor T1/2? Cmax
16. A few words on methadone Methadone Rises as a Painkiller With Big Risks By ERIK ECKHOLM and OLGA PIERCE Published: August 16, 2008 [Methadone] is implicated in more than twice as many deaths as heroin, and is rivaling or surpassing the tolls of painkillers like OxyContin and Vicodin. “This is a wonderful medicine used appropriately, but an unforgiving medicine used inappropriately,” said Dr. Howard A. Heit, a pain specialist at Georgetown University. www.pcssmentor.org - find a mentor on use of methadone in pain management
20. Gabapentin 600mg PO TIDOxycodone 80mg+60mg = 140mg/day 140mg PO oxy x (5mg IV morphine/10mg PO oxy) = 60 mg IV morphine/day 60mg IV morphine ÷ 24 hours = 2.5 mg/hour PCA basal rate 2mg/hour, bolus 0.5 or 1mg with 15 minute lockout
21. Case: In the ER Patient goes to the ER … He has been doubling his oxycodone dose on his own at home – “my foot pain is terrible!” “I’m out of my medication and I need more – help me!”
22. Slides adapted from: “Safe and effective opioid prescribing for chronic pain” Boston University School of Medicine Free online CME www.bumc.bu.edu/cme/educational-opportunities/online-programs/
23. Prescription Drug Abuse Major public health problem Abuse and misuse of opioids more than doubled during 1990s to present Most nonmedical users obtain drug from family or friend (medicine cabinet) Source where family/friend obtained drug: one clinician Source: SAMHSA, OAS, NSDUH data, July 2007
24. From 1997-2006, opioid prescriptions increased sevenfold Unintentional overdoses more than doubled Overall risk of opioid overdose remains very low (0.04%) Sources: 2007 National Vital Statistics System; JAMA 2011;305(13):1315-21 Deaths from prescription drug abuse
25.
26. Difficult to know the difference between inappropriate drug-seeking and appropriate pain-relief seeking behavior
40. Hx of severe depression or anxietyIves T et al BMC Health Services Research 2006, Reid MC et al JGIM 2002, Michna E et al JPSM 2004, Akbik H et al JPSM 2006 What is the risk of addiction?
79. What number best describes how, during the past week, pain has interfered with your enjoyment of life? (does not interfere – completely interferes)
95. Show commitment to continue caring about pt and pain, even without opioids
96. Always offer referral to addiction treatmentExit strategy: discussing lack of benefit
97. MA Online Prescription Monitoring Program Online database of prescriptions filled in MA Oct 2009-Dec 2010: Schedule II January 2011 onward: Schedule II-V Pharmacies report data weekly Up to 4 week lag in uploading data Registered providers may access online Requires patient first and last names, birthday Only provider may access (not nurse, MA) Only for patients for whom you are prescribing
98. Safe Disposal Federal: FDA, White House Office of National Drug Control Policy; US Environmental Protection Agency State: MA DCR; Mass DEP; MA Water Resources Authority Local: Take back programs When no longer needed
102. With opioids for chronic pain, use consistent approach but set level of monitoring to match risk
103. If there is benefit in the absence of harm, continue opioids
104.
105. Prevalence & Impact Chronic pain is one of the most common conditions for which people seek medical treatment 35% of Americans suffer from chronic pain >50 million Americans are partially or totally disabled by chronic pain 50 million workdays are lost per year $100 billion is the estimated annual cost in lost productivity, medical costs, and lost income
109. Barriers to treating pain Clinician-Related Limited knowledge of pain pathophysiology and assessment skills Biases against opioid therapy and overestimation of risks Fear of regulatory scrutiny/action Patient-Related Exaggerated fear of addiction, tolerance, side effects Reluctance to report pain: stoicism, desire to “please”clinician Concerns about “meaning” of pain (associate increased pain with worsening disease) System-Related Low priority given to pain and symptom control Limits on number of Rxs filled per month & number of refills allowed Reimbursement policies
110. Racial & ethnic barriers Language or cultural differences make pain assessment more difficult Clinicians’ perceptions and misconceptions: minority-group patients have fewer financial resources to pay for prescriptions higher drug-abuse potential among minority groups Patients’ lack of assertiveness in seeking treatment Lack of treatment expertise at many sites at which minority-group patients are treated Relative unavailability of opioids in some communities
111.
112. nerves become resistant to anti-nociceptive systemIf untreated, pain signals will continue even after injury resolves Chronic pain signals become embedded in the central nervous system
114. Clinician issues Over-prescribing Pts expect medication to solve problems Fear of confrontation and saying “no” to pt Under-prescribing Poor education about opioids Overestimate potency and duration of action Fear of being duped Exaggerated fear of addiction potential
123. Limited or no improvement in functioningBalantyne JC, Mao J NEJM 2003, Kalso E et al Pain 2004, Eisenberg E et al JAMA 2005, Martell BA et al Ann Intern Med 2007
Gabapentin also works on the dorsal horn – voltage gated calcium
AC (CABG)
Oxycontin 40mg PO BIDOxyIR 10mg PO q2 hours PRN– up to 6 per dayGabapentin 600mg PO TID= 80 + 60 = 140mg oxycodone per day on a bad day. Average 120mg per day on usual days.What would happen if we just did pca without basal rate?The patient would likely withdraw…So… how to safely provide adequate pain control? 120mg po oxycodone = 180 mg po morphine = 60 mg IV morphine/day= 60mg/24hours = 2.5 mg morphine per hourTo be conservative – start basal rate at 2mg/hourBolus dose should allow the patient to double or triple his hourly rate – thus0.5 or 1mg with 15 minute lockout would work.Conversion slide
This is where the case “turns” – AC/JR
Highly prevalent:30-50% in active treatment75-90% in advanced illnessPrinciples of Assessment Pain Historychronicityintensity and severitypathophysiology and mechanismtumor type and stage of diseasepattern of pain and syndromePhysical and Neurologic ExaminationRadiographic FindingsBack pain:60-85% lifetime prevalenceClinical CharacteristicsPreoccupation with pain Consistently disabled from painDepression and anxiety are common High incidence of psychiatric diagnosesDrug misuse is common, but addiction relatively rareOsteoarthritis:Affects over 80% of people over 5523% have limitation of activityDiagnosisHistory: age, functionality, degree of pain, stiffness, time of occurrence (e.g., morning, at rest, during activity)Physical examination:range of motion, tenderness, bony enlargement of jointLaboratory findings:radiograph, CBC, synovial fluid analysisMild-moderate: Tylenol; moderate: NSAID; severe: opioid; refractory: surgery