361 37157 PainManagementPowerpoint 000

Pain ManagementPain ManagementDrug Therapy Workshop Drug Therapy Workshop

Yale Interdisciplinary Palliative CareEducational Project

The Concept of Total Pain

PhysicalPhysical

SocialSocial

SpiritualSpiritual

PsychologicalPsychological Total PainTotal Pain

World Health Organization (WHO) Step Ladder Approach

Mild Pain 1-3/10

Moderate Pain 4-6/10

Severe Pain 7-10/10

ASA, Tylenol,NSAIDS

Weak opioids +/- non-opioids (e.g. Tylenol #3®)

Potent opioids (e.g.morphine) +/-non-opioids

Clinical Questions #1

Breakthrough pain dosing should be individualized, but a guide for determining the initial dose of bolus I.V. medication for a patient receiving a long acting oral form of morphine is that the initial breakthrough dose is what percentage of the total daily long-acting morphine dose?

a. 10% b. 20% c. 50% d. 100%

Answer #1

a. 10%

Rationale:10% would be the minimum dose,Titrated to effect. The range is 10-20%

Breakthrough PainBreakthrough Pain

Patients on long-acting med always need second, short-acting med, for breakthrough pain to take Q 4 hours or less.

Generally, dose of breakthrough opioid should be:

10% of 24 hour dose of analgesics and made available Q 2-4 hours.

Example: MS Contin 60mg q12hrs breakthrough dose should be immediate release morphine (MSIR), 10-15 mg Q 2-4 hrs prn.

Clinical Question #2

What is the maximum number of tablets of hydrocodone/acetominophen 5 mg/500 mg (e.g., Vicodin ®) you can safely prescribe for a 24 hour period.

a. 4 b. 6 c. 8 d. There is no ceiling dose/maximum

Answer #2

c. 8Rationale:

4,000mg of acetominophen in 24 hours is safe for most patients, BUT ceiling dose may need to be modified significantly or the drug not used in patients with: renal or liver disease history of significant alcohol intake consider starting at 50% of standard ceiling

dose for elders.

Clinical Question #3

A 40 yr. old women with stage IV ovarian cancer reports mild to moderate burning pain in her hands and feet. Ibuprofen has not been effective. You suggest:

a. A COX-2 inhibitor b. Topical capsaicin c. A steroid d. An adjuvant with activity in neuropathic pain

Answer #3

d. An Adjuvant with activity in neuropathic pain

Pain characterized by sharp, shooting, electric shocks, parethesias, dysesthesias, cold extremities

Neuropathic pain often responds poorly to NSAIDs and opioids

Drugs for Neuropathic Pain

opioids antidepressants anticonvulsants local anesthetics steroids other

Antidepressants Tricyclic antidepressants

Analgesic effects separate from anti-depressant effects.

Amitriptyline: most studied, but most side effects Nortriptyline & desipramine: better tolerated, less

well studied SSRIs: little evidence of analgesic effect. SNRI’s

inhibit both norepinephrine and serotonin reuptake efficacy in neuropathic pain syndromes or pain

associated with depression (duloxetine [Cymbalta®], venlafaxine [Effexor®])

Anticonvulsants

Agents for neuropathic pain gabapentin (Neurontin®) pregabalin (Lyrica®) clonazepam (Klonopin®) Other newer agents

Start low, go slow Watch for side effects Monitor serum levels, if available

Adjuvants to Opioid Therapy

Adjuvant Common indicationAlpha agonists Neuropathic pain

Anticonvulsants Neuropathic pain

Antihistamines Nausea, pruritus

Benzodiazepines Pain w/Anxiety

Bisphosphanates Bone pain (cancer)

Corticosteroids Bone pain (cancer)

NSAIDs / COX-2 I Musculoskeletal pain

Tricyclic anti-depressants

Neuropathic pain

Clinical Question #4

A 63 yr. old man with advanced prostate cancer has been stable on oral morphine 30 mg every 4 hours. He is now NPO and you are going to switch him to IV morphine. The correct IV dose is:

a. 4 mg IV q 4 hours b. 6 mg IV q 4 hours c. 10 mg IV q 4 hours d. 30 mg IV q 4 hours

Answer #4

c. 10 mg IV q 4 hours

Rationale: Equianalgesic ratio for

morphine is 1 mg IV = 3 mg PO.

When writing start time for the first dose, consider time of last oral dose.

ORAL DOSE (MG)

MED PAREN-TERAL DOSE (MG)

30 Morphine 10

7.5 Hydro-morphone(Dilaudid

®)

1.5

20 Oxycodone --

30 Hydro-codone

--

Parenteral OpioidsParenteral OpioidsIV is the route of choice if access is available. There is NO indication for IM opioids

(painful, no benefit over SQ route) All standard opioids can be given SQ, by

either bolus dose or by continuous infusion.

PCA (basal rate plus a patient initiated dose) is an effective and well accepted modality; either IV or SQ.

IV or SQ bolus doses have a shorter duration of action than oral doses; typically 1-3 hours.

The peak effect from an IV bolus dose is 5-15 minutes.

Dose escalation of parenteral opioids is the same as with oral—always by a percentage of the starting dose.

Parenteral Opioids (cont.)

Clinical Question #5

Mrs. Jones has advanced cervical cancer. She has been taking Percocet-5 (2 tablets PRN) for pain with good effect. The patient is now NPO & is requiring something for pain. An appropriate starting dose of PRN IV morphine is approximately:

a. 2 mg b. 3 mg c. 4 mg d. 5 mg e. 6 mg

Answer #5

c. 4 mg IV morphine

Rationale: Most equianalgesic tables use a ratio of 20 mg

po oxycodone = 10 mg IV morphine. Mathematically, answer is 5 mg IV morphine.

Clinically, account for possible incomplete cross-tolerance, so reduce the dose by about 25%-50%.

4 mg is a convenient dose of IV morphine. We might also have rounded down to 3 mg. 4 mg is almost certainly safe and analgesically appropriate for opioid non-naïve patient.

Incomplete cross-tolerance If switching from one opioid to another,

recommended to start the new opioid at ~50% of equianalgesic dose.

Why? :Because the tolerance a patient has towards one opioid, may not completely transfer (“incomplete cross-tolerance”) to the new opioid.

from

100%

to

50%of new Opioid

Clinical Question #6

A 69 yr. old patient with metastatic prostate cancer to the lumbar spine is taking OxyContin® (sustained release oxycodone) 100 mg every 8 hours. What should be the opioid for his breakthrough pain and at what dose and interval?

a. Oxycodone 30 mg PO every 4 hours b. Oxycodone 30 mg PO every 8 hours c. Morphine 10 mg PO every 4 hours d. Morphine 10 mg IV every 8 hours

Answer #6

a. Oxyocodone 30 mg PO every 4 hours

Rationale: In general, keep PRN, short acting opioid the same

drug as the long-acting opioid. Starting dose for breakthrough pain is 10% of the

total daily dose (and you can always titrate). Here total daily dose = 300 mg, so 10% of this = 30

mg. The PRN interval should never be longer than the expected analgesic duration (~4 hours in this case), and can often be less.

Oral dosing: onset in 20-30 min peak effect in 60-90 minutes duration of effect 2-4 hours Can be dose escalated or re-administered

every 2-4 hours for poorly controlled pain General guideline:

Moderate pain: increase 25-50% Severe pain: increase by 50-100%

Short Acting Opioids

B. Short Acting Opioids

Parenteral or Oral: morphine hydromorphone

(Dilaudid ®) Codeine

Onset & duration of action depends on route administration

Oral only: oxycodone (Percocet

® , Tylox ® ) hydrocodone (Vicodin ®

Lortab ®, Lorcet ®) propoxyphene (Darvon

®, Wygesic ®)

Note: hydrocodone is only available as a combination product.

Clinical Question #7

Ms. Nguyen is reporting 7/10 pain now in her left leg. She had vomited after her last pain medication, morphine 10 mg IV. What is your next analgesic order?

a. Dilaudid® (hydromorphone) 1.5 mg IV b. Fentanyl® Patch 25 mcg/hr q72 hours c. Dilaudid® 8 mg PO d. Percocet® 5/325 three tablets

Answer #7

a. Dilaudid® (hydropmorphone) 1.5 mg IV

Rationale: With severe pain we need rapid onset option. Onset too slow with Fentanyl patch and orals. IV morphine plus an antiemetic might be considered,

but easier option - change to another opioid (different patients have different side effect responses to various opioids).

Hydromorphone 1.5 mg IV is approx. equianalgesic to 10 mg IV morphine.

As patient currently in severe pain, reducing dose for potential incomplete cross tolerance not necessary.

Opioid Dose EscalationAlways increase by a percentage of the present dose based upon patient’s pain rating and current assessment

Mild pain 1-3/10

25% increaseModerate pain4-6/10

25-50% increase Severe pain7-10/10

50-100% increase

Frequency of dose escalation

The frequency of dose escalation (oral opioids) depends on the particular opioid … Short acting oral: q 2-4 hours Long acting oral, except methadone:

q 24 hours methadone: q 72 hours transdermal fentanyl: q 72 hours.

Clinical Question #8Mr. MacLean comes to your floor in excruciating pain (10/10). He receives morphine 4 mg IV, but reports no relief at all after 15 minutes. The intern or fellow then orders morphine 6 mg IV. After another 20 minutes the patient reports that she still has no relief. You note that the patient is wide awake (no sedation) with continued 10/10 pain. What would you recommend?

a. Tell the patient that the interval between doses is 4

hours and they will have to wait

b. Administer another dose of morphine 6 mg IV in one hour

c. Administer another dose of morphine 9-12 mg now

d. Call for a pain or palliative care consult

Answer #8

c. Administer another dose of morphine 9-12 mg now.

Rationale: Patient has no unacceptable side effects, so no

immediate reason to change to another drug. Patient is in a pain crisis. We should titrate

aggressively (i.e., 50-100% increase in each dose at approximately 15 minute intervals) until a response is observed.

Note:some protocols for pain crisis in cancer patients suggest that 1-2 doses of ketorolac (Toradol®) 30 mg IV be considered (if not otherwise contraindicated) in addition to the opioid.

Clinical Question #9

Ms. Santini, a 45 yr. old woman with colon cancer metastatic to the liver, had been admitted for uncontrolled pain. Her pain is now controlled and stable on PCA morphine of 10 mg/hr. The boluses are 5 mg q15 minutes PRN and work very well but she rarely needs to use the bolus doses for breakthrough pain. She is to be discharged home on oral opioids. What opioid/formulation and what dose would you recommend?

a. MS Contin 120 mg PO Q 12 hours b. MS Contin 240 mg PO Q 12 hours c. MS Contin 360 mg PO Q 12 hours d. Fentanyl patch 50 mcg Q 72 hours e. Dilaudid 8 mg PO Q 8 hours

Equianalgesic Doses: Opioid Analgesics

ORAL DOSE (MG)

ANALGESIC PARENTERAL DOSE (MG)

30 Morphine 10

7.5 Hydromorphone(Dilaudid ®)

1.5

20 Oxycodone --

30 Hydrocodone --

Answer #9

c. MS Contin 360 mg PO every 12 hours

Rationale: Patient already on morphine, so use same

opioid. Using long-acting formulation is the oral

equivalent of a continuous infusion. Total daily dose of morphine IV is 240 mg

and the oral equivalent is 720 mg of morphine, can be given as 360 mg of MS Contin PO every 12 hours.

C. Long Acting Opioids

Oral morphine:

MS Contin® Kadian® Oramorph SR

oxycodone Oxycontin® Oxycodone SR

oxymorphone Opana SR

methadone

Transdermal Fentanyl Patch

(Duragesic®) – Dosing Q 72 hours

Clinical Question #10

What breakthrough pain opioid/formulation would you recommend for Ms. Santini if she takes MS Contin 360 Mg Q 12 hours?

a. Morphine elixir 20 mg PO every 2-4 hours PRN

b. Morphine immediate release tablets 40 mg PO Q 2-4 hours PRN

c. Morphine immediate release tablets 60 mg PO Q 2-4 hours PRN

d. Morphine immediate release tablets 70 mg PO Q 2-4 hours PRN

Answer #10Answer #10d. Morphine immediate release tablets 70 mg PO

every 2-4 hours PRN.

Rationale: Breakthrough pain requires a short-acting formulation. Preferable to use same opioid as long-acting. PRN initially 10% of the total daily dose = 10% of

720mg = 72mg. Dosing interval is q2-3h PRN. We don’t expect that pts

will need to take 12 doses in 24hr (our pain regimen would be really off).

If patient requires >5 PRN doses/day, either the PRN dose needs adjusting or the basal dose or both.

Name one new fact you learned about the use of narcotics from this presentationand how you might use it clinically as a Sub- I

References

Portions of this presentation were originally developed by David E. Weissman, MD, Drew Rosielle, MD, Kathy Biernat, MS and Judi Rehm for:

EPERCEnd of Life/Palliative Education Resource Center

And:

Yale Cancer Center Supportive Oncology ProgramConnecticut Challenge Survivorship Clinic Kenneth Miller, MD & Thomas Quinn, APRN

References con’t

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Backonja M, Beydoun, A, Edwards KR, et al. Gabapentin for symptomatic treatment of painful neuropthy in patients with diabetes mellitus. JAMA 1998;280:1831-1836.

Breitbart W, Chandler S, Eagle B, et al. An alternative algorithm for dosing transdermal fentanyl for cancer pain. Oncology 2000:14:695-702.

Fohr SA. The double effect of pain medication: separating myth from reality. J Pall Med 1998; 1:315-328.

Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain. Clinical Practice Guideline No. 9. AHCPR Publication No. 94-0592. Rockville, MD. Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service, 1994.

Portenoy, RK. Chronic Opioid Therapy in Nonmalignant Pain. J Pain Symptom Manage 1990; 5: S46-S62.

Portenoy, RK. Continuous Infusion of Opioid Drugs in the Treatment of Cancer: Guidelines for Use. J Pain Symptom Manage 1986;1: 223-228.

Storey P, Hill HH, Jr., St. Louis RH, Tarver EE. Subcutaneous infusions for control of cancer symptoms. J of Pain Symptom Manage 1990; 5:33-41.