1 Overview of Pain and Symptom Management Narasimha Gundamraj MD PAIN • An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. (As defined by the International association for study of pain IASP) Pain • Pain is a protective mechanism for the body. • Pain prevents injuries •
32
Embed
An unpleasant sensory and emotional Overview of Pain and ...
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1
Overview of Pain and Symptom Management
Narasimha Gundamraj MD
PAIN
• An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. (As defined by the International association for study of pain IASP)
Pain
• Pain is a protective mechanism for the body.• Pain prevents injuries
• Effective April 1, 1999, the Pain and Symptom Management Advisory Committee was established under the Occupational Regulation sections of the Michigan Public Health Code, P.A. 421 of 1998. The Pain and Symptom Management Advisory Committee Report was issued in November 2002.
• The diagnosis and treatment of pain is integral to the practice of medicine. In order to implement best practices for responsible opioid prescribing, clinicians must understand the relevant pharmacologic and clinical issues in the use of opioid analgesics and should obtain sufficient targeted continuing education and training on the safe prescribing of opioids and other analgesics as well as training in multimodal treatments.
3
Decade of Pain Control and Research 2001-2010
Pain types
Based on duration• Acute pain• Chronic pain
Acute Pain
• Due to noxious stimuli: Thermal, mechanical, chemical.
• Nociception: Detection (by receptors), transduction(localized processing of pain) , transmission of noxious stimuli ( signal transmission through nerves and spinal cord)
• CNS excitability: Myoclonus, Siezures. Naloxone does not reverse,
13
Tolerance – Definition
• “Tolerance is a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug’s effects over time”
TOLERANCE
• Normal physiological adaptation• Tolerance is less predictable than physical
dependence and develops more rapidly than analgesia
• Tolerance to analgesia, CNS depression and nausea, opioid induced constipation
Opioid induced hyperalgesia
• Upregulation of nociceptive systems• Rotation of opioids• Combining with non opioid
Selection of opioid
• Type of pain• Acute use• Chronic use• Adverse effects• Liver function, kidney function• Cost, availability• Clinical trial
14
narcotics
• Are opioids narcotics?• Are all narcotics opioids?
Management of Chronic Pain
Assessment• Pain scores: may not be reliable• Subjective assessment: Vital signs, functionality
• Drug seeking behavior• Pain behaviors• Nurse shopping
Management of Chronic pain
• Oral bioavailability, gastrointestinal absorption, first pass hepatic clearence.
• Interpatient variability in opioid requirement• Age
• Opioid dependence• Opioid tolerance• Opioid or substance abuse or addiction
19
Addiction: DefinitionA primary, chronic, neurobiological disease, with
genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving
Consensus statement of the American society of addiction medicine, American academy of Pain medicine, American Pain Society
Addiction –A Neurobiological Disease
• The neurobiology of addiction encompasses more than the neurochemistry of reward
• There is altered impulse control, altered judgment, and the dysfunctional pursuit of rewards
• Susceptible individuals may have an alteration of the limbic or related system that causes sensitization to the reinforcing effects of drugs
• Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry
Addiction –Behavioral Manifestations
• A Inability to consistently Abstain• B Impairment in Behavioral control• C Craving; or increased “hunger” for
drugsor rewarding experiences
• D Diminished recognition of significantproblems with one’s behaviors andinterpersonal relationships, and
• E A dysfunctional Emotional response
20
• Physical dependence• Tolerance• Pseudoaddiction
Physical Dependence – Definition“Physical dependence is a state of
adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist”
• Normal predictable, physiological response
• Characterized by drug class specific physical withdrawal syndrome
• Can develop to opioids within a week• Taper the dose to prevent withdrawal• Opioid withdrawal symptoms can persist
for weeks to months in some persons
Tolerance – Definition
• “Tolerance is a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug’s effects over time”
21
• Normal physiological adaptation• Tolerance is less predictable than physical
dependence and develops more rapidly than analgesia
Pseudoaddiction
• Results from the undertreatment of pain• Manifested by behaviors similar to
addiction– Clock watching– Focus on obtaining drug– Aberrant behaviors
• Behaviors resolve when the pain is effectively managed
Substance abuse and Pain management
• Pain management in individuals with substance abuse issues
• Opioid pain management leading to misuse and substance abuse
Opioid Agreements
• Written documents signed by both clinician and patient
• Spell out expected behaviors and consequences of these behaviors
• Purpose is to promote safe and effective use of controlled substances
• Provide “informed consent” on risks and benefits of long-term opioid therapy
22
Assessment: Interview Tips• Be nonjudgmental• Explain importance of information• Assume use: how often do you use?• Estimate high quantities: do you drink
about a quart (or case) a day?• ? Feelings of impending withdrawal• Be aware of stages of change• Use established assessment tools
Analgesia
• Goal is to provide pain relief– Increased comfort should improve the
patient’s quality of life• Perform and document routine pain
assessments:– Average pain during the past week (0-10)– Worst pain during the past week (0-10)– % of pain relief in the past week– Inpatient assessment of patient’s pain behaviors
Activities of Daily Living
• Goal is to increase activities of daily living– Pain relief should improve function
• Conduct a routine functional assessment:– Physical functioning– Mood– Sleep– Relationships – Family and Social Networks– Overall
Adverse Events
• Goal is to minimize adverse events– Adverse events could affect adherence
• Conduct a routine assessment of side effects:– GI: Constipation, nausea, vomiting– CNS: Mental clouding, drowsiness, fatigue– Other: Itching
23
Assessment tools
• Current opioid misuse measure (COMM)• Screener and opioid assessment for
patients with pain-revised (SOAPP-R)• Substance abuse subtle screening
inventory (SASSI)(SASSI-A2)
Maintainence
• Routine follow up• Pill counts• Random Urine drug screen• MAPS
Guidelines for prescriptions
• State guidelines• Federal guidelines: FSMB, CDC
24
Michigan
• Evaluation of patient• Treatment plan• Informed consent and agreement for treatment: one physician, one pharmacy, urine drug screens, frequency of prescriptions, terms for discontinuation
• Periodic review• Consultation• Medical records• Compliance with controlled substances laws
Michigan automated prescription system MAPS
• Database of Michigan department of community health
• Drug, dosage, amount, date prescribed, date dispensed, prescribing physician name, pharmacy name
CDC GuidelinesMarch 15th 2016.
• Guidelines not rules• Primary care physicians not oncologists• Consider non opioid options: NSAIDs, physical therapy, behavioral treatments
• Not more than 7 day treatment for acute pain
CDC GuidelinesChronic therapy
• Follow up 1‐4 after initiation, then every 3 months
• Urine drug screens atleast once a year• MAPS review atleast every 3 months• Document: Benefits outweigh risks, non pharmacologic/non opioid therapy used, Improvement of function
25
CDC Guidelinesdosage recommendations
• Less than 50 mg morphine equivalents per day• 50 to 90 mg (MME) only when beneficial• >90 mg rarely used• Avoid benzodiazepines
Prescription opioids Pharmacist’s perspective
• E prescriptions• Michigan Chief Medical Executive ( Dr.Wells) Standing order for Naloxone
• Out of town patients• Number of pills• Cash pay• Circle of friends from same physician
Pain Management
• Cause of pain?• Is the pain adequately controlled?
• Risk of developing addiction with acute pain management is small
• Risk of developing addiction or aberrant behaviors in chronic pain patients is about 3%.
26
High risk predictors
• History of alcohol or illicit drug use• Family history• History of convictions for drunk driving or
drug use, cigarette smoking.• Aberrant behaviors in the course of
therapy.• Early refills, preoccupation with opioids,
doctor shopping
Aberrant Drug-Related Behaviors
• Goal is to detect aberrant drug-related behaviors early on to prevent abuse, diversion and protect the practice of pain management
• Consider– Cultural norms– Less predictive behaviors– More predictive behaviors
Aberrant Behaviors
• Borrowing drugs from family and friends• Hoarding drugs
– With improvement of symptoms– With resolution of the problem
Less Predictive Aberrant Behaviors
• Drug hoarding when symptoms are improved• Acquiring drugs from multiple medical sources• Aggressive demands for a higher dose• Unapproved use of a drug to treat a symptom,
e.g., use of an opioid to treat anxiety• Unsanctioned dose escalation (1-2x)• Reporting psychic effects• Requesting specific drugs
27
More Predictive Aberrant Behaviors• Selling prescription drugs• Forgery of prescriptions• Concurrent illicit drug use• Multiple prescription/medication losses• Ongoing unsanctioned dose escalations• Stealing and borrowing drugs• Obtaining prescription drugs from nonmedical source• Non-sanctioned route of administration• Repeated resistance to change – inflexibility
Causes of Aberrant Behaviors• Addiction or pseudoaddiction?• Pseudotolerance• Psychiatric disease
– Personality disorder– Depression, anxiety
• Organic encephalopathy • Situational stressors• Chemical coping• Criminal intent
Dispensing Issues
• One provider• One pharmacy• Limit the amount of medication given at
any one time– Weekly vs monthly
Urine drug testing
• GCMS, LCMS• Tests positive for medications prescribed• Tests negative for drugs not prescribed or other illicit substances of abuse
• Marijuana
28
Urine Drug testing
• Metabolites of prescribed medications• Medications not prescribed• Illicit drugs of abuse
When do you do UDS?
• Anytime• Start of prescribing either short term or long term opioids
Urine drug tests Urine drug tests
29
Urine Drug tests
Discontinuation Vs Weaning
• Suspicion of diversion• Negative urine tests• Positive urine tests along with illegal substances