August 2009 Agony of Pain Ethical and Rational Approach to Pain Management.

August 2009

Agony Agony of Painof PainAgony Agony of Painof Pain

Ethical and Rational Approach to Pain Management

Ethical and Rational Approach to Pain Management

Disclosure of Conflicts

I have no financial interests or significant relationships that constitute a conflict of interest related to this presentation in any of the following categories: Equity holdings (mutual funds and pension funds

excluded) Board membership, consulting services or fees,

honoraria, speakers fees, gifts or other compensation paid by any for-profit entity for speaking, attending meetings or serving on an advisory board.

August 2009

Objectives Recognize the multiple manifestations of pain. Describe the differences between Tolerance, Physical

Dependence, Psychological Dependence, and Addiction; and describe the approach towards patients with each of these phenomena.

Convert single parenteral doses of meperidine, morphine, hydromorphone, and fentanyl to any of the alternates. (Dose equivalence)

List 4 reasons that physicians under-prescribe opioids. List 4 patient behaviors that alert the physician to opioid misuse

or addiction.

August 2009

August 2009

Cancer Pain Impairs Quality of life

August 2009

What is Pain?

Pain is an unpleasant sensation and experience that in the acute state we commonly associate with or describe in terms of tissue damage.

Chronic pain frequently resembles an emotional state more than a sensation

August 2009

Clinical Picture of Chronic Pain

Pain Control

Constipation Nausea/Vomiting

Anxiety

Insomnia

Depression

August 2009

Current View of Pain Perception

August 2009

Long-term changes that can be measured in patients suffering from persistent pain.

New pain fibers recruited and stronger signals.

Inadequate Pain Control

Russell Portnoy: “more than 40% of cancer patients are under treated” for their pain.

August 2009

WHO Guidelines

By following the WHO Guidelines cancer pain can be controlled 70-90% of the time

August 2009

Reasons that physicians do not use adequate pain medications (1)

Failure to ask about or evaluate pain

Disbelief of patient report of pain

Fear that patient will become “addicted”

August 2009

Reasons that physicians do not use adequate pain medications (2)

Lack of knowledge about how to use opioids safely and effectively Fear of respiratory depression

(Sedation usually precedes)

Fear of accelerating death

Belief that some suffering is necessary Fear of regulatory sanctions

August 2009

Other factors that are associated with under treatment of pain

Minority or lower S-E status Women Elderly Dementia No family advocate (e.g. in nursing home) History of substance abuse Lack of availability Cultural differences

August 2009

Elderly & Pain Control

Nursing home study showed that in the last 3 months of life 70% of patients had severe or moderate pain

¼ of elderly cancer patients received no analgesic for daily pain

Patients over 85 are 50% less likely to receive any analgesia than patients 65-74

August 2009

Patient reluctance to take pain medications

Fear of the medications/misconceptions Fear of addiction, getting “hooked Wanting to save narcotics for when pain gets bad

Denial of the pain/disease process Stoicism Desire to be liked by the physician Concerns about distracting the physician from the

disease Non-compliance

August 2009

Pain in Cancer and Sickle Cell Anemia

Pain associated with malignancy or sickle cell disease is a constant reminder

the person’s condition (limited life span) imagined fate (worsening pain, shortness of

breath, painful death)

August 2009

Why Clock Watching? Inadequate Scheduled Dose

August 2009

The E.R.A. of Effective Pain Control

1. Evaluate the pain problem

2. Remove or reduce the physical source of the pain

3. Alleviate the symptoms

August 2009

Evaluation and Treatment Planning for Pain in Cancer (1)

What is the background of patient and pain problem? Nature of primary underlying disease Physical condition and performance status of

the patient, including co-morbid diseases Psychological, emotional, social situation of

patient Prior history of alcohol or drug use, misuse or

abuse

August 2009

Evaluation and Treatment Planning for Pain in Cancer (2)

Characteristics of the pain - requires thorough assessment Quality, Severity Onset, duration, frequency Exacerbating and alleviating factors Impact on function (work, sleep, eating,

relationships) What is the availability and practicality of potential

methods of pain relief?

August 2009

Evaluation and Treatment Planning for Pain in Cancer (3)

Steps in pain management Set Goals Plan Initial Analgesic Therapy Discuss Re-evaluation and Adjustment

How soon Consider Issues of tolerance, toxicity Make Adjustments for prior history of alcohol or drug

abuse, which may increase dose requirements Evaluation and treatment of other medical and

psychological problems

August 2009

Self Report Method of Pain Measurement

Procedures Verbal description of the pain

Pain score (0-10) Visual analog scale

Functional assessment of activity Value

Recognizes subjective nature of pain perception Observer’s bias not interjected Simple quantification

Limitations Influenced by psychological state and “drug-seeking”

behavior as well as nociceptive or neuropathic stimuli

August 2009

Signs of Pain

Agitated or irritable behaviors Depressed mood Loss of interest and decreased overall

activity level Decreased Mobility Disturbed sleep Reduced appetiteThese may differ in chronic and acute pain

August 2009

Clinical Mechanisms of Pain

Stimulation of peripheral pain receptors or damage to afferent fibers

Compression, stretching, invasion or chemical irritation of receptor, nerve, root, or plexus Inflammation, infection, necrosis, or other tissue damage Obstruction of a viscous Occlusion of a vessel with engorgement or ischemia Infiltration and tumefaction of tissue invested by capsule,

fascia, or periosteum Inflammation of nerves and vessels

Spontaneous activity in nerves damaged by disease or treatment

August 2009

Removal or Reduction of the Physical Source of the Pain

Surgery - Bypass or removal of obstructing lesion; fracture fixation; bypass arterial obstruction

Radiation Therapy - Shrink regional obstructing, infiltrating, stretching, or pressing tumor.

Chemotherapy - Reduce tumor burden systemically (e.g. lymphoma)

Antibiotics, corticosteroids - Decrease inflammation and cytokine production

Cytokine inhibitors - Anti-tumor necrosis factor alpha antibodies (infliximab) - mediation of immune function

August 2009

Alleviation of Symptoms

Reduce Peripheral Reception

Block Conduction of Impulses

Interfere with perception and affective responses

Steroids, NSAID’s, antipyretics

Local anesthetics, CNS

opioids, 2 adrenergic

agonists

Opioids, ? Adjuvants

(TCA’s, anti-convulsants, SSRI’s, SNRI’s steroids)

August 2009

Pain Types and Selection of Analgesic Agents

Somatic

Visceral

Neuropathic

NSAID’s, anti-pyretics, corticosteroids.

Opioids

Tricyclic anti-depressants, SSRI’s,selective serotonin and norepinephrine reuptake inhibitors (SNRI’s)

Anti-convulsants

August 2009

Principles of Analgesic Administration

Avoid parenteral route when possible

Administer majority of daily dose on a scheduled, not PRN basis

Give at a sufficient dose and short enough interval to prevent pain from becoming moderate or severe (< 5/10 on pain scale) >5/10 affects quality of life.

August 2009

PRN vs. Scheduled Doses

Toxic level

Effective Control

Pain

Toxic level

Effective Control

Pain

Poor Control

Good Control

August 2009

Desirable Characteristics of Analgesics for Patients with Chronic Pain

Effective by the oral or trans-dermal route

Moderate to long duration of action (4-12 hours)

Minimum of adverse side effects at effective doses

August 2009

Starting Doses of Strong Opioid AnalgesicsStarting Doses of Strong Opioid Analgesics

Drug Oral Parenteral

Morphine 5-15 mg q 3-4 hr 3-5 mg q 3-4 hr

Dilaudid 1-4 mg q 3-4 hr 0.5 - 1.5 mg q 3-4 hr

Oxycodone5-10 mg q 3-4 hr N/A

Fentanyl, transdermal: 25 micrograms/hr (Difficult to titrate)

Drug Oral Parenteral

Morphine 5-15 mg q 3-4 hr 3-5 mg q 3-4 hr

Dilaudid 1-4 mg q 3-4 hr 0.5 - 1.5 mg q 3-4 hr

Oxycodone5-10 mg q 3-4 hr N/A

Fentanyl, transdermal: 25 micrograms/hr (Difficult to titrate)

August 2009

Converting Parenteral to Long Acting Oral Narcotics

Determine 24 hour dose of IV morphineE.g., Total 24 hour dose IV morphine = 80

mg Calculate oral equivalent

80mg x 3 = 240 mg oral morphineStart with 50% of calculated dose

120 mg MS-Contin (60 q 12 h) or 80 mg Oxy-Contin (40 q 12 h)

August 2009

Quick and Dirty Dose Equivalence

Mepe ridine (Demerol) *

Morphine

Hydro morphone (Dilaudid)

Fentan yl (Durages ic)

Single IV Dos e

100 mg 10 mg 1 mg (1.5) 0.1 mg

Hourly IV Dos e

25 mg 2.5 mg 0.25 mg

50 mcg (Has shorter T1/2)

Q 4 h Oral dose

300 mg 30 mg 6-8 mg NA

Mepe ridine (Demerol) *

Morphine

Hydro morphone (Dilaudid)

Fentan yl (Durages ic)

Single IV Dos e

100 mg 10 mg 1 mg (1.5) 0.1 mg

Hourly IV Dos e

25 mg 2.5 mg 0.25 mg

50 mcg (Has shorter T1/2)

Q 4 h Oral dose

300 mg 30 mg 6-8 mg NA

* Not good for chronic pain

August 2009

Methadone - Effective Long-Acting Oral Opioid for Chronic Pain in Cancer

Morphine to Methadone Conversion

0

200

400

600

800

1000

1200

1400

0 10 20 30 40 50 60 70 80 90 100

Mg Oral Methadone

Mg Oral Morphine

Use short acting opioid for break-through pain

Estimated methadone per day (mg) = (oral morphine per day (mg) 15) + 15

W Plonk, J Palliat Med 8:478,2005

August 2009

Opioid Side Effects

Direct CNS or PNS - Sedation, euphoria, delirium (hallucinations), respiratory depression myoclonus (All dose related)

GI - Nausea, vomiting, constipation GU - Urgency, difficulty voiding, SIADH Cutaneous - Itching Dependence - Physical, psychological Tolerance

August 2009

Tolerance

The requirement for larger doses to obtain the effects observed with the original dose

A physiological phenomenon

Not a sign of weakness, moral turpitude, psychological dependence, or addiction

August 2009

Physical Dependence

An altered physiologic state produced by the repeated administration of the drug which necessitates the continued administration of the drug to prevent an abstinence or withdrawal syndrome.

August 2009

Psychological Dependence

The effects produced by the drug or the conditions associated with its use are necessary to maintain an optimal state of well being. (Perceived)

May lead to compulsive drug use or abuse.

August 2009

Addiction

A behavioral pattern of compulsive drug use characterized by overwhelming involvement with the use of the drug, the securing of its supply, and a high tendency to relapse after withdrawal. Function of patient is impaired.

Occurs RARELY in patients with cancer pain. (< 1/1000)

August 2009

Pseudoaddiction

Phenomenon seen in a patient who seeks additional medications appropriately or inappropriately because of significant undertreatment of their pain

An iatrogenic syndrome that may mimic behaviors usually associated with addiction, and which is caused by the under medication of pain

August 2009

Drug use impairs rather than improves patient function (Reduced occupational, social, and recreational activities.), medical condition,and quality of life

Drugs obtained from more than one physician or pharmacy after being asked to use only one

Frequent “losses” of drug Frequent occasions where greater opioid use than was

intended Selling prescription drugs Forging prescriptions Stealing drugs Injecting oral agents

Characteristics of Drug Abuse Predictive of Addiction in Patients Receiving Opioids for PainCharacteristics of Drug Abuse Predictive of Addiction in Patients Receiving Opioids for Pain

August 2009

Approaches to Pain Management of Patient with Substance Abuse Problems

Physician must set parameters for opioid use more closely than for other patients

Open discussion with patient about issues of concerns Avoid “blaming”, but don’t gloss over

magnitude of problem Let patient know that you can work

together, but there will be tight control

August 2009

Alternative Methods to Control Abuse in Patient with History of or Current Substance Abuse Problems

Written Contract that explicitly delineates the intention of the physician to help, the obligations of the patient who wishes the help, and the consequences of failure to fulfill the obligations.

Less formal understanding reached between the physician and patient

August 2009

Possible Consequences of Failure to Meet Obligations

Severing physician-patient relationship Discontinuation of ordering any opioids Notification of legal authorities,

pharmacies, other medical facilities Closer control of opioid availability by

decreasing interval for new prescription.

August 2009

Dependence Issues

Habituation abuse rarely a clinical problem 7/24,000 among patients with no history of addiction

Tolerance can be overcome by increasing the dose

Physical dependence effectively managed by tapering dose as the pain abates

Psychological dependence and pseudo-addiction minimized by giving sufficient doses at regular intervals

August 2009

Special Populations

Substance abuse history Active addict Person who injures self to get medication Geriatric Cognitively impaired (Difficult to assess) Dying

August 2009

Additional Cancer Pain Control MethodsUseful in Selected SituationsAdditional Cancer Pain Control MethodsUseful in Selected Situations

• Transdermal narcotics (Fentanyl)• Sub-lingual morphine, fentanyl “lollipops”• Transcutaneous electrical nerve stimulation• Epidural or sub-arachnoid opioids• Continuous infusion narcotic• Patient controlled analgesia (PCA) pumps• Biofeedback• Nerve, ganglion, plexus block

• Transdermal narcotics (Fentanyl)• Sub-lingual morphine, fentanyl “lollipops”• Transcutaneous electrical nerve stimulation• Epidural or sub-arachnoid opioids• Continuous infusion narcotic• Patient controlled analgesia (PCA) pumps• Biofeedback• Nerve, ganglion, plexus block

August 2009

Rational Approach to Cancer Pain Management - Summary

Pain impairs quality of life Most cancer pain can be controlled through

careful assessment, planning, and informed therapy

Physical and psychological side effects are real issues, but can be minimized

The knowledgeable and compassionate physician and nurse are key to effective care.

Thank You