Chronic Pain Management and the Pharmacist's Role
Sukhvir Kaur, PharmD, BCACPDirector of Assessment and Assistant Professor
California Northstate University College of Pharmacy
Disclosure
I or my spouse have no actual or potential conflict of interest in relation to this program.
Discuss the role of a pharmacist in the management of chronic pain.
Perform an appropriate pain assessment taking into account the characteristics and nature of the pain stimuli.
Discuss non pharmacologic and pharmacologic options available for the treatment of chronic pain including its place in therapy and potential risks with their use.
Develop a therapeutic plan for patients with chronic pain that maximizes patient response while minimizing adverse events and other drug-related problems.
Educate and advocate for patients about effective pain management strategies.
Learning Outcomes
Defined as “any pain that persists beyond the anticipated time of healing”
Nociceptive pain or neuropathic pain
International Association for the Study of Pain (IASP) states that pain is “an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage”
Highly SUBJECTIVE
Chronic Pain
Chronic Pain
EpidemiologyMore than 100 million people in United States live with chronic pain.
Estimated economic burden of chronic pain exceeds 500 billion dollars.
Despite all the efforts to treat pain adequately, it remains INAPPROPRIATELY treated. ◦ Reduces a patient’s independence and
ability to perform many daily activities◦ Places strains on social relationships,
mood, and sleep patterns.
Biopsychosocial concept of Chronic Pain
http://image.slidesharecdn.com/chronicpain-150128073452-conversion-gate01/95/chronic-pain-managment-17-638.jpg?cb=1423812958
Characteristics Acute Pain Chronic Pain
Relief of pain Highly desirable Highly desirable
Dependence and tolerance to medication Unusual Common
Psychological component Usually not present Major problem
Organic cause Common May not be present
Environmental/ family issue Small Significant
Insomnia Unusual Common
Treatment goal Pain reduction Functionality
Depression Uncommon Common
Description Obvious distress (trauma) No noticeable trauma
Symptoms Sharp, dull, shock like, tingling, shooting, radiating, fluctuating in intensity, varying in location
Sharp, dull, shock like, tingling, shooting, radiating, fluctuating in intensity, varying in location
Comorbid condition None Insomnia, anxiety and depression
Lab test No specific test, subjective to the patient No specific test, but can test for past trauma, VitD, TSH, and B12
Classification of Pain
Rapid pain relief or reduction in pain intensity is NOT the Goal
Improve or maintain the patient’s level of functionalitySet goals with the patient for functional improvement, and document them for future monitoring purposes to determine efficacy
Improving pain and function by ~30% is a success
Goal of Chronic Pain Management
1) Make diagnosis with a differential
2) Conduct psychological assessment, screening for addiction potential
3) Obtain informed consent
4) Utilize a treatment agreement
5) Conduct pre- and post intervention assessment pain level and function
6) Conduct an appropriate trail of opioid therapy with or without adjuvants
7) Conduct reassessment of pain score and level of function
8) Regularly assess “the 4 A’s of pain”
9) Periodically review all comorbid conditions
10) Document evaluations and follow-up appointments
The 10 Steps of Universal Precautions in Pain Medicine
Barbee J, Chessher Jaclyn, Greenlee, Max. Pain Management: The Pharmacist’s Evolving Role. Pharmacy Times. 2015.http://www.pharmacytimes.com/publications/health-system-edition/2015/july2015/pain-management-the-pharmacists-evolving-role. Accessed July 5, 2016.
http://www.pharmacytimes.com/publications/health-system-edition/2015/july2015/pain-management-the-pharmacists-evolving-role
Help minimize risk for patients using pain medications.◦ Assess and properly plan to minimize patient risk of Pain Medicine
◦ Proper Pain Assessment to understand pain and provide highly effective treatment while minimizing risk
◦ Educate the patients of the role of opioids in the treatment of chronic pain
Help patients live meaningful and productive lives with adequately managed pain
Monitor patient’s 4 As:◦ Analgesia
◦ Activities of daily living
◦ Adverse events
◦ Aberrant drug behaviors
Pharmacist’s Role
Pain Interview
Pain Interview “PQRST”
Provoke: What makes the pain worse?
Palliate: What makes the pain better?
Quality: Describe the pain?
Radiation/ Location: Where is the pain?
Severity/ Pain score: How does this pain compare with other pain you have experienced? What are the activities that you would like to perform that you cannot, due to the pain?
Timing/ onset/ duration: When did it began and how long has it been? Does the intensity of pain change with time?
Treatment of Chronic Pain - Video
https://www.theacpa.org/a-car-with-four-flat-tires
Treatment approaches to Management of Chronic pain
NON-PHARMACOLOGICAL THERAPY
Acupuncture
Local electrical stimulation including TENS
Brain stimulation
Surgery
Psychotherapy
Relaxation and medication therapies
Biofeedback
Behavior modification
Placebos?
PHARMACOLOGIC THERAPY
NSAIDs
Antidepressants
Anticonvulsants
Topical agents
Cannabinoids
Non-Opioids
Opioids
Intrathecal drug delivery systems
Non-pharmacological therapy Evidence/ Potential Place in Therapy
Acupuncture Evidence is conflicting and clinical studies to investigate its benefits are ongoing
Biofeedback Evidence for headache and back pain; Often used in combination without side effects
Chiropractic Evidence for chronic back pain relief
Cognitive-behavioral therapy Strong evidence for chronic pain, postoperative pain, cancer pain, and the pain of childbirth
Counseling Can be of help to learn about the physiological changes produced by pain
Electrical stimulations including transcutaneous electrical stimulation (TENS)
Can help reduce pain
Exercise Evidence with chronic pain for overall well being including light to moderate; shown efficacy to relief low back pain
Hypnosis Speculated to help a person concentrate and relax or is more responsive to suggestion
Low-power lasers Used by some physical therapists but method is NOT without controversy
Magnets Increasingly popular with athletes to control sport-related pain or other pain conditions
Nerve blocks Interventional to relieve nerve pain and pains related to cancer
Physical therapy and rehabilitation To increase function, control pain and gain recovery
Placebo Employed in studies, work by stimulating the brain’s own analgesics
R.I.C.E.—Rest, Ice, Compression, and Elevation Temporary muscle or joint injuries
Surgery Limited evidence to show which procedures work best for their indications
http://www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm#3084_15
Chronic Pain Medications and Dangers
Pain Algorithm Identify pain source if possible; Assess pain severity and quality using consistent method such as numeric rating scale (NRS); scale 0-10 out of 10
Mild (Score 1-4/10) Moderate (Score 5-7/10) Severe (Score 8-10/10)
APAP +/- NSAIDs when risk doesn’t outweigh benefits
Combo Opioid AND APAP/NSAID
Opioid Analgesics tailored to pain severity and patient characteristics
If pain relief is not adequate, step up therapy is recommended
Always monitor pain frequency and status, anticipate side effects, properly titrate doses based on patient characteristics, PO is preferred when possible, Consider around the clock dosing when appropriate, and PRN regimens for breakthrough or highly variable pain
Nonsteroidal Anti-inflammatory DrugsPlace in Therapy • Effective in the treatment of chronic low back pain as well as chronic pain due to osteoarthritis
• Modest effect In treating lumbar radiculopathy• The addition of an NSAID to a pain management regiment can have an opioid-sparing effect of
between 20-35%
Comments/Concerns • Minimal effect in treating neuropathic pain states
AntidepressantsPlace in Therapy • Effectiveness for antidepressants in the treatment of chronic pain disorders with a
strong neuropathic component has long been established in the literature• TCAs (Amitriptyline, imipramine, nortriptyline and desipramine):
• Shown to be effective in treating a variety of painful neuropathic conditions such as diabetic peripheral neuropathy (DPN), postherpectic neuralgia (PHN), painful polyneuropathy, postmastectomy pain, and centeral poststroke pain
• Analgesic effects are independent of the presence of any changes in depression or mood state.• Side effects that can be significant include postural hypotension, dry mouth, and sedation for
which reason these medications are typically taken at bedtime especially in the elderly population leading to increase risk of fall.
• Duloxetine and venlafaxine• Have shown efficacy in treating peripheral neuropathic pain and other chronic pain conditions.
• Duloxetine• Treatment of painful DPN, fibromyalgia, and chronic musculoskeletal pain• Mood-elevating effects have a significant contribution to the reported decreases in pain scores
AnticonvulsantsPlace in Therapy Side effects/concerns
Carbamazepine Trigeminal neuralgia but has NOT been shown to be as effective in treating other neuropathic pain disorders
somnolence, dizziness, and gaitDisturbanceMore serious adverse reactions that have been reported includeStevens-Johnson syndrome, toxic epidermal necrolysis, and blood dyscrasias
Valproic acid, oxcarbazepine, topiramateand lamotrigine
Inconsistent evidence of efficacy in treating neuropathic pain
Gabapentin DPN, PHN, painful polyneuropathy, neuropathic cancerpain, central poststroke pain, and spinal cord injury pain.
dizziness, somnolence,and ataxia, peripheral edema
Pregabalin *First line for treating neuropathic pain dizziness, somnolence,and ataxia.>Peripheral edema
Topical AgentsPlace in Therapy
Lidocaine (5% gel or patch) Peripheral neuropathic pain conditions with allodynia as well as PHN with allodynia
Topical NSAIDs (diclofenac, ibuprofen, and ketoprofen)
Short-term pain relief in the treatment ofSoft tissue injuries and chronic joint-related pain.
Topical high-dose capsaicin (8%) Effective in providing rapid and sustained pain relief in patients with PHN and painful human immunodeficiency virus (HIV)-associated neuropathies
CannabinoidsPlace in Therapy Mechanism of Action
Medicinal marijuana Neuropathic pain Activation of CB2 receptors on peripheral inflammatory cells has beenshown to decrease inflammatory cell mediator release, plasma extravasation, and the sensitization of afferent terminal.
OpioidsPlace in Therapy • Strong evidence in supporting the short-term use of opiates in managing BUT long-term use for non-
cancer pain is not strong.• Current recommendations for initiating chronic opiate therapy are intended to better identify patients
at risk for abusing and/or misusing opiate medications or from suffering their adverse physical effects. This includes a detailed medical history, psychiatric history, and substance use history as well as establishing a physical diagnosis and the medical necessity for chronic opiate therapy. Urine drug screening as well as establishing an agreement between the provider and patient in which the goals and expectations of the therapy are clearly stated reduces misuse, abuse, or diversion of opiate medications.
Comments/Concerns Unwanted adverse effects, such as opioid tolerance, dependence, constipation,respiratory depression, impaired cognitive ability, immune suppression, andopioid-related endocrinopathies, are only some of the known physical alterationsassociated with the chronic use of opiate medications.
Cost of chronic pain adds up to 635 billion each year.
It affects over 100 million adults.
About 41% of chronic pain patients reports that their pain is uncontrolled.
Facts about Chronic pain and Opioid treatment
Legislation and Regulatory Policies Should Limit Inappropriate Prescribing But Should Not Discourage Or Prevent Prescription Of Opioids Where Medically Indicated And Appropriately Managed.
Prescription Of Opioids For Chronic, Intractable Pain Is Appropriate When More Conservative Methods Are Ineffective And The Treatment Plan Is Reasonably Designed To Avoid Diversion, Addiction, And Other Adverse Effects.
Physicians Should Be Sensitive To And Seek To Minimize The Risks Of Addiction, Respiratory Depression And Other Adverse Effects, Tolerance, And Diversion. However, Some Commonly Held Assumptions About These Issues Need To Be Reviewed.
Opioids Should Be Prescribed Only After A Thorough Evaluation Of The Patient, Consideration Of Alternatives, Development Of A Treatment Plan Tailored To The Needs Of The Patient And Minimization of Adverse Effects, And On-Going Monitoring And Documentation.
Use of Opioids for the Treatment of Chronic Pain
Use of Opioids for the Treatment of Chronic Pain. American Academy of Pain Medicine. 2013. http://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf. Accessed August 3, 2016
http://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf
Why do you think prescribing opioids could be challenging for doctors?
What do you think is the role of a pharmacist is in opioid dispensing?
Questions to Think about?
Challenging◦Why?
◦ Under prescribing: due to fear of adverse effects as well as addiction.
◦ Over prescribing: due to multiple failed therapeutic response.
Issues with prescribing opioids.
Agents of choice for moderate to severe chronic pain as well as cancer related chronic pain
Dosing is based on patient’s previous history of opioid analgesic used, the specific patient’s needs, and on the delivery system being utilized.
Classified by:◦ Activity at the receptor site
◦ Pain intensity treated
◦ Duration of action (short acting vs. long acting)
Opioids
Patient is experiencing pain despite having a reasonable trial of both non-opioid analgesics and adjuvants
Severe pain that requires rapid relief
Patient has contraindication to the use of other analgesics
Patient Selection
Patient selection Opioid regimen should be individualized
Opioid naïve patients should be started on low dose
In July 2012, FDA requires REMS for all extended release and long acting opioid analgesics.
Generic Brand Agonist/antagonist or mixed
Histamine release that would cause N/V/itchiness
Route of Administration
Comments
Morphine Avinza Morphine like Agonist +++ IM, PO, IV, SR, Rectal Drug of choice for severe pain
Hydromorphone Dilaudid, Exalgo Morphine like Agonist IM, PO, IV, rectal Use in severe pain, more potent than morphineREMS program
Oxymorphone Opana Morphine like Agonist IM, IV, SQ, PO Severe pain, immediate with controlled, extended release to stop misuse
Codeine Morphine like Agonist +++ IM, PO CODEINE is metabolized by CYP2D6
Hydrocodone Norco Morphine like Agonist PO most effective when used with aspirin and acetaminophen,
Oxycodone Oxycontin, oxecta, Roxicodone
Morphine like agonist PO
Meperidine Demerol Meperidine like agonist +++ IM, PO Severe pain, oral is not recommended, should not be used for chronic pain
Commonly Prescribed Opioids
Generic Brand Agonist/antagonist or mixed
Histamine release that would cause N/V/itchiness
Route of Administration
Comments
Fentanyl Sublimaze, duragesic, lazanda, abstral. Actiq, onsolis, fentora, subsys
Meperidine like agonist IM, transdermal, buccal, transmucosal, sublingual, nasal inhaled
Severe pain, do not use patch in acute pain, always titrate the dose, can be used for breakthrough pain; TM, IN, SL are available through a REMS program.
Methadone Dolophine NMDA antagonistSNRI
IM/IV, PO Reverse opioid tolerance
Naloxone Narcan Antagonist IV
Tramadol Ultram, Antagonist Inhibits reuptake of serotonin and ER , used for neuropathic pain
PO Decreased dose in renally and hepatic insufficient patients and elderly.
Tapentadol Nucynta Antagonist PO REMS required.
Commonly Prescribed opioids
Frequency Stage of Pain
Around THE CLOCK (QD, BID etc.) Initial stage of pain Persistent chronic pain
As needed (prn) As the painful state subsides and the need for medication is decreased.Also for patients that may present with pain that is intermittent or sporadic in nature.
Around the clock and as needed (conjunction)
When patient experiences breakthrough pain.
Administration of Opioids
Route of Administration When to Uses
Oral (PO) Mostly commonly used and preferred method in most cases
Continuous IV infusion Postoperative pain
Epidural or intrathecal/ subarachnoid Control of acute, chronic non-cancer, and cancer pain
Route of Administration
Before initiating chronic opioid therapy, must assess risk vs. benefit for the patient.
Based on history, physical examination, assessment of risk of substance abuse, misuse or addiction.
Personal and family history of alcohol or drug abuse
Personal history of alcohol or drug abuse may be considered contraindicated for long term opioid therapy.
Evaluation prior to initiating Opioid regimen
DefinitionPhysical dependence- rapid discontinuation of opioid following prolonged administration, usually one month or longer, will result in withdrawal symptoms such as dysphoria, anxiety, and volatility of mood, as well as physical findings such as hypertension, tachycardia, and sweating.
Tolerance- is present when increasing amounts of opioid are required to produce an equivalent level of efficacy
Addiction- is a form of physiological dependence and refers to the extreme behavior patterns that are associated with procuring and consuming the drug.
Effect Manifestation
Mood changes Dysphoria, euphoria
Somnolence Lethargy, drowsiness, apathy, inability to concentrate
Stimulation of chemoreceptor trigger zone Nausea, vomiting
Respiratory depression Decreased respiratory rate
Decreased gastrointestinal motility Constipation
Increase in sphincter tone Biliary spasm, urinary retention
Histamine release pruritus,
Tolerance Larger doses for same effect
Dependence Withdrawal symptoms upon abrupt discontinuation
Major Adverse effects of opioid analgesics
Monitoring should occur during each visit
Documentation of pain intensity, functional status, progress toward therapy goals, side effects and adherence is critical.
Monitoring of Chronic Pain Management
Help minimize risk for patients using pain medications.◦ Assess and properly plan to minimize patient risk of Pain Medicine
◦ Proper Pain Assessment to understand pain and provide highly effective treatment while minimizing risk
◦ Educate the patients of the role of opioids in the treatment of chronic pain
Help patients live meaningful and productive lives with adequately managed pain
Monitor patient’s 4 As:◦ Analgesia
◦ Activities of daily living
◦ Adverse events
◦ Aberrant drug behaviors
Revisit a Pharmacist’s Role in Chronic Pain Management
A. Provide rapid pain relief or reduction in pain intensity is NOT the Goal
B. Report providers of the authorities who prescribe opioids to the authorities
C. Help patients live meaningful and productive lives with adequately managed pain
D. Manage patient’s chronic pain with the use of non-opioids
Which of the following statement describes the role of a pharmacist in chronic pain management?
A. Norco
B. Morphine
C. Duloxetine
D. Pregabalin
What is the preferred drug of choice in the treatment of chronic neuropathic pain?
A. NSAID
B. Antidepressant
C. Anticonvulsant
D. Cannabinoids
The addition of this class of pain medication has shown to have an opioid-sparing effect of between 20-35%.
Appropriate Opioid Use. Pharmacist’s Letter. 2015; 31(4):310407.
ACPA Recourse Guide to Chronic Pain Treatment: An Integrated Guide to Physical, Behavioral and Pharmacologic Therapy. 2016. https://theacpa.org/uploads/documents/ACPA_Resource_Guide_2016.pdf. Accessed August 10, 2016.
Barbee J, Chessher Jaclyn, Greenlee, Max. Pain Management: The Pharmacist’s Evolving Role. Pharmacy Times. 2015. http://www.pharmacytimes.com/publications/health-system-edition/2015/july2015/pain-management-the-pharmacists-evolving-role. Accessed July 5, 2016.
Baumann TJ, Herndon CM, Strickland JM. Chapter 44. Pain Management. In:DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 9e. New York, NY: McGraw-Hill; 2014. http://accesspharmacy.mhmedical.com/content.aspx?bookid=689&Sectionid=45310494. Accessed August 16, 2016.
Beal BR, Wallace MS. An Overview of Pharmacologic Management of Chronic Pain. Med Clin North Am. 2016;100(1):65-79.
Pain: Hope Through Research. Available at: http://www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm#3084_15. Accessed August 5, 2016.
Use of Opioids for the Treatment of Chronic Pain. American Academy of Pain Medicine. 2013. http://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf. Accessed August 3, 2016
References
https://theacpa.org/uploads/documents/ACPA_Resource_Guide_2016.pdfhttp://www.pharmacytimes.com/publications/health-system-edition/2015/july2015/pain-management-the-pharmacists-evolving-rolehttp://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf
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