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Understanding Pain Management and Daily Practice Management

This document provides information on understanding pain management and daily practice management. It discusses types of pain such as acute vs chronic pain and nociceptive, nocioplastic, and neuropathic pain. It also covers topics like pain physiology, receptors, assessment, goals of pain management, pharmacology of specific drugs like morphine, oxycodone, hydromorphone, fentanyl, hydrocodone, buprenorphine, and tramadol. The role of an interdisciplinary team in pain management is emphasized.

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Understanding Pain Management and Daily Practice Management Agron Ismaili MD | Regional Medical Director VITAS® Healthcare | agron.ismaili@vitas.com
CME Provider Information Satisfactory Completion Learners must complete an evaluation form to receive a certificate of completion. You must participate in the entire activity as partial credit is not available. If you are seeking continuing education credit for a specialty not listed below, it is your responsibility to contact your licensing/certification board to determine course eligibility for your licensing/certification requirement. Physicians In support of improving patient care, this activity has been planned and implemented by Amedco LLC and VITAS ® Healthcare. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
CE Provider Information VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through: VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved By: Florida Board of Nursing/Florida Board of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling. VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists through: VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number: 139000207/RT CE Provider Number: 195000028/Approved By the Illinois Division of Profession Regulation for: Licensed Nursing Home Administrators and Illinois Respiratory Care Practitioner. VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2021 – 06/06/2024. Social workers completing this course receive 1.0 ethics continuing education credits. VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of Registered Nursing, Provider Number 10517, expiring 01/31/2023. Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois.
Objective • Describe, define, and differentiate aspects of pain: – Acute vs. chronic, nociceptive, nociplastic, neuropathic • Discuss the importance of identifying pain: – Receptor sensing – Mechanism of transmission – Complex interaction of the elements of the peripheral and central nervous systems • Enhance assessment and management of both medication and non-medication measures used to treat total pain After this presentation, learners should be able to:
Goal To achieve an appropriate understanding of pain management’s multifaceted applications in the context of palliative and hospice care
Pain Definition • An unpleasant sensory and emotional experience associated with actual or potential tissue damage Merskey, H. et al. (1979). Pain terms: a list with definitions and notes on usage. Recommended by the IASP Subcommittee on Taxonomy. Pain, 6, 249-252.
Acute vs. Chronic Pain (Practice, Reality) • Acute pain is the most common reason for ED visits • Chronic pain comprises around 20% of physician office visits • $60 billion/year in lost productivity Zelaya, et al. (2020). Chronic Pain and High-impact Chronic Pain Among U.S. Adults, 2019. NCHS Data Brief No. 390. Available at: https://www.cdc.gov/nchs/products/databriefs/db390.htm Stewart, et al. (2003). Lost Productive Time and Cost Due to Common Pain Conditions in the US workforce. JAMA, 290(18), 2443-54. Van den Beuken-van Everdingen, et al. (2007). Prevalence of Pain in Patients With Cancer: A Systematic Review of the Past 40 Years. Annals of Oncology, 18(9), 1437-1449.
The Importance of Goals of Care • Patients’ values are honored • Symptoms are attended to quickly and effectively • Patient and family maintain control of treatment plan • Poorly defined goals can lead to: – Unwanted treatments – Inappropriate use of resources – Undue suffering – Miscommunication • Emergency clinicians establish GOC with patients daily • Any team member can assess GOC
Pain in response to an injury or stimuli; typically acute Nocioplastic Pain that arises from nocioceptive function, typically chronic Neuropathic Pain that develops when nervous symptom is damaged Fibromyalgia, irritable bowl syndrome, non-specific low back pain Post-operative pain, sports injuries, arthritis, sickle cell disease, mechanical low back pain Post-herpetic neuralgia, trigeneuralgia, distal polyneuropathy, CRPS, neuropathic low back pain Types of Pain Nociceptive Pain
Acute and Chronic Pain • Acute pain: – Usually hours to weeks, most likely responsive to multimodal therapies – Noted physiological changes and notable pain behaviors • Chronic pain: – > 3 months (persistent, with long-term conditions, can be expressed as anxiety, depression, irritability; may not respond easily to drug therapies; essentially to correlate with function) Source for Acute/chronic pain statistics (FSMB USA Model guidelines for the use of controlled substances for the treatment of pain, Euless, TX 1998 source 1/2/3.
Nociceptive, Nocioplastic, and Neuropathic Pain • Nociceptive: – Bone (aching, gnawing, localized) – Visceral (cramping, regionally localized or referred) – Somatic (easy to localize and describe) • Nocioplastic: – Central SENSITIZATION – Increased response to stimulation mediated by amplification of CNS (e.g., fibromyalgia, chronic back pain, etc.) • Neuropathic: – Damage or injury to the nerves that transfer information between the brain and spinal cord from the skin, muscles and other parts of the body – Burning sensation and affected areas are often sensitive to the touch Federation of State Medical Boards of the United States, Inc. (2005). Model Policy for the Use of Controlled Substances for the Treatment of Pain. Journal of Pain & Palliative Care Pharmacotherapy, 19(2), 73-8.
Types of Pain Antihistamine Acetaminophen Opioids and NMDA blockers Nerve blocks NSAIDs Topical/transdermal treatments Nocioplastic Anticholinergic Anticonvulsants TCAs and SNRIs Other serotonin agents Neuropathic Anticonvulsants Opioids and NMDA blockers Nerve blocks TCAs and SNRIs Generally not opioid responsive Nociceptive Pain
Prevalence in Older Adults, Barriers • Pain is in patients with and without cancer (present in 75% institutionalized and 50% community elderly) and about 25% of elderly do not receive adequate analgesia • Barriers • Patient • Prescribers • Pharmacy • System • Legal • Common: racial, elderly, lack of educational skills, fear of addiction, etc. J. Med.2007,120(4) 306-315 JAMA 1998; 279; (23)1877-1882 J.Am. Ger. Soc.,1999 47 (8) 936-942 Source 1, 2, 3
Pain Statistics: Emphasizing Multifactorial Nature, Importance in Daily Practice • Single or multifocal • Cancer (treatment vs. malignant process, direct and indirect effects) vs. non-cancer (pressure ulcers, RA, OA, sickle cell, osteomyelitis, back pain, headaches) • Pain is a serious problem for as much as 40% of the US population Resources 1/2/3
Integrated Pain Model Dame Cicely Saunders devised a new paradigm of the concept of pain beyond the confines of the physical body responses. • Total pain is characterized as the multidimensional nature of the pain experience and includes these domains of pain: – Physical – Psychological – Social – Spiritual Resources 1/2/3
Comprehensive Symptom Evaluation • Symptom ascertainment (PQRST tool, etc.) • Past medical and treatment history (pharmacologic/non- pharmacologic, comorbid, hx of opioid use-PDMP, the effectiveness of treatment) • Social, psychological, and family history (mental health, personal and family hx of polysubstance abuse, cultural background, social network, other behavioral patterns) • Opioid Risk Assessment (identifies persons at higher risk for SUD, possibly necessitates additional monitoring; ># high risk, mitigation, misuse, abuse, diversion, periodic UDS) • Physical exam and assessment (integrates hx with observation for corroboration of symptoms) • Pharmacologic and non-pharmacologic management plan Resources 1/2/3
Pain Physiology Half-Life • An important aspect in the management of pain issues • To determine dosage times by knowing how long the drug will continue to do its job • What is it? – How much time it takes for blood levels of a drug to decrease to half of what they were when the drug was at peak performance in the body Resources 1/2/3
Pain Physiology, Mechanisms & Receptors • Transduction: Noxious stimuli—to action potentials—peripheral nociceptor sensory fibers • Some of the substances produced can affect the pain: nociceptors, tissue damage, and inflammatory cells (bradykinin, prostaglandins, etc.) Resource: 1/2/3
Pain Physiology, Mechanisms & Receptors • Transmission: peripheral, central transmission by many pathways, such as: stomato-sensory thalamus, thalamic-cortical fasciculus, lateral spinothalamic funiculus, ventral spinothalamic tract • Complex interaction of glial cells, nociceceptors, neurons, biogenic amines, etc. Resource: 1/2/3
Pain Management Goals • Optimize patient comfort • Enhance FUNCTION, physical well-being, psychological well-being, spiritual well-being • Minimize side effects • Enhance quality of life Resource: 1/2/3
Role and Importance of Hospice IDT in Pain Management • Paint the picture, narrative subjective process, REASSESSMENT is very important • VITAS for many years has been the leader in effective pain management for patients with terminal diseases • Teamwork is vital for effective pain management • We as members of IDT have a responsibility to manage pain: – Team manager – Nurse – Hospice aide – Chaplain – Team physician – Volunteer Resource: 1/2/3
Pain Physiology, Receptors • Example of types of pain: – BONE/VISCERLA/SOMATIC-Nociceptive – Peripheral, Central-Neuropathic • Multiple mechanisms, multiple sites, consider chronic medical problems (esp. mental health issues) and how they affect patient’s perception of pain, etc. Resource: 1/2/3
Pain Assessment Tolerance: Physiologic phenomenon resulting from regular use of a drug in which increased use is needed to produce same effect • Common concern but uncommon phenomenon • E.g., N/V/fatigue (with opioids), developing tolerance leading to diminished side effects • ATTENTION: Tolerance does not develop for opioid constipation • Managing opioid tolerance • Rotation (uncontrolled pain, neurotoxicity) Physiologic Dependence: • Adaption manifested by drug class specific WITHDRAWAL syndrome – after abrupt cessation, rapid dose reduction, decreased blood levels, administration of antagonist; common after 1-2 weeks of continuous weeks of use. Treatment: reintroduction of opioid, clonidine, BZD, Imodium Resources 1/2/3
Pain Assessment (cont.) • Addiction: Impaired control, compulsive use, continued use despite harm, cravings • Pseudo-addiction: Inadequate pain management, disease progression, can creates mistrust with patient? inadequate prescriptions • Pain is a subjective process, narrative story; validate the experience Resources 1/2/3
Opioid Therapy: Pharmacology Morphine • Most frequent indications in the daily practice: – Pain/dyspnea/cough/ anesthesia, diarrhea • Few important steps in the mechanism of action: – Bind to opioid receptors, activate descending inhibitory pathway, prevent neurotransmitter release, reduce formation of action potentials • Receptors: – Mu: brain stem, medical thalamus, peripheral – Mu1-analgesia – Mu2-analgesia GI tract, respiratory depression, pruritus – Kappa: • Limbic system, brain stem, spinal cord, spinal analgesia, sedation, dysphoria • Delta: brain, periphery spinal analgesia, decreased GI motility, respiratory depression Resources 1/2/3
Morphine • Opioid like receptor (ORL-1): Affects stress, feeding, learning, memory? opioid tolerance • Sigma: It is not considered true opioid receptor, potential for psych mimetic effects, dysphoria • DEA class II • Strong MU and weak kappa and delta; metabolized in the liver, excreted by kidneys • Morphine-3-glucuronide and morphine-6-glucuronide toxicity concerns; generally not used in patients with end-stage renal disease • Management of side effects • Forms: Injectable, oral, rectal Resources 1/2/3
Pharmacology of Specific Drugs • Oxycodone: agonist MU/Kappa, metabolized with conjugation in the liver by CYP 450 to active/inactive metabolites • ATTENTION: Prolonged elimination in renal impairment/failure • It is combined with acetaminophen/aspirin • Hydromorphone • Main mechanisms • Mu agonist • Hepatic metabolism via glucouronidation to Hydromorphone 3G; excreted by kidneys Resources 1/2/3
Pharmacology of Specific Drugs (cont.) • Fentanyl – MU agonist • Has lipophilic effect • Hepatic metabolism to inactive metabolites-not dialyzed • ATTENTION: reduce dose in severe renal impairment • Oxymorphone preparation IR/ER • ATTENTION: can take 2 hours before or after as taking with meals can increase serum levels Resources 1/2/3
Pharmacology of Specific Drugs (cont.) Hydrocodone Derived from codeine • Can be combined with acetaminophen; DEA II Buprenorphine • MU partial agonist (high affinity, low potency), Kappa antagonist, lipophilic, first-pass metabolism, CYP 450, may cause QT prolongation; MAT (medication-assisted treatment-use in opioid use disorder; low ceiling effect; high doses lead to the same level of analgesia with more side effects) • Option for patient use with serious illness and opioids use disorder (used with or without naloxone) Resources 1/2/3
Pharmacology Tramadol Weak opiate agonist; SNRI effect like; CAUTION with SSRI use (can cause serotonin syndrome) MU agonist inhibits 5-HT/NE reuptake (similar to SNRI); NMDA antagonist; can use in treatment of neuropathic pain-central pain, opioid induced hyperalgesia METHADONE Synthetic DEA II; for pain any provider; for MAT needs special license/certification Methadone Pharmacology: Primary hepatic with some renal clearance; no active metabolites (IT IS CONSIDERED safe in renal impairment) • Takes time to build stores; Analgesic half life 9-59h • Special CAUTION in elderly, rapid dose titration; HIGHLY VARIABLE RESPONSE RATES; CYP450 inhibitor, drug-drug interactions, PROLONG QT, not a good choice for rapid titration Resources 1/2/3
Dosing and Management • Choosing an opioid: – ATTENTION: Review specific patient/diseases characteristics-ASSESSMENT • Short- vs long-acting – Short-acting: Intermittent/ breakthrough/incident dose frequency per time to peak effect – Long-acting: Continuous pain • Converting short-acting to long-acting – Assess and and determine total daily dose of opioid – Convert to oral morphine equivalents (MME) adjust and individualize new dosing; follow up in no more than 1 week Resources 1/2/3
Practical Example of Opioid Rotation • Morphine ER 80 mg po BID and oxycodone 10 mg po q4h prn pain • Inpatient/outpatient practice; pain not well controlled and reported side effects from morphine • Because of worsening side effects, decision to change/rotate opioids
Practical Example of Opioid Rotation • Morphine 80 mg po BID = 160mg/d – 160 mg/d-OME for above • Oxycodone is 1.5 times stronger than morphine • Oxycodone IR total 60mg = 90 mg po Morphine • Total OME 250mg • Conversion to Oxycodone 160 mg • Therefore Oxycodone 80 mg po bid ER form • Incomplete cross tolerance 40mg po bid
Management / Side Effects Specifics • Opioid rotation: – Dose-limiting side effects change in route CAUTIOUS OPIOID NAÏVE start low dose and individualize • APPRORIATE DOSING – reduces side effects; balances between side effects, rotations, multiple barriers etc.
Management / Side Effects Specifics Adverse effects: Sedation (often tolerance, modulate dose, non-opioid options, rotations, psychostimulants) Respiratory Depression brain system MU receptors activation, sedation occurs first pruritus (dose limiting, NOT TRUE hypersensitivity-tx MU antagonist, naloxone antihistamine, rotations, naloxone) Concomitant use of benzodiazepines anticholinergics, Neurontin, alcohol, sleeping medicines, and muscle relaxants is dangerous for respiratory depression Nausea/vomiting (GI slowing CTZ, vestibular; tolerance in 3-7 days; antiemetics, rotations) Tolerance anticipate constipation, schedule Methylnaltrexone, laxative, etc.
Opioid Management • Opioid selection variables: medication, patient, EBM • Initiation - consider following factors: Opioid Naïve, half-life • IR forms: Mild/moderate pain increase 25-50% – Severe/uncontrolled increase by 50-100%, dose frequency per time to peak effect • Re-ASSESSMENT FREQUENT and important (side effects, function, dose adjustments, temporal pattern • ER forms: Total of IR /daily dose (adjust for severity) – E.g., Oxycodone 5 mg po x 4 doses/d=20 mg ; 50-75% of above and convert to long-acting oxycodone CR 5 mg po bid Resources 1/2/3
Opioid Management (cont.) • Fentanyl transdermal; not effective for acute pain; lasts 48-72hrs, depending on patient metabolism; direct heat can increase drug absorption, still distributed after patch removed; 70% bound to albumin, so hypoalbuminemia decreases plasma levels (EOL frequently low albumin). Must be opioid tolerant to initiate this therapy. VITAS pharmacy can help manage these medications for patients on VITAS service. • Extended-release forms: improve adherence, CANNOT CRUSH or chew • Fentanyl transdermal every 48h-72h • Methadone 4-7 days Resources 1/2/3
Opioid Management Challenges • Challenges: with increasing dose escalations-increasing side effects – Incomplete cross-tolerance – Drug-receptor interactions • Safe to reduce equianalgesic dose by 25-50% to compensate • EXCEPTION: – Rotating to methadone, reduce more than 75%-90% – In EOL care • VERY IMPORTANT use of VITAS Pharmacy counselling to help physicians/other caregivers that prescribe pain meds, in managing complexities of pain. VITAS pharmacist significant assist in patient- centric and safe care. Resources 1/2/3
Opioid Management (cont.) • Opioid Controlled Analgesia (PCA) challenges: – Sedation precedes respiratory depression – Loading dose (initial dose administered by RN); Bolus (demand), Lockout 10-15 min based on peak effect), basal rate (hourly rate-not in opioid naïve) – Some control (alleviates anxiety, individualized) – Loading dose (initial dose administered by RN); Bolus (demand), Lockout (10-15 min based on peak effect), basal rate (hourly rate-not in “opioid naïve) • Please be aware a national shortage of parenteral opioids exists and is not available outside of the hospital Resources 1/2/3
Continue Non-Opioid Pain Management • NSAIDS: anti-inflammatory, periphery-acting, bind to plasma albumin, do not cross blood brain barrier, metabolized by the liver, low renal clearance (<10%) • Used in bone pain, soft tissue, visceral pain • Multiple negative side effects (GI, renal etc.) • Steroids: – Dexamethasone decreases inflammation; tumor shrinkage, anti-tumor effects, enhances appetite weight gain, improved sense of well being – Side effects: • Immunosuppression • Psychosis • Proximal muscle wasting Resource: 1/2/3
Non-Opioid Analgesia • PoorDrugs with additional analgesic properties • Some indications: – Response to opioid, marked predisposition to opioids, opioids side effects to increasing opioids dose • Different pain syndromes • Neuropathic pain • Bone pain • Myofascial pain • Safe use: – One adjuvant at a time – Increase dose until limiting side effects or analgesia – Can add another analgesic if partial analgesia and maximal dose Resources 1/2/3
Non-Opioid Pain Management • Neuropathic pain • Few meds that can be used: – TCAs (AVOID IN GERIATRIC populations mostly due to ANTICHOLINERGIC effects) – SNRI can be used: painful, neuropathy, post mastectomy, fibromyalgia – SSRI paroxetine painful neuropathy, Fluoxetine (if comorbid depression), avoid in geriatric population Resources 1/2/3
Non-Opioid Pain Management • Gabapentin can be used in neuropathic pain, pregabalin (faster titration) • Ketamine* NMDA antagonist can be used as neuropathic pain • OPIOID RESISTANT EMPASIZE role of VITAS Pharmacy education/assistance • OPIOID SPARRING effect (important with worsening shortage of opioids especially IV forms) • Post-op pain: much lower dose analgesic effect than anesthetic Resources 1/2/3
Non-Pharmacologic Pain Management • CBT (improving mental health, thoughts, beliefs and behaviors, QOL; anxiety, bereavement , insomnia • Acupuncture • Music therapy • Hypnotherapy • Massage • PT/OT • Heat therapy: – Increases circulation to affected tissues – Relieves joint stiffness and muscle spasm – Decreases sensitivity to pain – Chronic swelling may be reduced – Simple, easy to do, inexpensive and possibly effective in the short-term – Caution: prolonged use which may lead to irritation and actual burn of the over lying skin. Resources 1/2/3
Liver Failure • Liver responsible for metabolism of most drugs through CYP450 • Opioids in the liver failure • Oxycodone: oxymorphone by liver, increased half life, unpredictable levels • Morphine: first pass metabolism (no CYP450), less hepatic flow-increased bioavailability • Methadone (CYP 450), clearance not altered • Hydromorphone (first pass metabolism, GOOD CHOICE FOR LIVER DYSFUNCTION) • Patients frequently experience fatigue, mental and mood disorders • Patients, family and care providers may experience guilt, anger, sadness, fear, anxiety, and depressed mood • Additionally, there are effects on the health of care providers, family social interactions, and finances
Liver Failure (cont.) • All these responses may affect patient pain perception • Reduced response to medications • Loss of muscle and body mass through atrophy • Tissues become more ridged • The brain and spinal cord deteriorate which effects perception of pain and location • Wound healing is reduced and time to heal is longer • Scaring or incomplete healing occurs more often • Methadone (CYP, decreased hepatic flow–increased blood levels, avoid in severe liver dysfunction • NSAIDS (CYP450; inhibits prostaglandins • Acetaminophen-CYP 450-NAPQI-hepatotoxic;<2g /d
Renal Failure • Renal Failure • Responsible for clearance of many pain meds; • Accumulation (in renal failure) can cause: • Neurotoxicity, Hepatotoxicity • Codeine and its metabolites (morphine, hydrocodone) are excreted by kidney • M3G neurotoxic, MSG analgesic effects • Oxycodone can accumulate in renal failure • Hydromorphone/fentanyl considered Safe • Acetaminophen <3g/d; no significant changes observed in renal failure
Summary Ideas/Thoughts • It is important to note that increased social and spiritual interactions may well have a positive influence upon pain perception and are too often under-used as therapy. • Selected therapies based upon a thorough evaluation of the patient’s pain and ability to tolerate additional treatments is required of the practitioner. • Reevaluation to assess responses to these added therapies needs to occur as often as reassessment of analgesic therapy does. • It is far too easy to simply have tunnel vison and provide analgesia for pain and not consider the total pain concept, which is part of the benefit to a team approach to care management
Questions?
References 1. Hospice and Palliative Medicine Board Review-American Physician institute 2. Medical Knowledge 3. VITAS Resource Library 4. Merskey, H., et al. (1979). Pain terms: a list with definitions and notes on usage. Recommended by the IASP Subcommittee on Taxonomy. Pain, 6, 249-252. 5. JAMA 2003, 290(18)2443-24454 6. National Academy Press US 1997 7. Annal Oncology 2007;18(9) 1437-1449 8. Stewart, et al. (2003). Lost Productive Time and Cost Due to Common Pain Conditions in the US workforce. JAMA, 290(18), 2443-54. 9. Zelaya, et al. (2020). Chronic Pain and High-impact Chronic Pain Among U.S. Adults, 2019. NCHS Data Brief No. 390. Available at: https://www.cdc.gov/nchs/products/databriefs/db390.htm 10.Van den Beuken-van Everdingen, et al. (2007). Prevalence of Pain in Patients With Cancer: A Systematic Review of the Past 40 Years. Annals of Oncology, 18(9), 1437-1449.

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Understanding Pain Management and Daily Practice Management

  • 1.
    Understanding Pain Management and DailyPractice Management Agron Ismaili MD | Regional Medical Director VITAS® Healthcare | [email protected]
  • 2.
    CME Provider Information SatisfactoryCompletion Learners must complete an evaluation form to receive a certificate of completion. You must participate in the entire activity as partial credit is not available. If you are seeking continuing education credit for a specialty not listed below, it is your responsibility to contact your licensing/certification board to determine course eligibility for your licensing/certification requirement. Physicians In support of improving patient care, this activity has been planned and implemented by Amedco LLC and VITAS ® Healthcare. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  • 3.
    CE Provider Information VITASHealthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through: VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved By: Florida Board of Nursing/Florida Board of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling. VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists through: VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number: 139000207/RT CE Provider Number: 195000028/Approved By the Illinois Division of Profession Regulation for: Licensed Nursing Home Administrators and Illinois Respiratory Care Practitioner. VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2021 – 06/06/2024. Social workers completing this course receive 1.0 ethics continuing education credits. VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of Registered Nursing, Provider Number 10517, expiring 01/31/2023. Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois.
  • 4.
    Objective • Describe, define,and differentiate aspects of pain: – Acute vs. chronic, nociceptive, nociplastic, neuropathic • Discuss the importance of identifying pain: – Receptor sensing – Mechanism of transmission – Complex interaction of the elements of the peripheral and central nervous systems • Enhance assessment and management of both medication and non-medication measures used to treat total pain After this presentation, learners should be able to:
  • 5.
    Goal To achieve anappropriate understanding of pain management’s multifaceted applications in the context of palliative and hospice care
  • 6.
    Pain Definition • Anunpleasant sensory and emotional experience associated with actual or potential tissue damage Merskey, H. et al. (1979). Pain terms: a list with definitions and notes on usage. Recommended by the IASP Subcommittee on Taxonomy. Pain, 6, 249-252.
  • 7.
    Acute vs. ChronicPain (Practice, Reality) • Acute pain is the most common reason for ED visits • Chronic pain comprises around 20% of physician office visits • $60 billion/year in lost productivity Zelaya, et al. (2020). Chronic Pain and High-impact Chronic Pain Among U.S. Adults, 2019. NCHS Data Brief No. 390. Available at: https://www.cdc.gov/nchs/products/databriefs/db390.htm Stewart, et al. (2003). Lost Productive Time and Cost Due to Common Pain Conditions in the US workforce. JAMA, 290(18), 2443-54. Van den Beuken-van Everdingen, et al. (2007). Prevalence of Pain in Patients With Cancer: A Systematic Review of the Past 40 Years. Annals of Oncology, 18(9), 1437-1449.
  • 8.
    The Importance ofGoals of Care • Patients’ values are honored • Symptoms are attended to quickly and effectively • Patient and family maintain control of treatment plan • Poorly defined goals can lead to: – Unwanted treatments – Inappropriate use of resources – Undue suffering – Miscommunication • Emergency clinicians establish GOC with patients daily • Any team member can assess GOC
  • 9.
    Pain in responseto an injury or stimuli; typically acute Nocioplastic Pain that arises from nocioceptive function, typically chronic Neuropathic Pain that develops when nervous symptom is damaged Fibromyalgia, irritable bowl syndrome, non-specific low back pain Post-operative pain, sports injuries, arthritis, sickle cell disease, mechanical low back pain Post-herpetic neuralgia, trigeneuralgia, distal polyneuropathy, CRPS, neuropathic low back pain Types of Pain Nociceptive Pain
  • 10.
    Acute and ChronicPain • Acute pain: – Usually hours to weeks, most likely responsive to multimodal therapies – Noted physiological changes and notable pain behaviors • Chronic pain: – > 3 months (persistent, with long-term conditions, can be expressed as anxiety, depression, irritability; may not respond easily to drug therapies; essentially to correlate with function) Source for Acute/chronic pain statistics (FSMB USA Model guidelines for the use of controlled substances for the treatment of pain, Euless, TX 1998 source 1/2/3.
  • 11.
    Nociceptive, Nocioplastic, andNeuropathic Pain • Nociceptive: – Bone (aching, gnawing, localized) – Visceral (cramping, regionally localized or referred) – Somatic (easy to localize and describe) • Nocioplastic: – Central SENSITIZATION – Increased response to stimulation mediated by amplification of CNS (e.g., fibromyalgia, chronic back pain, etc.) • Neuropathic: – Damage or injury to the nerves that transfer information between the brain and spinal cord from the skin, muscles and other parts of the body – Burning sensation and affected areas are often sensitive to the touch Federation of State Medical Boards of the United States, Inc. (2005). Model Policy for the Use of Controlled Substances for the Treatment of Pain. Journal of Pain & Palliative Care Pharmacotherapy, 19(2), 73-8.
  • 12.
    Types of Pain Antihistamine Acetaminophen Opioidsand NMDA blockers Nerve blocks NSAIDs Topical/transdermal treatments Nocioplastic Anticholinergic Anticonvulsants TCAs and SNRIs Other serotonin agents Neuropathic Anticonvulsants Opioids and NMDA blockers Nerve blocks TCAs and SNRIs Generally not opioid responsive Nociceptive Pain
  • 13.
    Prevalence in OlderAdults, Barriers • Pain is in patients with and without cancer (present in 75% institutionalized and 50% community elderly) and about 25% of elderly do not receive adequate analgesia • Barriers • Patient • Prescribers • Pharmacy • System • Legal • Common: racial, elderly, lack of educational skills, fear of addiction, etc. J. Med.2007,120(4) 306-315 JAMA 1998; 279; (23)1877-1882 J.Am. Ger. Soc.,1999 47 (8) 936-942 Source 1, 2, 3
  • 14.
    Pain Statistics: EmphasizingMultifactorial Nature, Importance in Daily Practice • Single or multifocal • Cancer (treatment vs. malignant process, direct and indirect effects) vs. non-cancer (pressure ulcers, RA, OA, sickle cell, osteomyelitis, back pain, headaches) • Pain is a serious problem for as much as 40% of the US population Resources 1/2/3
  • 15.
    Integrated Pain Model DameCicely Saunders devised a new paradigm of the concept of pain beyond the confines of the physical body responses. • Total pain is characterized as the multidimensional nature of the pain experience and includes these domains of pain: – Physical – Psychological – Social – Spiritual Resources 1/2/3
  • 16.
    Comprehensive Symptom Evaluation •Symptom ascertainment (PQRST tool, etc.) • Past medical and treatment history (pharmacologic/non- pharmacologic, comorbid, hx of opioid use-PDMP, the effectiveness of treatment) • Social, psychological, and family history (mental health, personal and family hx of polysubstance abuse, cultural background, social network, other behavioral patterns) • Opioid Risk Assessment (identifies persons at higher risk for SUD, possibly necessitates additional monitoring; ># high risk, mitigation, misuse, abuse, diversion, periodic UDS) • Physical exam and assessment (integrates hx with observation for corroboration of symptoms) • Pharmacologic and non-pharmacologic management plan Resources 1/2/3
  • 17.
    Pain Physiology Half-Life •An important aspect in the management of pain issues • To determine dosage times by knowing how long the drug will continue to do its job • What is it? – How much time it takes for blood levels of a drug to decrease to half of what they were when the drug was at peak performance in the body Resources 1/2/3
  • 18.
    Pain Physiology, Mechanisms& Receptors • Transduction: Noxious stimuli—to action potentials—peripheral nociceptor sensory fibers • Some of the substances produced can affect the pain: nociceptors, tissue damage, and inflammatory cells (bradykinin, prostaglandins, etc.) Resource: 1/2/3
  • 19.
    Pain Physiology, Mechanisms& Receptors • Transmission: peripheral, central transmission by many pathways, such as: stomato-sensory thalamus, thalamic-cortical fasciculus, lateral spinothalamic funiculus, ventral spinothalamic tract • Complex interaction of glial cells, nociceceptors, neurons, biogenic amines, etc. Resource: 1/2/3
  • 20.
    Pain Management Goals •Optimize patient comfort • Enhance FUNCTION, physical well-being, psychological well-being, spiritual well-being • Minimize side effects • Enhance quality of life Resource: 1/2/3
  • 21.
    Role and Importanceof Hospice IDT in Pain Management • Paint the picture, narrative subjective process, REASSESSMENT is very important • VITAS for many years has been the leader in effective pain management for patients with terminal diseases • Teamwork is vital for effective pain management • We as members of IDT have a responsibility to manage pain: – Team manager – Nurse – Hospice aide – Chaplain – Team physician – Volunteer Resource: 1/2/3
  • 22.
    Pain Physiology, Receptors •Example of types of pain: – BONE/VISCERLA/SOMATIC-Nociceptive – Peripheral, Central-Neuropathic • Multiple mechanisms, multiple sites, consider chronic medical problems (esp. mental health issues) and how they affect patient’s perception of pain, etc. Resource: 1/2/3
  • 23.
    Pain Assessment Tolerance: Physiologic phenomenonresulting from regular use of a drug in which increased use is needed to produce same effect • Common concern but uncommon phenomenon • E.g., N/V/fatigue (with opioids), developing tolerance leading to diminished side effects • ATTENTION: Tolerance does not develop for opioid constipation • Managing opioid tolerance • Rotation (uncontrolled pain, neurotoxicity) Physiologic Dependence: • Adaption manifested by drug class specific WITHDRAWAL syndrome – after abrupt cessation, rapid dose reduction, decreased blood levels, administration of antagonist; common after 1-2 weeks of continuous weeks of use. Treatment: reintroduction of opioid, clonidine, BZD, Imodium Resources 1/2/3
  • 24.
    Pain Assessment (cont.) •Addiction: Impaired control, compulsive use, continued use despite harm, cravings • Pseudo-addiction: Inadequate pain management, disease progression, can creates mistrust with patient? inadequate prescriptions • Pain is a subjective process, narrative story; validate the experience Resources 1/2/3
  • 25.
    Opioid Therapy: PharmacologyMorphine • Most frequent indications in the daily practice: – Pain/dyspnea/cough/ anesthesia, diarrhea • Few important steps in the mechanism of action: – Bind to opioid receptors, activate descending inhibitory pathway, prevent neurotransmitter release, reduce formation of action potentials • Receptors: – Mu: brain stem, medical thalamus, peripheral – Mu1-analgesia – Mu2-analgesia GI tract, respiratory depression, pruritus – Kappa: • Limbic system, brain stem, spinal cord, spinal analgesia, sedation, dysphoria • Delta: brain, periphery spinal analgesia, decreased GI motility, respiratory depression Resources 1/2/3
  • 26.
    Morphine • Opioid likereceptor (ORL-1): Affects stress, feeding, learning, memory? opioid tolerance • Sigma: It is not considered true opioid receptor, potential for psych mimetic effects, dysphoria • DEA class II • Strong MU and weak kappa and delta; metabolized in the liver, excreted by kidneys • Morphine-3-glucuronide and morphine-6-glucuronide toxicity concerns; generally not used in patients with end-stage renal disease • Management of side effects • Forms: Injectable, oral, rectal Resources 1/2/3
  • 27.
    Pharmacology of SpecificDrugs • Oxycodone: agonist MU/Kappa, metabolized with conjugation in the liver by CYP 450 to active/inactive metabolites • ATTENTION: Prolonged elimination in renal impairment/failure • It is combined with acetaminophen/aspirin • Hydromorphone • Main mechanisms • Mu agonist • Hepatic metabolism via glucouronidation to Hydromorphone 3G; excreted by kidneys Resources 1/2/3
  • 28.
    Pharmacology of SpecificDrugs (cont.) • Fentanyl – MU agonist • Has lipophilic effect • Hepatic metabolism to inactive metabolites-not dialyzed • ATTENTION: reduce dose in severe renal impairment • Oxymorphone preparation IR/ER • ATTENTION: can take 2 hours before or after as taking with meals can increase serum levels Resources 1/2/3
  • 29.
    Pharmacology of SpecificDrugs (cont.) Hydrocodone Derived from codeine • Can be combined with acetaminophen; DEA II Buprenorphine • MU partial agonist (high affinity, low potency), Kappa antagonist, lipophilic, first-pass metabolism, CYP 450, may cause QT prolongation; MAT (medication-assisted treatment-use in opioid use disorder; low ceiling effect; high doses lead to the same level of analgesia with more side effects) • Option for patient use with serious illness and opioids use disorder (used with or without naloxone) Resources 1/2/3
  • 30.
    Pharmacology Tramadol Weak opiateagonist; SNRI effect like; CAUTION with SSRI use (can cause serotonin syndrome) MU agonist inhibits 5-HT/NE reuptake (similar to SNRI); NMDA antagonist; can use in treatment of neuropathic pain-central pain, opioid induced hyperalgesia METHADONE Synthetic DEA II; for pain any provider; for MAT needs special license/certification Methadone Pharmacology: Primary hepatic with some renal clearance; no active metabolites (IT IS CONSIDERED safe in renal impairment) • Takes time to build stores; Analgesic half life 9-59h • Special CAUTION in elderly, rapid dose titration; HIGHLY VARIABLE RESPONSE RATES; CYP450 inhibitor, drug-drug interactions, PROLONG QT, not a good choice for rapid titration Resources 1/2/3
  • 31.
    Dosing and Management •Choosing an opioid: – ATTENTION: Review specific patient/diseases characteristics-ASSESSMENT • Short- vs long-acting – Short-acting: Intermittent/ breakthrough/incident dose frequency per time to peak effect – Long-acting: Continuous pain • Converting short-acting to long-acting – Assess and and determine total daily dose of opioid – Convert to oral morphine equivalents (MME) adjust and individualize new dosing; follow up in no more than 1 week Resources 1/2/3
  • 32.
    Practical Example ofOpioid Rotation • Morphine ER 80 mg po BID and oxycodone 10 mg po q4h prn pain • Inpatient/outpatient practice; pain not well controlled and reported side effects from morphine • Because of worsening side effects, decision to change/rotate opioids
  • 33.
    Practical Example ofOpioid Rotation • Morphine 80 mg po BID = 160mg/d – 160 mg/d-OME for above • Oxycodone is 1.5 times stronger than morphine • Oxycodone IR total 60mg = 90 mg po Morphine • Total OME 250mg • Conversion to Oxycodone 160 mg • Therefore Oxycodone 80 mg po bid ER form • Incomplete cross tolerance 40mg po bid
  • 34.
    Management / SideEffects Specifics • Opioid rotation: – Dose-limiting side effects change in route CAUTIOUS OPIOID NAÏVE start low dose and individualize • APPRORIATE DOSING – reduces side effects; balances between side effects, rotations, multiple barriers etc.
  • 35.
    Management / SideEffects Specifics Adverse effects: Sedation (often tolerance, modulate dose, non-opioid options, rotations, psychostimulants) Respiratory Depression brain system MU receptors activation, sedation occurs first pruritus (dose limiting, NOT TRUE hypersensitivity-tx MU antagonist, naloxone antihistamine, rotations, naloxone) Concomitant use of benzodiazepines anticholinergics, Neurontin, alcohol, sleeping medicines, and muscle relaxants is dangerous for respiratory depression Nausea/vomiting (GI slowing CTZ, vestibular; tolerance in 3-7 days; antiemetics, rotations) Tolerance anticipate constipation, schedule Methylnaltrexone, laxative, etc.
  • 36.
    Opioid Management • Opioidselection variables: medication, patient, EBM • Initiation - consider following factors: Opioid Naïve, half-life • IR forms: Mild/moderate pain increase 25-50% – Severe/uncontrolled increase by 50-100%, dose frequency per time to peak effect • Re-ASSESSMENT FREQUENT and important (side effects, function, dose adjustments, temporal pattern • ER forms: Total of IR /daily dose (adjust for severity) – E.g., Oxycodone 5 mg po x 4 doses/d=20 mg ; 50-75% of above and convert to long-acting oxycodone CR 5 mg po bid Resources 1/2/3
  • 37.
    Opioid Management (cont.) •Fentanyl transdermal; not effective for acute pain; lasts 48-72hrs, depending on patient metabolism; direct heat can increase drug absorption, still distributed after patch removed; 70% bound to albumin, so hypoalbuminemia decreases plasma levels (EOL frequently low albumin). Must be opioid tolerant to initiate this therapy. VITAS pharmacy can help manage these medications for patients on VITAS service. • Extended-release forms: improve adherence, CANNOT CRUSH or chew • Fentanyl transdermal every 48h-72h • Methadone 4-7 days Resources 1/2/3
  • 38.
    Opioid Management Challenges •Challenges: with increasing dose escalations-increasing side effects – Incomplete cross-tolerance – Drug-receptor interactions • Safe to reduce equianalgesic dose by 25-50% to compensate • EXCEPTION: – Rotating to methadone, reduce more than 75%-90% – In EOL care • VERY IMPORTANT use of VITAS Pharmacy counselling to help physicians/other caregivers that prescribe pain meds, in managing complexities of pain. VITAS pharmacist significant assist in patient- centric and safe care. Resources 1/2/3
  • 39.
    Opioid Management (cont.) •Opioid Controlled Analgesia (PCA) challenges: – Sedation precedes respiratory depression – Loading dose (initial dose administered by RN); Bolus (demand), Lockout 10-15 min based on peak effect), basal rate (hourly rate-not in opioid naïve) – Some control (alleviates anxiety, individualized) – Loading dose (initial dose administered by RN); Bolus (demand), Lockout (10-15 min based on peak effect), basal rate (hourly rate-not in “opioid naïve) • Please be aware a national shortage of parenteral opioids exists and is not available outside of the hospital Resources 1/2/3
  • 40.
    Continue Non-Opioid PainManagement • NSAIDS: anti-inflammatory, periphery-acting, bind to plasma albumin, do not cross blood brain barrier, metabolized by the liver, low renal clearance (<10%) • Used in bone pain, soft tissue, visceral pain • Multiple negative side effects (GI, renal etc.) • Steroids: – Dexamethasone decreases inflammation; tumor shrinkage, anti-tumor effects, enhances appetite weight gain, improved sense of well being – Side effects: • Immunosuppression • Psychosis • Proximal muscle wasting Resource: 1/2/3
  • 41.
    Non-Opioid Analgesia • PoorDrugswith additional analgesic properties • Some indications: – Response to opioid, marked predisposition to opioids, opioids side effects to increasing opioids dose • Different pain syndromes • Neuropathic pain • Bone pain • Myofascial pain • Safe use: – One adjuvant at a time – Increase dose until limiting side effects or analgesia – Can add another analgesic if partial analgesia and maximal dose Resources 1/2/3
  • 42.
    Non-Opioid Pain Management •Neuropathic pain • Few meds that can be used: – TCAs (AVOID IN GERIATRIC populations mostly due to ANTICHOLINERGIC effects) – SNRI can be used: painful, neuropathy, post mastectomy, fibromyalgia – SSRI paroxetine painful neuropathy, Fluoxetine (if comorbid depression), avoid in geriatric population Resources 1/2/3
  • 43.
    Non-Opioid Pain Management •Gabapentin can be used in neuropathic pain, pregabalin (faster titration) • Ketamine* NMDA antagonist can be used as neuropathic pain • OPIOID RESISTANT EMPASIZE role of VITAS Pharmacy education/assistance • OPIOID SPARRING effect (important with worsening shortage of opioids especially IV forms) • Post-op pain: much lower dose analgesic effect than anesthetic Resources 1/2/3
  • 44.
    Non-Pharmacologic Pain Management •CBT (improving mental health, thoughts, beliefs and behaviors, QOL; anxiety, bereavement , insomnia • Acupuncture • Music therapy • Hypnotherapy • Massage • PT/OT • Heat therapy: – Increases circulation to affected tissues – Relieves joint stiffness and muscle spasm – Decreases sensitivity to pain – Chronic swelling may be reduced – Simple, easy to do, inexpensive and possibly effective in the short-term – Caution: prolonged use which may lead to irritation and actual burn of the over lying skin. Resources 1/2/3
  • 45.
    Liver Failure • Liverresponsible for metabolism of most drugs through CYP450 • Opioids in the liver failure • Oxycodone: oxymorphone by liver, increased half life, unpredictable levels • Morphine: first pass metabolism (no CYP450), less hepatic flow-increased bioavailability • Methadone (CYP 450), clearance not altered • Hydromorphone (first pass metabolism, GOOD CHOICE FOR LIVER DYSFUNCTION) • Patients frequently experience fatigue, mental and mood disorders • Patients, family and care providers may experience guilt, anger, sadness, fear, anxiety, and depressed mood • Additionally, there are effects on the health of care providers, family social interactions, and finances
  • 46.
    Liver Failure (cont.) •All these responses may affect patient pain perception • Reduced response to medications • Loss of muscle and body mass through atrophy • Tissues become more ridged • The brain and spinal cord deteriorate which effects perception of pain and location • Wound healing is reduced and time to heal is longer • Scaring or incomplete healing occurs more often • Methadone (CYP, decreased hepatic flow–increased blood levels, avoid in severe liver dysfunction • NSAIDS (CYP450; inhibits prostaglandins • Acetaminophen-CYP 450-NAPQI-hepatotoxic;<2g /d
  • 47.
    Renal Failure • RenalFailure • Responsible for clearance of many pain meds; • Accumulation (in renal failure) can cause: • Neurotoxicity, Hepatotoxicity • Codeine and its metabolites (morphine, hydrocodone) are excreted by kidney • M3G neurotoxic, MSG analgesic effects • Oxycodone can accumulate in renal failure • Hydromorphone/fentanyl considered Safe • Acetaminophen <3g/d; no significant changes observed in renal failure
  • 48.
    Summary Ideas/Thoughts • Itis important to note that increased social and spiritual interactions may well have a positive influence upon pain perception and are too often under-used as therapy. • Selected therapies based upon a thorough evaluation of the patient’s pain and ability to tolerate additional treatments is required of the practitioner. • Reevaluation to assess responses to these added therapies needs to occur as often as reassessment of analgesic therapy does. • It is far too easy to simply have tunnel vison and provide analgesia for pain and not consider the total pain concept, which is part of the benefit to a team approach to care management
  • 49.
  • 50.
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