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Presentation on theme: "CHRONIC PAIN MANAGEMENT"— Presentation transcript:

Michael Marschke, MD Medical Director of Horizon Hospice

Episodic pain syndromes: Headaches – migraine, tension, cluster… Ischemic episodes – claudication, angina, sickle cell disease Visceral pain – biliary colic, irritable bowel, pre-menstrual syndrome, renal colic Somatic pain - gout

Chronic pain syndromes: Somatic – degenerative and inflammatory arthitis, trauma, vertebral compression fractures, boney metastases, fibromyalgia Visceral – abdomenal cancers, chronic pancreatitis Neuropathic – diabetic neuropathy, phantom limb pain, spinal stenosis/sciatica, spinal mets, HIV, drug induced

Psychologic factors – depression, anxiety, somatization Socioeconomic factors – cultural differences, urban poor, gender Spiritual factors – spiritual suffering, meaning of pain Physical factors – VERY complex neuroanatomy creating the pain sensation, from pain receptors to afferent nerves to spinothalamic tract, to thalamus to cortex with modulators all along the way Therefore best approach is multi-disciplinary Studies show depression and anxiety create more pain and stronger pain. Pure psychologic pain. Poor under report pain for fear of being a burdn, mistrust of richer docs, addiction running around neighborhood. Subtle cultural diffenences – ex – Eastern European rate pain worse than Asians or African Amer. Gender – females tolerate visceral pain better, males – somatic. Spiritual suffering can increase pain and different religions have different meaning behind physical suffersing – “cruxifixion complex”

GOALS: Determine etiology to better treat this pain Determine if correctable, intractable, or potentially dangerous causes Determine impact on patient’s life Take a detailed pain history to aid in controlling this pain Etiology helpful to correct problems, verify reality of the pain for more aggressive pain control. Correctable – injections, surgery, meds…. Intractable or terminal conditions for prognosis… Dangerous – dissecting aneurysm, DVTs, cerebral bleeds… Impact – affecting ADLs, work, secondary gains – disability, QOL, QOD Pain history – severity 0-10 (quantifiable per pt), quality, timing, location, exacerbaters, alleviaters, a/w – worst in last 24 hrs, ever go away, what do you want it at – what is tolerable/livable, emotional/spiritual meaning? – help with determining physiologic pain syndrome, how to use meds, how to best treat it and follow it

6 PAIN HISTORY O = Other associated symptoms ( nausea with stomach cramps, swelling with somatic pain, depression, anxiety…) P = Palliative/provocative factors (mobility, touching, eating…) Q = Quality R = Region/radiation S = Severity ( 0 to 10 ) T = Timing (when started, continuous/intermittent, time of day…) U = Untoward effects on activity or quality of life, including psychosocial, spiritual effects

Somatic – focal, ache/throb/sharp, maybe with swelling/edema/redness, tender, worse with movement, better at rest, maybe from trauma Visceral – viscous organ – colicky, vague, diffuse, worse with meals, liver/spleen/pancreas – may be more constant, more focal, worse with eating, uterine – colicky, pelvic, maybe with discharge Neuropathic – burning, sharp, tingling, either dermatomal or stocking-glove, worse with touch, maybe with numbness

8 WHEN FIRST TREAT CHRONIC PAIN, created in 1990 when The World Health Organization realized physicians across the globe were ill-prepared to treat chronic pain, so tried to simplify and teach a model

Step 1: Acetomenophen, Tramadol (Ultram) plus adjuvant Step 2: Tylenol #2/3/4, Vicoden, Darvocet, Percocet Step 3: Morphine, Dilaudid, Fentanyl, Demerol, Methadone, Oxycodone, Levodromaran WHO ladder falls short because separate step 2 from step 3 drugs, playing into doctor’s fears about using “stronger” narcotics; when the reality is that even step 3 drugs when used in small amounts can be less potent that Tylenol #3 or Vicoden… In past step 3 drugs needed special presriptions to be able to use – doctors feared scrutiny

10 Marschke’s Modified Pain Escalator

Non-pharmacologic: Ice, heat Physical therapy Chiropractic/osteopathic manipulations Massage Acupuncture Yoga Topical agents (Ben Gay/Icy Hot – with menthol, salcylates, Capcaicin) Local injections (steroids, lidocaine) Glucosamine shown to help with osteoarthritis Pharmacologic: NSAIDs Cox 2 inhibitors Steroids Muscle relaxants Capsaicin (Zostrix) – red hot chili pepper juice – used for centuries in S. America, burns for first few days then wears out substance P in pain receptors PT/chirpracter/massage/yoga/acupuncture in some studies equally effective in certain conditions like low back pain NSAIDs – beware of GI side effects and platelet effects, though the Salcylate class and Diflunisal have less of these effects. NSAIDs in studies shown to decrease narcotic use by up to 40% in things like wide-spread boney mets Relaxants – soma, flexeril, benzodiazepines

Boney mets: Local RT Pamidronate and other diphosphonates Strontium 89 and other radioactive isotopes, taken up by osteoclasts Vertebral compression fractures: Calcitonin Pamidronate Vertebroplasty Calcitonin – 8IU/kg sq, intranasal MIacalcin, 1squirt alt nostrils qd Pamidronate 30-90mg IV q2-4wks

13 VISCERAL PAIN Anti-cholinergics for colicky pain
H2 blockers/PPIs for PUD/GERD Steroids for enlarged organs with capsular swelling NSAIDs for uterine pain Nitrates for angina Others – celiac/pelvic plexus blocks, RT for enlarged organs, massage, herbs, aromatherapy, acupuncture, healing touch Herbs – chamomile, ginger, cola, aromas - peppermint

14 NEUROPATHIC PAIN Tricyclic antidepressants Anti-epileptics
Anti-arrhythmics Topical agents – lidocaine, capsiacin Steroids for spinal radiculopathies Others – RT for spine mets, TENS/PENS units and also spinal electrical stimulators CAM - Acupuncture, massage, PT, yoga, healing touch Tricyclics and anti-epileptics work within 4-6 days, but may need to push up to therapeutic drug levels. Most anti-epileptics work 60-70% of time compared to placebo 30%. Tegretol most well used, $10/mo, levels easy to monitor. Neurontin shown only with dosing TID, costs over $300/mo and sedation in elderly/debilitated common and no drug levels. Anti-arrhythmics not used because arrhythmogenic.

15 OTHER CAM ADJUVANTS Herbals/supplements – glucosamine shown to be useful in osteoarthritis, certain herbs like chamomile useful for colicky pain Homeopathies/flower essences – for relaxation, visceral pain Healing touch/Reiki – using energy techniques, useful with emotional components Neuro Emotional Technique – A chiropractic technique also useful with emotional components Mind – focusing therapies: Meditation, yoga, guided-imagery, hypnosis, biofeedback Art/music/humor therapy, pet therapy By distraction, found to lower HR/RR and decrease pain up to 10-20%

16 ADDING AN OPIOID To achieve quick pain relief: (LOAD)
1. Start low dose, short-acting 2. Dose q peak 3. P.C.A. not “prn” (Patient controls it) 4. Re-eval in 4 hrs. to figure out what dose is needed

17 “prn” dosing Studies show the average time it takes patients in hospitals to get a prn drug is 2 hrs! (to have enough pain to want to get to the call light, get the secretary to find the nurse who 9 times out of 10 is busy, then RN needs to evaluate pt, then needs narcotic key and second RN to get the drug, not even including the time it takes the drug to kick in), Most nursing homes are NOT staffed to be able to give any prn drugs.

18 Low-dose, short-acting opioids
Tylenol #3, 1-2 tabs Vicoden, Norco, Lortab 1-2 tabs Darvocet N-100, 1-2 tabs Percocet, 1-2 tabs Vicuprofen, 1-2 tabs DOSING LIMITED BY ATTACHED DRUG (max Tylenol a day is 4000mg) MSIR/Roxanol,5-10mg PO, 1-3MG IV/SQ Dilaudid, 1-2mg PO, IV/SQ OxyIR, 5-10mg PO NEVER USE DEMEROL IN CHRONIC PAIN!!!

1. Go long (convert 24hr total of short acting directly to long acting) 2. REM breakthru = 10-20% of total daily dose, as short-acting, immediate release 3. Re-eval, if 4+ breakthru/d, increase maintainance dose Use 24 hrs of a dose of short acting that works, add up total, tell patient to take as soon as pain starts to keep ahead of the pain, don’t wait til pain peaks

20 LONG-ACTING OPIOIDS MS Contin, Oramorph, q12hr, in 15,30,60, 100, and 200mg tabs Kadian, Avinza, q24hr, in 20,50, 100mg time-release capsules (can be opened to ease swallowing or put thru gastric tubes) OxyContin, q12hrs, in 10,20,40,80, and 100mg tabs Duragesic (Fentanyl) patches in 25,50,75, and 100 ug/hr q48-72hrs. Palladone (Dilaudid) q24hr, in time released capsules

21 CAVEATS IN OPIOID USE With pure agonists, the sky is the limit
80% of the time dose needs to be increased because the disease is advancing; 20% because of tolerance. Mixed or partial agonists (Stadol, Talacen, Talwin) have a ceiling, neurotoxicity, and can induce withdrawal if on other opioids Methadone – q8-24hr drug, may be better with neuropathies & addiction because inhibits the NMDA receptor in the brain, though half-life 6-100hrs so watch for accumulation Demerol – neurotoxic metabolite can build up in 1 wk, in 1 day with renal failure Oral, sublingual, rectal short acting meds peak within 1 hr., IV/SQ peak within 10 minutes. Choose oral if they can do it. Use conversion tables to switch narcotics, start at % of equivalent dose To taper drug, decrease by 25% a day.

22 OPIOID SIDE EFFECTS Constipation is a given, no tolerance develops, use stimulants (Senokot, Bisocodyl, Pericolace) Nausea/vomiting – tolerance can occur in 2-5 days, compazine/reglan can help Sedation – tolerance can occur in 2-3 days, changing drug or Ritalin can help if persists Clonic jerks – usually hi doses, can change drug or benzodiazepam can help Respiratory suppression in toxic doses, never see it if have pain or use the drugs the right way

PHYSICAL DEPENDENCE: Tolerance (20-40%) – up-regulate opioid receptors to need higher dose for sustained effect Withdrawal (20-40%) – after 2 wks, withdrawing drug leads to adrenaline response (sweating, tachycardia, tachypnea, cramps, diarrhea, hypertension); avoid by decreasing drug 25% a day. PSYCHOLOGIC DEPENDENCE: Addiction (0.1% in CA pain) – a need to get “high” where drug controls your life, compulsive uncontrolled behavior to get the drug; lie, cheat, steal.

24 PSEUDO-ADDICTION: Physical dependence confused with psychologic dependence Pain-relief seeking, not drug-seeking When right dose used, patient functions better in life, whereas opposite true with the true addict To help diffentiate: one MD controls the drug under a specific contract with pt., one pharmacy, frequent visits, pill counts


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