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Introduction to Non-Opioid and Opioid Pain Therapy Developed by: Jillian Baer, PharmD, BCPS Updated by: Jennifer L. Johansen, PharmD, BCPS Sr. Manager,

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Presentation on theme: "Introduction to Non-Opioid and Opioid Pain Therapy Developed by: Jillian Baer, PharmD, BCPS Updated by: Jennifer L. Johansen, PharmD, BCPS Sr. Manager,"— Presentation transcript:

1 Introduction to Non-Opioid and Opioid Pain Therapy Developed by: Jillian Baer, PharmD, BCPS Updated by: Jennifer L. Johansen, PharmD, BCPS Sr. Manager, Drug Information Presented by: Steve Gilbert, BSc, MBA, CGP, BCPS Director, Clinical Support

2 Disclaimer Statements This presentation is for educational purposes only. It is not intended as legal or professional advice. Any reproduction by Third Parties of this presentation or materials contained herein is prohibited in the absence of written permission obtained from the author. Review or discussion of any agent does not alter in any way the conditions for use contractually agreed upon and outlined in the Hospice Pharmacia Medication Use Guidelines. excelleRx, Inc. All Rights Reserved. 2012

3 Release date: 11/28/2012; Expiration date: 11/28/2013 This program was developed for the beginner to advanced nurse working in the hospice and/or palliative care environments. Requirements for statement of credit: –Listen to entire presentation; Complete and submit post-test via Xeris with a passing score of at least 70%. Statements of credit: Awarded and sent via , within 4 weeks after receipt of post- test This program may contain content that discusses the off-label use of various medications The program developer/presenter declare no conflicts of interest or relevant financial relationships No financial support was obtained or provided for any component of the educational activity from any commercial interest or any other organization. There are no registration fees. There is a small, processing fee of $11 to be accessed per statement of credit issued to hospice partner participants and will appear on the hospice organizations monthly bill. Provider approved by the California Board of Registered Nursing, Provider Number CEP for 1.0 contact hours

4 Learning Objectives Describe how pain is classified Discuss and perform a proper pain assessment Recognize the differences between the various common non-opioid and opioid therapies used in pain management Recommend appropriate non-opioid and opioid pain therapies excelleRx, Inc. All Rights Reserved. 2012

5 Why this topic? > 50 million Americans suffer from chronic pain, and ~25 million Americans experience acute pain each year due to injuries or surgery ~70% of patients w/cancer experience significant pain during their illness, yet < 1/2 receive adequate pain treatment. ~50% of all hospitalized patients have moderate to severe pain in their last days of life. > 20% of Americans aged 60 and over have chronic pain due to arthritis, other joint pain or back pain. National Pain Survey, Conducted for Ortho-McNeil Pharmaceutical,1999 Stuart Grossman et al, Correlation of patient and caregiver ratings of cancer pain. Journal of Pain and Symptom Management 1991 (6:2) 53ff.; Jamie H. Von Roenn, et al, Physician Attitudes and Practice in Cancer Pain Management. Annals of Internal Medicine 15 July 1993 (119:2) 121ff SUPPORT investigators, A controlled trial to improve the care for seriously ill hospitalized patients. Journal of the American Medical Association 1995 (274): 1591ff excelleRx, Inc. All Rights Reserved. 2012

6 Pain never killed any one. True or False? Post-op pain can delay healing and contribute to complications that may be life-threatening excelleRx, Inc. All Rights Reserved. 2012

7 Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage. (APS, 1992) Whatever the patient says it is! (McCaffery, 1968) Impacts psychosocial and physical functioning excelleRx, Inc. All Rights Reserved. 2012

8 Classification of Pain: Chronic vs. Acute CharacteristicAcute PainChronic Pain TemporalRecent onset, expected to last no longer than days or weeks; generally follows tissue injury and resolves with healing Remote, often ill-defined onset IntensityVariable Associated EffectAnxiety if pain is severe or cause unknown; sometimes irritability Irritability or depression Associated behaviorsPain behaviors (e.g. moaning, rubbing, splinting) may be prominent when pain is severe May or may not give any indication of pain; specific behaviors (e.g., assuming a comfortable position may occur) Associated FeaturesSympathetic hyperactivity if severe pain (e.g., tachycardia, hypertension, sweating, mydriasis) May or may not have vegetative signs such as: lassitude, anorexia, weight loss, insomnia, loss of libido excelleRx, Inc. All Rights Reserved. 2012

9 Classification of Pain: Incident vs. Breakthrough Incident –Precipitated by movement or procedures Breakthrough –Between regularly scheduled doses of pain medication excelleRx, Inc. All Rights Reserved. 2012

10 Classification of Pain: Nociceptive vs. Neuropathic excelleRx, Inc. All Rights Reserved. 2012

11 Nociceptive Pain: Somatic Pain Arises from bone, joint, muscle, skin, or connective tissue Described as: aching, throbbing, sharp, worsens with movement Well localized Examples: muscle spasm, bone metastases, incisions, tumor invasion into surrounding tissue, broken bone. Pain Nociceptive SomaticVisceral Neuropathic excelleRx, Inc. All Rights Reserved. 2012

12 Nociceptive Pain: Visceral Pain Stretching or distention of pelvic, thoracic, or abdominal viscera Described as: deep, squeezing, pressure Often poorly localized, may be referred along a dermatome Examples: Myocardial infarction, hepatic metastases, bowel obstruction Pain Nociceptive SomaticVisceral Neuropathic excelleRx, Inc. All Rights Reserved. 2012

13 Neuropathic Pain Pain reports may be disproportionate to physical findings Serves no protective function Described as: sharp, shooting, tingling, stabbing, electric, numbness, burning Examples: spinal cord compression, shingles, peripheral neuropathy Pain NociceptiveNeuropathic excelleRx, Inc. All Rights Reserved. 2012

14 UnrelievedPain Metabolic Cardiovascular Respiratory Genitourinary GastrointestinalMusculoskeletal Cognitive Immune Quality of Life (McCaffery, 1999) excelleRx, Inc. All Rights Reserved. 2012

15 Unassessed pain = Untreated Pain Physical –Fatigue, decreased activity –Nausea –Insomnia –Poor appetite Psychological –Depression –Anxiety –Anger, irritability, agitation –Loss of control –Decreased cognition excelleRx, Inc. All Rights Reserved. 2012

16 Assessment Overview The APS (American Pain Society) calls pain the 5 th Vital Sign –Assess when HR, BP, RR & Temp. are measured Goal of initial assessment –Characterize pain by location, intensity, etiology Detailed history Physical Exam Psychosocial assessment Diagnostic evaluation excelleRx, Inc. All Rights Reserved. 2012

17 When Should Assessment Occur? Upon admission –To identify a pain problem –Establish a baseline/history –Serve as a guide for care/treatment At regular, ongoing intervals after starting treatment With each new report of pain At appropriate intervals after intervention (i.e hours after fentanyl patch initiation) –KEY: know the onset of action and peak effect of the medication excelleRx, Inc. All Rights Reserved. 2012

18 Elements of a Comprehensive Pain Assessment Physical Exam Complete History Laboratory and Radiologic Tests excelleRx, Inc. All Rights Reserved. 2012

19 PQRSTU Pain Assessment Mnemonic P: Palliating/Precipitating factors –What makes your pain better? Worse? Movement? Hygiene care? Q: Quality –Describe your pain for me? R: Radiation or pattern –Does the pain move from one place to another or does it stay in one place? Where? S: Severity or site –On a scale of 0-10 with 0=no pain and 10=worse pain possible, where is your pain now? At its worst? At its best? After you take pain medication? T: Temporal nature –Is your pain constant or intermittent? How long have you had this pain? U. YOU! –What are your pain management goals including intensity, QOL and activity level? What does your pain mean to you? excelleRx, Inc. All Rights Reserved. 2012

20 Pain Assessment Scales Simple Descriptive Pain Distress Scale [1] None Annoying Uncomfortable Dreadful Horrible Agonizing |___________|___________|____________|__________|___________| 0-10 Numeric Pain Distress Scale [1] No Distressing Unbearable pain pain pain |_____|_____|_____|_____|_____|_____|_____|_____|_____|_____| Visual Analog Scale (VAS) [2] No Unbearable distress distress |___________________________________________________________| Wong-Baker FACES Pain Rating Scale excelleRx, Inc. All Rights Reserved. 2012

21 Patients at Risk for Poor Assessment Children Elderly Cognitively impaired persons/unconscious Non-English speaking Substance abuse history excelleRx, Inc. All Rights Reserved. 2012

22 Pain Assessment in Special Populations: Impaired Cognition Common finding in hospice patients Difficulty due to decreased memory, poor orientation, visual, and spatial skills excelleRx, Inc. All Rights Reserved. 2012

23 Pain Assessment in Special Populations: Impaired Cognition - Suggestions May need to repeat the scale more than once and give sufficient time for an answer Scale of 0-5 may be easier to use than 0-10 scale May require assessment by third party in nonverbal patients Need to use behavioral cues: –Facial expressions –Muscle tension –Gestures Look over a 5-minute period for frequency, intensity, and duration to rule out transitory, meaningless gestures excelleRx, Inc. All Rights Reserved. 2012

24 Pop Quiz! Andrew is 25 years old and this is his first day after abdominal surgery. As you enter the room, he smiles at you and continues talking and joking with his visitor. Your assessment reveals the following information: BP: 120/80HR: 80RR: 18 On a scale of 0-10 (0 = no pain, 10 = worst pain), he rates his pain as an 8. On the patient s record you must mark his pain on the scale below. What is the number that represents your assessment of Andrew s pain? No pain Worst pain excelleRx, Inc. All Rights Reserved. 2012

25 Assessment Clinical Pearls Patient knows best – only the patient can describe and rate the pain! Choose the appropriate tool given the patient s clinical status Once the appropriate tool has been selected, use it consistently with that patient to enable symptom tracking PQRSTU can be used for any patient complaint! excelleRx, Inc. All Rights Reserved. 2012

26 Medication Therapy excelleRx, Inc. All Rights Reserved. 2012

27 Drug Therapy: Overview of Pain Management Standards Right drug, right dose, right route, right schedule Start with minimal effective dose Reassess frequently Constant pain needs around-the-clock dosing AND breakthrough Plan/monitor for side effects & treat accordingly Use non-pharmacological therapies when appropriate Provide education Adjuvants for specific pain (ex. bone, neuropathic) excelleRx, Inc. All Rights Reserved. 2012

28 World Health Organization Approach By the mouth –Use oral route & least invasive route whenever possible By the clock –Give ATC for constant pain with appropriate breakthrough By the ladder –Assess pain severity & treat accordingly For the individual –Selection of medication is patient- based With attention to detail –Assess pain regularly, adjust ATC based on breakthrough, watch side effects, etc. excelleRx, Inc. All Rights Reserved. 2012

29 Pain Treatment Options Non-pharmacologic –Heat/cold therapy –Massage –Physical/Occupational therapy –Aromatherapy –Music therapy –Spiritual/Religious counseling Pharmacologic –Non-opioids –Opioids –Adjuvants excelleRx, Inc. All Rights Reserved. 2012

30 Pop Quiz! True or False? Non-opioids are not useful analgesics for severe pain. FALSE…depends on the type of pain! excelleRx, Inc. All Rights Reserved. 2012

31 Non-opioids Acetaminophen (Tylenol ® ) NSAIDS (Non-steroidal anti-inflammatory drugs) Corticosteroids (Decadron ®, Prednisone ® ) excelleRx, Inc. All Rights Reserved. 2012

32 Acetaminophen (Tylenol ® ) Mild musculoskeletal pains (osteoarthritis); Fever No anti-inflammatory effects Ceiling effect Fewer adverse effects –No risk for GI bleeding Liver toxicity (>4gm/day) –Elderly/patients with liver disease should use 3gm/day –Inc. risk with underlying liver disease or chronic alcoholism excelleRx, Inc. All Rights Reserved. 2012

33 NSAIDS Mild-moderate inflammation related pain; Fever –Bone metastasis, arthritis, soft-tissue infiltration, recent surgery Can enhance opioid-based analgesia –When inflammation is causing pain, addition of NSAID will often reduce opioid requirements and provide better pain relief Combination of multiple NSAIDS not recommended –No evidence to suggest improved levels of analgesia –Increased risk for adverse effects and drug interactions Ceiling effect excelleRx, Inc. All Rights Reserved. 2012

34 NSAIDS Adverse Effects GI toxicity –Reduced by adding a proton pump inhibitor, H2 antagonist, misoprostol Kidney dysfunction –Inc. risk if patient dehydrated; Altered kidney blood flow Confusion Fluid retention –May exacerbate heart failure & hypertension Salicylism –Ringing in ears (tinnitus), nausea, vomiting Platelet dysfunction –Reversed by stopping NSAID –Stop Aspirin therapy 7 days prior to invasive procedure excelleRx, Inc. All Rights Reserved. 2012

35 Corticosteroids: Place in Therapy Reduces cerebral and spinal cord edema/compression Reduces edema in other areas: –Rectal/cervical tumor affecting sacral area –Reduces capsular stretch in liver, spleen, lymph nodes and adrenal glands causing visceral distention Stimulates appetite; creates feeling of well-being (euphoria) Effective for bone pain if inflammation is involved Overall effects: Mood elevation, anti-inflammatory, anti-emetic, euphoria, appetite stimulation, increased weight excelleRx, Inc. All Rights Reserved. 2012

36 Corticosteroids: Potency DrugEqual Dose Anti- inflammatory Potency Sodium- Retaining Potency Cortisone25 mg0.8 Dexamethasone0.75 mg250 Hydrocortisone20 mg11 Methylprednisolone4mg50.5 Prednisone5mg40.8 Dexamethasone produces the least amount of mineralocorticoid effect, with the highest amount of anti-inflammatory effect! excelleRx, Inc. All Rights Reserved. 2012

37 Corticosteroids: Adverse Effects Key Adverse Effects: –Insomnia/nervousness - Give last dose no later than 2-3pm in order to minimize insomnia –Hyperglycemic effects – Monitor patients with diabetes for changes in glucose control –Edema, facial hair growth (with long term use) –Weigh risks vs. benefits for use in patients with relative contraindications e.g. Diabetes; immunosuppression – What is more important at this point? excelleRx, Inc. All Rights Reserved. 2012

38 Case Discussion Current medications: Lisinopril 20mg PO QD Metoprolol 50 mg PO BID Digoxin 0.125mg PO QD Furosemide 80mg PO QAM K-Dur 20 mEq PO QD Fluoxetine 20mg QD Loperamide 2-mg after each loose stool Allergies: Sulfa drugs Assessment results: P: Constant; worsens with movement; Aspercreme & heating pad Q: Achy R: Stays over joints; no radiation S: Almost all joints; Rates as 1-2/10; will increase to 3-4/10 with movement T: Occurs at rest, at night, and w/ movement. U: Stiffness in knees/hips in the AM, but decreases after dressing. Denies fatigue, weakness, and joint redness/swelling GB is a 68-year-old male with a primary diagnosis of heart failure. His past medical history is significant for a seizure disorder, hypertension, and depression. He is complaining of generalized pain and his nurse would like to get a pharmacist recommendation. excelleRx, Inc. All Rights Reserved. 2012

39 Opioids Pain relief through binding to mu, kappa, & delta receptors –In brain & spinal cord –Binding prevents release of certain neurotransmitters involved in transmission of pain –Mu Analgesia, resp. depression, pupil constriction, euphoria, reduced GI motility –Kappa Analgesia, resp. depression, pupil constriction, dysphoria, psychomimetic effects –Delta Analgesia excelleRx, Inc. All Rights Reserved. 2012

40 Types of Opioids excelleRx, Inc. All Rights Reserved Opioid AgonistsCodeine Hydrocodone Oxycodone Meperidine Propoxyphene Fentanyl Hydromorphone Oxymorphone Morphine Opioid Agonists/NMDA Receptor Antagonists LevorphanolMethadone Opioid Agonist/ Norepinephrine Reuptake Inhibitors TapentadolTramadol Mixed Opioid Agonist/Antagonists Butorphanol Morphine/Naltrexone Pentazocine Buprenorphine Nalbuphine AntagonistsNaloxoneNaltrexone

41 Major Opioid Adverse Effects EffectManifestation Mood changesDysphoria, euphoria SomnolenceLethargy, drowsiness, apathy, inability to concentrate Stimulation of CTZ; Delayed gastric emptying Nausea, vomiting Respiratory depressionDecreased respiratory rate Decreased GI motilityConstipation Increased sphincter toneBiliary spasm, urinary retention Histamine releaseHives, itching, asthma exacerbation (rare) ToleranceLarger doses for same effect DependenceWithdrawal symptoms w/ abrupt d/c Adapted from Dipiro et al. excelleRx, Inc. All Rights Reserved. 2012

42 Morphine Short-acting (MSIR ®, Roxanol TM ) Long-acting (MsContin, ® Kadian ® ) Gold Standard of opioid agonists - most experience and data Can be administered via many routes, i.e. oral, rectal, sublingual, IV/ IM/SC, epidural/intrathecal Pharmacokinetics: –Significantly metabolized in the liver: Morphine 3-glucuronide (toxic) Morphine 6-glucuronide (active, potentially toxic) –Bioavailability ~ 40% Hepatic disease/impairment can actually increase bioavailability –Eliminated via glomerular filtration (risk in patients with renal dysfunction) excelleRx, Inc. All Rights Reserved. 2012

43 Hydromorphone Short-acting (Dilaudid ® ) Alternative to morphine – not superior in efficacy Can be administered via many routes, i.e. oral, rectal, sublingual, IV/ IM/SC, epidural/intrathecal Pharmacokinetics –Significantly metabolized in the liver: Hydromorphone 3-glucuronide (toxic) Hydromorphone 6-hydroxy metabolites (active in animals, not in humans) –Bioavailability ~ 60% Hepatic disease/impairment can actually increase bioavailability –Eliminated via urine primarily as hydromorphone 3-glucuronide (potential for renal accumulation of toxic metabolite) excelleRx, Inc. All Rights Reserved. 2012

44 Oxycodone Short-acting (OXYIR ®, Oxyfast ® ) Alternative to morphine – not superior in efficacy Routes of administration: oral, rectal (except long-acting) Available in combination with acetaminophen (Percocet ® ) or aspirin (Percodan ® ) Pharmacokinetics –Oxidized in the liver: Approximately 95% noroxycodone (inactive, questionable toxicity) Approximately 5% oxymorphone (active, twice as potent, accumulates in renal impairment) excelleRx, Inc. All Rights Reserved. 2012

45 Fentanyl Long-acting (Duragesic ® ) Alternative to morphine – not superior in efficacy, one study reports less constipating Various routes of administration – transdermal, IV/IM/SC, transmucosal, intranasal, epidural/intrathecal Pharmacokinetics –Poor oral bioavailability –Metabolized in the liver to inactive metabolites –Does not accumulate in renal dysfunction – may be preferred in patients with renal dysfunction excelleRx, Inc. All Rights Reserved. 2012

46 Transdermal Fentanyl (Duragesic) Rate of drug delivery is not the same on all 3 days –Day 1 – concentration gradient jump-started –Day 2 – concentration gradient established and starts to slow down –Day 3 – concentration gradient reaches equilibrium Significant amount of fentanyl left in patch after dosing interval is complete Never occlude, cut, or half patches to titrate dose excelleRx, Inc. All Rights Reserved. 2012

47 Transdermal Fentanyl: Patient Considerations Patient s pain is unstable –12-17 hour delay in onset of pain relief for transdermal fentanyl makes titration difficult in the face of a changing pain picture Secondary diagnoses: DM, PVD, CHD, HTN, etc. –Patient s circulation may not be sufficient to carry fentanyl from the subcutaneous depot to central sites Lean body mass –May not be enough subcutaneous fat to allow for a depot Subject to changes in body temperature –Changes in skin temperature will change absorption rate of fentanyl Medication Requirement –Not for opioid na ï ve patients. Should only be used in patients who have demonstrated tolerance and who require total daily dose of at least equivalent to transdermal fentanyl 25mcg/hr (i.e. oral morphine of 60mg.day) –Doses > mcg/hr are difficult to administer due to limitation of areas to rotate patch application excelleRx, Inc. All Rights Reserved. 2012

48 Methadone (Dolophine ®, Methadose ® ) Synthetic Opioid Quick onset of action (~30-60 mins) and high bioavailability (~ 80% PO) Long-acting properties naturally –The only liquid long acting opioid –Acute dosing has relatively short half-life –Elimination half-life increased with chronic dosing Up to 130 hours –Long acting properties start to take effect with chronic use No toxic metabolites –No dosage adjustment needed for renal impairment Typical starting dose: 2.5mg-5mg PO q12h or q8h excelleRx, Inc. All Rights Reserved. 2012

49 Methadone: Mechanism of Action R-isomer has opioid properties –Different receptor activity from traditional opioids –Greater affinity for delta receptors –Very potent analgesic –Less affinity for mu receptors –Less constipation, hallucinations, euphoria S-isomer has neuropathic adjuvant properties –NMDA receptor antagonist –Can undo wind up phenomenon –Norepinephrine reuptake inhibitor –Serotonin reuptake inhibitor Methadone is a racemic mixture (R+S) excelleRx, Inc. All Rights Reserved. 2012

50 Potential Situations for Methadone Use for Pain Morphine AllergyRenal ImpairmentNeuropathic Pain Opioid Adverse EffectsNot swallowing solid dosage forms Refractory Pain excelleRx, Inc. All Rights Reserved. 2012

51 Methadone…Challenging Situations Limited PrognosisMultiple Drug Interactions Lives alone, unreliable, poor cognitive functioning Syncope, Arrhythmia, QT Prolonging Drugs excelleRx, Inc. All Rights Reserved. 2012

52 Methadone prescribing requires knowledge of its: Unique pharmacodynamic and pharmacokinetic properties Potential for drug interactions and side effects Complex conversion ratios and protocols excelleRx, Inc. All Rights Reserved. 2012

53 Consult with knowledgeable prescriber and/or pharmacist BEFORE starting therapy with methadone excelleRx, Inc. All Rights Reserved. 2012

54 Methadone For … Pain Control vs. Addiction Maintenance Federal law prohibits pharmacies from dispensing methadone for addiction maintenance There are no limitations for dispensing methadone for pain control Common doses for addiction are high and given once daily excelleRx, Inc. All Rights Reserved. 2012

55 Long-Acting Opioid Cost Considerations Equianalgesic drug regimenQty {15 day supply}Approximate cost Exalgo ® (Hydromorphone) 32mg daily 15 tablets$$$$$$ Morphine LA tablet 60mg q12h 30 tablets$$$ Kadian ® (LA Morphine capsule) 120mg daily 15 capsules$$$$$ OxyContin ® (Oxycodone) 40mg q12h 30 tablets$$$$$$ Transdermal Fentanyl 50mcg q72h 5 patches$$$$$ Methadone 5mg q8h 45 tablets$ excelleRx, Inc. All Rights Reserved. 2012

56 Case Discussion Current medications include: Insulin glargine 40 units once daily Insulin aspart SSI prior to meals Casodex (Bicalutamide) 150mg PO once daily Amlodipine 5 mg PO once daily Allergies: No known allergies Assessment: P: Woke up with pain one AM & has remained since. Has not tried any medication for the pain. Q: Nagging throb R: Pain does not really go anywhere. S: Located primarily in hips and legs. 2/10 at worst. T: Pain started ~3 days ago and has continued intermittently. Worsens when transferring from wheel chair to bed. U: Has made transferring and requires help of his wife - difficult for her due to decreased strength. She fears that she will be unable to get him in and out of his wheel chair and that he will then become isolated JW is a 65-year-old male with a primary diagnosis of prostate cancer. He is experiencing generalized pain. He has a history of chronic renal insufficiency, hypertension, and diabetes. He is restricted to a wheel chair secondary to an injury he sustained while enlisted in the military. As a result of his disease process, he has also begun to complain of a loss of appetite leading to weight loss. excelleRx, Inc. All Rights Reserved. 2012

57 Opioid Combination Products Takes advantage of central and peripheral mechanisms of action potentiated analgesic effect Primary limitation: maximum daily dosage of non-opioid component (APAP, ibuprofen) –Examples: Hydrocodone/acetaminophen Hydrocodone/ibuprofen Oxycodone/acetaminophen Oxycodone/aspirin Codeine/acetaminophen Tramadol/acetaminophen excelleRx, Inc. All Rights Reserved. 2012

58 Opioid Selection: Poor Choices for Chronic Pain Meperidine –Poor absorption and toxic metabolites Propoxyphene –Poor efficacy, low potency and toxic metabolites Mixed agonist-antagonist –Compete with agonists -> possible withdrawal –Analgesic ceiling effect excelleRx, Inc. All Rights Reserved. 2012

59 Approach to Opioid Dosing Opioid Naïve: Start low, go slow! Opioid Tolerant Intermittent Pain: PRN Doses Persistent/Chronic Pain 1. PRN doses x 48 hrs 2. Determine ATC needs and give breakthrough q3-4 h: 10-20% of TOTAL long acting requirement Stable and Tolerating: Stay on current regimen Stable and Not Tolerating: Consider opioid rotation Unstable and Tolerating: Keep current opioid, but by % depending on pain severity Unstable and Not Tolerating: Consider opioid rotation excelleRx, Inc. All Rights Reserved. 2012

60 Titrate only when there is inadequate pain relief without side effects excelleRx, Inc. All Rights Reserved. 2012

61 When Do We Consider Opioid Rotation? Unmanageable or intolerable adverse effects Lack of acceptable analgesia/therapeutic effect Change in patient status –Patient difficulty in adhering to regimen –Difficulty swallowing –Transition from inpatient to home care excelleRx, Inc. All Rights Reserved. 2012

62 Goals for Opioid Rotation Select an opioid analgesic and develop a dosing regimen that will: –Effectively and safely manage the patients pain –Minimize the risk for adverse effects excelleRx, Inc. All Rights Reserved. 2012

63 What to do after converting? It may take 3-5 days or longer for a complete transition to occur During this time, it is essential to reassess the patient s pain and monitor for adverse effects. Titrate the new opioid as needed –Short-acting, oral immediate release, single ingredient opioids: May be increased every 2 hours –Long-acting, oral sustained-release opioids: May be increased every 24 hours Does not include methadone or transdermal fentanyl excelleRx, Inc. All Rights Reserved. 2012

64 Pain in Last Days of Life Clinical presentation –Facial grimacing –Body stiffening –Diminished kidney function Decreased perfusion, decreased clearance and accumulation of toxins excelleRx, Inc. All Rights Reserved. 2012

65 Pain in Last Days of Life What do we do? –Assess patient to best ability and patient tolerability –Rule out other causes of distress if possible & treat other symptoms if present Agitation, constipation, urinary retention –Try opioid to see if behaviors diminish –Palliative sedation may be the only viable option Intolerable pain and/or suffering Refractory to various aggressive interventions Intention is mitigation of distress, not to hasten death excelleRx, Inc. All Rights Reserved. 2012

66 Thank you for your participation! Any Questions? excelleRx, Inc. All Rights Reserved. 2012

67 References 1. American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 4th Ed Bauman T. Pain Management. In. Dipiro JT, et al. Pharmacotherapy: A Pathophysiologic Approach, 5th ed pp FitzGerald GA. Coxibs and Cardiovascular Disease. NEJM 2004; 351(17): FitzGerald GA. COX-2 and beyond: approaches to prostaglandin inhibition in human disease. Nat Rev Drug Discov 2003;2: FitzGerald GA, Patrono C. The coxibs, selective inhibitors of cyclooxygenase-2. NEJM 2001;345(6): Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain. Clinical Practice Guideline No. 9. AHCPR Publication No Rockville, MD. Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service, March Levy MH. Pharmacologic treatment of cancer pain. NEJM 1996;335(15); NSAID Alternatives. Med Lett Drugs Ther 2005;47:8. 9. Payne R. Opioid Pharmacotherapy. In. Berger A, Portenoy RK, Weissman DE. Eds. Principles and Practice of Palliative Care and Supportive Oncology. Philadelphia pp Solomon DH, et al. Relationship between selective cyclooxygenase-2 inhibitors and acute myocardial infarction in older adults. Circulation2004;109: Wallenstein D, Portenoy R. Nonopioid and Adjuvant Analgesics. In. Berger A, Portenoy RK, Weissman DE. Eds. Principles and Practice of Palliative Care and Supportive Oncology. Philadelphia pp Walsh D. Pharmacological management of cancer pain. Semin Oncol 2000;27: Wong DL et al. Wong s Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p Copyrighted by Mosby, Inc. 14. Drug Information Handbook. 9th ed. Lexi-Comp Inc; © Thomson MICROMEDEX. All rights reserved. MICROMEDEX(R) Healthcare Series Vol. 123 expires 3/2005. excelleRx, Inc. All Rights Reserved. 2012


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