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How to Use Pain Medicine Safely: Tips for Seniors
Tatyana Gurvich, Pharm.D., BCGP Assistant Professor of Clinical Pharmacy USC School of Pharmacy UCI Department of Geriatrics
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Historical Perspective
1950’s-1980’s: A multidisciplinary approach 1990’s: Pain is the 5th Vital Sign 2000’s: DEA’s Balanced Policy : OPIOID CRISIS!! John Bonica, MD Hospital- and clinic-based programs with physicians, psychologists, PT/OT. Narcotics were used sparingly Problems with insurance coverage emerge… “Pain is whatever the patient says it is” “Treatment of Pain is a Universal Right” - WHO Cancer pain/terminal care pain management guidelines Long-acting medicines like Oxycontin emerge… JCAHO (accredits and certifies health care facilities) mandates pain assessment and treatment JG, Compton P. Providing chronic pain management in the "Fifth Vital Sign" Era: Historical and treatment perspectives on a modern-day medical dilemma. Drug Alcohol Depend Apr 1;173 Suppl 1:S11-S21.
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The Numbers behind the Opioid Crisis
20% of patients with chronic pain receive an opioid prescription >420,000 emergency department visits related to the misuse or abuse of opioids in 2011 259 million prescriptions written for opioids in 2012 * Updated CDC guidelines for prescribing opioids Enough for every adult in the United States to have a bottle of pills
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The Opioid Crisis and Seniors
Opioid misuse among older Americans is also on the rise Older adults who misuse opioids is expected to double by 2020 In 2016, more than 500,000 Seniors received opioids in doses higher than recommended by the manufacturer *SAMHSA: State Technical Assistance Contract
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Pain is a common medical problem
50% of older Americans suffer from chronic pain Arthritis Fibromyalgia Nerve pain Chronic back pain Other chronic musculoskeletal conditions *SAMHSA: State Technical Assistance Contract
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Strong Pain Medicines related to Morphine
All work on the same receptors in the brain to relieve pain Tramadol Tylenol with Codeine Norco/Vicodin Percocet Morphine/MS Contin Oxycodone/Oxycontin Dilaudid Fentanyl Patch
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All Opioids are NOT the SAME
Short acting (4-6hrs) Long acting (12-72hrs) Combinations with Tylenol Norco, Percocet, Tylenol w/Codeine (Tylenol #3) All Have Different Potencies If Dilaudid were a Hamburger.... 5 to 7mg of Morphine equals 1mg Dilaudid Tramadol & Codeine < Hydrocodone & Morphine < Oxycodone < Dilaudid < Fentanyl (LEAST) (MOST)
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Side Effects & How to Mitigate
Constipation Chronic: laxatives (Senna/Dulcolax) + ↑ fiber intake & hydration, ↑ physical activity, stool softeners Dry Mouth Chronic: Practice regular dental hygiene, have regular dental visits, Biotene, ice cubes, drinking water Nausea/Vomiting Usually transient (2-3 days) Anti-nausea medicine can be used as necessary Consider switching to another opioid Drowsiness Usually transient when starting therapy or increasing dose Avoid drinking alcohol, operating heavy machinery, or driving Confusion Usually transient but in frail seniors may persist
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But, am I an Addict? Tolerance: Need a higher dose to get the same pain relief Dependence: Withdrawal symptoms if stopped abruptly Addiction: Dependence with abusive pleasure-seeking behavior
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Additional Risks Associated with Opioid Uses
Physical side effects : Mood changes, urination difficulties, depressed breathing, itching, osteoporosis, sexual dysfunction Symptoms of withdrawal: Abdominal cramping, pain, diarrhea, sweating, irritability Victimization: Risk of theft, deceit, assault, or abuse by persons seeking to obtain the patient’s opioids Hyperalgesia: Increased sensitivity to and/or increasing experience of pain and may require change or discontinuation Sleep apnea may be caused or worsened Driving under the influence of drugs: Especially at initiation of therapy or with changes in doses opioids can impair ability to drive or operate machinery. It is against the law and unsafe to drive or operate machinery when impaired. Life-threatening irregular heartbeat with methadone, EKG monitoring required Overdose or using with alcohol or other drugs can result in slowed breathing, coma, brain damage, death
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Factors that increase risk of dangerous side effects
History of substance abuse History mental disease High dose of Opioids:(>50 Mg Morphine/day) First time opioid user Anti-anxiety/ sleep medicine Heart and lung disease Kidney and liver disease Sleep apnea
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Seniors face additional risks
Reduced kidney function Long history of lung disease Increased risk of overdose Increased confusion Increased fall risk Polypharmacy concerns Increased risk of side effects and drug interactions Medication errors
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Recognizing Emergencies
Seek Medical Attention Urgently: CALL 911! Severe dizziness Inability to stay awake Hallucinations Heavy or unusual snoring Slow breathing Slow or no heartbeat Aren’t breathing Others can’t wake you up Lips are blue Can’t speak clearly While asleep making gasping, gurgling, or snorting sounds
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How to Use Opioids Safely
DO: FOLLOW SAFE PRACTICES DO NOT USE WITH OPIOIDS! Use: As needed only For as short a time as possible Don’t: Drive or operate machinery until you know how the medication affects you Never: Take more than prescribed Take someone else’s medicine Share your medicine Alcohol Anti-Anxiety medicines: Xanax, Ativan, Klonopin, Valium Sleep Aids: Ambien, Lunesta, Sonata, Restoril, Halcion Muscle Relaxants: Soma, Flexeril, Robaxin Other Opioids
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Talk to Your Doctor! Establish treatment goals for pain relief and function A plan should be in place for stopping opioids if treatment is unsuccessful Continue opioids only if meaningful improvement in pain AND function is observed by you and your doctor Discuss any side effects you have promptly
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It is now harder to get Opioid prescriptions
Physician’s offices Have protocols in place May require more frequent appointments Reluctant to prescribe for prolonged period of time Stay away from long acting opioids: Oxycontin/MS Contin/Fentanyl Pharmacies Reluctant to refill opioids long term Insurance companies may only pay for a 7 day supply Extra authorization is needed Delays in getting your medicine
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Tools your doctor may use when prescribing Opioids
A pain contract between you and your doctor Risks and realistic benefits of opioid therapy Patient AND Provider responsibilities for managing this therapy A pain diary to document when you use medicines Is your pain relieved? Are you better able to move about and do your activities? 24-hour recall of medication use Adjuvant Pain Medications A CURES report is now a requirement Urine drug testing Naloxone to keep you safe
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Naloxone (Narcan) It is a medication which quickly reverses the effect of an opioid medication It should ONLY be used when overdose is suspected Comes as an Injection, Spray or an Auto-Injector IF Naloxone is used you must call 911 immediately
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Who will get a Prescription for Naloxone (Narcan)
Higher-dose opioid prescription Receiving ANY opioid prescription PLUS anti-anxiety or insomnia medicine Voluntary request from patient or caregiver Patients who may have difficulty accessing emergency medical services (distance, remoteness) If you have been in an overdose situation before Suspected history of substance abuse Starting a treatment program for addiction
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Safer Alternatives
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Non-Opioid Pain Medicines
Drug Name Comments Acetaminophen (Tylenol) Doesn’t relieve inflammation Caution with liver disease Maximum dose 2-3gm daily (4 to 6, 500 mg tablets) NSAIDS Naproxen (Aleve) Also relieve inflammation Caution with kidney disease and stomach problems. Can increase blood pressure, cause fluid retention and worsening of heart failure Use lowest effective dose Ibuprofen (Motrin) Celecoxib (Celebrex) Meloxicam (Mobic)
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Selected Topical Medicines
Drug Start Dose Max Dose Concerns Lidocaine 4% Patch 1-3 patches for 12 hrs/day Rash, skin irritation 4% Gel/ Cream Apply to affected area 3-4x/day 5% Ointment & Patch Single application (5 gm or ~6 inches) 17-20 grams/day Diclofenac (Voltaren) 1% Gel 2-4 grams topically 4x/day (2g = ~1.25 inches) 8 grams/day (arms/hands) 16 grams/day (legs/feet) Application site reactions Capsaicin (Zostrix, Salonpas- HOT) Cream/ patch Thin film to affected area 3-4x/day No MAX dose Burning sensation Misc agents: Camphor oil/Menthol Biofreeze, Bengay, Tiger Balm Apply liberally Generally well tolerated
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Medicines which Prevent Pain
Drug Concerns Duloxetine (Cymbalta) Increased BP, drug/drug interactions; kidney disease; Low sodium, falls Venlafaxine (Effexor) Gabapentin (Neurontin) Sedation, dizziness, risk of falling, water retention, kidney disease Pregabalin (Lyrica) Dosages start low and increase slowly
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Where does this leave us?
Opioid use can be a problem, especially for older adults If they are necessary, they should be used with extra caution for as short a time as possible Adjuvants medications must be tried They are effective They should reduce the amount of opioids you take, and in some cases,can completely eliminate them
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Contributors to this Lecture Presentation
Ana Barron, Pharm. D. Candidate 2019 Amy Nham, Pharm.D. Candidate 2019 Liana So, Pharm.D. Candidate 2019 Katelyn Swafford, Pharm.D. Candidate 2019 USC School of Pharmacy
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