Download - Pain Management in the Aging Population
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Pain Management
in the Aging
Population
Janice Summach, BSP
June 8, 2016
Prepared for the Saskatchewan Seniors Association Annual Conference 2016. Heritage Inn
Saskatoon.
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Disclosure
• Clinical Pharmacist at Wellive
Pharmacy Services in Saskatoon
• Specialty in Seniors Medicine
• I disclose that I am on salary while
speaking at the conference today
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Definitions• Pharmacist -- dispenser of medication.
Provide medication information to
patients.
• Clinical Pharmacist -- review patient
medical information, make
recommendations to patients,
prescribers and drug plans to ensure
clinical appropriateness of medication.
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Definitions continued
• Pain -- an unpleasant sensory and
emotional experience arising from
tissue damage
Canadian Agency for Drugs and Technologies in Health (CADTH Rapid Response Service)
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Three Main Pain
Types• Classifications:
• Acute
• Chronic
• Palliative
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Acute Pain• Caused by injury, surgery or sudden
illness
• Often intense pain that goes away -- with
or without treatment
• could be osteoporosis / fracture pain
• could be stomach pain / GI pain / liver /
kidney / gout
• Acute pain has its own treatment protocol WebMD
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Palliative Pain• End of Life Care
• Comfort is the focus of treatment
• Preserve quality of life
• No concern about addiction
• Palliative Pain has its own treatment
algorithm
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Chronic Pain
• Everyday Pain
• Sometimes worse sometimes better
• Present for 6 months or longer
• Common in the older population
• Reported in 20% - 50% of patients
Canadian Agency for Drugs and Technologies in HealthInternational Association for the Study of Pain
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Common Causes of
Chronic Pain• Joint Pain or Bone Pain
• Muscle / Tendon Pain
• Nerve Pain
• Headache
• Lower Back Pain
Canadian Agency for Drugs and Technologies in Health
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Prescribing Guidelines• Are people falling through the cracks in our
healthcare system?
• Why?
• Are we treating people? The whole person?
• Or are we treating disease?
• clinical trials vs. complex lives of real people
• Lets treat the patient, not the pain
http://rxrisk.org/too-many-drugs/. Mangin D. May8, 2016.
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Adjusting the Mind-Set• I suffer (in these ways) because I have
pain almost all of the time
• or
• I want to live well despite my
(background) pain
• complete pain resolution is
unrealistic in chronic pain
Rx Files. June 2013. Regeir L. Opioids and CNCP - what pharmacists can do to better address both pain & addiction /
diversion.
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Multimodal Approach• Goal Orientation (what would success look like
to you?)
• Oral Medications
• Topical Medications
• Pain Journal
• Exercise | Pacing Techniques | Relaxation Techniques (anxiety
increases pain) | Stress Management (worry increases pain) |
Behavior Therapy | Breathing Techniques
Rx Files. June 2013. Regeir L. Opioids and CNCP - what pharmacists can do to better address both pain & addiction /
diversion.
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Aging Organs Affect
how we Process
Drugs• liver
• kidney
• GI tract
• heart
• lungs Increasing side effects
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Our Focus for Today
• Relatively healthy older adult
• Experiencing symptoms of Chronic Pain
• Lets talk about options and solutions
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Oral Medications
• have a place in pain therapy
• adverse effects
• evaluate risks vs. benefits
• adverse effects increase with age
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Narcotics (Opioids)• can induce a slow heart rate, weak pulse, dizziness
• increased risk of falls / fractures
• can cause confusion, hallucinations (dementia)
• increased risk of bowel obstruction & constipation
• can be habit forming people will do anything, to cure
dementia...except stop taking their narcotic) (
sweetest person turns into a monster- try taking away)
• can cause problems with urinationRx Files. Lorne Regier. March 2011. The comparative safety of analgesics in older adults with arthritis (Solomon et al)
Canadian Agency for Drugs and Technologies in Health
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Acetaminophen• most popular over the counter pain medication
• commonly used for osteoarthritis of the knee or hip
• very safe for people who do not consume alcohol
• toxic if taken in quantities greater than recommended on
the package
• avoid in patients with decreased liver function (reduce
dose in senior population [1/2])
• #1 cause of liver failure in the USA
Canadian Agency for Drugs and Technologies in Health
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NSAIDS Non-Steroidal Anti-Inflammatory Drug
Aspirin, Ibuprofen, diclofenac, naproxen,
indomethacin
• Great anti-inflammatory properties
• Risk of:
• Gastro Intestinal Upset and Bleeding
• Cardiovascular Complications
• Renal ImpairmentRx Files. Lorne Regier. March 2011. The comparative safety of analgesics in older adults with arthritis (Solomon et al)
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Not all Topical
Medications are
Equal• Base
• Active Ingredient
• Qualified Personnel, Regulated Facility
• emerging evidence
• under-utilized
• misunderstood
Carbno R. May 2016. Transdermal Pain Talk. Wellive Pharmacy Services
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Technologically
Advanced Base• not available in all pharmacies
• how deep does it carry medication
into the tissue?
• how well does it absorb into the skin?
• will patients use it? Is it
pharmaceutically elegant?
Carbno R. May 2016. Transdermal Pain Talk. Wellive Pharmacy Services
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Ingredients of the
Highest Quality• are medication powders manufactured in a facility
that is regulated by the FDA or Health Canada?
(molecules from China cost less, but hold no
guarantees)
• compounder must know how best to design a
custom medication that incorporates the
ingredients required
• does the pharmacy send samples away to a lab for
quality assurance testing?
Carbno R. May 2016. Transdermal Pain Talk. Wellive Pharmacy Services
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Certified Compounding
Personnel• Does the compounding pharmacy
require that compounding specialists be
specially trained?
• Does the pharmacy have specialized
equipment to ensure all molecules
properly are incorporated into the
cream in exact amounts?
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Benefits of
Transdermal• less adverse events
• dizziness
• stomach upset
• liver
• kidney
• less medical
condition
interactions
• high blood
pressure
• heart disease
• stomach ulcers
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Transdermal Options• gabapentin -- nerve pain
• ketoprofen -- affinity for
synovial joint space
• amitriptyline--nerve pain
• baclofen-muscle relaxant
• lidocaine -- anesthetic
• Cetyl Myristoleate --
osteoarthritis
• glutathione -- supports
cartilage
• magnesium -- supports
cartilage, and muscle
function
Glasnapp A. 2016. A new approach to arthritis. PCCA Apothogram.
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Alternative Therapies
• chiropractor
• physiotherapy
• massage
• Hot water bottle / heating pad
• Puzzles
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Supplements for Pain• Magnesium Glycinate (less diarrhea)
• Fish Oil (small fish contain less heavy
metal contamination)
• Glucosamine Sulfate
• Vitamin D
• good Multi Vitamin
Glasnapp A. 2016. A new approach to arthritis. PCCA Apothogram.
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Before we move on:
Summarize• we’ve talked about
• differences is processing meds as we
age
• different types of pain
• different pain treatment options
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now lets talk about
• Money
• cost to the patient
• cost to society
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Two Reasons to
Take Medications• Medications that keep us
well now
• improve daily quality of
life
• reduce pain
• increase energy
• Medications that prevent
future illness
• consider ones life
expectancy
• consider an individuals
risks and benefits
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There is a Move to Reduce
Medications in the Elderly• Improve Quality of Life
• Maintain Kidney and Liver Function
• Reduce the Chance of Falls
• Reduce the Risk of Adverse Events
BPJ issue 27. a practical guide to stopping medicines in older people
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The road to --
Too many meds• knee pain
• ibuprofen added (1)
• time passes
• dr visit
• high blood pressure
• diuretic added (2)
• time passes
• gout (3,4)
• stomach pill (5)
• sleep (6)
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the cost of too many
meds• topical cream
~$95/m
• ibuprofen ($10)
• diuretic (20/3=$7)
• gout (20/3=$7) + ($20)
• stomach pill ($20)
• sleep pill ($20-$46)
• $84- $100/m
Saskatchewan Drug Formulary
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De-Prescribing
• more pills = more drug interactions (a single
pill may be beneficial on its own, but added to
other medications and conditions could cause
more problems then it solves)
• evaluate benefits vs. risk of continuing med
• is this a no benefit seen for 10y med?
• stop or decrease only one medication a month
http://rxrisk.org/too-many-drugs/. Mangin D. May8, 2016.
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Reassess Treatment
Often
• when a drug does more to you than for
you
• it is time to re-assess therapy
BPJ issue 27. a practical guide to stopping medicines in older people
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Everything in
Moderationa) more is better -- may increase side effects without
improving benefit
b) less is more -- must take lowest effective dose to
receive benefit
c) balance-- key to quality of life
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Blood Levels• lower limit
• upper limit
• toxic levels
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Choosing the Right
Treatment for You
• understand that you have lots of options
• understand that every option has good
and bad
• rely on a healthcare team that you trust
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Regular Medication
Reviews• Make an appointment to speak to a pharmacist annually
• What was best for you last year, may not be best for you
this year
• Sask Health will pay for 1 x15minute review once yearly,
and 2 x 5 minute followups (improving safety)
• Complex consults take up to 1 hour, and are associated
with extra costs (improving QOL)
BPJ issue 27. a practical guide to stopping medicines in older people
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Not all Medications Qualify
for the Seniors Drug Plan• over-the-counter medications not
covered
• topical compounds-- not covered if
active ingredient is available in oral
form
• new medications are not on the benefit
list
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What You Can Do• Talk to your legislators
• Recognize that topical meds cost $
• but, Global Savings to be Realized
• < drug interactions
• < organ damage
• = < hospitalization $$
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Questions?