John F. Manfredonia, DO FACOFP FAAHPM HMDCNational Medical Director Gentiva / Kindred Hospice

25th Annual Southwestern Conference on MedicineApril 28, 2016

John.manfredonia@gentiva.com

Its Assessment & Concerns

with

A little bit of Management

Tucson Osteopathic Medical Foundation

It's Not About The Nail - YouTubehttps://www.youtube.com/watch?v=-

4EDhdAHrOg

https://www.youtube.com/watch?v=-4EDhdAHrOg

Disclosure Statement

Information presented is not a substitute

for

Common Sense

This in-service is intended for educational purposes only.

This presentation is in the context of chronic pain.

Objectives

►Pain Assessment

►Abbreviate Look

at

Pain Management• Non-Pharmacologic

• Pharmacologic

—Non-Opioids

—Opioids

—Adjuvant Medication

• Side-effects

• Breakthrough Pain & Rescue Dosing

Essentials of Pain Management

Upon completion of this presentation, participants will be better able to understand and describe the essential elements of…

Enhance Skills & Competencies

Promote Critical Thinking

Our Goals

Understand the basics of good optimal pain management.

With good assessment and communication skills this should assist

you in managing most patient with pain.

However

There are those patients with complex pain syndromes that require

advanced skills.

Remember

Thorough Assessment coupled with

Good Pain Management + Education and

Communication = ↓ suffering

Essentials of Pain Management

Prescription drug abuse is now the second leading cause of unintended death in the United States.

A flood of opioids, a rising tide of deaths N Engl J Med. 2010 Nov 18;363(21):1981-5.

The number of annual opioid prescriptions written in the United States is now roughly

equal to the number of adults in the population.

Centers for Disease Control and Prevention. Vital signs:opioid painkiller prescribing. July 2014 (http://www .cdc .gov/vitalsigns/ opioid-prescribing).

SAMHSA. (2013). Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.

NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD.

First-Time Use of Specific Drugs Among Persons Age ≥ 12 (2012)

8 | © CO*RE 2016

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Additional Goals and Concerns

Awareness & Management of chronic non-

malignant pain

Awareness & Management of Diversion—If suspect…need to address & document

—Responsibility to the community

—Pain Management Agreement

—Query state PDMP

—Regular visits

—Limited prescriptions (quantity)

Essentials of Pain Management

Substance Use

Disorder

Chemical Coping

Types of Pain

Essentials of Pain Management

NeuropathicNociceptive

Somatic Visceral

Intracranial

Psychogenic

Inflammation

Skin Wounds

Infection

Arthritis

Constipation

Neuropathy

Urinary Outlet Obstruction

Visceral MetastasesSpinal Metastases Bone Metastases

Bowel Obstruction

Trauma / InjuryCephalgia

Ischemia

DVT

Low Back Syndrome

Cancer Chemotherapy

Radiation Therapy Abdominal Colic

Immobility

Fracture

Renal Colic

Sciatica

What about Psychogenic Pain

►Amplification of Pain

• Contributory Co-morbidities —Depression

—Anxiety

—Post-traumatic Stress Disorder

—Substance Abuse

—Psychiatric Illness

Essentials of Pain Management

The above conditions are factors to be considered in the assessment and treatment of pain but should never contribute the dismissal of a

complaint of pain.

Assessing Pain IntensityComfortable / Uncomfortable

Severe Symptoms

Moderate Symptoms

Mild SymptomsNo Symptoms

Tolerable / Intolerable

Spontaneous…..Incidental……Continuous

Pain Scales• We should be familiar with the 10-point scale

• We also know some pts insist on 12+ points

Pain

Assessment

Essentials of Pain Management

Intensity

Location

Character

Onset

Duration

Exacerbates/Palliates

…Pain AssessmentEssentials of Pain Management

Know their Medications• Current Pain Regimen

• Dose• Route• Frequency

• Around-the-Clock• Rescue Dosing(PRN)

• Effectiveness?• Compliance• OTC

• Medications History• ETOH Consumption?• Recreational Drugs?• Medical Marijuana

Breakthrough Pain

►Definitions

• Breakthrough Pain - “a transient exacerbation of pain

that occurs either spontaneously, or in relation to a

specific predictable or unpredictable trigger, despite

relatively stable and adequately controlled background

pain”

Davies AN, Dickman A, Reid C, Stevens AM, Zeppetella G. The management of cancer-related breakthrough pain:

recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain

and Ireland. E J pain 2009;13;331-338

• Background Pain = constant or continuous pain of long

duration usually ≥ 12 hours / day.

Essentials of Pain Management

…Breakthrough Pain

Essentials of Pain Management

Types

Spontaneous Pain

Incidental Pain

Occurs Unexpectedly

Impacts Sleep & Mood

Maybe Unresponsive to Opioids

Related to Specific Events

Precipitated

Impacts of ADLs

Movement RelatedWt-bearing ActivitiesIdentifiable TriggersProcedures

…Breakthrough Pain

Acute onset of short duration

Peak ≈ 5-10 minutes

Duration ≈ 45-60 minutes

Intensity: moderate to severe

Essentials of Pain Management

Deandrea S, Corli O. A New Focus on Breakthrough Cancer Pain: Commentary on Davies et al. JPSM: Vol.46 No. 5, Nov 2013: 618-628

Characteristics(Cancer)

Uncontrolled

Pain

Essentials of Pain Management

Is the dose too low?

Is the interval too long?

PRN Dose administered?

Allodynia? / Hyperalgesia?

“Total Pain” Physical

Spiritual

Mental

Social

Recognize their Suffering

Consequences of Inadequate Pain Control

Impact

Function

Sleep

Psychosocial

↓ Activity↓ Appetite

DisturbanceDeprivation

DepressionAgitation & AnxietyFearIsolationMarital and Family DysfunctionIncreased demands on caregivers

Deconditioning

SUFFERING

Types of Pain & Pharmacologic Management

Essentials of Pain Management

NeuropathicNociceptive

Somatic Visceral

Intracranial

•Non-opioids-Acetaminophen

-NSAIDs

•Opioids

•Adjuvant Medication-Antispasmodics-Corticosteroids

•Opioids

• Opioids• Adjuvant

-Anticonvulsants-Antidepressants-Bisphosphonates-Corticosteroids-Local Anesthetics-NMDA Antagonist

• Non-Opioid• Adjuvant

-Steroid• Opioids

1st Line /Mild pain

2nd Line / Moderate-Severe Pain

Refractory Pain

Spinal/Epidural Opioids

± alpha-2 agonists

± local anesthetics

+ other agents

Selective nerve blocks

Neurostimulation

Neuroablation

IV Lidocaine

Subanesthetic ketamine

Palliative Sedation

Opioids

+ NSAIDs

+ AdjuvantsAcetaminophen

Aspirin/NSAIDs

± Adjuvants

Modified Pain ManagementStep Ladder

Fine PG. The evolving and important role of anesthesiology in

palliative care. Anesth Analg 2005; 100:183-188.

Approaching Pain Management

►Non-pharmacologic

• Many treatments

• Listening and acknowledging pain is one important

modality

►Pharmacologic

• Non-opioids

—Acetaminophen

—Nonsteroidal anti-inflammatory drugs

• Opioids

• Adjuvant Medications…see appendix B

Essentials of Pain Management

Non-Pharmacological Management of Pain

• Physical Therapy

• Manipulation

• Massage

• Psychotherapy

• Acupuncture

• Hypnosis

• Integrative Medicine

• Exercise

• Guided imagery

• Distraction

• Provide companionship

• Misc Therapies

Needs to be a Comprehensive Integration of Care

Listening

►Therapeutic Dialogue

• Generally safe

• Wide Therapeutic Index

• Over-dose very rare

• Non-invasive

• Low side-effect profile

• Efficacious

• Cost Effective

Essentials of Pain Management

Acknowledge the Pain….Address the Fear

…Non-pharmacologic

…Approaching Pain Management

►Pharmacologic

• Non-opioids

—Acetaminophen

—Nonsteroidal anti-inflammatory drugs

• Opioids

• Adjuvant Medications…see appendix B

Essentials of Pain Management

Non-Opioids Mild-to-Moderate Pain

Acetaminophen…relatively safe but…

• Analgesic / Antipyretic

• Liver toxicity possible if >3gm / 24 h

• Risk

—Advanced age / Hepatic Disease / Heavy Alcohol use

—Overdose leading cause of liver failure in US

—Combination Medication

NSAIDs…especially if inflammation is present

• Analgesic / Antipyretic / Anti-inflammatory

• Risk

—GI bleeding / Renal failure / Cardiovascular events

—Rate increases with longer exposure

—Multiple formulations available

Essentials of Pain Management

…Approaching Pain Management

►Pharmacologic

• Non-opioids

—Acetaminophen

—Nonsteroidal anti-inflammatory drugs

• Opioids

• Adjuvant Medications…see appendix B

Essentials of Pain Management

Choosing an Opioid: Factors Essentials of Pain Management

Past History

Hepatic Insufficiency

Patient’s Location

Hx of Addiction?

Allergies

Route of DeliveryAdvanced Age

Ease of Delivery

Familiarity

Optimal Rescue Dose

Opioid Naïve / Opioid Tolerant

Cost-Efficient?

Renal Insufficiency

Appropriate Dose

Best Cost

Already On

Dosing Interval

Side-effects

FormulationEquianalgesic Dose

Which Opioid do you Choose First?

Morphine is considered the Gold Standard

However

“The data show no important differences between morphine, oxycodone, and hydromorphone given by the oral route and permit a weak recommendation that any one of these three drugs can be used as the first choice step III opioid for moderate to severe cancer pain.”

Lancet Oncol 2012; 13: e58-68

MorphineEssentials of Pain Management

Usually 1st opioid of choice Bio-availability ≈ 35% orally Peak effect Duration ≈ 3-6 hours Route: PO / SL / PR / SC / IV Ratio: PO to SC/IV = 3 : 1 Pharmacology

Metabolism: LiverTolerated with mild-moderate hepatic impairmentMetabolites

Morphine-3-glucuronide (M3G)Morphine-6-glucuronide (M6G)

Excretion: 85% Urine Caution: Renal Insufficiency / Failure

Recommendation: reduce dose and/or frequency

• Oral ≈ q 60 min*• SC ≈ q 20 min*• IV ≈ q 10 min*

*approximation

Standard Protocol

Morphine …pharmacokineticsEssentials of Pain Management

Route

IV

SQ

PO

Onset

(minutes)

5-10

10-20

30-60

Peak

(minutes)

15-30

30-60

60-90

Duration(hours)

3-4

3-4

3-4

Titration(minutes)

10

10-20

120

McCaffery M, Pasero. Pain: Clinical Manual, pp 241-243. Mosby, Inc 1999

- PROPRIETARY AND CONFIDENTIAL -These materials are for internal purposes only.

Not for disclosure outside Gentiva except by written agreement.

Equianalgesic Dosing Chart

Essentials of Pain Management

PO/PR (mg)

• 30

• 30

• 7.5

• 20

• NA

Analgesic

• Morphine

• Hydrocodone

• Hydromorphone

• Oxycodone

• Fentanyl

SC/IV/IM (mg)

• 10

• NA

• 1.5

• NA

• 0.1

Methadone is too complex to include in this chart

(100mcg)

*based on single dose studies

Based on single dose studies

Table 4

Oral Route

Parenteral RoutesIntravenous / Subcutaneous / Intramuscular

Transdermal Route

Rectal RouteEffective Pain Management

Opioid Medication

Epidural / Intrathecal

Treatment Plan

Remember!

In the Beginning……It’s a Trial

Oral Route Preferable

Appropriate Dose

Under-treatment

Individualize Treatment

Over- treatment

Large Intra-individual Variation

Side-effects? Neurotoxicity

Around-the-Clock Dosing for Continuous Pain

Competent Caregiver? Hx of Substance Abuse?

Treatment Plan…opioid naive

Moderate-to-Severe Pain

1. Consider oral analgesic

2. Start with a short-acting opioid

• Hydrocodone/Acetaminophen 5/325mg 1 or 2 q 4 hrs as

needed for pain (has a ceiling dose)

or

• Oxycodone (with or without acetaminophen) 5mg q 4 hrs as

needed for pain

or

• Morphine 10mg q 4 hrs as needed for pain

3. Consider lower dose in the elderly

Essentials of Pain Management

- PROPRIETARY AND CONFIDENTIAL -These materials are for internal purposes only.

Not for disclosure outside Gentiva except by written agreement.

Treatment Plan…opioid naive

4. Titrate immediate release opioid to control pain

• If analgesia insufficient…increase dosage in 25-50%

increments until pain relief is adequate

• Caution with combination medication

• Short-acting opioid can be dosed every 1-2 hours

5. Consider switch to equivalent long-acting medication

when pain controlled…if appropriate

6. Initiate bowel protocol

7. Prescribe an Anti-emetic if necessary

8. Consider adjuvant medication…see Appendix B

Essentials of Pain Management

- PROPRIETARY AND CONFIDENTIAL -These materials are for internal purposes only.

Not for disclosure outside Gentiva except by written agreement.

Treatment Plan…opioid tolerant

Severe Pain

1. Determine current medication dose and frequency

2. Determine how much and what opioids were taken in the preceding 24 hours. .If necessary, calculate the total morphine equivalent dose

3. If appropriate, continue or increase extended release/long-acting opioid

Essentials of Pain Management

- PROPRIETARY AND CONFIDENTIAL -These materials are for internal purposes only.

Not for disclosure outside Gentiva except by written agreement.

Treatment Plan…opioid tolerant

Severe Pain

4. Titrate short-acting opioid to control the pain

-Prescribe 10% (5 to 15%) of the of the preceding 24 hr total dose every 1-2 hours until adequate pain control is achieved or distressing side-effects occur.…Avoid combination medications

5. Adjust or implement around-the-clock dosing*

-Combine the total equianalgesic dose of both the short-acting and long-acting opioids and administer every 8 to 12 hours around-the-clock

Essentials of Pain Management

- PROPRIETARY AND CONFIDENTIAL -These materials are for internal purposes only.

Not for disclosure outside Gentiva except by written agreement.

*Steady State PharmacokineticsWhen the rate of drug input and elimination are equivalent. It takes somewhere between 5 and 6 half-lives for a medication to reach steady state.

…Treatment Plan…opioid tolerant

6. Continually adjust / titrate the rescue dose of the short-

acting opioid to 10% (5 to 15%) of the total 24-hour

opioid dose and administer every 1-2 hours as needed

7. Monitor bowel movements…bowel protocol may need to

be adjusted

8. Consider an adjuvant medication…see Appendix B

Essentials of Pain Management

- PROPRIETARY AND CONFIDENTIAL -These materials are for internal purposes only.

Not for disclosure outside Gentiva except by written agreement.

Rescue Dosing Review

Rescue Dosing for Breakthrough Pain

► Calculate total daily dose taken

► Recommended to use same opioid

• Immediate Release

► Rescue dose is

• ~10% (5% - 15%) of the total daily dose

► May repeat after peak effect reached

► Oral ≈ q 1 h

► SC ≈ q 20 min

► IV ≈ q 10 min

Essentials of Pain Management

…Rescue Dosing Review

►If taking ≥ 3 rescue doses within 24 hours and

pain is expected to continue, re-evaluate and

increase baseline if indicated.

Essentials of Pain Management

RememberSteady State Pharmacokinetics

Opioid Titration Review

► For mild pain, a 25% increase.

► For moderate pain, 25-50% increase.

► For severe pain, 50% increase.

► For excruciating pain, 100% increase may be needed.

► Around the clock scheduled dose used within the last 24 hours + the total amount of rescue doses within 24 hours x percent increase (see above) = the new total opioid dose around the clock:

Essentials of Pain Management

24-hour Baseline Opioid

Dose

24-hour Rescue Opioid Dose

24-hour Total

Opioid Dose

+

= x

%Increase(see above)

AdditionalOpioid Dose

Required

New 24-hour Total

Opioid Dose

=

10% of this dose q 1-2 hrs

for Rescue Dosing

Opioid Adverse Effects(Usually Dose-Related and Drug-Specific)

Common

– Constipation

– Dry Mouth

– Nausea/Vomiting

– Sedation

– Sweats

47

Less Common– Respiratory Depression– CNS

• Cognitive • Bad Dreams • Hallucinations• Delirium• Myoclonus/Seizures

– Pruritus/Urticaria– Urinary Retention– Endocrine Dysfunction

Specific Characteristics

For detailed information, refer to online PI:

DailyMed at www.dailymed.nlm.nih.gov Drugs@FDA at www.fda.gov/drugsatfda

Know the opioid products you prescribe:

Drug

substanceFormulation Strength

Dosing

interval

Specific information about

product conversions, if availableSpecific drug interactions

Key

instructions

Use in opioid-

tolerant

patients

Product-

specific safety

concerns

Relative

potency to

morphine

Collaborative for REMS Education. © CO*RE 2015. www.core-rems.org

Remember

Optimal Pain Management can only be

achieved when the patient is properly assessed.

A thorough history

Appropriate physical examination

Identification of potential barriers

Efficient, Effective & Timely Communication →

Consistent and Timely Reassessment

Accurate and Comprehensive Documentation

Education…education…education

Essentials of Pain Management

SBAR

Summary

►You need to be particularly sensitive with

patients who have unstable psychiatric

disorders, a history of substance abuse, or

other flags for opioid misuse and may be at

increased risk for poorer outcomes with

chronic opioid therapy.

Essentials of Pain Management

Our Legacy

“…the alleviation of suffering is the

warrant of medicine and its test of

adequacy…it is a test that contemporary

medicine fails despite the brilliance of its

science and its awesome technological

power.”• Eric J. Cassell. N Engl J Med 1982; 306(1 l):639-45

Essentials of Pain Management

Questions?

Appendix A

Essentials of Pain Management

Morphine

First Drug of Choice

Onset…5-20 minutes

Titration…10-20 minutes

Conversion

PO to SQ/IV…..3:1

Parenteral Concentration

10mg/ml to 50mg/ml

Range of Daily Dose

Average…400-600mg

10%……..>2000mg

Rare…….20,000mg

Hydromorphone

Alternative to Morphine

Onset…same as morphine

Titration…10-20 minutes

Conversion to Hydromorphone SQ/IV

PO to SQ/IV……..…...5:1

Oral Morphine……....20:1

SQ/IV Morphine…… 5:1*

Parenteral Concentration

5mg/ml to 100mg/ml

*4-7 variable ratio

Table 2

Conversions

Morphine PO : SQ/IV 3 : 1

Hydromorphone PO : SQ/IV 5 : 1

Morphine to Hydromorphone

PO : PO 4 : 1

PO : SQ/IV 20 : 1SQ : SQ/IV 5 : 1 (4-7)

Fentanyl to Morphine

Parenteral: 0.1mg : 10mg (1 : 100)

2x Patch Strength = 24hr Oral Morphine Dose (mg)*

*Example: Fentanyl Patch 100ug/hr = Morphine 200mg/24-hrs

Table 3

Equianalgesic Dosing Chart

Essentials of Pain Management

PO/PR (mg)

• 30

• 30

• 7.5

• 20

• NA

Analgesic

• Morphine

• Hydrocodone

• Hydromorphone

• Oxycodone

• Fentanyl

SC/IV/IM (mg)

• 10

• NA

• 1.5

• NA

• 0.1

Methadone is too complex to include in this chart

(100mcg)

*based on single dose studies

Table 4

Patients considered opioid tolerant are

taking at least

– 60 mg oral morphine/day

– 25 mcg transdermal fentanyl/hr

– 30 mg oral oxycodone/day

– 8 mg oral hydromorphone/day

– 25 mg oral oxymorphone/day

– An equianalgesic dose of another opioid

Still requires caution when rotating a

patient on an IR opioid to a different

ER/LA opioid

Opioid-Tolerant Patients

The ER/LA Opioid Analgesics Risk Evaluation & Mitigation Strategy. Selected Important Safety Information. Abuse potential & risk of life-threatening respiratory depression. www.er-la-opioidrems.com/IwgUI/rems/pdf/important_safety_information.pdf. 2012.

≥ 1 Wk

Terms

► Allodynia — Pain resulting from a stimulus (such as light touch) that does

not normally elicit pain

► Analgesia — Absence of pain in response to stimulation that normally is

painful.

► Dysesthesia — An unpleasant abnormal sensation, whether spontaneous

or evoked.

► Hyperalgesia — Increased response to a stimulus that normally is painful.

Exaggerated response to noxious stimulus

► Hyperesthesia — Increased sensitivity to stimulation, excluding the special

senses. Exaggerated response to touch

► Hypesthesia — Diminished sensitivity to stimulation, excluding the special

senses.

► Hypoalgesia — Diminished response to a normally painful stimulus.

► Paresthesia — An abnormal sensation, whether spontaneous or evoked.

Essentials of Pain Management

Appendix B

Essentials of Pain Management

Adjuvant Medication

► Anti-epileptic

• Gabapentin

• Pregabalin

► Antidepressants

• TCA’s

• SSRI’s (minimally effective)

• SNRI’s

— Duloxitine (Cymbalta)

— Venlafaxine (Effexor)

• Trazadone

► Alpha-2 blockers

► Bisphosphonates

► Cannabinoid

► Corticosteroids

• Dexamethasone

• Prednisone

► NMDA antagonist

• Ketamine

• Methadone

► NSAID’s

• Cox 1

• Cox 2

► Miscellaneous

• Capsaicin

• Lidocaine

— Topical

— Patch (expensive)

— IV

Essentials of Pain Management

…Adjuvant Medication

Systemic CorticosterioidsDexamethasone (Decadron ®)

Dose: 4 to 16mg/24hrsFrequency: once or twice dailyRoute: PO / SC / IVRecommend

Consider PPI Taper if > 3 wks

AnticonvulsantsGabapentin (Neurontin ®)

Dose: 300 to 3600mg/24hrsFrequency: QD to TIDRoute: PO Onset of action ≈ 7 daysCaution

Sedation / Fatigue

Pregabalin (Lyrica ®) Dose 75 to 300mg BID

Commonly Used & Preferred

AntidepressantsNortriptyline (Pamelor ®)

Dose: 10 to 150mg/24hrsFrequency: usually at HSRoute: PO Onset of action ≈ 7 daysCaution

Anticholinergic effect

Duloxetine (Cymbalta ®)Dose: 60 QD or 60mg BIDFrequency: once or twice dailyRoute: PO Onset of action ≈ 14 days

Adjuvant Medication for….

Bone Pain

• NSAID

• Corticosteroids

• Bisphosphonates IV

• Radiation

Abdominal Colic (Obstruction)

● Anticholinergic

- Scopolamine

- Glycopyrrolate

● Corticosteroid

● Octreotide

Neuropathic Pain

Frequent UseGabapentinPregabalinNortriptylineDuloxetine

Infrequent Use BaclofenLidocaineKetamineMethadone?VenlafaxineAmitriptyline

Pain in Advanced Dementia (PAIN-AD) Scale

0 1 2

Breathing Normal Occasional labored breathing, short period of hyperventilation

Noisy labored breathing, long period of hyperventilation

Negative vocalization

None Occasional moan or groan, low-level speech with a neg. quality

Repeated calling out, loud moaning, groaning, crying

Facial Expression

Smiling or inexpressive

Sad, frightened, frowning

Facial grimacing

Body Language Relaxed Tense, distressed, pacing, fidgeting.

Rigid, fists clenched, hips flexed, pushing, pulling, striking out

Consolability No need to console Distracted or reassured by voice or touch

Unable to console, distract or reassure

Explanation in Appendix