A case based perspectiveJohn E. Agens, MD

Associate Professor GeriatricsFSU College of Medicine

Copyright 2008, Florida State University College of Medicine. This work was supported by a grant from the Donald W. Reynolds Foundation. All rights reserved.

ObjectivesKnow common risks of medication options for

moderate chronic non-malignant pain in the context of medical comorbidities common in elderly patients.

Begin to approach and manage dosage increases of long acting opioid pain medication in the context of more severe chronic pain in a palliative setting.

Use functional improvement as part of a care plan for a patient who requires opioid therapy where there is provider concern about development of addiction.

Discuss adjuvant pain meds for herpes zoster pain.

Today’s AgendaWe will divide into four small groups for 8-10

minutes.

Each group will discuss a case and some questions.

There may be more than one correct option.

We will then reconvene to discuss all four cases.

Case I: Osteoarthritis PainA 73 year old female has osteoarthritis of the

knees, hips, and spine present for years but worse for six months. She has three stairs to climb into her three story home. It is so painful to do this and transfer in and out of the car that she is minimizing going out.

Acetomenophen 1000mg every 6 hours on a schedule no longer works as well as it did. Pain is ranked 5/10 throughout the day while awake and 8/10 during the above mentioned activities. She refuses joint replacement.

Consider optionsA walking program plus one of the following:add propoxyphene every six hoursadd tramadol 50 mg every six hourschange to ibuprofen 600mg every six hourschange to celexocib 100mg dailyadd codeine 30mg every six hours plus daily

senna add hydrocodone 5mg every six to eight hours prnadd oxycodone 5mg every six hours plus daily

senna

World Health Organization

Pain Management “Ladder”

Non-opiate; + / - AdjuvantAspirin, NSAID, Acetaminophen

Step 1 Mild Pain

MODERATE Opiate Plus Non-opiate; + / - Adjuvant Codeine

Hydrocodone Tramadol

Oxycodone

Step 2 Moderate Pain

POTENT Opiates Plus Non-opioid; + / - Adjuvant

Morphine Hydromorphone

Methadone Fentanyl

Step 3 Severe Pain

Medical Co-Morbidities Congestive heart failure from ischemia on

lisinopril/HCTZ 20/25mg well compensated but with 1+ chronic edema.

Chronic atrial fibrillation on warfarin 5mg dailyDepression on sertraline 150mg dailyChronic renal failure with estimated CrCl of 40ml/minPast medical history of gastric ulcer, h. pylori negative.

Do the above co-morbidities lead one to narrow the choices from the earlier slide?

Propoxyphene and TramadolPropoxyphene is metabolized to nor-

propoxyphene a cardiotoxic, non-opioid metabolite. American Journal of Therapeutics “Propoxyphene (Dextropropoxyphene): A Critical Review of a Weak Opioid Analgesic That Should Remain in Antiquity” Barkin RL, et. al. 13(6) 2006 pp 534-542

Tramadol in combination with serotonin reuptake inhibitors risks development of serotonin syndrome. British Journal of Clinical Pharmacology “Uncovering the potential risk of serious serotonin toxicity in Australian veterans using pharmaceutical claims data” July 2008 pp 1-8

Cox 2 Inhibitors and Kidney Kidney adverse effects of the Cox 2 inhibitors

are no less common then they are with traditional NSAIDS and, in the elderly, are as common as the GI side effects.

Swan SK, Rudy DW, Lasseter KC et al. Effect of cyclooxygenase-2 inhibition on renal function in elderly persons receiving a low-salt diet: A randomized,controlled trial.

AnnIntern Med 2000;133:1–9.

Drug Concernpropoxyphene Beer’s list drug, not better than

acetomenophen, toxic metabolites

tramadol increased risk of seratonin syndrome with SSRI’s like sertraline

ibuprofen risk of worse CHF, renal function, and GI bleeding

celexocib risk of worse CHF, renal function, and GI bleeding

codeine constipation, short duration of action, not a bad choice

hydrocodone as needed prn less effective than scheduled dosing

oxycodone constipation, short duration of action but does have a long acting form

Selected Guideline Osteoarthritis Research Society International 2008Sixteen experts from six countries and four

disciplines Guideline 20 “The use of weak opioids and

narcotic analgesics can be considered for the treatment of refractory pain in patients with hip or knee OA, where other pharmacological agents have been ineffective, or are contraindicated. Stronger opioids should only be used for the management of severe pain in exceptional circumstances.”

Osteoarthritis and Cartilage Volume 16 Issue 2 Feb 2008 pp 137-162

Case II: Severe Chronic PainAn 78 year old man with moderate to severe chronic

lung disease has, over the past year, developed severe pain in the left hip due to aseptic necrosis from prednisone. Surgeons will not operate because of the lung disease and chronic renal failure from prior naproxen use. He uses a cane to shift weight from the affected side which helps. Even so, he requires morphine sulfate IR 30mg every four hours except when he sleeps longer than four hours. Pain on awakening.

He ranks pain at 6/10 but it increases to 10/10 when he walks. His children take turns dressing him and getting him up daily. He can’t bend the hip without wincing.

Consider optionsIn addition to inquiring about medical power or

attorney for health care, living wills, and end of life care preferences you choose to:

simply double the short acting morphine to 60mg q 4havoid further escalation of opoids because of the riskadd long acting morphine 80mg every 12 hoursadd long acting morphine and double morphine IRadd amitriptyline 25mg at bedtime to morphine IR switch to meperidine orally every four hours

Bad Optionsmeperidine is metabolized to normeperidine

which has toxic metabolites that are renally excreted

amitriptyline can cause orthostatic hypotension, confusion, urinary retention, falls, and cardiac arrhythmias and has very high anticholinergic activity

using only short acting opioids for severe chronic pain

Severe Pain in the Elderly “… comorbidities—including cancer and noncancer pain,

osteoarthritis, rheumatoid arthritis, and postherpetic neuralgia—and patient functional status need to be taken carefully into account when addressing pain in the elderly.”

“no specific studies in the elderly have been performed, but it can be concluded that opioids have shown efficacy in noncancer pain, which is often due to diseases typical for an elderly population.”

“in practice, the art of medicine is realized when we individualize care to the patient.”

Pergolizzi J, et. Al.“Opioids and the Management of Chronic Severe Pain in the Elderly: Consensus Statement of an International Expert Panel with Focus on the Six Clinically Most Often Used World Health Organization step III Opioids (Buprenorphine, Fentanyl, Hydromorphone, Methadone, Morphine, Oxycodone)” Pain Practice Volume 8 Issue 4 pp287-313

Discussion questionsThe patient decides he wants CPR and mechanical

ventilation in the event of a cardiopulmonary arrest. How does this impact the decision making?

The patient is end stage with respect to the chronic pulmonary disease. Given the patient’s wishes above, would you still consider hospice for palliation?

After 3 weeks of MS Contin 80mg q 12h, pain is better but a total of 30mg prn short acting morphine is still needed as much as 3 X each day. What dosage of MS Contin now?

Case III: Addiction Concern68 year old female has multiple symptomatic

osteoporotic compression fractures, a history of open reduction and internal fixation of a hip fracture one year ago, and several vertebroplasty operations which failed to help her back pain. Self medicated w/ETOH.

She quit drinking alcohol after the hip surgery one year ago. She partnered with a substance abuse counselor. She attends AA on a regular basis. She smokes 2 packs of cigarettes per day. She lives alone, no family near.

She takes a bisphosphonate, calcium, and vitamin D.

Case III: Addiction ConcernInitially the patient took oxycodone/APAP

5mg/325mg every six hours. She was still in pain, but it improved enough for her to catch up with her laundry and housecleaning.

When her physician added oxycodone 12 hour long acting formulation 10mg every 12 hours she was able to do even more. When she inquired about a dosage increase her physician told her she would need to find another doctor.

The patient wants you to Rx. Write a plan for pain.

Federal Regulations 21 CFR 1306.07

May administer, prescribe or dispense a Schedule II CS to a person with intractable pain, which no relief or cure is possible or none has been found after a reasonable effort.

This is the definition of a chronic pain

patient.

Federal Regulations 21 CFR 1306.07

May treat acute / chronic pain with a Schedule II CS in a recovering narcotic – addicted patient. Federal law or regulations do not restrict the

prescribing, dispensing or administering of a narcotic medication to a narcotic–addicted patient for the purpose of alleviating pain, if such prescribing is medical appropriate within standards set by the medical community. One must keep good records to document the physician is

treating a pain syndrome, notnot the disease of narcotic addiction.

Plan of Care for PainPROBLEM INTERVENTION GOAL

LOW ACTIVITY

WALKING PROGRAM

INCREASE FUNCTION

MODERATE PAIN SCORE

OXYCONTIN q12 hours

REDUCE PAIN to MILD SCORE andWHILE INCREASING FUNCTION

ALCOHOLISM

CONTINUE AA NEGATIVE RANDOM URINE TESTS

ADDICTION RISK

DRUG CONTRACT concerning timing of med refills, not filling lost prescriptions, etc.

NO REQUESTS FOR EARLY REFILLSNO LOST PRESCRIPTIONSEXPECTED OXYCONTIN IN BLOODMD DETERMINES PLAN SUCCESS

PSYCH-BEHAVIOR

PSYCHOLOGY ASSESSMENT/ PLAN

IMPROVED MOOD, RELAXATION, PAIN BEHAVIOR

SOCIAL ISOLATION

ENGAGE IN A SENIOR CENTER ACTIVITY

VENTURE OUTSIDE OF HOME BEYOND NECCESSITIES

SMOKING ASSESS READINESS TO QUIT SMOKING

GOAL DEPENDING ON READINESS

CASE IV: NEUROPATHIC PAINA 77 year old healthy male has pain in the right

chest in a dermatomal distribution which is burning in nature. He is recovering from shingles in that same dermatomal distribution. He is getting only partial relief from hydrocodone/APAP 10mg/ 500mg every six hours. He is sleeping poorly because of the pain and has lost five pounds because he is eating less two.

On physical exam he has a depressed mood and the skin lesions from the shingles are healed. He has mild BPH. He is on no other medications.

Consider Options gabapentin 100mg three times a day, then titrating

to 300mg three times a day.

duloxetine 30mg a day, then titrating to 60mg/ day

nortriptyline 10mg bedtime, titrating up as needed

pregabalin 50mg twice a day, then titrating to 100mg

Tyring, Stephen “Management of herpes Zoster and Postherpetic Neuralgia” Journal of the American Academy of Dermatology 57(6) Supplement 1 Dec 2007 S136-162

DRUG COST SIDE EFFECTS

gabapentin $60/ mo. dizziness, somnolence, ataxia, fatigue

duloxetine $130/ mo.

nausea, dry mouth, constipation, urinary hesitancy, orthostatic hypotension, somnolence

nortriptyline $ 13/mo orthostatic hypotension, dizziness, dry mouth, confusion, QT prolongation

pregabalin $73/ mo. dizziness, somnolence, ataxia, edema