Pain Management vs. Diversion Part Ipharmacy.auburn.edu/oti/pdf/oti-jackson4.pdf · 2019-06-26 ·...

Pain Management vs. DiversionPart I

Kenny Jackson, PharmD

Professor and Senior Associate Dean of Academic Affairs

Larkin University College of Pharmacy

Editor-in-Chief

Journal of Pain and Palliative Care Pharmacotherapy

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Disclosure/Conflict of InterestI, Kenny Jackson, have no actual or potential conflict of interest in relation to this program.

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“The Larger Bowl”“While others only see the worst, such a lot of pain on the earth…”

“Such a lot of pain on this earth, it's somehow so badly arranged…”

Lyrics by Neal PeartSnakes and Arrows / Rush 2007

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Learning Objectives – Part 1

Define pain including distinction of acute versus chronic pain syndromes

Discuss use of pain assessment tools in opioid naive patients and opioid experienced patients

Describe a multi-modal pain treatment approach

Review pros/cons for available non-opioid treatment options for pain

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Our Patient• LS is a 49 year old Hispanic female that presents to your clinic.

• History Type 2 NIDDM, Hypertension, Dyslipidemia, OA knees Present with worsening ambulation and bilateral foot pain (NRS 7/10)

• Height 5’4”; Weight 190 lbs; BMI 34; HR 80; BP 130/80

• Labs: A1C 9; LDL 220; HDL 40; TG 200; BMP WNL

• Medications Hydrocodone/APAP 5/325 PRN Naproxen 220 mg (OTC) PO PRN Omeprazole 10 mg (OTC) PO PRN Acetaminophen 500mg (OTC) PO PRN Glipizide 5 mg PO once daily Furosemide 20 mg PO once daily Atorvastatin 10 mg PO once daily 5

PainPain is an unpleasant sensory andemotional experience associated with actual or potential tissue damage ordescribed in terms of such damage.

International Association for the Study of Pain, 1979

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Pain is a Problem!Condition Incidence Source

Chronic Pain 100 million AmericansInstitute of Medicine

of The National Academies

Diabetes

25.8 million Americans

(diagnosed & estimated

undiagnosed)

American Diabetes Association

Coronary Heart Disease

(heart attack & chest pain)

16.3 million Americans American Heart

Association

Stroke 7.0 million Americans

Cancer 11.9 million Americans

American Cancer Society

http://www.painmed.org/PatientCenter/Facts_on_Pain.aspx.7

Neal DR, Jackson KC. Pain Management, in Boh’s Pharmacy Practice Manual: A Guide to the Clinical Experience, 4th Ed. 2015 8

Pain Pathophysiology• Transduction Noxious stimulus initiates impulse at source

• Transmission From periphery to CNS

• Perception At cerebral cortex Prior to this, the impulse is nociception, not pain

• Modulation Lessening of pain through downward impulses Endorphin system

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The Pain Pathway

Pain stimulus

Dorsal horn

Sensorycortex

Dorsal rootganglia

Perception

Modulation

Transmission

Transduction

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Pain ContinuumAcute Recent onset, transient,

typically associated with traumatic incident

Chronic (Malignant or Nonmalignant)

Persistent or recurrent pain, beyond usual course of acute illness or injury

Breakthrough Transient pain, severe or excruciating, over baseline of moderate to severe pain

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Chronic Pain• 22% of primary care visits focus on pain• Chronic pain patients visit primary care providers up to

5 times more often than patients with other chronic conditions

• Cost to United States (US) healthcare is $261-300 billion/year

• Lost productivity estimated $297-336 billion/year• Opioids accounted for 20% of overall drug cost

• $3.57 billion/year between 2000-2007

Rasu RS, et al. J Manag Care Pharm. 2014. 13

Pain TypesPathological perspective

• Nociceptive Somatic Visceral

Neuropathic Peripheral Central

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Nociceptive Pain• Activation leads to signal initiation

• Involves a number of inflammatory agents protons, prostaglandins, bradykinin, serotonin,

adenosine, histamine, cytokines

• Activation and Sensitization of “healthy” nociceptors • Can be thought of as “normal” pain

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Dorsal Horn

Primary Afferent

NociceptiveTransmission

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Primary Afferent

Substance PCholecystokininProstaglandinBradykininOthers

Nociceptive Transmission

Neuronal Impulse

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Dorsal Horn

Primary Afferent

NociceptiveTransmission

Substance PCholecystokininProstaglandinBradykininOthersNeuronal Impulse

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Neuropathic Pain• Etiology Primary lesion or dysfunction in the nervous system

(IASP) Disordered peripheral or central nerves Compression, transection, infiltration, ischemia,

metabolic injury

• Independent of afferent nociceptive pathways Can occur without peripheral nociceptive stimulation

• Varied types peripheral, deafferentation, complex regional syndromes

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Primary Afferent

Nociceptive Transmission

Neuronal Impulse

Excitatory (Chemical)Glutamate

Inhibitory (Chemical)GABA? NE/SE

DorsalHorn

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Dorsal Horn

Primary Afferent

Neuropathic Transmission

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Primary Afferent

Neuropathic Transmission

Ectopic ImpulsesNerve ImpingementMetabolic destructionChemical destruction

Dorsal Horn

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Our Patient – What Type of Pain?Spend 2 minutes with your Neighbor…

• LS is a 49 year old Hispanic female that presents to your clinic.




• Medications Hydrocodone/APAP 5/325 PRN Naproxen 220 mg (OTC) PO PRN Omeprazole 10 mg (OTC) PO PRN Acetaminophen 500mg (OTC) PO PRN Glipizide 5 mg PO once daily Furosemide 20 mg PO once daily Atorvastatin 10 mg PO once daily

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Mixed Type

Nociceptive vs Neuropathic?

NociceptivePain

Neuropathic Pain

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Pain Assessment: Goals• Characterize the pain Identify pain syndrome Infer pathophysiology

• Evaluate physical and psychosocial co-morbidities Interaction with pain Impact on treatment

• Understand medication/substance use• Assess pain impact on life Annoyance vs disability

• Develop a therapeutic strategy

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Components of Pain Assessment

• Pain type (nociceptive, neuropathic, both)

• Pain intensity

• Pain source if known

• Pain location

• Pain duration

• Time course persistent, intermittent, fluctuating

• Alleviating factors medications, positioning, heat, cold,

etc

Aggravating factors walking, sitting, lying on back, etc

Pain affect Mood

Effects on activities of daily life Effects on quality of life Effects on functional capacity Presence of common barriers Patient’s goal History or risk factors for substance

misuse

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Question• What is the primary source of information for pain

assessment?

• Discuss your perception of which elements of pain assessment you struggle with or possibly have neglected.

• Discuss for 3 minutes…

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Pain HX MnemonicO Other associated SX (e.g. N/V, depression)

P Palliative/provocative factors (e.g. use of heat/cold, medications, massage)

Q Quality (e.g. burning, tingling)

R Region/radiation (e.g. LBP w/tingling in legs)

S Severity (AKA pain intensity)

T Timing (e.g. when started, time of day, continuous vs intermittent)

U Untoward effects on ADL & QOL

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General Pain History• Temporal features: onset, duration, course, pattern

• Intensity: average, least, worst, and current pain

• Location: focal, multifocal, generalized, referred, superficial, deep

• Quality: aching, throbbing, stabbing, burning

• Exacerbating/alleviating factors: position, activity, weight bearing, cutaneous stimulation

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Other Factors in Pain History• History of substance misuse or risk of a substance use disorder Prescription and illicit substances

• Presence of common barriers Assessment and TX

• Patient’s goal Intensity Function ADL (Activities of Daily Life) QOL (Quality of Life)

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Validated Pain Scales• Pain is subjective

• Visual analog scale (VAS) 10 cm line

• Numerical rating scale (NRS) Scale of 0-10, with zero as no pain and 10 being pain as bad as it can be,

what is your pain number now?

• Specialized scales Wong-Baker Faces scale Poker chip tool

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Determining When to Initiate or Continue Opioids for Chronic Pain

• Recommendation 2: (category: A; evidence type: 4)• Before starting opioid therapy for chronic pain, clinicians

establish treatment goals, including realistic goals for pain & function, & consider how opioid therapy will be discontinued if benefits do not outweigh risks.

• Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain & function that outweighs risks to patient safety. Clinicians may use validated instruments such as the 3-item

“Pain average, interference with Enjoyment of life, & interference with General activity” (PEG) Assessment Scale to track patient outcomes.

Clinically meaningful improvement has been defined as a 30% improvement in scores for both pain & function.

• Because depression, anxiety, & other psychological comorbidities often coexist with & can interfere with resolution of pain, clinicians should use validated instruments to assess for these conditions & ensure that treatment for these conditions is optimized.

CDC Opioid Guidelines Recommendation Highlights

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PEG

Krebs EE, Lorenz kA, Bair MJ, et al. Developing and Initial Validation of the PEG, a Three-Item Scale Assessing Pain Intensity and Interference. J Gen Intern Med. 2009.

24(6):733-8. 36

Our Patient – Take turns Assessing Pain… (5 minutes)

• LS is a 49 year old Hispanic female that presents to your clinic.





Screening Tools for Opioids & Substance Misuse

• ORT: Opioid Risk Tool Simple 5 Question Tool

• SOAPP: Screener Assessment for Patients with Pain Proprietary Multiple versions (8, 14, & 24 Question Versions)

• CAGE-AID: CAGE Adapted to Include Drugs Simple 4 Question Tool

• COMM: Current Opioid Misuse Measure Proprietary 17 Questions

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Common pharmacological treatments• NSAIDS/APAP

• Antidepressants Tricyclics (TCAs) SNRIs

• Anticonvulsants Gabapentinoids

Gabapentin & Pregabalin

• Topical agents Lidocaine Capsaicin

• Opioids

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APAP & NSAIDS• Generally helpful for initial mild (maybe moderate) pain presentations and

for short-term use

• Widely Available and Used! APAP

OTC/Rx Single and multi ingredient agents

NSAIDs OTC/Rx

• Toxicity APAP – Hepatotoxicity NSAIDs – GI, Renal, Cardiac

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TCAs

• Tertiary amines

Amitriptyline (Elavil, Endep, generic)

Clomipramine (Anafranil, generic)

Doxepin (Adapin, Sinequin, generic)

Imipramine (Tofranil, generic)

Trimipramine (Surmontil)

• Secondary amines• Desipramine (Norpramin, generic)

• Nortriptyline (Pamelor, generic)

• Protriptyline (Vivactil)

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Adverse Effects• Anticholinergic effects Dry mouth, constipation, blurred vision, urinary retention, dizziness, tachycardia,

memory impairment, delirium

• Sedation

• α1-adrenergic effects Orthostatic hypotension/syncope

• Cardiac conduction delays/heart block Arrhythmias, Q-T prolongation

• Other side effects Weight gain Excessive perspiration Sexual dysfunction

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Tertiary vs. Secondary• Mechanism of action Mixed 5-HT/NE presynaptic reuptake inhibitors Tertiary amines: 5-HT > NE (except for clomipramine) Secondary Amines: NE > 5-HT

• Side effect profile Anticholingeric: 3º > 2º Sedation: 3º > 2º Orthostatic hypotension: 3º > 2º Seizures: 3º > 2º Conduction abnormalities: 3º > 2º

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Anticonvulsants: Neuropathic Pain• Variety of mechanisms• Old versus New• Trigeminal neuralgia• Sharp, shooting, electrical, shock-like

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Anticonvulsants: Neuropathic Pain• 1st Generation Carbamazepine Phenytoin Valproic Acid

• 2nd Generation Gabapentin Oxcarbazepine Lamotrigine Topiramate

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Anticonvulsants & Neuropathic PainFirst Generation• Data• Toxicity• Serum Monitoring

Second Generation• Better SE profile• NO serum monitoring • Lack of “hard” data compared to 1st

generation

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Gabapentin Titration

• 100 mg po q d to tid, then titrate Increase dose q 1–3 d

Usual effective dose 900–1800 mg / d; max may be > 3600 mg / d

Adverse effects

Sedation, dizziness and gait issues, headache and peripheral edema

Tolerance can develop within days for CNS issues

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Dworkin, et al. Mayo Clin Proc March 2010; 85(3)(suppl):s3-14. 48

Muscle Relaxants• Heterogeneous MOA

• Primarily work via CNS mechanism

• Potentially useful in acute musculoskeletal pain Conflicting evidence Often used in combination with NSAID

• Controversial in chronic musculoskeletal pain No FDA indication Lack of quality evidence

• Adverse effect profiles limit utility

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Agents by MOATraditional Agents• Antihistamine Orphenadrine

• CNS Depression (Sedatives) Carisoprodol (Metabolized to meprobamate; Schedule IV) Chlorzoxazone, metaxalone, methocarbamol

• TCA-like Cyclobenzaprine

Antispasticity Agents• Central Alpha-2 Agonists Clonidine (intrathecal), tizanidine (antispasticity agent)

• GABA Agonists Baclofen (antispasticity agent) Benzodiazepines (also Schedule IV)

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SMR: Acute LBP Overview• Appear to decrease discomfort Analgesia or sedation?

• Adverse effects complicate use Gait, sedation

• Beneficial with NSAID?

• May be option when NSAID and/or Opioid not indicated

• Avoid carisoprodol (meprobamate metabolite)

Van Tulder M, et al. The Cochrane Library 2003.Browning R, et al. Arch Intern Med 2001.

Jackson KC. Drugs of Today 2004. 51

Multimodal Analgesia• Strictly defined Administration of 2 or more drugs that act by different mechanisms for providing

analgesia.

• Broader definition A balanced approach to treating pain by combining adjuvants, analgesics, opioids,

and regional techniques.

Moucha CS, Weiser MC, Levin EJ. Current strategies in anesthesia and analgesia for total knee arthroplasty. J Am Acad Orthop Surg. 2016;24(2):60-73.

Gritsenko K, Khelemsky Y, Kaye AD, et al. Multimodal therapy in perioperative analgesia. Best Pract Res Clin Anaesthesiol. 2014;28(1):59-79. 52

Goals of Multimodal Analgesia• Provide superior pain control Modify several pain pathways

• Minimize adverse effects

• Decrease or eliminate need for use of opioid medications

Moucha CS, Weiser MC, Levin EJ. J Am Acad Orthop Surg. 2016;24(2):60-73.

Gritsenko K, Khelemsky Y, Kaye AD, et al. Best Pract Res Clin Anaesthesiol. 2014;28(1):59-79.

American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116(2):248-273. 53

Neuropathic Pain: Rational Polypharmacy

• Examples of Options Antidepressant + Anticonvulsant

Duloxetine + Gabapentin Multiple Anticonvulsants

Pregabalin + Topiramate Opioid + Antidepressant + Anticonvulsant

Oxycodone CR/IR + Desipramine + Oxcarbazepine

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Our Patient: What Next?• LS is a 49 year old Hispanic female that presents to your clinic.





Pain Management vs. Diversion Part Ipharmacy.auburn.edu/oti/pdf/oti-jackson4.pdf · 2019-06-26 ·...

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