General guideline for pain therapy and opioid usage

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General guideline for pain therapy and opioid
usage

• Kongkiat Kulkantrakorn, M.D.
• Associate Professor of Neurology
• Faculty of Medicine, Thammasat University

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Barriers to Effective Pain ManagementCancer and
Non-Cancer

• Failure of
• patients to comply with medication regimens
• healthcare professionals to adhere to guidelines
  and standards
• institutions to adopt and enforce guidelines and
  standards

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Healthcare ProfessionalBarriers to Effective
Pain Management

• Inadequate training in pain management
• -52 of oncologists surveyed (1994 Oregon)
  considered their training to be poor
• Poor assessment of pain
• Concern about
• -regulation of controlled substances
• -tolerance
• -side effects management
• Fear of addiction
• (AHCPR 1994,AAPM APS 1997)

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JCAHO Revised Standards for Pain Management

• Pts. have the right to appropriate assessment and
  management of pain
• Pts. are involved in all aspects of their care,
  including making care decisions about managing
  pain effectively.Counseling
• The goal of the pt.s care is to provide
  individualized care in setting responsive to
  specific pt. needs

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APS Guidelines Treatment of Acute Pain and
Cancer Pain

• Individualize therapy
• Administer analgesics regularly
• Know your opioids
• Give infant and children adequate doses
• Follow patients closely
• Use equianalgesic doses when switching opioids
• Recognize and treat side effects

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APS Guidelines Treatment of Acute Pain and
Cancer Pain

• 8. Be aware of hazards of meperidine and mixed
  agonist-antagonists
• 9. Do not use placebos to assess pain
• 10. Treat tolerance
• 11. Be aware of the development of physical
  dependence and prevent withdrawal
• 12. Do not confuse addiction with physical
  dependence and tolerance
• 13. Be alert to the psychological state of the
  patients

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AAPM and APS Consensus Statement

• Principles of good medical practice should guide
  the prescribing of opioids
• Evaluation of the patient
• Rx plan tailored to the pt.s needs and problems
• Consultation as needed, (pain medicine,
  psychology)
• Periodic review of Rx efficacy
• Documentation to support Rx plan

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AHCPR Guidelines Management of Cancer Pain

• Clinicians should
• reassure pts. and families ? most pain can be
  relieved safely/effectively
• assess pts./if pain is present, provide optimal
  relief throughout the course of illness
• collaborate with pts./families, taking costs of
  drugs and techno. into accounts in selecting Rx
  strategies
• educate pts/families about pain and its Rx plan
• encourage pts. to be active participants in pain
  Mx

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Planning of treatment in cancer pain

• Explaining the disease, course of the disease and
  its nature to the patient and his family
• Making sure his understanding
• Giving correct instructions
• Warning about possible side effects
• Taking steps to prevent drug abuse

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• - Dr. Jules Blank Oncologist and
  member,Wisconsin Cancer Pain Initiative

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ADDICTION

• A PSYCHOLOGICAL AND BEHAVIOURAL DISORDER
• HAS NOTHING TO DO WITH PHYSICAL DEPENDENCE
• CHARACTERIZED BY
• Loss of control (compulsive use)
• Continuation of drug use despite adverse
  consequences
• Preoccupation with obtaining/ using the drug
  despite adequate analgesia

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Misunderstanding Addiction

• Results in unnecessary withholding of opioid
• Pts.may be mislabeled as an addict but real
  problem is that pain is not adequately treated

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Opioid and Addiction

• Risk of addiction is rare in pts. with no Hx of
  addiction who are prescribed opioid for the Mx of
  pain
• Exposure to an opioid, even for prolonged periods
  does not produce the aberrant behaviours
  consistent with addiction

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Tolerance

• Tolerance A physiologic state resulting from
  regular use of a drug in which an increased
  dosage is needed to produce the same effect or a
  reduced effect is observed with a constant dose.
• Tolerance does not usually develop to the
  pain-relieving effects of opioids.

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Pseudotolerance

• Pseudotolerance is the need to increase dosage
  that is not due to tolerance ,but due to factors
  such as
• 1.Disease progression 5.Change in Rx
• 2.New disease 6.Drug interaction
• 3.Increases physical activities 7.Addiction
• 4.Lack of compliance 8.Diversion

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Approaches to Cancer pain management

• Pharmacologic Management
• NSAIDs/ Acetaminophen
• Opioid analgesics
• Adjuvant analgesics
• 2.Nonpharmacologic Management
• Physical modalities Exercise/ TENS
• Psychological interventions Relaxation/
  Distraction
• Invasive therapies Neuroablative / Radiation/
  Anesthetic nerve blocks

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WHO Analgesic Ladder

• Developed by WHO a guide to pharmacological Rx
  for cancer/ chronic pain
• Drug Rx cornerstone of cancer pain Rx
• 70-90 of pts. obtain adequate pain relief from
  analgesic drugs alone
• A further 20will require additional interventions

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WHO Analgesic Ladder
19
??????????????????????????????? (WHO
Recommendations for treatment of Cancer Pain)

• ???????????? (By the mouth)
• ??????????????? (By the clock)
• ????????????????? (By the ladder)
• ????????????????? (For the individual)
• ???????????????? ??????????????? (With attention
  to detail)
• WHO 1996

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• ??????????????????????????????
• ????????????????????????? ??????????????? /
  ???????????
• ??????????????????????????????,
  ????????????????????
• ??????????????????????????? ???????????????????
• ??????????????????????????????????????????????????
  ????????? (breakthrough pain)
• ??????????????????????????????
• ????????????????????? (adjuvants)
• ???????????????????????????????
• ????? ??????????????????????????
• ??????????????????????????

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???????????????????????????????
?????????????? - ?????????? - ???????? -
??????
????????????????????????????????
- ????
- ????????
- organic disease ???? ??????????,??????,
???????, ??????,
????? ???
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3-Step ladder Step 1 Primary Pharmacological
treatment
Drug therapy 1. Opioids ???? morphine,
methadone, fentanyl, tramadol,
buprenorphine 2.Neuropathic medication ????
carbamazepine, clonazepam, sodium
valproate, phenytoin, Amitriptyline, mexiletine
3.Anti-inflammatory medication ???? NSAIDs,
steroid 4.Antidepressants amitriptyline,
nortriptyline 5. ?????? ? ???? haloperidol
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Step 2 Alternate routes for opioid therapy
Systemic Intravenous Subcutaneous
infusion Transdermal
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Step 3 Alternate Routes for Opioid therapy
Celiac plexus block Splanchnic nerve
block Paravertebral nerve block Superior
hypogastric plexus block Stellate ganglion
block T1 sympathetic ganglion block Lumbar
sympathetic nerve block
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Opioid therapy in non-malignant indication
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Opioid Therapy in Chronic Nonmalignant Pain

• Undertreatment is likely because of
• Barriers (patient, clinician, and system)
• Published experience of multidisciplinary pain
  programs
• Opioids associated with poor function
• Opioids associated with substance use disorders
  and other psychiatric disorders
• Opioids associated with poor outcome

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Opioid Therapy in Chronic Nonmalignant Pain

• Use of long-term opioid therapy for diverse pain
  syndromes is increasing
• Slowly growing evidence base
• Acceptance by pain specialists
• Reassurance from the regulatory and law
  enforcement communities

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Addiction?

• Addiction
• Chronic neurobiology
• Impaired Control over use
• Compulsive use
• Continued use despite harm
• Craving
• Physical dependence
• Specific withdrawal syndrome for each drug
• Tolerance
• Adaptation diminution of drug effect over time

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• Prevalence varied from 0 up to 50 in chronic
  non-malignant pain patients, and from 0 to 7.7
  in cancer patients depending of the subpopulation
  studied and the criteria used.

Hojsted J, et al. Addiction to opioids in chronic
pain patients a literature review. Eur J Pain.
2007 Jul11(5)490-518.
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Positioning Opioid Therapy

• Consider as first-line for patients with
  moderate-to-severe pain related to cancer, AIDS,
  or another life-threatening illness
• Consider for all patients with moderate-to-severe
  noncancer pain, but weigh the influences
• What is conventional practice?
• Are opioids likely to work well?
• Are there reasonable alternatives?
• Are drug-related behaviors likely to be
  responsible, or problematic so as to require
  intensive monitoring?

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Universal precaution in pain medicine

• Diagnosis with appropriate differential dx
• Psychological assessment including risk
• Informed consent (written vs verbal)
• Treatment agreement
• Pre/Post intervention assessment of pain level
  and function
• Appropriate trial of opioid therapy /- adjuvants

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Universal precaution in pain medicine

• 7. Reassessment of pain score and level of
  function
• 8. Regularly assess four As of pain medicine
• Analgesia
• Activity
• Adverse reaction
• Aberrant behaviour
• 9.Periodic review of pain diagnosis, co-morbid
  conditions and addictive disorder
• 10. Documentation

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Opioid therapy for NeP

• Should be titrated for efficacy vs AE
• Prefer fixed dose regimen, rather than prn
• Proactive management of side effects
• Understand distinction among addiction, physical
  dependence, and tolerance
• Document treatment plan and outcome with common
  understanding among involved parties

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Gabapentin and opioid
Gilron I, et al. N Engl J Med 20053521324-34
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J Pain Symptom Manage 2007 34183-9
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Migraine and other headaches

• Not the first line treatment, esp in ER
• May be effective as rescue treatment, but may
  cause quick tolerance
• Not use for long term daily treatment, lose
  efficacy overtime and high recurrence
• For chronic headache, needs to rule out other
  causes, esp medication overuse

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Others

• Fibromyalgia
• Weak opioid can reduce pain, along with other
  treatment (TCA, exercise, etc)
• Musculoskeletal pain
• Weak opioid as first option
• For patients who failed NSAIDS or Paracetamol
• Study in OA, chronic back pain 30 mg per day
• Visceral pain
• Example chronic pancreatitis, pelvic pain

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Recommendations for using opioids inchronic
non-cancer pain

• European Journal of
  Pain, 2003

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• A clear-cut diagnosis of the cause seems to
  improve patient outcome with opioids
• Use of opioids without a clear Dx is
  appropriate if the pain is severe continuous,
  and is responsive to opioids

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• Opioids should not be prescribed for idiopathic
  pain
• Chronic pain is likely to benefit from a
  multimodal therapy
• Strong opioids should not be used as monotherapy

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• The baseline pain level, QOL, functional
  status should be assessed carefully
• At the end of the trial period, pain level,
  intensity of A/E, QOL, functional status
  should be assessed again
• The balance between pain relief A/E must be
  acceptable to Pt

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• Full assessment of psychosocial status Hx
• If Pt has Hx psychiatric illness, a full
  psychiatric analysis should precede initiation of
  opioid prescription

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• Pt with drug or alcohol abuse should be referred
  to pain clinic
• If a pain team considers that Pts compliance
  would be inadequate, then Pt should not receive
  opioid prescription

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• Such preparations should be taken regularly (by
  the clock) rather than as needed
• As a rule, short-acting opioids should be avoided
• The optimum dose is essentially determined by the
  patient

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• Monitoring of Patient includes
• - pain relief
• - adverse effects
• - Pts functional status
• - QOL
• - Pts use of other drugs
• Functional goals must be individualized, will
  depend on Patient

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• Ideally, a single physician or members of one
  team should be responsible for the prescription
  of opioids
• Hx non-compliance or abusive behaviour, access
  should be restricted to
• 1 prescribing physician / team and
• 1 dispensing pharmacy

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• Fully informed about the nature of their Px, and
  its possible benefits harmful effects
• Agreement about the conditions for stopping
  opioid treatment
• Agreeing a contract shows that Pt is committed to
  the aims of treatment

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• Treatment may be stopped, or the dose reduced
• Treatment should be stopped in case of poor
  compliance.

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Useful questions for assessing patients before
opioid treatment

• Has a realistic attempt been made to diagnose
  the underlying cause of pain?
• Have other reasonable treatments been properly
  tested and exhausted?

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• Does the patient have a history of mental
  illness, or substance or alcohol abuse?
• What is the patients current functional status?
• What improvement in functional status is
  desired, and how will this be measured?

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• Has the patient kept a pain diary?
• Does the patient understand and accept the goals
  of treatment?
• What is the patients physical and psychosocial
  status?

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Factors predicting outcome with opioid treatment
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Negative predictors

• Non-opioid responsive pain type
• Evoked pain, paroxysmal pain or pain on weight
  bearing
• History of drug or alcohol abuse
• History of psychotic illness
• Patient without a clear idea or desire for
  functional improvement

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Positive predictors

• Continuous pain with high pain intensity
• Clear-cut pain diagnosis
• Spontaneous pain
• Limited treatment period
• Positive outcome of intravenous opioid testing

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Positive predictors

• Younger age (fewer adverse effects)
• Patient accepts treatment goals
• Patient has kept a pain diary
• Patient makes attempts to maintain physical
  fitness
• Patient has good psychosocial status

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