Severe

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Severe ChronicPain Management

• Michael Rotblatt, MD, PharmD
• Associate Clinical Professor of Medicine, UCLA
• Sepulveda VA / Olive View-UCLA Medical Center

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Case 1 inpatient

• A 59 y.o. M truck driver with a hx of IVDU is
  admitted for acute pancreatitis
• You order MS 4-6mg IM q 4-6 hrs prn pain
• He routinely tells you that the shots dont last
  4 hrs, the nurses rarely come when called, and he
  is frequently in pain (pain scale 9/10)

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Pain is often inadequately treated

• Knowledge
• Inaccurate estimates of effective doses/durations
• Exaggerated fears/misconceptions of addiction,
  respiratory depression, regulatory scrutiny, etc.
• Attitude
• Bias against complainers, drug-seekers, IVDU
• Hassle factor Rx refills/visits, documentation

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Types of Pain

• Somatogenic (organic/physiologic)
• Nociceptive - aching or pressure
• Neuropathic - sharp, shooting, electrical,
  burning
• ex Post-herpetic, DM, Complex Regional Pain
  Syndrome (RSD -- CRPS), trigeminal neuralgia,
  phantom limb...
• Mixed
• Psychogenic - without organic explanation

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Acute vs. Chronic Pain

• ACUTE CHRONIC
• Function To warn None (destructive)
• Etiology Usually Clear Complex/obscure
• Pt. Mood Anxiety/fear Depression/anger
• MD impact Comforting Frustratr/draining
• Role of tx Control/cure Improve fxn/QOL

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Case 2

• 45 y.o. M with chronic LBP has required dosage
  escalation of Percocet twice in the last year
• At times he says his pain is 9/10 in severity,
  but his pulse is always 60-70 and BP is 130/75
• He tried stopping his medications abruptly but he
  experienced mild withdrawal sxs.
• Is he addicted to Percocet?

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Misconception 1

• Opiates tolerance dependence addiction
• Tolerance need for increasing doses with time
• Not typical may require drug-holidays
• Physical dependence dcing or abruptly reducing
  doses results in withdrawal/abstinence sxs
• N/V/D/cramps, insomnia/anxiety,
  diaphoresis/salivation/yawning
• Addiction (psychologic dependence)
• Compulsive use resulting in physical,
  psychological, or social harm
• Results in drug-seeking behavior for more than
  pain relief
• Rare in pts w/o hx of substance abuse
• Beware of labeling patients an addict

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Pseudo-addiction

• Fear of using opioids
• --- inadequate prescribing
• --- inadequate pain control
• --- appropriate drug seeking behavior
• --- patient labeled inappropriately as a
  drug- seeker
• --- inadequate prescribing.

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Misconception 2

• Pain can be measured
• Pain is subjective
• Acute pain activates the sympathetic NS -- VS
  changes
• Chronic pain does not
• Pain scale 0-10
• Pts description must be accepted at face value
• Individual tolerance is highly variable
• Emotional states, coping styles, belief systems,
  genetic differences
• Optimal dose and duration of analgesic varies
  widely

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Case 2 45 y.o. M with chronic LBP - chronic
pain - nl VS - dosage escalation of Percocet
- withdrawal sxs when stopping Percocet

• Addiction?
• Chronic pain does not affect VS
• Tolerance
• Physical dependence
• --- pseudo-addict without appropriate pain
  control

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Case 3 outpatient

• A 68 y.o. M has chronic low back pain from
  prostate CA metastases, and painful peripheral
  neuropathy from DM
• He takes 1-2 tabs of T3 about every 6 hours,
  without good relief
• He doesnt want to take anything more powerful
  that will become addicting

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Treatment Analgesic Sequence

• NSAIDS/Acetaminophen ---
• /- adjuncts
• Weak opioids ---
• /- adjuncts
• Strong opioids ---
• /- adjuncts
• Invasive procedures

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NSAIDS

• Relatively equal analgesia at max doses
• ceiling (maximum) dose
• Injectable ketorolac (Toradol) IM/IV
• Bone pain additive effects with opioids
• Adverse effects
• GI (dyspepsia, ulcers), renal, platelets,
  (allergic)
• Poor choice for chronic pain

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Acetaminophen (Tylenol)

• May be slightly weaker than NSAIDs
• Additive effects with opioids
• Safe
• Overdoses - hepatotoxicity
• Higher risk in pts with hepatic disease?
• Max dose 4 gm/day
• 325 mg tablet x 12 (2 tabs q 4 hrs)
• 500 mg tablets x 8 (2 tabs q 6 hrs)

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Opioids

• Bind to 4 CNS receptors - mu receptor
• No ceiling for analgesic effect
• Maximum dose relief of pain, side effects,
  (tylenol)
• Tolerance, dependence, addiction
• SEs
• constipation, N/V, sedation/confusion/dizzy, dry
  mouth, pruritus
• hypotension, respiratory depression
• Respiratory depression - rare rapidly develop
  tolerance
• Much higher risk of undertreating pain than
  causing resp. depr.
• Increased risk
• Opioid-naive, rapid IV bolus
• (very elderly, underlying respiratory disease,
  long half-life drugs, other drugs affecting
  respiration)

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Opioid Dosing Issues

• Maximum dose of morphine ___mg?
• Initial doses of MS
• IV
• IM
• SQ
• Scheduled vs. prn
• Duration of activity is variable
• Incomplete cross-tolerance

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Weak Opioids

• Propoxyphene (Darvon)
• pain relief aspirin, tylenol, placebo
• Darvocette
• Codeine
• T2 15mg tylenol 300mg
• T3 30mg tylenol 300mg
• T4 60mg tylenol 300mg

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Stronger Opioids Codeine congeners

• Hydrocodone - PO, DEA III
• Vicodin 5/500mg, ES 7.5/750mg HP 10/660mg
• Oxycodone - PO, DEA II
• Combinations
• Percocet, Percodan, Tylox.
• 5/325mg (typical Percocet )
• Roxicodone... 5mg
• OxyContin 10, 20, 40mg (CR)
• OxyContin abuse/black market - Oxy, Hillbilly
  heroin

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Stronger Opioids - Morphine congeners

• Morphine - PO, CR, IM/SQ, IV/PCA pump, PR
• CR MS-Contin, Oramorph SR, Kadian (QD)
• 15, 30, 60, 100 mg BID (- TID)
• Injectable Dosing 2-4 mg IV, 8-12 mg IM/SQ
• Hydromorphone (Dilaudid) - PO, IM/SQ, IV, PR
• No CR products
• Dosing 2, 4, 8 mg tabs 3 mg supps

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Stronger Opioids - Synthetics

• Meperidine (Demerol) - PO, IM/SQ, IV
• Shortest duration, most irritating, CNS toxicity
  (normeperidine), MAOI interaction
• Dose ____ mg IM/SQ
• No reason to use
• Fentanyl - IV, patch q 72 hrs, lollypop
• Patch 25, 50, 75, 100 mcg/hr
• Onset 12-24 hrs
• Methadone - long t-1/2 (24-36 hrs) --
  accumulation
• Maintains long duration crushed, NG, SL, PR, inj

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Misc. Agents

• Opioid agonist-antagonists
• Partial agonists
• buprenorphine (Buprenex)
• dezocine (Dalgan)
• Mixed agonists-antagonists
• pentazocine (Talwin-Nx)
• butorphanol (nasal spray - Stadol) for migraines
• nalbuphine (Nubain)
• No reason to use
• Addictive potential, respiratory compromise
• Ceiling effects, can precipitate withdrawal, more
  CNS SEs (delerium)
• Exception buprenorphine SL (Subutex, Suboxone)

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Misc. Agents

• Tramadol (Ultram) - 50mg tab, Ultracet (37.5/325)
• Not a controlled substance less abuse potential
• Mech
• weak opioid agonist (selective mu)
• norepi/serotonin reuptake inhibitor
• 50-100mg QID or q 4-6 hrs (400mg/day max)
• Ceiling effect not as effective as strong
  opioids
• SE/Cautions
• Nausea, constipation
• Accumulates in RF, HF, elderly
• C/I seizures (esp. pts taking an antidepressant,
  antipsychotic, MAOI)
• Potential drug intx SSRI

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Federal DEA Schedules

• Schedule 1 Extremely abusable/no medical use
• Heroin, LSD
• Schedule 2 High abuse potential triplicates
• Morphine, Dilaudid, Percocet, Codeine,
  amphetamines, ritalin, cocaine, dronabinol (THC)
  (11159.2 exemption)
• Schedule 3
• Tylenol w/Codeine, Vicodin
• Schedule 4
• Benzodiazepines, Talwin, Darvon, chloral hydrate
• Schedule 5
• Tylenol w/Codeine elixer and codeine cough
  syrups, lomotil

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Analgesic Adjuvants

• Neuropathic pain
• Antidepressants
• TCAs - amitriptyline, nortriptyline/desipramine
  (less SEs)
• Start with 10-25mg qhs
• SSRIs - inferior to TCAs
• Anticonvulsants
• Phenytoin, carbamazepine, valproate, lamotrigine,
  topiramate...
• Gabapentin (Neurontin)
• less SEs, no drug intxs, no drug levels
• Dose start 300mg/day --- 3,600mg/day max

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Analgesic Adjuvants

• Pharmacologic
• Topical Capsaicin cream, lidocaine
• Benzodiazepines - anxiolytic/muscle relaxant
• Muscle relaxants
• cyclobenzaprine (Flexeril), carsiprodal (Soma),
  methocarbamol (Robaxin), orphenidrine (Norflex)
• Dietary supplements
• glucosamine, chondroitin, SAMe, MSM...

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Analgesic Adjuvants

• Non-pharmacologic
• TENS/electrical stimulation, heat/cold
• Stretching/exercise, massage, swimming/aquatic
• Biofeedback, acupuncture, chiropractic, hypnosis,
  relaxation therapies
• Referral
• Psychiatry/psychology
• Rehab/PT
• Pain clinic
• Neurology, anesthesiology, neurosurgery

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Invasive Procedures

• Trigger point/joint injections
• Nerve blocks, neuroablation
• Intraspinal infusions
• Epidural blocks
• Intrathecal pump - morphine, clonidine, baclofen
• Spinal cord stimulator --

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Case 1 (inpatient) 59 y.o. IVDU with acute
pancreatitis not controlled on MS 4-6mg IM q
4-6 hrs prn

• the shots dont last 4 hours, the nurses rarely
  come when called, and Im frequently in pain
• MS 8-12mg IM/SQ q 4 hrs ATC (pt may refuse)
• If still not effective
• Talk to the nurses
• change the dose (10-15mg) or the frequency (q 3
  hrs)
• Consider adjuncts (sedative, muscle relaxant,
  Elavil)
• Switch to another narcotic (dilauded, fentanyl
  patch)

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Case 3 (outpatient) 68 y.o. M with metastatic
prostate CA and DM neuropathy poorly controlled
on 1-2 tabs T3 q6 hrs prn

• Place on MS Contin 15 mg Q12 hrs, with Dilaudid 2
  mg q 4 hrs prn for breakthrough pain, and Elavil
  10 mg QHS for neuropathy and sleep
• Pt returns in one month with better pain control
  but requiring Dilaudid 3-4 x/day for breakthrough
• Increase MS Contin to 30 mg Q12 hrs and increase
  Elavil to 25mg --- pt reports much better pain
  relief (only rarely uses dilaudid) and better
  sleep
• For chronic pain, many patients wont become
  pain free -- goal tolerable pain, enhance
  functioning/QOL

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Case 4

• 47 y.o. M new patient, walks in to clinic without
  an appt, presenting with chronic LBP
• He states he takes MS Contin 120 mg BID, 4
  percocets/day, flexeril 20 mg TID, and
  Nortriptylline 150 mg QHS.
• NSAIDS -- stomach upset
• He requests RXs for everything

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Potential Substance Abusers Drug Seekers

• Draining to the health care system to the
  provider
• Pseudo-addiction ? ? addiction
• Many substance abusers have real pain and do
  require strong analgesics
• Current legislative climate
• sue for under-treatment of pain
  over-prescribing pain meds

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Signs of addiction/aberrant behavior?

• Frequently requesting extra/increasing doses
• Requesting refills from different prescribers
• Lost/stolen meds
• Manipulation or deceit
• Problems with family/friends, job, the law
• Insist on injectable or short-acting drugs
• Hx of abuse with other drugs (ETOH)
• Signs/sxs - slurred speech, abscess, needle mark

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What do you do?

• To tx or not to tx?
• Occasional misjudgment preferable to withholding
  meds from patients who are in pain
• Utilize consultants/specialists - Psych, Pain
  clin
• Address addiction directly
• Objective evidence - urine drug testing
• Seeking pain relief or pain medication?
• Enlist family members
• Encourage treatment (chemical dependency/detox
  programs)

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What to do?, cont...

• Written contract (agreement)
• Identifies a single primary provider to provide
  meds
• Specifies responsibilities and conditions
• Document (Get out of Jail Free card)

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Take-Home Points

• Pain is often inadequately treated
• fears and misconceptions of using opioids
• Pain is subjective
• Tolerance vs. dependence vs. addiction
• Pseudo-addiction
• Scheduled preferred over prn dosing
• Duration of activity is variable
• Tylenol maximum dose 4 gm/day
• Narcotic maximum dose pain relief or SEs

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Take-Home Points...

• Respiratory depression is rare/difficult
• SQ/IM usually 2-3 x the IV dose
• Dont use Demerol or partial agonists/antagonists
• Use long acting oral agents (e.g. MS Contin)
• Utilize analgesic adjuncts
• Refer - Psych, Rehab/PT, Neuro, Anesth, Pain
• Substance abusers/addicted patients
• Confront addiction, single provider, written
  contract
• Document