Chronic Pain Management and the Pharmacist's Role

Sukhvir Kaur, PharmD, BCACPDirector of Assessment and Assistant Professor

California Northstate University College of Pharmacy

Disclosure

I or my spouse have no actual or potential conflict of interest in relation to this program.

Discuss the role of a pharmacist in the management of chronic pain.

Perform an appropriate pain assessment taking into account the characteristics and nature of the pain stimuli.

Discuss non pharmacologic and pharmacologic options available for the treatment of chronic pain including its place in therapy and potential risks with their use.

Develop a therapeutic plan for patients with chronic pain that maximizes patient response while minimizing adverse events and other drug-related problems.

Educate and advocate for patients about effective pain management strategies.

Learning Outcomes

Defined as “any pain that persists beyond the anticipated time of healing”

Nociceptive pain or neuropathic pain

International Association for the Study of Pain (IASP) states that pain is “an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage”

Highly SUBJECTIVE

Chronic Pain

Chronic Pain

EpidemiologyMore than 100 million people in United States live with chronic pain.

Estimated economic burden of chronic pain exceeds 500 billion dollars.

Despite all the efforts to treat pain adequately, it remains INAPPROPRIATELY treated. ◦ Reduces a patient’s independence and

ability to perform many daily activities◦ Places strains on social relationships,

mood, and sleep patterns.

Biopsychosocial concept of Chronic Pain

http://image.slidesharecdn.com/chronicpain-150128073452-conversion-gate01/95/chronic-pain-managment-17-638.jpg?cb=1423812958

Characteristics Acute Pain Chronic Pain

Relief of pain Highly desirable Highly desirable

Dependence and tolerance to medication Unusual Common

Psychological component Usually not present Major problem

Organic cause Common May not be present

Environmental/ family issue Small Significant

Insomnia Unusual Common

Treatment goal Pain reduction Functionality

Depression Uncommon Common

Description Obvious distress (trauma) No noticeable trauma

Symptoms Sharp, dull, shock like, tingling, shooting, radiating, fluctuating in intensity, varying in location

Sharp, dull, shock like, tingling, shooting, radiating, fluctuating in intensity, varying in location

Comorbid condition None Insomnia, anxiety and depression

Lab test No specific test, subjective to the patient No specific test, but can test for past trauma, VitD, TSH, and B12

Classification of Pain

Rapid pain relief or reduction in pain intensity is NOT the Goal

Improve or maintain the patient’s level of functionalitySet goals with the patient for functional improvement, and document them for future monitoring purposes to determine efficacy

Improving pain and function by ~30% is a success

Goal of Chronic Pain Management

1) Make diagnosis with a differential

2) Conduct psychological assessment, screening for addiction potential

3) Obtain informed consent

4) Utilize a treatment agreement

5) Conduct pre- and post intervention assessment pain level and function

6) Conduct an appropriate trail of opioid therapy with or without adjuvants

7) Conduct reassessment of pain score and level of function

8) Regularly assess “the 4 A’s of pain”

9) Periodically review all comorbid conditions

10) Document evaluations and follow-up appointments

The 10 Steps of Universal Precautions in Pain Medicine

Barbee J, Chessher Jaclyn, Greenlee, Max. Pain Management: The Pharmacist’s Evolving Role. Pharmacy Times. 2015.http://www.pharmacytimes.com/publications/health-system-edition/2015/july2015/pain-management-the-pharmacists-evolving-role. Accessed July 5, 2016.

http://www.pharmacytimes.com/publications/health-system-edition/2015/july2015/pain-management-the-pharmacists-evolving-role

Help minimize risk for patients using pain medications.◦ Assess and properly plan to minimize patient risk of Pain Medicine

◦ Proper Pain Assessment to understand pain and provide highly effective treatment while minimizing risk

◦ Educate the patients of the role of opioids in the treatment of chronic pain

Help patients live meaningful and productive lives with adequately managed pain

Monitor patient’s 4 As:◦ Analgesia

◦ Activities of daily living

◦ Adverse events

◦ Aberrant drug behaviors

Pharmacist’s Role

Pain Interview

Pain Interview “PQRST”

Provoke: What makes the pain worse?

Palliate: What makes the pain better?

Quality: Describe the pain?

Radiation/ Location: Where is the pain?

Severity/ Pain score: How does this pain compare with other pain you have experienced? What are the activities that you would like to perform that you cannot, due to the pain?

Timing/ onset/ duration: When did it began and how long has it been? Does the intensity of pain change with time?

Treatment of Chronic Pain - Video

https://www.theacpa.org/a-car-with-four-flat-tires

Treatment approaches to Management of Chronic pain

NON-PHARMACOLOGICAL THERAPY

Acupuncture

Local electrical stimulation including TENS

Brain stimulation

Surgery

Psychotherapy

Relaxation and medication therapies

Biofeedback

Behavior modification

Placebos?

PHARMACOLOGIC THERAPY

NSAIDs

Antidepressants

Anticonvulsants

Topical agents

Cannabinoids

Non-Opioids

Opioids

Intrathecal drug delivery systems

Non-pharmacological therapy Evidence/ Potential Place in Therapy

Acupuncture Evidence is conflicting and clinical studies to investigate its benefits are ongoing

Biofeedback Evidence for headache and back pain; Often used in combination without side effects

Chiropractic Evidence for chronic back pain relief

Cognitive-behavioral therapy Strong evidence for chronic pain, postoperative pain, cancer pain, and the pain of childbirth

Counseling Can be of help to learn about the physiological changes produced by pain

Electrical stimulations including transcutaneous electrical stimulation (TENS)

Can help reduce pain

Exercise Evidence with chronic pain for overall well being including light to moderate; shown efficacy to relief low back pain

Hypnosis Speculated to help a person concentrate and relax or is more responsive to suggestion

Low-power lasers Used by some physical therapists but method is NOT without controversy

Magnets Increasingly popular with athletes to control sport-related pain or other pain conditions

Nerve blocks Interventional to relieve nerve pain and pains related to cancer

Physical therapy and rehabilitation To increase function, control pain and gain recovery

Placebo Employed in studies, work by stimulating the brain’s own analgesics

R.I.C.E.—Rest, Ice, Compression, and Elevation Temporary muscle or joint injuries

Surgery Limited evidence to show which procedures work best for their indications

http://www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm#3084_15

Chronic Pain Medications and Dangers

Pain Algorithm Identify pain source if possible; Assess pain severity and quality using consistent method such as numeric rating scale (NRS); scale 0-10 out of 10

Mild (Score 1-4/10) Moderate (Score 5-7/10) Severe (Score 8-10/10)

APAP +/- NSAIDs when risk doesn’t outweigh benefits

Combo Opioid AND APAP/NSAID

Opioid Analgesics tailored to pain severity and patient characteristics

If pain relief is not adequate, step up therapy is recommended

Always monitor pain frequency and status, anticipate side effects, properly titrate doses based on patient characteristics, PO is preferred when possible, Consider around the clock dosing when appropriate, and PRN regimens for breakthrough or highly variable pain

Nonsteroidal Anti-inflammatory DrugsPlace in Therapy • Effective in the treatment of chronic low back pain as well as chronic pain due to osteoarthritis

• Modest effect In treating lumbar radiculopathy• The addition of an NSAID to a pain management regiment can have an opioid-sparing effect of

between 20-35%

Comments/Concerns • Minimal effect in treating neuropathic pain states

AntidepressantsPlace in Therapy • Effectiveness for antidepressants in the treatment of chronic pain disorders with a

strong neuropathic component has long been established in the literature• TCAs (Amitriptyline, imipramine, nortriptyline and desipramine):

• Shown to be effective in treating a variety of painful neuropathic conditions such as diabetic peripheral neuropathy (DPN), postherpectic neuralgia (PHN), painful polyneuropathy, postmastectomy pain, and centeral poststroke pain

• Analgesic effects are independent of the presence of any changes in depression or mood state.• Side effects that can be significant include postural hypotension, dry mouth, and sedation for

which reason these medications are typically taken at bedtime especially in the elderly population leading to increase risk of fall.

• Duloxetine and venlafaxine• Have shown efficacy in treating peripheral neuropathic pain and other chronic pain conditions.

• Duloxetine• Treatment of painful DPN, fibromyalgia, and chronic musculoskeletal pain• Mood-elevating effects have a significant contribution to the reported decreases in pain scores

AnticonvulsantsPlace in Therapy Side effects/concerns

Carbamazepine Trigeminal neuralgia but has NOT been shown to be as effective in treating other neuropathic pain disorders

somnolence, dizziness, and gaitDisturbanceMore serious adverse reactions that have been reported includeStevens-Johnson syndrome, toxic epidermal necrolysis, and blood dyscrasias

Valproic acid, oxcarbazepine, topiramateand lamotrigine

Inconsistent evidence of efficacy in treating neuropathic pain

Gabapentin DPN, PHN, painful polyneuropathy, neuropathic cancerpain, central poststroke pain, and spinal cord injury pain.

dizziness, somnolence,and ataxia, peripheral edema

Pregabalin *First line for treating neuropathic pain dizziness, somnolence,and ataxia.>Peripheral edema

Topical AgentsPlace in Therapy

Lidocaine (5% gel or patch) Peripheral neuropathic pain conditions with allodynia as well as PHN with allodynia

Topical NSAIDs (diclofenac, ibuprofen, and ketoprofen)

Short-term pain relief in the treatment ofSoft tissue injuries and chronic joint-related pain.

Topical high-dose capsaicin (8%) Effective in providing rapid and sustained pain relief in patients with PHN and painful human immunodeficiency virus (HIV)-associated neuropathies

CannabinoidsPlace in Therapy Mechanism of Action

Medicinal marijuana Neuropathic pain Activation of CB2 receptors on peripheral inflammatory cells has beenshown to decrease inflammatory cell mediator release, plasma extravasation, and the sensitization of afferent terminal.

OpioidsPlace in Therapy • Strong evidence in supporting the short-term use of opiates in managing BUT long-term use for non-

cancer pain is not strong.• Current recommendations for initiating chronic opiate therapy are intended to better identify patients

at risk for abusing and/or misusing opiate medications or from suffering their adverse physical effects. This includes a detailed medical history, psychiatric history, and substance use history as well as establishing a physical diagnosis and the medical necessity for chronic opiate therapy. Urine drug screening as well as establishing an agreement between the provider and patient in which the goals and expectations of the therapy are clearly stated reduces misuse, abuse, or diversion of opiate medications.

Comments/Concerns Unwanted adverse effects, such as opioid tolerance, dependence, constipation,respiratory depression, impaired cognitive ability, immune suppression, andopioid-related endocrinopathies, are only some of the known physical alterationsassociated with the chronic use of opiate medications.

Cost of chronic pain adds up to 635 billion each year.

It affects over 100 million adults.

About 41% of chronic pain patients reports that their pain is uncontrolled.

Facts about Chronic pain and Opioid treatment

Legislation and Regulatory Policies Should Limit Inappropriate Prescribing But Should Not Discourage Or Prevent Prescription Of Opioids Where Medically Indicated And Appropriately Managed.

Prescription Of Opioids For Chronic, Intractable Pain Is Appropriate When More Conservative Methods Are Ineffective And The Treatment Plan Is Reasonably Designed To Avoid Diversion, Addiction, And Other Adverse Effects.

Physicians Should Be Sensitive To And Seek To Minimize The Risks Of Addiction, Respiratory Depression And Other Adverse Effects, Tolerance, And Diversion. However, Some Commonly Held Assumptions About These Issues Need To Be Reviewed.

Opioids Should Be Prescribed Only After A Thorough Evaluation Of The Patient, Consideration Of Alternatives, Development Of A Treatment Plan Tailored To The Needs Of The Patient And Minimization of Adverse Effects, And On-Going Monitoring And Documentation.

Use of Opioids for the Treatment of Chronic Pain

Use of Opioids for the Treatment of Chronic Pain. American Academy of Pain Medicine. 2013. http://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf. Accessed August 3, 2016

http://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf

Why do you think prescribing opioids could be challenging for doctors?

What do you think is the role of a pharmacist is in opioid dispensing?

Questions to Think about?

Challenging◦Why?

◦ Under prescribing: due to fear of adverse effects as well as addiction.

◦ Over prescribing: due to multiple failed therapeutic response.

Issues with prescribing opioids.

Agents of choice for moderate to severe chronic pain as well as cancer related chronic pain

Dosing is based on patient’s previous history of opioid analgesic used, the specific patient’s needs, and on the delivery system being utilized.

Classified by:◦ Activity at the receptor site

◦ Pain intensity treated

◦ Duration of action (short acting vs. long acting)

Opioids

Patient is experiencing pain despite having a reasonable trial of both non-opioid analgesics and adjuvants

Severe pain that requires rapid relief

Patient has contraindication to the use of other analgesics

Patient Selection

Patient selection Opioid regimen should be individualized

Opioid naïve patients should be started on low dose

In July 2012, FDA requires REMS for all extended release and long acting opioid analgesics.

Generic Brand Agonist/antagonist or mixed

Histamine release that would cause N/V/itchiness

Route of Administration

Comments

Morphine Avinza Morphine like Agonist +++ IM, PO, IV, SR, Rectal Drug of choice for severe pain

Hydromorphone Dilaudid, Exalgo Morphine like Agonist IM, PO, IV, rectal Use in severe pain, more potent than morphineREMS program

Oxymorphone Opana Morphine like Agonist IM, IV, SQ, PO Severe pain, immediate with controlled, extended release to stop misuse

Codeine Morphine like Agonist +++ IM, PO CODEINE is metabolized by CYP2D6

Hydrocodone Norco Morphine like Agonist PO most effective when used with aspirin and acetaminophen,

Oxycodone Oxycontin, oxecta, Roxicodone

Morphine like agonist PO

Meperidine Demerol Meperidine like agonist +++ IM, PO Severe pain, oral is not recommended, should not be used for chronic pain

Commonly Prescribed Opioids

Generic Brand Agonist/antagonist or mixed

Histamine release that would cause N/V/itchiness

Route of Administration

Comments

Fentanyl Sublimaze, duragesic, lazanda, abstral. Actiq, onsolis, fentora, subsys

Meperidine like agonist IM, transdermal, buccal, transmucosal, sublingual, nasal inhaled

Severe pain, do not use patch in acute pain, always titrate the dose, can be used for breakthrough pain; TM, IN, SL are available through a REMS program.

Methadone Dolophine NMDA antagonistSNRI

IM/IV, PO Reverse opioid tolerance

Naloxone Narcan Antagonist IV

Tramadol Ultram, Antagonist Inhibits reuptake of serotonin and ER , used for neuropathic pain

PO Decreased dose in renally and hepatic insufficient patients and elderly.

Tapentadol Nucynta Antagonist PO REMS required.

Commonly Prescribed opioids

Frequency Stage of Pain

Around THE CLOCK (QD, BID etc.) Initial stage of pain Persistent chronic pain

As needed (prn) As the painful state subsides and the need for medication is decreased.Also for patients that may present with pain that is intermittent or sporadic in nature.

Around the clock and as needed (conjunction)

When patient experiences breakthrough pain.

Administration of Opioids

Route of Administration When to Uses

Oral (PO) Mostly commonly used and preferred method in most cases

Continuous IV infusion Postoperative pain

Epidural or intrathecal/ subarachnoid Control of acute, chronic non-cancer, and cancer pain

Route of Administration

Before initiating chronic opioid therapy, must assess risk vs. benefit for the patient.

Based on history, physical examination, assessment of risk of substance abuse, misuse or addiction.

Personal and family history of alcohol or drug abuse

Personal history of alcohol or drug abuse may be considered contraindicated for long term opioid therapy.

Evaluation prior to initiating Opioid regimen

DefinitionPhysical dependence- rapid discontinuation of opioid following prolonged administration, usually one month or longer, will result in withdrawal symptoms such as dysphoria, anxiety, and volatility of mood, as well as physical findings such as hypertension, tachycardia, and sweating.

Tolerance- is present when increasing amounts of opioid are required to produce an equivalent level of efficacy

Addiction- is a form of physiological dependence and refers to the extreme behavior patterns that are associated with procuring and consuming the drug.

Effect Manifestation

Mood changes Dysphoria, euphoria

Somnolence Lethargy, drowsiness, apathy, inability to concentrate

Stimulation of chemoreceptor trigger zone Nausea, vomiting

Respiratory depression Decreased respiratory rate

Decreased gastrointestinal motility Constipation

Increase in sphincter tone Biliary spasm, urinary retention

Histamine release pruritus,

Tolerance Larger doses for same effect

Dependence Withdrawal symptoms upon abrupt discontinuation

Major Adverse effects of opioid analgesics

Monitoring should occur during each visit

Documentation of pain intensity, functional status, progress toward therapy goals, side effects and adherence is critical.

Monitoring of Chronic Pain Management

Help minimize risk for patients using pain medications.◦ Assess and properly plan to minimize patient risk of Pain Medicine

◦ Proper Pain Assessment to understand pain and provide highly effective treatment while minimizing risk

◦ Educate the patients of the role of opioids in the treatment of chronic pain

Help patients live meaningful and productive lives with adequately managed pain

Monitor patient’s 4 As:◦ Analgesia

◦ Activities of daily living

◦ Adverse events

◦ Aberrant drug behaviors

Revisit a Pharmacist’s Role in Chronic Pain Management

A. Provide rapid pain relief or reduction in pain intensity is NOT the Goal

B. Report providers of the authorities who prescribe opioids to the authorities

C. Help patients live meaningful and productive lives with adequately managed pain

D. Manage patient’s chronic pain with the use of non-opioids

Which of the following statement describes the role of a pharmacist in chronic pain management?

A. Norco

B. Morphine

C. Duloxetine

D. Pregabalin

What is the preferred drug of choice in the treatment of chronic neuropathic pain?

A. NSAID

B. Antidepressant

C. Anticonvulsant

D. Cannabinoids

The addition of this class of pain medication has shown to have an opioid-sparing effect of between 20-35%.

Appropriate Opioid Use. Pharmacist’s Letter. 2015; 31(4):310407.

ACPA Recourse Guide to Chronic Pain Treatment: An Integrated Guide to Physical, Behavioral and Pharmacologic Therapy. 2016. https://theacpa.org/uploads/documents/ACPA_Resource_Guide_2016.pdf. Accessed August 10, 2016.

Barbee J, Chessher Jaclyn, Greenlee, Max. Pain Management: The Pharmacist’s Evolving Role. Pharmacy Times. 2015. http://www.pharmacytimes.com/publications/health-system-edition/2015/july2015/pain-management-the-pharmacists-evolving-role. Accessed July 5, 2016.

Baumann TJ, Herndon CM, Strickland JM. Chapter 44. Pain Management. In:DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 9e. New York, NY: McGraw-Hill; 2014. http://accesspharmacy.mhmedical.com/content.aspx?bookid=689&Sectionid=45310494. Accessed August 16, 2016.

Beal BR, Wallace MS. An Overview of Pharmacologic Management of Chronic Pain. Med Clin North Am. 2016;100(1):65-79.

Pain: Hope Through Research. Available at: http://www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm#3084_15. Accessed August 5, 2016.

Use of Opioids for the Treatment of Chronic Pain. American Academy of Pain Medicine. 2013. http://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf. Accessed August 3, 2016

References

https://theacpa.org/uploads/documents/ACPA_Resource_Guide_2016.pdfhttp://www.pharmacytimes.com/publications/health-system-edition/2015/july2015/pain-management-the-pharmacists-evolving-rolehttp://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf

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