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[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
6/16/20151
Easing the Pain…Approaches to Managing Pain Associated with Serious Illness
6/16/2015
Christine S.Ritchie, MD, MSPH, FACP, FAAHPMHarris Fishbon Distinguished Professor
6/16/20152
Courtesy J Kutner
DefinitionsAcute pain:
• “An unpleasant sensation and emotional response to that sensation”
• Cut, bruise, bone fracture, tooth ache
Chronic pain:
• Unpleasant sensation that continues for prolonged period of time “beyond expected time of healing”
‒ Pain on most days for more than 3 (or 6) months
‒ May or may not be associated with identified disease process
3
Pain---how common is it?
Community-dwelling adults: 30-50%
Nursing homes: 60-80%
Among palliative care patients: 83%
• 25% have severe or overwhelming pain
Pidgeon T, et al. BMJ Supportive & Palliative Care 2015
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Pain--A complex experience
7
Bio
SocialPsycho
Environmental stressorsClose personal relationships
DistressAngerFearTraumatic life events
Disease-related mechanismsBiologic mechanisms of psychiatric illness
Gatchel, Am Psychol, 2004; Gatchel, Psychol Bull, 2007
PainA complex experience
8Sibille et al. Pain. 2012 September ; 153(9): 1789–1793
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6/16/20153
Pain--Multimodal management
9
Bio
SocialPsychoHealthcareFamilyWork
CognitionsEmotionsBehaviorsAttention
MedicationExerciseSurgerySleep
Therapeutic Strategies for Pain
• Pharmacotherapy
• Nonpharmacologic:
‒Rehabilitative approaches
‒Behavioral approaches
‒Complementary and alternative approaches
‒Lifestyle changes
Pharmacotherapy: WHO 3-step Ladder
1 mild1 mild
2 moderate2 moderate
3 severe3 severe
Morphine
Hydromorphone
Methadone
Fentanyl
Oxycodone
± Adjuvants
A/Codeine
A/Hydrocodone
A/Oxycodone
A/Dihydrocodeine
Tramadol
± Adjuvants
ASA
Acetaminophen
NSAIDs
± Adjuvants
Acetaminophen
Safest pain medication on market
Max allowable dose (4 grams over 24 hours)
• Most individuals take considerably less
• Safe for those over 70 to set limit at 3gm/day
• Need to read labels regarding presence of acetaminophen in other products
• Too much acetaminophen can cause liver damage
Recommended first-line therapy
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6/16/20154
Non-Steroidals- NSAIDS(e.g. ibuprofen, naproxen)
Most popular analgesic agents on market
Significant safety issues
• > 100, 000 hospitalizations each year
• > 16,000 deaths each year
Can precipitate heart failure episodes, worsen blood pressure, worsen kidney function
Can increase risk of stroke/heart attack
Frequent monitoring required
Opioids(e.g. morphine, oxycodone, hydrocodone, fentanyl patch)
Many side effects (constipation, lethargy, nausea, itching)
Effective at treating pain
• Likely underused by older adults
Many barriers to use
• Patient
• Physician
Treatment Considerations
Overdose
Abuse/Misuse patient or contact
Addiction
Drug-drug and drug-disease Interactions
Physical dependence and tolerance
Analgesia
Improved function
Improved quality of life
Adverse effects
Comprehensive Benefit to Harm Evaluation
Kotalik J Controlling pain and reducing misuse of opioids. Can Fam Physician 2012;58
History and Physical and Appropriate Evaluation
Benefits Associated With NSAID/Opioid Use (Effect Sizes)
Oral NSAIDs1 TopicalNSAIDs2
Opioids3
Pain reduction 0.32 0.24 0.58
Physical functioning
0.22 ? 0.43
Sleep improvement
? ? 0.87
Quality of life ? ? ?
Socialization ? ? ?
Effect sizes: <0.50 small, 0.50-0.79 moderate, ≥ 0.80 large.
1 Bjordal et al BMJ 2004 BMJ. 2004; 329(7478): 1317. 2Biswal et al J Rheum 2006;33:1841-44. 3Papaleontiou J Am Geriatr Soc 2010; 58:1353-69.
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6/16/20155
Risks Associated With NSAID/Opioid Use
Selective NSAIDs
Topical NSAIDs
Opioids
Renal
Acute kidney injury NR
CKD progression NR
Cardiovascular
Stroke NR
Heart Attack NR
Congestive heart failure NR
Blood Pressure increase NR
O’Neill et al. Am J Geriatr Pharmacother 2012;10:331-42. Solomon et al. Arch Intern Med 2010;170:1968-78. Makris et al. J Rheumatol 2010;37:1236-43.
NR = not reported.
Risks Associated With NSAID/Opioid Use
Nonselect. NSAIDs
Selective NSAIDs
Topical NSAIDs
Opioids
Falls/fractures NR
GI
Ulceration/bleed
NR
Dyspepsia
Hospitalization NR
1 Bjordal et al BMJ 2004 BMJ. 2004; 329(7478): 1317. 2Biswal et al J Rheum 2006;33:1841-44. 3Papaleontiou J Am Geriatr Soc 2010; 58:1353-69.
NR = not reported.
Public Health Impact of Treatment-Related Adverse Effects
NSAIDs
• Hospitalizations (GIBleeding & Acute Kidney Injury)
• CHF exacerbations
Opioids
• Falls/fractures
• Constipation/obstipation
• Mental status changes/Sedation
• Overdoses
Constipation
Most common adverse effect encountered during chronic opioid therapy
No tolerance developed to this side effect
Multifactorial
Prophylactic laxatives are indicated
PREVENTION IS KEY!
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Constipation: Management
Softeners
• Docusate
Cathartics
• Senna
• Biscadoyl (Dulcolox)
Osmotic Laxatives
• Magnesium/aluminum salts
• Lactulose
• Sorbitol
Enemas
Fiber- usually not indicated in frail or end-of-life patients
Sedation and Cognitive Impairment
Discontinue non-essential medications.
Evaluate and treat other potential causes.
If analgesia satisfactory, decrease dose by 25%.
If analgesia inadequate or symptoms persist despite dose reduction:
• trial of psychostimulant (if sedation) or neuroleptic (if delirium).
• switch to an alternative opioid.
• trial of other invasive/non-invasive approach to decrease systemic opioid requirements.
When dose-limiting side effects occur with opioid pharmacotherapy...
More aggressive treatment of adverse effect(s)
Opioid-sparing strategies
• Analgesic adjuvants
• Alternate route (e.g. intraspinal)
• Anaesthetic/Neurolytic procedures
• PM&R approaches
• Cognitive therapy
• Complementary therapies
‒ e.g., acupuncture, massage, music therapy
Opioid rotation
Opioid Prescribing Over Past 16 Years
Olfson et al. J Clin Psych 2013;74:932-39.
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6/16/20157
Opioid Overdose Deaths 1999-2009
Ballantyne K. J Med Toxicol 2012;8:417-23.
1
Group Health Consort Study, 1997‐2005; Dunn KM, et al. Ann Intern Med. 2010 Jan 19;152(2):85‐92.
Percent Use
Dose and Overdose Risk
Therapeutic Strategies for Pain
• Pharmacotherapy
• Nonpharmacologic:
‒Rehabilitative approaches
‒Behavioral approaches
‒Complementary and alternative approaches
‒Lifestyle changes
Nonpharmacologic Approaches
• Good for preserving function
• Underused
• Passive
‒Heat/ice packs
‒TENS
‒Ultrasound
• Active
‒Stretching
‒Strengthening/pain relief
Physical therapy
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6/16/20158
Cognitive-Behavioral Therapy
• Replacing maladaptive cognitions, emotions, behaviors with more adaptive ones
• Increasing functional capacity through improved coping
Other Behavioral Therapies
• Relaxation training
• Mindfulness based stress reduction
Nonpharmacologic ApproachesBehavioral Therapies
Nonpharmacologic Therapies
Areas addressed by CBT:
• catastrophizing
• acceptance of the pain condition
• avoidance of activity due to unrealistic concerns about harm
Cognitive Behavioral Therapy (CBT)
30
CBT
Your thoughts
Your behaviors
Your emotions
Relaxation Training
Deep breathing
Guided imagery
Progressive muscle relaxation
Many tools online:
http://theacpa.org/Relaxation-Guide
https://nccih.nih.gov/health/stress/relaxation.htm
31
Mindfulness-based Stress Reduction
Awareness and thinking as different capacities.
• awareness balances out inflammations of thought, emotional agitations and distortions
• Paying attention to one’s pain
6/16/201532John Kabot Zin The Mindfulness Solution to Pain; http://elishagoldstein.com/videos/page/2/
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6/16/20159
Mindfulness-based Stress Reduction
Body Scan- bringing awareness to each body part.
Breathing- “calming your mind and grounding your breath.”
Distractions- games, conversations, reading a book
6/16/201533John Kabot Zin The Mindfulness Solution to Pain; http://elishagoldstein.com/videos/page/2/
Complementary and Alternative Approaches
Acupuncture
Herbs:
• Feverfew
• Butterbur .
• Cayenne (capsaicin)
• Chamomile tea .
• Dandelion
• Ginger
• Gingko
• Stinging Nettle
• Willow Bark.
6/16/201534
Tailored Interdisciplinary Assessment &Treatment Plan
Intake ReviewTailored Plan of Care
Symptommanagement
Coordination
SupportiveCare and
CounselingNutrition Support Spiritual CareFinancial and Social Support
Whole Person Approach
Follow-up
Supportive Pain Management = Team Care
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6/16/201510
Summary
Pain is common in the setting of serious illness
Pain is a complex experience influenced by biology, environment and one’s emotions and cognitions
Many effective medicines for pain also have significant side effects
A holistic approach includes pharmacologic and nonpharmacologic approaches to pain with input and support from an interdisciplinary team.
6/16/201537