Topical Pain Managementfor

Medco Health SolutionsLas Vegas, NV

3/13/11

by

Joe Creadrjecdo@gmail.com

Crea Healthcare PartneringPowell, OH

Disclosure Information

I have the following financial relationships to disclose:

• Honoraria and expenses paid by:

Medco Health Solutions

through

Business Services International, Inc.

• I have no other financial relationships to disclose.

• I will not discuss any investigational uses.

• I will not discuss any off label uses.

Epidemiology

> 50 million people are partially or totally disabled due to pain

• 70 to 90% of patients with advanced disease from cancer have significant pain that requires the use of opioid drugs.

• Severe, unrelenting pain interferes with patients' quality of life, including their activities of daily living, their sleep, and their social interactions.

Epidemiology (cont.)

• 80% of elderly patients have chronic pain. • 66% have pain in the last month of life• ~ ½ of hospitalized patients with pain are

under-medicated. • Estimated cost of pain is $150 billion per year • Up to 50% of patients who are taking pain

medication do not experience adequate relief

Economics

• Chronic pain causes 700 million lost work days/year in the U.S.

• > $ 9 billion per year on OTC pain products.

What is Pain?

Medical Definition:“Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.”

International Association for the Study of Pain, 1979

“An unpleasant sensation induced by noxious stimuli and generally received by specialized nerve endings.”

CancerWEB, 2011

Operative Definition:“Pain is whatever the experiencing person says it is, existing whenever he/she says it does.”

Margo McCaffery, 1999

Physiologic Effects of Pain

Pain Behaviors

Presentation of PainAcute• Often obvious distress• Can be sharp, dull, shock-like,

tingling, shooting, radiation, fluctuating in intensity, and varying in location (occur in timely relationship to noxious stimuli)

• Comorbid conditions not usually present

• May see HTN, increased HR, diaphoresis, pallor…

Chronic• Can appear to have no

noticeable suffering• Can be sharp, dull, shock-

like, tingling, shooting, radiation, fluctuating in intensity, and varying in location (do NOT occur in timely relationship to noxious stimuli)

• Symptoms may change over time

• Usually NO obvious signs

Four Types of Pain Behaviors

• Facial/audible expression of distress

• Distorted ambulation or posture

• Negative affect

• Avoidance of activity

Autonomic Response to Pain

• Grimacing• Restlessness• Guarding• Increased respirations• Increased heart rate• Increased blood pressure• Diaphoresis

Emotions, Coping, and Pain

Chronic pain is associated with higher levels of anger, fear, sadness, anxiety and stress, but often fewer observable outward physical changes/signs.

Pain and the Brain

Pain Terminology, Classifications, and Pathophysiology

Pain terms

• Allogenic substances– chemicals released at the site of the injury

• Nociceptors– afferent neurons that carry pain messages

• Referred pain– pain that is perceived as if it were coming from

somewhere else in the body

PainPain disorders classified into several categories based upon origin: •Acute (Nociceptive)

– Somatic• Superficial (nociceptors of skin)• Deep [body wall (muscle, bone)]

–Visceral (sympathetic system; may refer to superficial structures of same spinal nerve)

•Chronic–Malignant (cancer) –Nonmalignant• Neuropathic (nerve injury)• Inflammatory (musculoskeletal)• Mixed or unspecified• Psychogenic

Acute Pain

• Travels into the spinal cord along the appropriate nerve root. • Nerve root splits into a front

division and a back division and carries pain sensation to the CNS (spinal cord and brain). • Passed to a short tract of nerve

cells (interneurons), which in turn synapse with a nerve tract that runs to the brain .

Acute Pain

• Sent out to the rest of the brain, connecting with thinking and emotional centers.

• A modifier pathway from the brain modifies pain at the synapses in the back part of the spinal cord (acute pain is decreased rapidly after tissue injury).

Peripheral Nerve Fibers Involved in Pain Perception

• A-delta fibers–small, myelinated fibers that transmit sharp pain

• C-fibers–small unmyelinated nerve fibers that transmit dull or aching pain.

Chronic Pain• Neuropathic - severe pain disorder that

results from damage to the central and peripheral nervous systems. –Centrally generated–Peripherally generated

• Inflammatory - results from the effects of inflammatory mediators.

Chronic Pain Conditions

• Neuralgia– an extremely painful condition consisting of

recurrent episodes of intense shooting or stabbing pain along the course of the nerve.

• Causalgia– recurrent episodes of severe burning pain.

• Phantom limb pain– feelings of pain in a limb that is no longer there

and has no functioning nerves.

Pain Without Physical Findings

• Persists long after healing

• May spread and increase in intensity

• May become stronger than was the initial pain from the injury

Pain Assessment and Management

Pain Assessment: PQRST mnemonic

• P: Precipitating and palliating factors•Q: Quality•R: Region and radiation• S: Severity• T: Time

Pain Assessment: Instruments

• Single-dimension–Visual analog scale–Verbal numerical scale–Verbal rating scale

•Multidimensional – assesses the pain as well as the emotional and behavioral effects of the pain.

Pain Assessment: Single-dimension Instruments

Visual analog and Verbal numerical scales

Pain Assessment: Single-dimension Instruments

Verbal rating scale• No pain = 0•Mild pain = 1-3•Moderate pain = 4-6• Severe pain = 7-9•Worst ever = 10

WHO Analgesic Ladder

Non-pharmacologic Pain Management

• Neurostimulation• TENS• Acupuncture• Anesthesiology• Nerve block• Surgery• Physical therapy• Exercise• Heat/cold• Psychological approaches

• Cognitive therapies(relaxation, imagery, hypnosis)

• Biofeedback• Behavior therapy• Psychotherapy• Complementary tx• Massage, art, music,

aroma therapy

Pharmacology of NociceptionFour Steps:1. Transduction– NSAIDs, Local Anesthetics & Anticonvulsants

2. Transmission– Opioids, NMDA Antagonists

3. Perception– Distraction, Relaxation, Imagery

4. Modulation– Tricyclic Antidepressants, Opioids, GABA Agonists

Pharmacology of Nociception

Pharmacology of Nociception

Routes of Administration

• Intramuscular• Intravenous • Intraspinal • Local/Regional blocks• Oral • Rectal • Subcutaneous • Sublingual • Transdermal / Topical**

Three Major Classes of Drugs Used to Treat Pain

• NSAIDs & Acetaminophen– Peripherally acting

• Opioid Analgesics– Centrally acting (bind to brain opioid receptors)

• Adjuvant Analgesics– Affect non-pain conditions (e.g. emotions that can

exacerbate pain condition)

Pain Type: Nociceptive (Visceral & Somatic)

Non-Opioids – WHO first lineThese agents act peripherally.

• Often used to treat acute pain (e.g. strains, sprains, sore muscles) and OA

• Most topical analgesics fall into this class– Many are these used in conjunction with oral

analgesics (e.g. ASA, APAP, NSAID)

Nociceptive (Visceral & Somatic)

Traditional Oral Choices:

1. Acetaminophen (Tylenol®) 325-1000 mg q 4-6hPO/PR Max= 4 gm/day. Recommended as first-line

2. Salicylates• Choline/Magnesium Salicylates (Trilisate®) 750-

1500mg PO BID (Max= 3 gm/day)• Aspirin 325-650 mg PO q4h (Max=4 gm/day)

Nociceptive (Visceral & Somatic)

Traditional Oral Choices:

3. NSAIDsa. Non-selective COX Inhibitors

• e.g. Ibuprofen (Motrin®, Advil®) 200-800 mg po q6h Max=3200 mg/day

• e.g. Naproxen (Naprosyn®) 250-500 mg po BID-TID Max= 1500 mg/day

b. COX-2 Selective Inhibitors• e.g. Celecoxib (Celebrex®) 100-400 mg po

QD-BID

Topical NSAIDs, Salicylates, Capsaicin

• Only considering those commercially available; excludes compounded combinations.

• Trials in the past 5 yrs:– Diclofenac diethylamine gel– Diclofenac solution– Ketoprofen gel– Ibuprofen cream or gel

Topical Non-Opioids

• Provide local pain relief• Many Formulations (cream, gel, oil, patch)• 3 Main Classes:

1. NSAIDs2. Counter-irritants

a. camphor, eucalyptus, menthol (e.g. IcyHot®, ArthriCare®)

b. Salicylates (e.g. Aspercreme®)3. Capsaicin

Topical vs Oral NSAIDs?

• NSAIDs: – considered efficacious for OA pain– Dose-dependent risk of renal & GI toxicity

• Pharmacology:– Relieve pain by inhibiting COX• COX: promotes the formation of inflammatory

mediators such as prostacyclin, prostaglandin, and thromboxanes

• Few trials evaluating topical vs. oral NSAIDs

Topical vs Oral NSAIDs

– European Guidelines:• Topical NSAIDs preferred over Oral NSAIDs, if:–Knee or hand–Few joints involved–Mild-moderate severity–Sensitivity to oral NSAIDs

– Why isn’t this the case in the US?• US Guidelines: list capsaicin and salicylates

only.• Discussion

Topical NSAID: Diclofenac sodium

• Diclofenac 1% gel – First Topical NSAID (Rx)– ~$35-$40/100 g tube – for OA

• Diclofenac 3% gel – for actinic keratosis only• Diclofenac 1.3% patch – for strains, sprains

and contusions– applied to most painful area 2x/day

• Penetrates skin ~ 3-4 mm

Diclofenac 1% gel

• Oral NSAIDs, but NOT topical NSAIDs have been linked to increased GI, renal, & CV complications & hospitalizations– Despite low systemic exposure, carries same Black

Box warning and safety precautions as oral diclofenac.

• Hand and Knee OA:– Clinically significant reductions in pain &

improvement in physical function

Patient Counseling w/ topical NSAID

• Gently massage into intact skin – cover entire AA• Use dosing card (1 per application) to apply the gel.• Avoid showering/bathing > 1hr after applying• Avoid external heat and/or occlusive dressings• Do not cover with clothing/gloves for at least 10

minutes• Concomitant use of diclofenac gel with oral NSAIDs

has not been evaluated; may increase NSAID ADEs.

Topical Diclofenac Dosing• Diclofenac gel:– Lower extremities, including the knees, ankles,

and feet: • Usual Dosage: 4 g to the affected foot, knee, or ankle

4x/day. Max: 16g/d to any single lower extremity joint • Maximum Dose: 32 g per day, over all affected joints.

– Upper extremities, including the elbows, wrists, and hands:• Usual Dosage: 2 g to affected hand, elbow, or wrist

4x/day. • Max Dose: 8 g/day to any single joint of the upper

extremities.

NSAID Adverse Effects• Highest incidence of adverse events• Gastropathy– ASA benefits offset by ADEs– Provide gastric cytoprotection for NSAIDs, if

appropriate.– Cox-2 selective inhibitors have decreased risk.

• Renal insufficiency– Maintain adequate hydration

• Inhibition of platelet aggregation– Assess for coagulopathy

Salicylates (OTC)

• Derivatives of acetylsalicylic acid (ASA), but different MOA

• MOA: counter-irritant, stimulating pain receptors with the hope of desensitizing them over time.– Interference with transcription factors and kinases

involved in inflammation?– Do not appear to inhibit COX enzymes.

Salicylates • Skin penetration: ~ 3-4 mm• Use:– Painful acute conditions– Not recommendation for chronic pain conditions

(poor to moderate efficacy)• OA may be an exception.• Very FEW clinical trials published reg. topical salicylate

in tx of OA

• Examples:– Trolamine salicylate (e.g. Aspercreme®)– Methyl salicylate (e.g. BenGay®, IcyHot®)

Salicylates

• Safety:– Have been associated with severe toxicity and

death after topical application and intention/unintentional ingestion.

– Like NSAIDs, may increase risk of bleeding; therefore, pharmacointeraction w/ warfarin

• Point: OTC does not necessarily mean safer than Rx!

Capsaicin (OTC)

• MOA: – Counterirritant, eventually desensitizing nerves (a

result of apparent reversible nerve degeneration)– Depletion of Substance P and calcitonin gene-

related peptide.

• Skin penetration – Negligible; may be less effective analgesic than

salicylates or topical NSAIDs.

Capsaicin – Efficacy: • OA: Clinical trials showed modest benefit in OA pain

relief, even after excluding treatment failures from study data analysis.• Chronic musculoskeletal pain: poor-to-moderate

efficacy as monotherapy. May have a role as adjunctive therapy.

– Safety:• No serious adverse events reported• Extreme irritation if contact with eye or mucosal tissue.

– Tolerability:• Effects not immediate; therefore, patients may

discontinue prematurely.

Additional Considerations

• Adherence– Topical NSAID: 4x/day– Topical salicylates & capsaicin: prn

• Administration – Rubbing an already sore joint/painful area?– Inconvenient?– Messy?

Agent Pharmacology Efficacy Safety Cost (US$)

Topical NSAID

Diclofenac gel

COX-2 inhibition w/ reduced COX inhibition

Penetrates 3-4mm

Suitable for OA of knee or hand

Effective monotherapy for mild-mod OA of hand or knee

Equivalent analgesia to PO

NNT for 50% pain reduction: 3

AEs: local

Low risk of GI, CV or renal Ses

Same Black Box as oral

Do not combine w/ other NSAIDs

$35-40/100g tube

Salicylates Counterirritant – desensitizes pain receptors

Modest efficacy in chronic painNo data for OAAdjunct to NSAIDsNNT: 5.3

Excessive use or ingestion can be toxic

$6.99 - $8.99/ 57 g tube

Capsaicin Counterirritant – desensitizes pain receptors

Modest adjunctive txMinimal as monotxNNT: 8.1

Application site; pain & burning early on

$19.99- $22.49/57g tube

Neuropathic Pain• Tricyclic Antidepressants: – First line for non-stabbing pain– Examples• Desipramine (Norpramin®) • Nortriptyline (Pamelor®)• Doxepin (Sinequan®) • Imipramine (Tofranil®)• Amitriptyline (Elavil®)

– Usual dose: 10-25 mg q HS, titrate up to 150

• Serotonin/Norepinephrine Reuptake Inhibitor– Duloxetine (Cymbalta®)

Neuropathic Pain

• Anticonvulsants–�First line for stabbing pain– Examples• Gabapentin (Neurontin®) 300-1200 mg TID Up to 6

g/d• Pregabalin (Lyrica ®) 50-100mg TID• Carbamazapine (Tegretol®) 200-400 mg QID• Divalproex Na(Depakote®) 500-2000 mg q HS

Neuropathic Pain

• Lidocaine transdermal patch – Only topical for neuropathic pain– Indicated for post-herpetic neuralgia• Apply up to 3 patches, only once, for up to 12

hrs. within a 24 hours period• Apply to cover skin in most painful area

– MOA: Inhibits conduction of nerve impulses– Penetration: allows for local analgesia, but

insufficient to result in complete sensory block.– Pearl: patches can be cut if done b/f removing

release liner

Moving from Peripherally Acting Agents to Centrally Acting:

Opioids

Nociceptive Pain (Visceral & Somatic)

WHO 2ND or 3rd line• Opioid/non-opioid combinations– Hydrocodone/APAP (Vicodin®, Lortab®)– Oxycodone 5 mg /APAP 325mg (Percocet®)– Codeine/APAP (Tylenol with Codeine®)– Propoxyphene/APAP (Darvocet N®)

(Maximum APAP/24hours = 4000 mg)

WHO Analgesic Ladder

Chemical Classes of Opioids

• PHENANTHRENES– Morphine – Codeine – Hydromorphone– Hydrocodone– Oxycodone

• DIPHENYLHEPTANE DERIVATIVE– Methadone– Propoxyphene

• PHENYLPIPERIDINE DERIVATIVES– Meperidine – Fentanyl

Not recommended . . .• Propoxyphene (Darvon®, Darvocet®)– No better than placebo; low efficacy at commercially

available doses.– Toxic metabolite at high doses.– Gone in Europe since 2005.

• Mixed agonist-antagonists– Compete with agonists →withdrawal– E.g. pentazocine (Talwin®),butorphanol (Stadol®),

nalbuphine (Nubain®) – Analgesic ceiling effect– High risk of psychotomimetic ADEs w/ pentazocine,

butorphanol

Opioids & The Skin?• New field of interest– Small RCTs demonstrate effectiveness in chronic

pain management

• Growing evidence regarding opioid receptors (OR) in various skin structures– Peripheral nerve fibers– Keratinocytes– Melaninocytes– Hair follicles– Immune cells

• Potential Benefits?

Opioids

• Receptor response on activation:– Mu: analgesia, respiratory depression, miosis,

euphoria, reduced gastrointestinal motility

– Kappa: analgesia, dysphoria, psychotomimetic effects, miosis*, respiratory depression*

– Delta: Analgesia*Less intense than with Mu activation

Opioids• Opioids: Immediate release

Morphine (MS IR®, Morphine Sol. Tabs)Hydromorphone (Dilaudid®)Methadone Oxycodone (Oxy IR®)Oxymorphone (Opana ®)Codeine, hydrocodone, morphine, hydromorphone, oxycodone

– Dose q 4 h & adjust dose daily depending on pain – Mild-mod pain: increase daily dose by 25-50%– Mod to severe pain: increase daily dose by 50-100%

Opioids

–Opioids Sustained Release• Morphine SR 8-12 hr (MS Contin®)• Oxycodone SR (OxyContin®)• Morphine SR 24 Hr (Avinza®)• Fentanyl Transdermal (Duragesic®)**• Oxymorphone ER (Opana ER ®)

– Long Acting • Methadone

Opioids• Extended-release preparations– Improve compliance, adherence– Dose q 8, 12, or 24 h (product specific)– Do not crush or chew tablets– May flush time-release granules down feeding

tubes– Adjust dose q 2-3 days (once steady state

reached)

Breakthrough Dosing

• Use immediate-release opioids– 5%–15% of total 24-hour dose– Offer breakthrough dose after Cmax reached• po / pr ≈q 1 h• Sub-Q, IM ≈q 30 min• IV ≈ q 10–15 min

• Do NOT use extended-release opioids for breakthrough pain!

Opioid Allergy

• Anaphylactoid/-ic reactions are the only true allergies.

• Incidence 1:200,000

• Urticaria (hives) with diffuse rash can be allergies. Needs careful assessment!

Opioid Adverse EffectsCommon Uncommon

Constipation Bad dreams/hallucinations

Dry mouth Dysphoria/delirium

N/V Myoclonus/seizures

Sedation Pruritus/urticaria

Sweating Respiratory depression

Urinary retention

Constipation from Opioids

Occurs with all opioids:• Pharmacologic tolerance develops slowly or not at

all.• Dietary interventions alone usually not sufficient.• Avoid bulk-forming agents in debilitated patients.• Stimulant Laxative + Stool Softener is ideal (e.g.

Senna S).

Adverse Effect Management

• Constipation (prophylaxis or treatment)

• Urticaria

• Senna Docusate ‐ 1 2 tabs ‐po hs or bid Bisacodyl 5 10 mg po daily ‐+/ docusate 100 mg po ‐bid

• Hydroxyzine 25 100 mg ‐q4 6h prn‐

• Diphenhydramine 25 50 ‐mg q6h prn

Respiratory Depression• Opioid effects differ

between patients

• Pain: a potent stimulus to breathe

• Loss of consciousness precedes respiratory depression

• Rapid pharmacologic tolerance

RespiratoryDepression

Loss of Consciousness

Sedation

Analgesia

Pain

DOSE

Opioid-Induced Neurotoxicity

• Patients on morphine or hydromorphone– Morphine > Hydromorphone– May continue to have pain with neuro-excitatory

side effects.– Renal insufficiency> Normal renal function– High dose > low dose

• Further increase of dose exacerbates excitatory behaviors.

• ***Can Occur with ALL Opioids at High Doses

Primary Causes of Opioid-Induced Neurotoxicity

• Depends on both dose and duration of therapy.• Opioid metabolites– Oral morphine metabolized in the liver & GI mucosa.– 50% morphine 3-glucuronide (M3G) • No analgesia• Neurotoxic side effects

– 10% morphine-6-glucuronide• Analgesic activity• Longer t½ than morphine

…..Opioid-Induced Neurotoxicity

• Other precipitating factors include:– Underlying delirium– Dehydration– Acute renal failure– Advanced age– Psychoactive medications (e.g. BZDs, TCAs)

• Increasing reported incidence as practitioners get more comfortable and aggressive with opioids.

Opioid-Induced Neurotoxicity

• Early recognition is critical:• Myclonus –twitching of large muscle groups• Delirium• Hallucinations/Seizures• Rapidly escalating dose requirement• Hyperalgesia/Allodynia• Pain “doesn’t make sense”; not consistent w/ recent

pattern or known disease.

Treatment

• Rotate to a structurally dissimilar opioid (i.e. differing receptor affinity profiles or chemical class.)

• Hydration• Benzodiazepines for neuromuscular excitation• Behavioral excitation resolves over hours to

days with treatment.

Chemical Classes of Opioids

• PHENANTHRENES– Morphine – Codeine – Hydromorphone– Hydrocodone– Oxycodone

• DIPHENYLHEPTANE DERIVATIVE– Methadone– Propoxyphene

• PHENYLPIPERIDINE DERIVATIVES– Meperidine – Fentanyl

Fentanyl (Duragesic®)is the only topical opioid in U.S.

Advantages• Useful as an alternative to

parenteral administration

• May improve compliance/adherence

• For mgmt of persistent moderate – severe pain requiring ATC treatment

Disadvantages• Difficult to dose correctly• Slow onset/offset of action• Difficult to respond to

changing pain– Dependent on physiological

state of patient– Cachexia– Fever– Diaphoresis

• Expensive

Fentanyl

• Important Considerations:– ONLY for patients opioid tolerant and requiring a

total daily opioid dose of at least fentanyl 25 mcg/h patch• Tolerant: morphine (or equiv) 60mg/day for > 1wk

– Must evaluate pain control using IR system prior to using extended/modified-release system

– Follow WHO guidelines!

Fentanyl • Dosage Titration:

• Starting dose: • based on daily morphine dose. Generally conservative.

• Dose Increases: • Increase dose only after 3 days, based on the amt of IR opioid

needed for break-through pain in days 2 & 3.• (45 mg oral morphine: 12.5 mcg/h increase in patch dose)

• New equilibrium: • May not occur until 6 days after dose increase.• Wait at least 2 applications before further increasing dose!

Fentanyl Transdermal

• Criteria for use:– Not cachectic – Unable to take PO/PR/SL– Patient compliance– Caregiver availability– Opioid abuse or diversion – Patient request

Fentanyl Dose Conversion Chart – ONLY WHEN CONVERTING ORAL TO PATCH & NOT WHEN CONVERTING PATCH TO ORAL!!)

Current Analgesic Daily Dose (mg/day)

Oral morphine 60 to 134 135 to 224 225 to 314 315 to 404

IM/IV morphine 10 to 22 23 to 37 38 to 52 53 to 67

Oral oxycodone 30 to 67 67.5 to 112 112.5 to 157 157.5 to 202

IM/IV oxycodone 15 to 33 33.1 to 56 56.1 to 78 78.1 to 101

Oral codeine 150 to 447 448 to 747 748 to 1,047 1,048 to 1,347

Oral hydromorphone 8 to 17 17.1 to 28 28.1 to 39 39.1 to 51

IV hydromorphone 1.5 to 3.4 3.5 to 5.6 5.7 to 7.9 8 to 10

IM meperidine 75 to 165 166 to 278 279 to 390 391 to 503

Oral methadone 20 to 44 45 to 74 75 to 104 105 to 134

IM methadone 10 to 22 23 to 37 38 to 52 53 to 67

Recommended fentanyl transdermal system dose

Fentanyltransdermal system 25 mcg/h 50 mcg/h 75 mcg/h 100 mcg/h

Facts & Comparison 4.0. Accessed May 10, 2009

Cancer Pain

• Multiple possible etiologies of cancer pain• Classes of medications other than those

traditionally considered “analgesics” used to address these

• As with non-cancer pains, topical analgesics options include:– lidocaine & capsaicin: neuropathic pain– fentanyl transdermal: chronic pain

Physical Dependence

• A process of neuro-adaptation• Abrupt withdrawal may → abstinence

syndrome• �If dose reduction required, reduce by 25-

50% q 2–3 days; avoid antagonists.

Tolerance

• Reduced effectiveness to a given dose over time.

• If dose is increasing– suspect opioid tolerance– disease progression – psychological/spiritual pain

Addiction

• Acceleration of abuse patterns onto a primary illness.

• Characteristics:– psychological dependence– compulsive use– loss of control over amount and frequency of use– loss of interest in pleasurable activities– continued use of drugs in spite of harm

Pseudoaddiction

• Drug seeking behavior associated with a person’s need to relieve pain and suffering, not an obsession with the mood altering affects of medication.

Wesson et al, 1993

Chronic Pain Medical Issues

• Physical Exam• History documenting prescribing rationale• Pain assessment documentation

Legal Issues

• Accurate prescription records–Controlled substance laws– Schedule II• Emergency Telephone Prescriptions• Terminally Ill/Nursing Home Patients Fax

prescriptions

Skilled Prescribing

• Patient –Physician Partnership• Pain management expectations• Medication responsibilities• One physician • One pharmacy

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