Pain management in LTC - Virginia Medial Director`s Association

Report
Mary P. Evans MD CMD FACOG FAAHPM
Blue Ridge Long Term Care Associates
President, Virginia Medical Directors Association
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Discuss the most common pain syndromes in the LTC
population
Describe several classes of pain medications and their
indications
Understand non-pharmacologic approaches to pain
management and their use in LTC
Describe appropriate pain regimen options for the LTC
population
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45-80% of residents in nursing facilities have chronic
pain
51% of residents who report intermittent pain have pain
every day
Of these patients, 84% had order for prn pain meds, but
only 15% of patients received prn med
Nationally, LTC facilities are doing poorly on pain
quality measures
Ferrell et al, Pain in the Nursing Home,
JAGS 1990;38:409-414
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Back pain
Arthritis
Previous fx
Neuropathy
Leg cramps
Foot pain
Claudication
Headache
Generalized
Cancer
40%
29%
14%
11%
9%
8%
8%
6%
3%
3%
Stein et al, Pain in the Nursing Home.
Clin Geriatr Med 1996;12:601-613
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Incident pain
Acute pain
Chronic pain
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Musculoskeletal pain
Bone pain
Visceral pain
Neuropathic pain
Malignancy pain
Psychosocial pain/existential pain
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Physical pain: medical conditions
Emotional pain: anger, depression, anxiety
Social pain: loneliness, family issues, financial issues
Spiritual pain: life’s meaning, leaving a legacy,
hopelessness, abandonment
*Think of these concepts with patients who have pain
that is difficult to control
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Unrecognized pain
Difficulty communicating needs
Lack of assessing for pain
Unavailability of pain med order
Pain med not available
Narcotic script issues
Cultural barriers and beliefs
Personal opinions and beliefs
Family interactions
Physician attitudes, beliefs, biases, skills
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Use of pain medication:
Physical dependence on pain medication – normal state
of adaptation to ongoing pain med use
Addiction to pain medication – psychological
dependency
Pseudoaddiction to pain medication – apparent drugseeking or asking for increased dosage when pain is
undertreated
Tolerance to pain medication – may need increased
dose due to lessened effect or disease progression
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Chronicity: Acute, chronic, constant, intermittent
Onset timing: Incidental, procedural, breakthrough,
disturbance
Quality, intensity
Alleviating factors
Exacerbating factors
Associated symptoms, radiation of pain
How it affects the patient: what is the patient no longer
able to do as a result of the pain? What does this pain
mean to the patient?
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What has been tried before to help the pain?
Which pain medications have been tried?
Were they helpful?
Which medication, dose, timing seems to work best?
Any difficulties taking oral meds?
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Pain is likely under-recognized, under-treated
Communication difficulty
Assessment difficulty
Non-verbal pain assessment scales:
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FACES pain scale
FLACC scale (face, legs, arms, consolability, cry)
Discomfort scale
PAINAD scale
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Facial expression- grimacing, frown, grinding teeth
Posture – guarding, bracing, defensive posture
Movement – rocking, rubbing, fidgeting, restlessness
Behaviors – agitation, physical aggression, resisting
cares, yelling out
Vocalization - crying, groaning, whining, sighing
Activities – ADL function, participation, gait
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Occurs with particular activities
Getting out of bed
Taking a shower
Transferring to chair
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Anticipate the pain
Oral pain med 30-60 min prior to procedure
Premedicate before procedures:
◦ Dressing changes for wounds
◦ Moving patient for shower
◦ Transfer to hospital for procedure
By mouth – oral or sublingual, avoid injections
By the clock – schedule routinely, appropriate interval
By the ladder –
Step 1 – Acetaminophen (limit dosage), NSAID
Step 2 – Opioid or combination Acetaminophen/Opioid
Step 3 – Pure opioid, addition of adjuvant
By the individual – can add adjuvants at any step; can
start at higher step to relieve pain initially; quality of
life; comorbidities, family support
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Morphine PO
Morphine SC or IV
Oxycodone PO
Hydrocodone PO
Hydromorphone PO
Hydromorphone SC or IV
Transdermal Fentanyl patch
30 mg
10 mg (1/3 dose)
20-30 mg
30 mg
7.5 mg (1/4 dose)
1.5 mg
12 mcg-25 mcg
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Muscles, ligaments, tendons, bones, nerves, joints
Sprains, strains, overuse syndromes
Bruises, bumps
Inflammation, infection
Loss of blood flow to muscle
Low back pain in the most common chronic
musculoskeletal pain
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Aching, stiffness
“pulled muscle” feeling
Fatigue, disrupts sleep
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Acetaminophen
Acetaminophen/narcotic combo
Pure opioid
Corticosteroid
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Muscle spasms:
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Cyclobenzaprine
Orphenadrine
Metaxalone
Methocarbamol
Carisoprodol
Tizanidine
Baclofen
Benzodiazepines
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PT/OT
Splint for immobilization, rest
Mobilization
Heat, cold
Relaxation, biofeedback
Stretching exercises
Therapeutic massage
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Described as aching, dull, deep, boring, constant, may
be weather-dependent
Difficult to localize
Present at rest and with movement
Somatic pain
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Fractures
Healed fracture
DJD
Metastasis to bone (breast, lung, prostate)
Sickle cell disease
Myeloma
Paget’s disease
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Corticosteroids
Calcitonin
Bisphosphonates (*GI symptoms, keep upright)
Palliative radiotherapy
Nonsteroidal anti-inflammatory drugs
Narcotic pain meds
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Distension of hollow organ
Stretching of smooth muscle
Stomach
Small and large intestines
Gall bladder
Kidney/ureter
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Crampy, intermittent pain
May be difficult to localize
Can be mild to severe
History is important – especially timing of pain
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Evacuation of the distended hollow viscus
Relief of constipation, disimpaction
Surgical treatment
Prevent future episodes
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Bowel obstruction:
◦ Octreotide ($$$$)
◦ Anticholinergics: hyoscine, scopolamine, glycopyrrolate ($)
◦ Corticosteroids ($)
◦ especially end of life care
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Appendicitis
Early inflammation – crampy abdominal pain, nausea
and vomiting
◦ Patient is uncomfortable, writhing on table
◦ Visceral pain, difficult to localize
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Later in course – localization of pain to right lower
quadrant, fever, malaise, leukocytosis
◦ Patient lies still, + rebound
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Compression of nerve
Post-entrapment nerve injury
Regional pain syndromes
Skeletal muscle spasms
Post-herpetic neuralgia
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Acetaminophen
Acetaminophen/narcotic combo
Pure opioid
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Add adjuvant meds, therapies early on
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Administered by therapist
Transcutaneous electrical nerve stimulation
Battery-operated, portable units
Electrical current disrupts pain signal
Questionable validity (Cochrane Collaboration, 2008)
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Heat, cold application
Muscle massage, stretching, ROM
Ultrasound, TENS
Acupuncture, acupressure
Physical and occupational therapy
Positioning, devices, pillows, chairs
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Meditation, relaxation
Spiritual counseling and prayer
Hypnosis, biofeedback
Aromatherapy, herbal therapy
Music and sound therapy
Art therapy
E-stim
Diathermy
Laser therapy
Heat/cold application
Topical treatments – menthol, capsaicin
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First documented use in ancient Rome, AD 63
Scribonius Largus described pain relief by standing on
an electrical fish at the seashore
16th-18th century – electrostatic devices for headaches
and pain
Benjamin Franklin was a proponent of electrical
stimulation treatment of pain
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Administered by therapist
Electrical current causes contraction of muscle or
muscle group
Helps strengthen affected muscle
Promotes blood supply to area – promotes healing
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Active component of chili peppers
Ointment, spray, cream forms
Minor aches, pains, DJD, strains and sprains
Post-herpetic neuralgia
Neurons are depleted of neurotransmitter (substance P),
fatigues nerves
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“Start low, go slow”
Don’t forget the bowel regimen
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Constipation – add stool softener, stimulant right away
Nausea, vomiting – often transient for 3-4 days
Sedation – no driving, methylphenidate, caffeine
Delerium – lorazepam
Pruritis – usually dissipates; antihistamine
Urinary retention – monitor output, comfort
Myoclonic jerks – metabolite buildup; lower dose or
consider rotating to a different opioid
Respiratory depression – uncommon except when
starting fentanyl patch in opioid-naïve patient
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Hospice, end of life care
Multiple drug allergies
Route of administration alternatives:
◦ Transdermal fentanyl
◦ Oral meds administered rectally
◦ Avoid injectable meds if possible
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Addition of antidepressants
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TCA’s: Amitriptyline, nortriptyline*
SSRI‘s: paroxetine, citalopram
NSRI: venlafaxine*
Other: bupropion
* watch for anticholinergic symptoms
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Addition of neuroleptics:
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Gabapentin
Topiramate
Lamotrigine
Carbamazepine
Levetiracetam
Pregabalin
Phenytoin
Valproic Acid
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NMDA antagonists:
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Ketamine
Dextromethorphan
Memantine
Amantadine
Local Anesthetics:
◦ Lidocaine – gel, patch
◦ Mexiletine
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Other:
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Baclofen
Cannabinoids
Methylphenidate
Capsaicin
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Alpha-adrenergic agonists: clonidine, tizanidine
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Corticosteroids:
◦ Dexamethasone (intracranial pressure)
◦ Prednisone (DJD, bone pain)
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Pain despite escalating doses
Consider possibility of drug diversion
Consider existential/psychosocial pain
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Chronic pain – may try rotating to another opioid
“Opioid fatigue”, tolerance
Remember to reduce calculated conversion dose by
50% for cross-tolerance
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Post-op patients:
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Schedule pain meds x 7 days
prn pain meds available
Treat pain aggressively until comfortable
Remember the bowel regimen!
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Patients with dementia, behaviors:
Difficulty asking for meds, communicating
Schedule acetaminophen tid-qid
Have opioid available for pain not relieved by
acetaminophen
Consider lidocaine patch
Consider scheduled opioid for daily moderate to severe
pain (bowel regimen!)
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Hospice, end of life care:
Have liquid morphine, liquid lorazepam available
Rectal acetaminophen
Can also administer oral meds via rectal route
Transdermal fentanyl patch (appropriate dose) if unable
to swallow (not in opioid naïve patients)
Long-acting opioids once optimal 24h dose achieved
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Acyclic analog of morphine, heroin
NMDA receptors – neuropathic pain
Used in hospice, end of life care
Long half-life, long-acting
Strong analgesic
Cheap ($)
Chronic pain use – anti-addictive
Less sedative than other opioids
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Many metabolites
Liability risk (?)
Variable metabolism/half-life in the elderly
Use cautiously in select patients
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Approved in the US for detoxification treatment of
opioid addiction
Must follow strict federal regulations in detox
programs
Programs must be certified by Federal Substance Abuse
and Mental Health Services Administration
Programs must be registered with the Drug
Enforcement Agency (DEA)

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