Use of Opioids: Acute / Chronic Pain Management

Report
What to Do
About
Pain
Nirmala Abraham Hidalgo, MD
Assistant Director, UCLA Pain Management Center
Assistant Professor, Dept. of Anesthesiology
UCLA - David Geffen School of Medicine
What is Pain?
“Pain is an unpleasant sensory and/or
emotional experience associated with
actual or potential tissue damage, or
described in terms of such damage”
-International Association for the Study of Pain
Objectives
Basic information regarding the treatment of
pain
 Medical management

– WHO Ladder
– Use of opioids in chronic pain

Interventional management
– Pain pump
Pain Management

Realistic goals and expectations must be discussed with
patient

Maintaining functionality is most important goal for
overall pain management plan

Honesty is crucial in establishing patient – provider trust

Do not assume that pain was discussed by others

Non-pharmacological treatment should be incorporated
Selecting an Analgesic Regimen

Complete History
– Type of pain
– Location
– Severity

Anticipated duration of pain
– Acute vs. Chronic condition

Routes of administration available

Pain History
Non-Opioid Analgesic Drugs for
Pain Management



Acetaminophen – no anti-inflammatory effect
NSAIDs / ASA – inhibits platelet aggregation
– Non-Selective COX Inhibitors
– Selective COX – 2 Inhibitors
Others / Adjuvants
– Antidepressants
– Anticonvulsants
– Corticosteriods
– Others
The “WHO” Analgesic Ladder
WHO Analgesic Guidelines
Oral Medications whenever possible
 Dose “around the clock” and have PRN
medication for breakthrough pain
 Titrate the dose to affect
 Use appropriate dosing intervals
 Be aware of potencies
 Treat side effects
Step 1: Minor Pain – Non-Opioid

Non-steroidal anti-inflammatories (NSAIDs)
– are effective after minor surgery
– ↓ Opioid requirement
– Excellent analgesia for Children after minor surgery
Dyspepsia/abdominal pain – use H2 Blocker if mild
 Contraindications:
– Coumadin

 Can increase anticoagulation by altering platelet function
–
–
–
–
Thrombocytopenia
Potential for bleeding
GI bleeding / ulcers
Impaired renal function
Step 2: Moderate Pain – Weak Opioid

± Non-Opioid and add Opioid

± Adjuvant

Use a Combination Agent (weaker Opioid)
– Opioid + Acetaminophen (APAP) or ASA
– Do not exceed 3gm APAP / 24 hrs
– Codeine, hydrocodone, propoxyphene
Step 3: Severe Pain – Strong Opioid

± Non-Opioid and Opioid

± Adjuvant

Morphine, hydromorphone, methadone,
fentanyl, oxycodone

Watch for Side Effects
 Opium is the dried powdered mixture of 20
alkaloids obtained from the unripe seed
capsules of the poppy plant
 Opiate refers to any agent derived from
opium
 Opioid refers to all substances, exogenous or
endogenous, synthetic or semi-synthetic, with
morphine-like properties
Agonists
Strong







Morphine
Hydromorphone
(Dilaudid)
Meperidine (Demerol)
Oxymorphone (Opana)
Fentanyl (Duragesic)
Methadone (Dolophine)
Oxycodone (Oxycontin)
Weak
Codeine
 Propoxyphene
(Darvon)
 Hydrocodone

Important Points for Opioids

Titration for Pain
– Mild – Moderate: ↑ dose by 25 – 50%
– Moderate – Severe: ↑ dose by 50 – 100%

Breakthrough Pain Management
– Very dependent on cause of pain and patient’s
response to medications

Equianalgesic dosing – requires calculation
Opioid Side Effects

Constipation - most common
– Does not improve with use




Sedation
N/V – 50% of patients, improves with use
Respiratory Depression – less with ↑ use
Pruritis
– More common with IV/epidural/intrathecal

Urinary Retention
– More common with epidural/intrathecal



Orthostatic Hypotension
Euphoria (or hallucinations)
Physical Tolerance/Dependence
Contraindications / Precautions
Seizures
 Severe Respiratory Depression
 Decreased Respiratory Reserve

– Elderly, Infants
– Asthma
Increased ICP
 Pregnancy
 Undiagnosed acute abdominal conditions

Side Effect Management

Constipation
– Stool softener, laxative, combination may be best
– Docusate, Senna, Lactulose

Nausea / Vomiting
– Compazine, Reglan, Zofran/Anzemet

Sedation/Mental Clouding
– Dose reduction
– CNS stimulants (caffeine, dextroamphetamine, Provigil)

Myoclonis/Delirium/Hallucinations
–
–
–
–
Hydrate
Consider changing/discontinuing opioid
Rule out renal failure and other aggravating factors
Treat symptoms (haloperidol)
Opioid Tolerance / Dependence







Rate of tolerance varies
Tolerance develops with ↑ dosing over time
Intermittent dosing generally does not lead to
tolerance
Chronic use often leads to tolerance
Physical dependence occurs with or without
development of tolerance
The appearance of abstinence syndrome defines
physical dependence on opioids, which can
occur after 2 weeks of opioid use
Dependence is NOT the same as ADDICTION
Withdrawal - Abstinence

6-8 hours
– Drug “seeking”, restless, anxious

8-12 hours
– Dilated pupils
– ↑ Blood pressure and heart rate
– Yawning, chills, rhinorrhea, lacrimation, goosebumps, sweating,
restless sleep

48-72 hours (peak): all of the above plus
–
–
–
–
–

Cramps (muscle weakness, aches)
Nausea / Vomiting and Diarrhea
Dehydration
Sweating
↑ Blood pressure, ↑ heart rate, ↑ respiratory rate, ↑ temperature
Treatment of symptoms  Clonidine
Intrathecal Drug Delivery
Advantages
 Effective
pain relief
 Decreased systemic drug
dose
- Decreased side effects
- Decreased drug cost
 Improved
ability to
perform ADLs, enhanced
quality of life
 Long-term cost
effectiveness
Advantages of Intrathecal Drugs
for Cancer Pain
Allows patients to be coherent and accessible to
their families
 Cost effective vs. external pump if life
expectancy is greater than 3 months
 Life expectancy may be extended with the stress
of severe pain removed
 May provide relief for the approximately 5-15%
of cancer pain patients who do not receive
adequate relief from systemic opioids

Conclusion

Pain is the “5th Vital Sign”

Should not be afraid of treating pain because of
the medications involved

Patients need to be appropriately educated
regarding their condition and expected outcome

Healthcare providers need to stay educated
about latest options for treatment of pain

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