Pharmacist's Role in Pain Management

Range of Involvement

(5)

1.  Brief counseling when filling Rx

2.  Extension role in assessing and management

3.  Consultation with MD

4.  Assessement of Drug Use and Effect

5.  Assist with the management of SE

Pain Assessment

Failure to rountinely assess pain and pain relief is the most common reason for unrelieved pain

Factors which can influence pain perception and subsequent treatment

(6)

Cultural, racial, or educational differences from care giver

Socioeconomic differences from caregiver

Gender

Age Differences

Cognitively and Emotionally Impairment

History of Substance Abuse

Pain Perception

Gender Differences

(6)

1.  Females more likely to report pain

2.  Females generally have lower pain threshold

3.  Females have a greater ability to discriminate pain

4.  Females are more likely to describe how the pain affects their personal life

5.  Males are more likely to describe how the pain will affect their work

6.  Females are more likely to seep help for their pain

Pain Perception

Age Differences

(3)

1.  Neonates and infants are difficult to assess

2.  Toddlers and Preschool aged children have trouble localizing pain

3.  Some geriatic patients may not complain to their health care provider especially in LTCF

Patients at Greast Risk of Problems during Pain Assessment

(5)

Minorities

Women

Cognitively-Impaired

Infants

Geriatric Patients

Less than adequate pain management may be due to...

(6)

Limited access to care

Problematic Assessment

Economic Barriers

Communications

Attitudes

Individual Values-Patient Perception

Clinician-Related Barriers to Effective Pain Assessment and Treatment

(5)

Lack of pain training in medical school

Insufficient Knowledge

Lack of pain-assessment skills

Rigity or timidity in prescribing practices

Fear of regulatory oversight

Patient-Related Barrier to Effective Pain Assessment and Treatment

(3)

Reluctance to report pain

Reluctance to take opioid drugs

Poor Adherence

System-Related Barriers to Effective Pain Assessment and Treatment

(4)

Low priority given to symptom control

Unavailability of opioid analgesics

Inaccessability of specialized care

Lack of insurance coverage for outpatient pain medication

Pain Assessment Goals

(6)

Characterize the pain

Identify pain syndrome

Infer etiology and pathophysiology

Evaluate physical and psychological comorbidities

Assess degree and nature of disability

Develop a therapeutic strategy

Pain History

(5)

Temporal Features (Onset, Duration, Course, Pattern)

Intensity (Average, Least, Worst, and Current Pain)

Location (Focal, Multifocal, Generalized, Referred, Superficial, Deep)

Quality (Aching, Throbbing, Stabbing, Burning)

Exacerbating/Alleviating Factors (Position, Activity, Weight Bearing, Cutaneous Stimulation)

Questions to Ask

(8)

Site(s) and Radiation

Timing

Quality

Severity

Aggrevating Factors

Relieving Factors

Impact (on sleep, mood, activity)

Previous Therapy

Pain Intensity Scales

(4)

Verbal Rating

Numeric Scale

Visual Analogue Scale

Scales for Children

Cancer Pain Syndrome

(4)

Bone pain

Pathologic Fracture

Cord Compression

Bowel Obstruction

Noncancer-related Pain Syndrome

(4)

Atypical facial pain

Failed lower-back syndrome

Chronic tension headache

Chronic pelvic pain of unknown etiology

Monitoring Parameters

(8)

1.  Type and location of pain

2.  Pain scale rating

3.  Type and dose of analgesic

4.  Use of PRN doses of analgesics

5.  Use of other CNS medications

6.  Impact on sleep, mood, appetite, ADLs

7.  Impact of pain on QOL

8.  SE associated with analgesic therapy

Nonverbal Pain Indicators

Infants and Children

(4)

BP

HR

Facial Grimaces

Decibel of Cry

Nonverbal Pain Indicators

Elderly-Dementia-Cognitively Impaired

(6)

Vocal Complaints (sigh, moans, groans)

Facial Grimaces/Winces (narrowed eyes)

Bracing

Restlessness

Rubbing

Vocal Complaints (ouch)

Effective Pain Management

(4)

Patient Specific

Pathology Specific

Goals/Identified Outcomes

Patient Education

Desired Outcomes for Pain Management

(4)

Relieve by 50%, 75%, 90%

Restore functionality-prevent disability

Maintain and/or Restore QOL

Minimize SE from Medication

Managemtn of Mild to Moderate Acute or Chronic Pain

Use (6)

Dosing for Ibuprofen, Aspirin, Acetaminophen, Naproxen

For headaches, neuralgia, myalgia, dysmenorrhea, dental pain,minor trauma

APAP 650 mg PO q4-6 hours

Aspirin 650 mg PO q4-6 hours

Ibuprofen 400 mg PO q4-6 hours

Naproxen 220-440 mg PO q8-12 hours

Role of Non-Opioid Analgesics

(8)

1.  NSAIDs are very effective for pain due to inflammation (NOT APAP)

2.  Most agents having a ceiling analgesic effects

3.  No tolerance or addiction

4.  Few SE associated with short-term use

5.  More SE associated with long-term use

6.  NSAIDs are effective for Metastatic Bone Pain

7.  Must be aware of total daily dose of APAP (4g)

8.  Role of COX-2 Inhibitors => no role in acute pain risk with prolonged use

Side Effects of NSAIDs

(6)

GI intolerance

GI Ulcers

Renal Dysfunction

Increased risk of bleeding in some patients

Compromise treatment for HTN and CHF

Risks with chronic use are much greater!!!

Managemtn of Mild to Moderate Pain

STEP 2

(3)

Options

Patient does not respond to Step 1

Sufferes from more severe acute trauma

Post-op outpatient surgery

Combination Products:  Non-opioid (APAP or ibuprofen) + weak opioid

Codeine/APAP (CIII)

Codeine is NOT active and must be converted to Morphine by CYP2D6 (drug interactions)

Hydrocodone/APAP (CIII) Strengths

Vicodin

Norco

Lortab

Hydrocodone/Ibuprofen (CIII) Strengths

Vicoprofen

2.5/325, 5/325, 7.5/325

5/325, 7.5/325, 10/325

5/325, 7.5/325, 10/325

7.5/200

Oxycodone/APAP (CII) Strengths

Percocet

Roxicet

Tylox

Oxycodone/Ibuprofen (CII) Strengths

Combunox

2.5/325, 5/325, 10/325

5/325

5/325

5/400

Management of Mild to Moderate Pain

Option 2: Tramadol

MOA

SEs (9)

Weak mu agonist, inhibits 5HT and NE uptake

NV

Dizziness

Somnolence

Drowsiness

Constipation

Restlessness

Sweating

Headache

Increase Risk of Seizures

Tramadol Dosing

50 to 100 mg q4-6 hours (Max:  400 mg)

Max of 300 mg/day in patients > 75 yo

Extended dosing interval in patients with CrCl < 30 mL/min

Ultram => 50 mg tablet

Ultracet (Tramadol/APAP) => 37.5/325 mg APAP

Diclofena Epolamine 1.3% Flector Patch

Indication

Dosing

Contraindications (2)

Indicated to treat acute pain d/t minor strains, sprains, and contusions

Applied to most painful areas twice daily

Do not apply to damaged or non-intact skin

Not to be used in combination with oral NSAIDs

Managemtn of Moderate to Severe Acute Pain

Indications

(5)

Trauma

Injury

Post-op

Procedures

Breakthrough Pain

Management of Moderate to Severe Pain Options

(5)

Opioids

Ketorolac Injectable

Narcotic Agonist/Antagonist

Butorphanol Nasal Spray

Ketorolac Nasal Spray

Management of Moderate to Severe Pain

Opioid Dosing

Morphine

Merperidine

Hydromnorpone

Fentanyl

10-15 mg IM q 4hrs PRN

75-100 mg IM q3-4 hrs PRN

1.5-2 mg IM q4hrs PRN

50-100 mcg IV q 1-2hrs PRN

Role of Opioid Analgesics

(6)

Agents of choice for moderate to severe pain

Stimulate opioid receptors (mu-primarily responsible for analgesia)

Use for limited period of time in most Patients

No ceiling dose

Offers flexibility in dosing and dosage forms

Analgesia + Sedation

Side Effects of Opioid Analgesics

(3)

Greater Variation in SE among patient

More ADRs associated with peak drug levels

Tolerance often develops to SE

Ketorolac (Toradol)

Dose (2)

Recommendation

15-30 mg IM/IV q4-6 hrs (120 mg max)

10 mg PO q 4-6 hrs

NOT recommended for more than 5 DAYS

Narcotic Agonist/Antagonist

Uses (5)

Short-term use only; not for chronic pain

Patients with acute pain (ER or post-op)

Patients with history of narcotic abuse

Patients with severe respiratory disease or dysfunction

During Labor and Delivery

Narcotic Agonist/Antagonist

Problems (3)

Lack of PO dosage form limits use

Can precipitate narcotic withdrawl

Overall benefits are minimal

Narcotic Agonist/Antagonist

Dosing

Buprenorphine

Butorphanol

Nalbuphine

Pentazocine

0.3 mg IV/IM q4-6 hrs

1-3 mg IV/IM q3-4 hrs

10 mg IV/IM q3-6 hrs

30 mg IV/IM q3-4 hrs

Butorphanol Nasal Spray

Dose (3)

Abuse

10 mg/mL in 2.5 mL metered dose pump

1 mg (1 spray in one nostril)

For severe pain, an initial 2 mg dose (1 spray in each nostril)

Risk of abuse is significant

Ketorolac Nasal Spray

Dose (2)

Duration

One 15.75 mg spray in each nostril q6-8 hrs

Maximum dose daily = 126 mg

Not be used for > 5 days

Management of Severe Chronic Pain

(4)

Individualize drug selection and dosage

Administer regularly

Use oral therapy whenever possible

Become familiar with onset, peak, duration, dosage forms, and parenteral to oral conversion of different agents

Opioid Side Effects

(8)

Sedation

Pruritis vs. Allergy

Constipation

Sweating

Nausea and Vomiting

Urinary Retention

Respiratory Depression

Dizziness/Lightheadness

Treatment of constipation associated with Opioids

(2)

Stimulant Laxative often Required

Methylnaltrexone for patients who fail stimulants

Neurotoxicity

Explaination

Manifestations

(6)

Can develop in patients on HIGH DOSES of MORPHINE for long periods of time due to accumulation of methyl-3-glucuronide metabolite

Myoclonus

Tingling of the Face and Arms

Impaired Cognition

Hallucinations

Delrium

Severe Constipation

Managment of Severe Chronic Pain

(2)

Be aware of tolerance, cross-tolerance, physical and psychological dependence

Use drug combinations that enhance analgesic effects and/or minimize side effects of the opioid analgesics

Chronic Malignant Pain Managment

(3)

Pain relief

No ceiling dose for opioids

Enhance QOL

Non-Chronic Malignant Pain Management

(5)

Pain relief

Restore of function

Enhancing coping mechanisms

Minimizing SE

Avoiding drug-seeking behaviors

Stepwise approach to managing patients with severe chronic pain

(9)

Evaluate frequency of use of opioid (or other) analgesics

When q4-6 hrs meds are being used rountinely, swith to LA dose

Determine the most appropriate LA doage form for the patient

Determine most appropriate SA dosage form agent for breakthrough pain

Monitor effectiveness of dosing changes

Increase dose of LA dosage form when patients use > 2 rescues/day

Add adjunctive therapy IF APPROPRIATE to minimize opioid total dose

Consider a change in route of administration to ease administration

Consider Opioid Rotation

Treatment of Chronic Pain with Opioids

General Facts

(6)

1.  Food may increase the extent of GI absorption

2.  Food may decrease the rate of absorption but NOT EXTENT or absorption of ER products

3.  Avoid taking any ER product with EtOH

4.  Clearance of drugs and metabolites often rescued in patients with decreased renal and hepatic function

5.  Geriatric patients often require lower doses and are at greater risk of toxicites

6.  Many of these products are NOT indicated for Opioid Naive Patients