Barbara Ziegler Palliative Care Program

12th Annual Palliative Care Symposium

Broward Health Medical Center

November 8, 2013

Neil Miransky DOPalliative Medicine Physician

Challenges in the Treatment of Non-Cancer Related Pain

CDC 2010 top 15 causes of death

Mortality rates are not the same as morbidity rates. People suffer from multiple conditions which will never kill them but will significantly impact their lives.

Definitions

• PAIN: "An unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain is always subjective….” (International Association for the Study of Pain)

• PHYSICAL DEPENDENCE: “Is a state of adaptation indicated by a medication class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreased blood level of the drug or administration of an antagonist.” (American Pain Society)

• ADDICTION: “Is a primary, chronic and neurobiological disease. It’s development and manifestations are influenced by genetic, psychosocial and environmental factors. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm and craving. (American Pain Society)

• Symptom: Any morbid phenomenon or departure from the normal in structure, function, or sensation, experienced by the patient and indicative of disease. Stedman’s Medical Dictionary 27th Edition

• Sign: Any abnormality indicative of disease, discoverable on examination of the patient; an objective indication of disease , in contrast to a symptom, which is a subjective indication of disease. Stedman’s Medical Dictionary 27th Edition

• Patient Experience = Symptom

• Clinician Observation = Sign

• IT IS POSSIBLE TO HAVE A SYMPTOM WITHOUT A SIGN

• IT IS POSSIBLE TO HAVE A SIGN WITHOUT A SYMPTOM

Non-cancer pain management Challenges

• Few to no objective tests

• Requires good patient / treatment team communication based on trust and honesty

• Medications can be habit forming (Dependence)

• Some people feign pain to get “DRUGS” (Addiction)

• Scant formal training for physicians most

• Concern about side effects

• Concern about harming patient

• Can require use of DEA controlled substances (Fear Of Loosing License)

Clinical Concerns: Non-Cancer Pain• Concerns are based on a belief that symptom management can / will cause harm

• Respiratory Depression

• decreased sensitivity to hypercarbic drive

• Hypotension

• decreased systemic vascular resistance

• CNS Depression / Altered Mental Status

• Constipation / Ileus / Nausea

Concerns are Justified : Non-Cancer Pain• If medications are administered rapidly, negative cardiac effects may be precipitated.

• If medications doses are inappropriate, respiratory depressive effects may be precipitated.

• If the wrong medication amongst a class is selected then no benefit or significant undesired side effects may result.

Concerns are justified: Non-cancer Pain

• If the right medications are administered in the right manner, in the right the dose, to the right patient, they will benefit.

• Fellowship training in Palliative Medicine is necessary.

• Dermatologists don't manage vents and pulmonologists don't do neurosurgery (at least not well).

A person’s quality of life and level of function are the reasons we treat pain.

A Brief Overview of Pain

Acute Pain

• Identifiable cause

• Protect site to prevent reinjures

• Short duration with beginning and end

• Subjective and physical signs are present

• Has a purpose - warns of a problem, diagnostic gauge for healing

Chronic pain

• Identifiable cause not always present

• Ongoing without foreseeable end

• Few if any subjective and physical signs are present

• Frequently results in physiologic depression

• Has no therapeutic purpose

Patients with an acute pain may also have related or unrelated chronic pain syndrome.

World Health Organization Ladder/VA

The WHO ladder portrays a progression in the doses and types of analgesic drugs for effective pain management. The best choice of modality often changes as the patient’s condition and the characteristics of the pain change.

The first step in this approach is the use of acetaminophen, aspirin, or another Non-steroidal Anti-inflammatory Drug (NSAID) for mild to moderate pain. Adjuvant drugs to enhance analgesic efficacy, treat concurrent symptoms that exacerbate pain, and provide independent analgesic activity for specific types of pain may be used at any step.

When pain persists or increases, an opioid such as codeine or hydrocodone should be added (not substituted) to the NSAID. Opioids at this step are often administered in fixed dose combinations with acetaminophen or aspirin because this combination provides additive analgesia. Fixed combination products may be limited by the content of acetaminophen or NSAID, which may produce dose-related toxicity. When higher doses of opioid are necessary, the third step is used. At this step separate dosage forms of the opioid and non-opioid analgesic should be used to avoid exceeding maximally recommended doses of acetaminophen or NSAID.

Pain that is persistent or is of moderate to severe intensity from the outset should be treated by increasing the dosage or with more potent opioids. Drugs such as codeine or hydrocodone are replaced with more potent opioids (usually morphine, hydromorphone, methadone, fentanyl, or levarphanol).

Medications for persistent cancer-related pain should be administered on an around-the-clock schedule, with additional "as needed" doses, because regularly scheduled dosing maintains a constant level of drug in the body and helps to prevent a recurrence of pain. Patients who have moderate to severe pain when first seen by the clinician should be started at the second or third step of the ladder.

Reference: U.S. Department of Health and Human Services, Agency for Health Care Policy and Research Clinical Practice Guidelines, Number 9, March 1994.

U.S. Department of Veterans Affairs - 810 Vermont Avenue, NW - Washington, DC 20420

Reviewed/Updated Date: February 18, 2010

A Brief Primer on Pain Medications

Adjuvant Agents• NSAIDs

• Steroids

• Anesthetics

• Bisphosphonate

• Anticonvulsants

• Tri-cyclic Antidepressants

• NSRI Antidepressants

• Steroids

• Benzodiazepine

• Alpha Antagonists

• NMDA Agonist

• Ketamine

NSAIDs

Acetaminophen

Equianalgesic Dosages- Oral

Equianalgesic Dosages- Parenteral

Principals of opioid dosing• Individualize dose by escalation until development of adequate analgesia or intolerable or

unmanageable side effects.

• No therapeutic ceiling effect.

• “Around the clock dosing” for continuous or frequently recurring pain.

• As needed (“prn”) dosing for dose finding and for “rescue doses”.

Some Examples and Discussion

Sickle Cell

Rheumatoid Arthritis

Non-cancer Pain

RSD PVD

Peripheral Neuropathy

Traumatic Injuries

Questions & Comments