Jena Torpin, Pharm.D. Mary Cunningham, APRN November 6, 2013 Acute Pain Management Jena Torpin, Pharm.D. Mary Cunningham, APRN November 6, 2013

Objectives  List 3 patient outcomes impacted by appropriate management of acute pain Describe key patient assessment parameters in evaluating pain outcomes Formulate an appropriate pharmacologic treatment regimen for patients experiencing acute post-operative pain.    Demonstrate the use of an opioid equianalgesic chart to compare opioid potencies Differentiate opioid dosing for acute pain in opioid naïve and opioid tolerant patient

Background Pain Acute Pain Chronic Pain Persists > 3 months Etiology less clear Nerve injury Musculoskeletal Serves no purpose Acute Pain Clear cause < 3 months serves a purpose Pain, 1986; Managing Acute Pain A Guide For Patients, 2006; D’Arcy, Acute Pain Management, 2011

Manifestations of Pain Acute Increased BP, P, R Dilated pupils Sweating Focus Reports pain Crying, moans, restless Grimace Chronic Normal vitals Normal pupils Dry skin Distraction No report of pain Quiet, sleep, rests Blank/normal facial expression Behavioral Physiologic

Agreement Between Caregiver and Patient VAS 7-10 (15) VAS 3-6 (35) VAS 0-2 (53) Patient and Nurse 7% 51% 82% Patient and House Officer 20% 26% 66% Patient and Fellow 27% 29% 70% Patient and Professional 13% 37% 79% Grossman, S., et al. (1991). J Pain & Symptom Management 6: 53-57.

Factors Influencing Assessment Chronicity Presence of pathology Age Gender Ethnicity Functional status Socioeconomic status Value systems

Physiologic Consequences of Pain Increased metabolic rate Increased blood clotting Water retention Tissue breakdown Impaired immune function Autonomic hyperactivity Pulmonary dysfunction Delayed return of bowel function Development of chronic pain syndromes Carbonara Baugh, Acute Pain, 2011; Managing Acute Pain A Guide For Patients, 2006; Macintyre, Acute Pain Management, 2007; http://www.americanpainsociety.org/uploads/pdfs/npc/section_1.pdf

Impact of Pain on Activity and QOL Relationships Walking Sleep Activity level Mood Work Enjoyment of life 3 4 5 6 7 8 Pain Intensity Cleeland C., et. al. (1994). NEJM 330.

Pain Is CO$TLY Decreased patient/family (staff) satisfaction Increase co-morbidities Increase LOS CMS reimbursement based on satisfaction. Public distribution of UMHC scores Pain management is a quality indicator in value based purchasing

Hospital Compare www.medicare.gov.

Pharmacologic Pain Treatment Strategies Etiology Mechanism of action Match dosing formulation to temporal pattern of pain Use a preventative approach Tailor potency to severity Equianalgesic dosing Anticipate side effects Cost

Degree of Pain: The W.H.O. Ladder Image: http://www.who.int/cancer/palliative/painladder/en/; Vargas-Schaffer, 2010; Pharmacist’s Letter, 2010

Non-Opioids TYLENOL Good option for: Bad option for: Patients with kidney dysfunction Heart failure/heart disease GI bleeds/ulcers Bariatric patients Bad option for: Patients with liver disease Alcoholism Malnutrition Carbonara Baugh, Acute Pain, 2011; Managing Acute Pain A Guide For Patients, 2006; D’Arcy, Acute Pain Management, 2011

Not all NSAIDs are created equally: Non-Opioids NSAIDS Not all NSAIDs are created equally: Low CV Risk: Naproxen, Piroxicam High CV Risk: Celebrex, Meloxicam, Diclofenac, Ketorolac Low GI Risk: COX-2 Inhibitors High GI Risk: Diclofenac, Ketorolac Good option for: Pain with an inflammatory component Bad option for: Patients with kidney dysfunction Heart failure/heart disease GI bleed/ulcers Bariatric surgery patients Carbonara Baugh, Acute Pain, 2011; Managing Acute Pain A Guide For Patients, 2006; D’Arcy, Acute Pain Management, 2011

Mild-Moderate Pain: Oral Options: Opioids Wouldn’t Recommend: -Codeine -Methadone -Meperidine Mild-Moderate Pain: Oral Options: -Tramadol -Hydrocodone Severe Pain: -Morphine -Oxycodone -Hydromorphone -Fentanyl IV Carbonara Baugh, Acute Pain, 2011; Managing Acute Pain A Guide For Patients, 2006

Fentanyl Patch Aside… 60% of use was inappropriate for new starts DUE: February 2013 60% of use was inappropriate for new starts Suggested approach to starting fentanyl patches: Continuation of home medication = appropriate Starting a fentanyl patch: Only Indication: CHRONIC PAIN Opioid tolerance Equianalgesic patch dose: Previous 24-hour requirements + reduction for cross-tolerance Minimum 3 days or 6 days depending on dose titration

Pharmacokinetics/Dynamics IV vs PO: Oral access  oral route preferred Draw back: onset averages 45 minutes IV option appropriate when… Severe acute pain (“rescue therapy”) No oral access Delayed gastric emptying Dipiro, 2008

Initial Doses of Opioids in Naïve and Tolerant Patients Opioid Naïve Opioid Tolerant Oral IV Hydrocodone 5-10 mg q4-6 h N/A Oxycodone 5 mg-10 mg q4-6 h Morphine 15mg q4h-6h 2-4 mg q3-4 h 6-8mg q3-4 h Hydromorphone 2 mg-4mg q4-6h 0.5-1 mg q2-3 h 2mg q2-3 h Fentanyl 12.5-50 mcg q1-2 h 50-100mcg q1-2h Equianalgesic Dosing of Opioids for Pain Management. Micromedex, 2012, Pharmacist’s Letter, 2012, Lexicomp, 2013

Initial Doses of Opioids in Opioid Naive Elderly Patients IV Dose PO Dose Hydromorphone 0.5mg q 3h 2mg q 4h Morphine 2-4mg IV q 3h 5-10mg q 4h Oxycodone N/A 2.5mg-5mg q 4h Start on the lower end of the dosing range for frail elderly patients Fosnight S, Delerium in the elderly, PSAP VII,

UMHS PCA Order Set

PCA Usage

Epidurals Good options for patients with… Thoracotomy Large abdominal surgeries Aortic aneurysm repair Orthopedic surgery Labor and delivery ALL medications must be preservative free

Patient Factors: Allergies True Allergy Intolerance Anaphylaxis Management Avoid cross reaction Switch to opioid in different class Itching Constipation Sedation Nausea Phenantherenes Phenylpiperidines Diphenylhepatmones Morphine Codeine Meperidine Methadone Fentanyl Hydrocodone Hydromorphone Levorphanol Oxycodone Carbonara Baugh, Acute Pain, 2011; Dipiro, 2008

Formulary Agents Shortages Cost Continually changing… unfortunately Oral is always less expensive than IV

Effectiveness of pain regimen Usage of PRNs Maxing out their PRN usage Consider long acting agents or oral options Consider scheduling pain medications

Pain Management Summary

Preventing, monitoring, and alleviating ADR Constipation: bowel regimen at the time of opioid initiation Sedation: decrease dose, hold other sedatives Nausea/Vomiting: take with food, decrease dose, antiemetic, scopolamine patch, change to a different opioid class Itching: antihistamine such as diphenhydramine Avoid morphine (histamine release) Consider oxymorphone, oxycodone, or fentanyl (less histamine release) Carbonara Baugh, Acute Pain, 2011; Dipiro, 2008; Managing Acute Pain A Guide For Patients, 2006; D’Arcy, Acute Pain Management, 2011

Preventing, monitoring, and alleviating ADR Respiratory Depression: hold opioid, may consider naloxone 0.4 mg Naloxone Administration: Mix 0.4 mg in 9 mL NS and administer 0.5 mL q 2 minutes Mood Changes (dysphoria > euphoria): decrease dose, consider longer acting agent Increase in sphincter tone (urinary retention): utilize more non-opioid agents, catheterize Analgesic Tolerance (need larger doses for same effect): increase opioid dose, opioid rotation Dependence (withdrawal symptoms if abrupt d/c): taper patient down Carbonara Baugh, Acute Pain, 2011; Dipiro, 2008; Managing Acute Pain A Guide For Patients, 2006; D’Arcy, Acute Pain Management, 2011

Equianalgesic Dosing MEDICATION IV (mg) PO (mg) RATIO DURATION (Hours) Morphine 10 30 3 3-4 Hydromorphone (Dilaudid) 0.75-1.5 4-8 3-5 Oxycodone (Tylox, Percocet) 15 3-6 Meperidine (Demerol) 75 300 4 2-4 Hydrocodone (Lortab) Codeine 130 200 .75 4-6 http://www.texascancer.info/gftocp/titlepage.html

Opioid Conversion Change drug, keep route Example: Change ER morphine 90 mg q 12 hours to oral hydromorphone Calculate the 24 hour current dose: 90 mg Q12 hours x 2 doses = 180 mg PO morphine/24 hours Use the equianalgesic ratio: 30 mg PO morphine = 7.5 mg PO hydromorphone Calculate new dose using ratios: 180 mg = ___X___ X= 45 mg PO hydromorphone/24 hours 30 mg 7.5 mg Reduce dose 50% (incomplete cross-tolerance): 45 mg x 0.5 = 22 mg/24 hours = 4 mg oral hydromorphone q 4 hours

Opioid Conversion Change drug and route Example: Change ER Morphine 90 mg q 12 hours to IV Hydromorphone Calculate the 24 hour current dose: MSER 90 mg Q12 hours x 2 doses = 180 mg PO morphine/24 hours Use the equianalgesic ratio of PO to IV morphine: 30 mg po morphine = 10 mg IV morphine Calculate new dose using ratios: 180 mg_ = __X__ X = 60 mg IV morphine/24 hours 30 mg 10 mg

Opioid Conversion Change drug and route Example: Change ER Morphine 90 mg q 12 hours to IV hydromorphone Use the equianalgesic ratio of IV morphine to IV hydromorphone: 10 mg morphine = 1.5 mg hydromorphone Calculate new dose using ratios: 60 mg = __X__ X= 9 mg IV hydromorphone/24 hours 10 mg 1.5mg Reduce dose 50% (incomplete cross-tolerance): 9 mg x 0.5 = 4.5 mg/24 hours = 0.2 mg/hour IV continuous infusion hydromorphone

Example CB is a 63 year old male who underwent right knee arthroplasty 2 days ago Opioid use in the past 24 hours: 2 doses of 100 mcg IV fentanyl 3 doses of oxycodone 10 mg His pain is decreasing, but you would like to send the patient out on an equivalent dose of MSIR PRN What is the equivalent dose of morphine?

Example Calculate total fentanyl dose: 0.1 mg x 2 = 0.2 mg daily Calculate total oxycodone dose: 10 mg x 3 = 30 mg daily Convert fentanyl IV to morphine using the equianalgesic chart: 0.1 mg Fentanyl = MSIR 30 mg 0.2 mg = __X__ X= MSIR 60 mg 0.1 mg 30 mg Convert oxycodone PO to MSIR using chart 30 mg = __X__ X= MSIR 45 mg 20 mg 30 mg

Example Add total Morphine Dose: Reduce dose by 25-50%: 60 mg + 45 mg = 105 mg IR Morphine/Day Reduce dose by 25-50%: Decreased by 25%: 105 * 0.75 = 78.8 mg/Day Decreased by 50%: 105 * 0.5 = 52.5 mg/Day Daily Dosing Range: 52.5 - 78.8 mg/Day Divide by dosing interval and round to nearest tablet size: 78.8 mg/6 times per day = 10 -15 mg q 4 hours PRN 52.5 mg/6 times per day = 10 mg q 4 hours PRN

What would you do? Ms Ima Lone 57 yr old with small cell lung cancer receiving concurrent chemoradiation Taking MS Contin 200 mg q 12 hours Dilaudid 4-8 mg po q 2 hours PRN (Required 6 doses in past 24 hours) Developed esophagitis and no longer able to take oral medications. Staff were developing change in therapy as she fell in outpatient RAD ONC and broke R hip She is out of RR after repair, unable to swallow, and reporting pain Start Ms Lone on a PCA pump

What would you do? ML 46 yr old healthy man underwent Whipple as curative surgery for pancreatic cancer On minimal pain medication prior to surgery Post-op RX: Morphine 1 mg q 6 min IV prn (Max 12) Over past 24 hrs: 75 PCA doses/113 attempts Awake all night; Unable to get out of bed due to pain; Does not want to cough What would you do?

What would you do? 75 PCA doses x 1 mg = 75 mg MS IV/24 hours Basal: 50% of 24hr total = 37.5 mg/24 hours 37.5 mg ÷ 24 hours = 1.5 mg/hours PCA dose considerations Percentage of 1 hour dose 100% - 200% Intensity of pain Temporal pattern

Questions/Discussion?