1. 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

2. 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

3. Objectives Basic information regarding the treatment of pain Basic information regarding the treatment of pain Medical management Medical management –WHO Ladder –Use of opioids in chronic pain Interventional management Interventional management –Pain pump

4. Pain Management Realistic goals and expectations must be discussed with patient 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 Honesty is crucial in establishing patient – provider trust Do not assume that pain was discussed by others Do not assume that pain was discussed by others Non-pharmacological treatment should be incorporated Non-pharmacological treatment should be incorporated

5. Selecting an Analgesic Regimen Complete History Complete History –Type of pain –Location –Severity Anticipated duration of pain Anticipated duration of pain –Acute vs. Chronic condition Routes of administration available Routes of administration available Pain History Pain History

6. Non-Opioid Analgesic Drugs for Pain Management Acetaminophen – no anti-inflammatory effect Acetaminophen – no anti-inflammatory effect NSAIDs / ASA – inhibits platelet aggregation NSAIDs / ASA – inhibits platelet aggregation –Non-Selective COX Inhibitors –Selective COX – 2 Inhibitors Others / Adjuvants Others / Adjuvants –Antidepressants –Anticonvulsants –Corticosteriods –Others

7. The “WHO” Analgesic Ladder

8. WHO Analgesic Guidelines Oral Medications whenever possible Dose “around the clock” and have PRN medication for breakthrough pain Dose “around the clock” and have PRN medication for breakthrough pain Titrate the dose to affect Titrate the dose to affect Use appropriate dosing intervals Use appropriate dosing intervals Be aware of potencies Be aware of potencies Treat side effects Treat side effects

9. Step 1: Minor Pain – Non-Opioid Non-steroidal anti-inflammatories (NSAIDs) 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 Dyspepsia/abdominal pain – use H2 Blocker if mild Contraindications: Contraindications: –Coumadin  Can increase anticoagulation by altering platelet function –Thrombocytopenia –Potential for bleeding –GI bleeding / ulcers –Impaired renal function

10. Step 2: Moderate Pain – Weak Opioid ± Non-Opioid and add Opioid ± Non-Opioid and add Opioid ± Adjuvant ± Adjuvant Use a Combination Agent (weaker Opioid) Use a Combination Agent (weaker Opioid) –Opioid + Acetaminophen (APAP) or ASA –Do not exceed 3gm APAP / 24 hrs –Codeine, hydrocodone, propoxyphene

11. Step 3: Severe Pain – Strong Opioid ± Non-Opioid and Opioid ± Non-Opioid and Opioid ± Adjuvant ± Adjuvant Morphine, hydromorphone, methadone, fentanyl, oxycodone Morphine, hydromorphone, methadone, fentanyl, oxycodone Watch for Side Effects Watch for Side Effects

12.  Opium  Opium is the dried powdered mixture of 20 alkaloids obtained from the unripe seed capsules of the poppy plant  Opiate  Opiate refers to any agent derived from opium  Opioid  Opioid refers to all substances, exogenous or endogenous, synthetic or semi-synthetic, with morphine-like properties

13. Agonists Strong Morphine Morphine Hydromorphone (Dilaudid) Hydromorphone (Dilaudid) Meperidine (Demerol) Meperidine (Demerol) Oxymorphone (Opana) Oxymorphone (Opana) Fentanyl (Duragesic) Fentanyl (Duragesic) Methadone (Dolophine) Methadone (Dolophine) Oxycodone (Oxycontin) Oxycodone (Oxycontin)Weak Codeine Codeine Propoxyphene (Darvon) Propoxyphene (Darvon) Hydrocodone Hydrocodone

14. Important Points for Opioids Titration for Pain Titration for Pain –Mild – Moderate: ↑ dose by 25 – 50% –Moderate – Severe: ↑ dose by 50 – 100% Breakthrough Pain Management Breakthrough Pain Management –Very dependent on cause of pain and patient’s response to medications Equianalgesic dosing – requires calculation Equianalgesic dosing – requires calculation

15. Opioid Side Effects Constipation - most common Constipation - most common –Does not improve with use Sedation Sedation N/V – 50% of patients, improves with use N/V – 50% of patients, improves with use Respiratory Depression – less with ↑ use Respiratory Depression – less with ↑ use Pruritis Pruritis –More common with IV/epidural/intrathecal Urinary Retention Urinary Retention –More common with epidural/intrathecal Orthostatic Hypotension Orthostatic Hypotension Euphoria (or hallucinations) Euphoria (or hallucinations) Physical Tolerance/Dependence Physical Tolerance/Dependence

16. Contraindications / Precautions Seizures Seizures Severe Respiratory Depression Severe Respiratory Depression Decreased Respiratory Reserve Decreased Respiratory Reserve –Elderly, Infants –Asthma Increased ICP Increased ICP Pregnancy Pregnancy Undiagnosed acute abdominal conditions Undiagnosed acute abdominal conditions

17. Side Effect Management Constipation Constipation –Stool softener, laxative, combination may be best –Docusate, Senna, Lactulose Nausea / Vomiting Nausea / Vomiting –Compazine, Reglan, Zofran/Anzemet Sedation/Mental Clouding Sedation/Mental Clouding –Dose reduction –CNS stimulants (caffeine, dextroamphetamine, Provigil) Myoclonis/Delirium/Hallucinations Myoclonis/Delirium/Hallucinations –Hydrate –Consider changing/discontinuing opioid –Rule out renal failure and other aggravating factors –Treat symptoms (haloperidol)

18. Opioid Tolerance / Dependence Rate of tolerance varies Rate of tolerance varies Tolerance develops with ↑ dosing over time Tolerance develops with ↑ dosing over time Intermittent dosing generally does not lead to tolerance Intermittent dosing generally does not lead to tolerance Chronic use often leads to tolerance Chronic use often leads to tolerance Physical dependence occurs with or without development of 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 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 Dependence is NOT the same as ADDICTION

19. Withdrawal - Abstinence 6-8 hours 6-8 hours –Drug “seeking”, restless, anxious 8-12 hours 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 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 Treatment of symptoms  Clonidine

20. Intrathecal Drug Delivery Advantages Effective pain relief Effective pain relief Decreased systemic drug dose Decreased systemic drug dose -Decreased side effects -Decreased drug cost Improved ability to perform ADLs, enhanced quality of life Improved ability to perform ADLs, enhanced quality of life Long-term cost effectiveness Long-term cost effectiveness

21. Advantages of Intrathecal Drugs for Cancer Pain Allows patients to be coherent and accessible to their families Allows patients to be coherent and accessible to their families Cost effective vs. external pump if life expectancy is greater than 3 months 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 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 May provide relief for the approximately 5-15% of cancer pain patients who do not receive adequate relief from systemic opioids

22. Conclusion Pain is the “5 th Vital Sign” Pain is the “5 th Vital Sign” Should not be afraid of treating pain because of the medications involved Should not be afraid of treating pain because of the medications involved Patients need to be appropriately educated regarding their condition and expected outcome 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 Healthcare providers need to stay educated about latest options for treatment of pain