Lecture 13 Flashcards
Pain Management
1
Q
Are patients with pain usually under or overtreated?
A
Undertreated
2
Q
Are the pathophysiologic mechanisms for pain well understood?
A
No, they are complex and usually do not translate into necessary skills for managing pain in most patients.
3
Q
Marks & Sachar
A
Evidence of Undertreatment
- 1973
- 38 inpatients treated for pain
- 37% continued to experience severe distress and 41% experienced moderate distress despite analgesics
- Chart reviews showed records of significant undertreatment compared to doses ordered and knowledge deficits among physicians
4
Q
Brescia et al
A
Evidence of Undertreatment
- 1992
- 1103 patients hospitalized with advanced cancer
- 73% had pain upon admission
- Only 36% received regular, around-the-clock dosing
- Actual pain amount not assessed
5
Q
Anand et al
A
Evidence of Undertreatment
- 1992
- Neonates undergoing cardiac surgery were either given deeper anesthesia with higher doses of opioids post-surgery or lower doses of each
- Those who had deeper anesthesia and higher doses of opioids had decreased stress responses and lower incidents of sepsis, acidosis, clotting, and death
6
Q
Cleveland et al
A
Evidence of Undertreatment
- 1994
- Examined pain control in outpatients with cancer treatment
- 42% of 597 patients had inadequate analgesic therapy
- Patients at centers serving predominantly minorities were 3x more likely to be undertreated
- Discrepancy between patient and physician judgement of pain severity
7
Q
Reasons for Undertreatment (5)
A
- Lack of routine assessment
- Lack of Advocacy
- Lack of prescriber and patient education
- Lack of multidisciplinary team-based care
- Lack of availability
8
Q
Lack of Assessment
A
- Pain isn’t visible if it isn’t assessed and documented
- Examples of assessment scales - 0-10, smiley scales
- Patients are best judge of their pain severity
9
Q
Lack of Advocacy
A
- Patients may not advocate for their own analgesia out of concerns that they’ll be viewed as malingering or drug seeking
- Health professionals may need to be the patient’s advocate
- May need to change the system in order to provide routine pain assessments or hire anesthesiologists or intensivists to provide aggressive analgesic support (use propofol/fentanyl) for children’s pain
10
Q
Lack of Multidisciplinary Teams
A
-Critical for patients with more complex chronic pain syndromes
11
Q
Lack of Availability
A
- Opioids may be unavailable for patients with severe pain in inner city neighborhoods (esp. in minority neighborhoods)
- Studies showing this may not be accurate based on calling pharmacists and pharmacists not providing truthful information
- NM study by the COP showed the opposite of this and that availability wasn’t a concern and that pharmacists were willing to order opioids for those with severe pain
- Perceived lack of availability may be related to underprescribing of opioids to minority patients
12
Q
Bastian et al, Psychological Science
A
- Study using experimental pain and its connection with guilt
- Revealed that those who had identified as feeling guilty from a recent event felt less pain when exposed to the ice water bath
- Guilt ratings then drop after the exposure, suggesting a cathartic effect
13
Q
Regulatory Concerns (2)
A
- Growing fear of prosecution among providers
2. Concerns of addiction, tolerance, and toxicity
14
Q
Fear of Prosecution
A
- Connected to marked increase of opioid overdoses in recent years
- Most overdoses are connected to misuse or lack of education between prescribers, patients, and relatives
- Can also be connected to pill mills or healthcare system problems like fee for service
- Mismanagement, lack of team-based care, and lack of adequate patient education/follow-ups all lead to overdoses
- The push back of under-prescribing patients with legitimate pain will likely be significant due to this
15
Q
Concerns of Addiction/Tolerance/Toxicity
A
- Includes physical dependence, tolerance, and physiological dependence (cravings)
- Patients with no addiction history have not been shown to develop it from appropriate analgesic therapy
- Addiction usually developed at a young age and is connected to genetic predisposition and socialization in early life, not by using opioids
- One opioid isn’t less addictive than another
16
Q
Respiratory Depression
A
Possible side effect of using opioids. Doesn’t occur when using opioids that are doses and titrated appropriately
17
Q
Types of Pain (3)
A
- Acute
- Malignant
- Chronic/Non-malignant
18
Q
Acute Pain
A
- Immediate pain due to an obvious injury
- Managable with various analgesics
- Mild - Moderate: NSAID possible with opioids as well
- Severe: Opioids
19
Q
Malignant Pain
A
- Can be acute and readily response to chemotherapy initiation
- Short term opioid treatment is usually sufficient
- Can be chronic, usually after failure of chemotherapy. Use long term opioid therapy
20
Q
Chronic/Non-Malignant
A
- Examples: low back pain, fibromyalgia, arthritis, neuropathic pain
- Requires combination of analgesic therapy (NSAIDs + Opioids +/- adjuvant medications) in conjunction with other interventions (counseling, chiropractics, relaxation)
- Most poorly understood and hard to control
- Most likely to be undertreated and associated with opioid-related problems
- Opioids minimize suffering in this case but aren’t the main solution
21
Q
Factors that Influence Pain Perception
A
- Many factors alter pain perception
- Include emotional state, past experience with pain, and cultural factors
- Child’s cognitive development, learned behaviors, and emotional distress effect their perception of pain
22
Q
Appropriate Management of Pain
A
- Several simple principles allow for appropriate management
- Choice & use of agent, titration, use of adjuvants, management of adverse events, adjustment of route of administration
- Multiple opioids are almost never necessary or appropriate
- Goal is <3 on a 0-10 scale
23
Q
Opioid
A
Morphine or other agonist of mu receptor
24
Q
Non-opioid
A
Non-morphine like analgesic (NSAID)
25
Q
Adjuvant
A
Usually antidepressants or anticonvulsants
26
Q
Bone Pain
A
- Example: Infiltration of a malignancy into bony tissue that causes the release of prostaglandins and increased nerve sensitivity
- Consider an agent that lowers prostaglandin synthesis (NSAID)
27
Q
Neurogenic
A
- Example: From infiltration of a malignancy into nervous tissue or from damage to nervous tissue
- Can result in abnormal nervous transmission and often “burning or shooting” pain
- Usually doesn’t respond well to Opioids and may require an adjuvant
28
Q
Tolerance
A
- Can be partially mediation by NMDA stimulation
- May require use of opioid with NMDA antagonist activity or use of an adjuvant with NMDA antagonist activity (ketamine)
29
Q
Goals of Pain Control (3)
A
- Pain free at night
- Pain free at rest
- Pain free upon movement
30
Q
Use of Analgesics
A
- Use appropriate analgesic for type of pain
- Use regularly scheduled doses to anticipate and prevent pain
- Titrate dose to patient’s specific analgesia
- Use smaller doses in the elderly or with those who have hepatic or renal impairment
- Prevent adverse effects and be aware of dose-limiting adverse effects
- Avoid combinations of drugs with same mechanism of action
31
Q
Opioids Properties (3)
A
- Titratability
- Tolerability
- Tolerance
32
Q
Titratability
A
- Choose an agent with a short half-life to allow for rapid titration
- Opioids with long half-lives should be reserved for special situations
33
Q
Tolerability
A
- Some opioids release histamine and can lead to severe urticaria
- All opioids cause constipation, but severe pain can also cause ileus especially when not properly managed
34
Q
Tolerance
A
- Will eventually develop to most most opioids with chronic dosing which may require dosage increases
- Those with tolerance may be converted to low doses of methadone since this doesn’t have a cross-tolerance with other opioids
35
Q
Approaching a Patient (2)
A
- Be familiar with patient, their type and degree of pain, and their analgesic needs (to validate orders).
- Pharmacists can provide valuable assistance but are often unengaged.
36
Q
Services Pharmacists can Provide
A
- Educating patients about opioids – what to do, what not to do, how to manage adverse effects, medication storage/security, etc.
- Titrating analgesics
- Simplifying analgesic regimens (eliminating duplicative medications)
- Managing adverse effects
- Dispelling myths
- Following up with patients to optimize use
