Mary P. Evans MD CMD FACOG FAAHPM

Blue Ridge Long Term Care Associates President, Virginia Medical Directors Association

 Discuss the most common pain syndromes in the LTC population  Describe several classes of pain medications and their indications  Understand non-pharmacologic approaches to pain management and their use in LTC  Describe appropriate pain regimen options for the LTC population

 45-80% of residents in nursing facilities have chronic pain  51% of residents who report intermittent pain have pain every day  Of these patients, 84% had order for prn pain meds, but only 15% of patients received prn med  Nationally, LTC facilities are doing poorly on pain quality measures Ferrell et al, Pain in the Nursing Home, JAGS 1990;38:409-414

          Back pain Arthritis Previous fx Neuropathy Leg cramps Foot pain Claudication Headache Generalized Cancer 40% 29% 14% 11% 9% 8% 8% 6% 3% 3% Stein et al, Pain in the Nursing Home. Clin Geriatr Med 1996;12:601-613

 Incident pain  Acute pain  Chronic pain

 Musculoskeletal pain  Bone pain  Visceral pain  Neuropathic pain  Malignancy pain  Psychosocial pain/existential pain

 Physical pain: medical conditions  Emotional pain: anger, depression, anxiety   Social pain: loneliness, family issues, financial issues Spiritual pain: life’s meaning, leaving a legacy, hopelessness, abandonment  *Think of these concepts with patients who have pain that is difficult to control

          Unrecognized pain Difficulty communicating needs Lack of assessing for pain Unavailability of pain med order Pain med not available Narcotic script issues Cultural barriers and beliefs Personal opinions and beliefs Family interactions Physician attitudes, beliefs, biases, skills

 Use of pain medication:  Physical dependence on pain medication – normal state of adaptation to ongoing pain med use  Addiction to pain medication – psychological dependency  Pseudoaddiction to pain medication – apparent drug seeking or asking for increased dosage when pain is undertreated  Tolerance to pain medication – may need increased dose due to lessened effect or disease progression

 Chronicity: Acute, chronic, constant, intermittent  Onset timing: Incidental, procedural, breakthrough, disturbance  Quality, intensity  Alleviating factors  Exacerbating factors  Associated symptoms, radiation of pain  How it affects the patient: what is the patient no longer able to do as a result of the pain? What does this pain mean to the patient?

 What has been tried before to help the pain?

 Which pain medications have been tried?

 Were they helpful?

 Which medication, dose, timing seems to work best?

 Any difficulties taking oral meds?

 Pain is likely under-recognized, under-treated  Communication difficulty  Assessment difficulty  ◦ ◦ ◦ ◦ Non-verbal pain assessment scales: FACES pain scale FLACC scale (face, legs, arms, consolability, cry) Discomfort scale PAINAD scale

 Facial expression- grimacing, frown, grinding teeth  Posture – guarding, bracing, defensive posture  Movement – rocking, rubbing, fidgeting, restlessness  Behaviors – agitation, physical aggression, resisting cares, yelling out  Vocalization - crying, groaning, whining, sighing  Activities – ADL function, participation, gait

 Occurs with particular activities  Getting out of bed  Taking a shower  Transferring to chair

 Anticipate the pain  Oral pain med 30-60 min prior to procedure  ◦ ◦ ◦ Premedicate before procedures: Dressing changes for wounds Moving patient for shower Transfer to hospital for procedure

By mouth – oral or sublingual, avoid injections By the clock – schedule routinely, appropriate interval By the ladder – Step 1 – Acetaminophen (limit dosage), NSAID Step 2 – Opioid or combination Acetaminophen/Opioid Step 3 – Pure opioid, addition of adjuvant By the individual – can add adjuvants at any step; can start at higher step to relieve pain initially; quality of life; comorbidities, family support

 Morphine PO  Morphine SC or IV  Oxycodone PO  Hydrocodone PO  Hydromorphone PO  Hydromorphone SC or IV  Transdermal Fentanyl patch 30 mg 10 mg (1/3 dose) 20-30 mg 30 mg 7.5 mg (1/4 dose) 1.5 mg 12 mcg-25 mcg

 Muscles, ligaments, tendons, bones, nerves, joints  Sprains, strains, overuse syndromes  Bruises, bumps  Inflammation, infection  Loss of blood flow to muscle  Low back pain in the most common chronic musculoskeletal pain

  Aching, stiffness “pulled muscle” feeling  Fatigue, disrupts sleep

 Acetaminophen  Acetaminophen/narcotic combo  Pure opioid  Corticosteroid

 ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Muscle spasms: Cyclobenzaprine Orphenadrine Metaxalone Methocarbamol Carisoprodol Tizanidine Baclofen Benzodiazepines

 PT/OT  Splint for immobilization, rest  Mobilization  Heat, cold  Relaxation, biofeedback  Stretching exercises  Therapeutic massage

 Described as aching, dull, deep, boring, constant, may be weather-dependent  Difficult to localize  Present at rest and with movement  Somatic pain

 Fractures  Healed fracture  DJD  Metastasis to bone (breast, lung, prostate)  Sickle cell disease   Myeloma Paget’s disease

 Corticosteroids  Calcitonin  Bisphosphonates (*GI symptoms, keep upright)  Palliative radiotherapy  Nonsteroidal anti-inflammatory drugs  Narcotic pain meds

 Distension of hollow organ  Stretching of smooth muscle  Stomach  Small and large intestines  Gall bladder  Kidney/ureter

 Crampy, intermittent pain  May be difficult to localize  Can be mild to severe  History is important – especially timing of pain

 Evacuation of the distended hollow viscus  Relief of constipation, disimpaction  Surgical treatment  Prevent future episodes

 ◦ ◦ ◦ Bowel obstruction: Octreotide ($$$$) Anticholinergics: hyoscine, scopolamine, glycopyrrolate ($) Corticosteroids ($) ◦ especially end of life care

 Appendicitis  Early inflammation – crampy abdominal pain, nausea ◦ ◦ and vomiting Patient is uncomfortable, writhing on table Visceral pain, difficult to localize  Later in course – localization of pain to right lower ◦ quadrant, fever, malaise, leukocytosis Patient lies still, + rebound

 Compression of nerve  Post-entrapment nerve injury  Regional pain syndromes  Skeletal muscle spasms  Post-herpetic neuralgia

 Acetaminophen  Acetaminophen/narcotic combo  Pure opioid  Add adjuvant meds, therapies early on

 Administered by therapist  Transcutaneous electrical nerve stimulation  Battery-operated, portable units  Electrical current disrupts pain signal  Questionable validity (Cochrane Collaboration, 2008)

 Heat, cold application  Muscle massage, stretching, ROM  Ultrasound, TENS  Acupuncture, acupressure  Physical and occupational therapy  Positioning, devices, pillows, chairs

 Meditation, relaxation  Spiritual counseling and prayer  Hypnosis, biofeedback  Aromatherapy, herbal therapy  Music and sound therapy  Art therapy

E-stim Diathermy Laser therapy Heat/cold application Topical treatments – menthol, capsaicin

 First documented use in ancient Rome, AD 63  Scribonius Largus described pain relief by standing on an electrical fish at the seashore  16 th -18 th century – electrostatic devices for headaches and pain  Benjamin Franklin was a proponent of electrical stimulation treatment of pain

 Administered by therapist  Electrical current causes contraction of muscle or muscle group  Helps strengthen affected muscle  Promotes blood supply to area – promotes healing

 Active component of chili peppers  Ointment, spray, cream forms  Minor aches, pains, DJD, strains and sprains  Post-herpetic neuralgia  Neurons are depleted of neurotransmitter (substance P), fatigues nerves

  “Start low, go slow” Don’t forget the bowel regimen

        Constipation – add stool softener, stimulant right away Nausea, vomiting – often transient for 3-4 days Sedation – no driving, methylphenidate, caffeine Delerium – lorazepam Pruritis – usually dissipates; antihistamine Urinary retention – monitor output, comfort Myoclonic jerks – metabolite buildup; lower dose or consider rotating to a different opioid Respiratory depression – uncommon except when starting fentanyl patch in opioid-naïve patient

 Hospice, end of life care  Multiple drug allergies  ◦ ◦ ◦ Route of administration alternatives: Transdermal fentanyl Oral meds administered rectally Avoid injectable meds if possible

 ◦ ◦ ◦ ◦ Addition of antidepressants TCA’s: Amitriptyline, nortriptyline* SSRI‘s: paroxetine, citalopram NSRI: venlafaxine* Other: bupropion  * watch for anticholinergic symptoms

 ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Addition of neuroleptics: Gabapentin Topiramate Lamotrigine Carbamazepine Levetiracetam Pregabalin Phenytoin Valproic Acid

 ◦ ◦ ◦ ◦ NMDA antagonists: Ketamine Dextromethorphan Memantine Amantadine  ◦ ◦ Local Anesthetics: Lidocaine – gel, patch Mexiletine

 ◦ ◦ ◦ ◦ Other: Baclofen Cannabinoids Methylphenidate Capsaicin

 Alpha-adrenergic agonists: clonidine, tizanidine  ◦ ◦ Corticosteroids: Dexamethasone (intracranial pressure) Prednisone (DJD, bone pain)

 Pain despite escalating doses  Consider possibility of drug diversion  Consider existential/psychosocial pain

  Chronic pain – may try rotating to another opioid “Opioid fatigue”, tolerance  Remember to reduce calculated conversion dose by 50% for cross-tolerance

 ◦ ◦ ◦ ◦ Post-op patients: Schedule pain meds x 7 days prn pain meds available Treat pain aggressively until comfortable Remember the bowel regimen!

 Patients with dementia, behaviors:  Difficulty asking for meds, communicating  Schedule acetaminophen tid-qid  Have opioid available for pain not relieved by acetaminophen  Consider lidocaine patch  Consider scheduled opioid for daily moderate to severe pain (bowel regimen!)

 Hospice, end of life care:  Have liquid morphine, liquid lorazepam available  Rectal acetaminophen  Can also administer oral meds via rectal route  Transdermal fentanyl patch (appropriate dose) if unable to swallow (not in opioid naïve patients)  Long-acting opioids once optimal 24h dose achieved

 Acyclic analog of morphine, heroin  NMDA receptors – neuropathic pain  Used in hospice, end of life care  Long half-life, long-acting  Strong analgesic  Cheap ($)  Chronic pain use – anti-addictive  Less sedative than other opioids

 Many metabolites  Liability risk (?)  Variable metabolism/half-life in the elderly  Use cautiously in select patients

 Approved in the US for detoxification treatment of opioid addiction  Must follow strict federal regulations in detox programs  Programs must be certified by Federal Substance Abuse and Mental Health Services Administration  Programs must be registered with the Drug Enforcement Agency (DEA)