Module 2: Part II

Part II: A. Nonopioid medications for pain management B. Opioid medications C. Management of analgesic side effects E L N E C Geriatric Curriculum

ELNEC Attribution Statement

The End-of-Life Nursing Education Consortium (ELNEC) Project is a national end-of-life educational program administered by City of Hope National Medical Center (COH) and the American Association of Colleges of Nursing (AACN) designed to enhance palliative care in nursing. The ELNEC Project was originally funded by a grant from the Robert Wood Johnson Foundation with additional support from other funding organizations (Oncology Nursing, Aetna, Archstone, and California HealthCare Foundations; National Cancer, and Open Society Institutes). Materials are copyrighted by COH and AACN and are used with permission. E L N E C Geriatric Curriculum

Part II A: Nonopioid Medications for Pain Management

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Objectives: Discuss types and uses of nonopioid analgesics Describe cautions regarding use of specific nonopioids in older adults E L N E C Geriatric Curriculum

Medication Management

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Nonopioids Acetaminophen (APAP) Nonsteroidal anti-inflammatory drugs (NSAIDs) Adjuvants/co-analgesics Antidepressants Anticonvulsants Topicals Misc E L N E C Geriatric Curriculum

Acetaminophen (APAP)

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For mild to moderate pain Best for nociceptive pain First line therapy particularly in the frail elderly

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Mode of action not well understood Routine dosing up to 2000 – 3000 mg/day maximum in older adults E L N E C Geriatric Curriculum

Acetaminophen (APAP)

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Scheduled dosing works best for older adults with constant or daily pain

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Avoid in hepatic compromise With renal disease, use

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q 6 h dosing rather than q 4h Be aware of “hidden” doses of APAP in combination products E L N E C Geriatric Curriculum

NSAIDs

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Indicated for pain from acute inflammatory process (such as gout), bone metastases, or pain refractory to opioids

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Effective for mild to moderate pain E L N E C Geriatric Curriculum

Selective and Nonselective NSAIDs

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Examples of nonselective: ibuprofen (eg, Advil®), naproxen (eg, Naprosyn®, Aleve®)

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Examples of selective COX-2 inhibitors: Celebrex® E L N E C Geriatric Curriculum

Selective and Nonselective NSAIDs

E L N E C Geriatric Curriculum

NSAIDs

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Use topical NSAIDs (e.g. Flector ® --new diclofenac patch) Use proton pump inhibitor or nonacetylated NSAIDs (e.g., Trilisate ® ) to reduce GI effects Avoid chronic use Avoid COX-2 agents in residents with active cardiovascular or cerebrovascular disease; use the nonselective agents cautiously E L N E C Geriatric Curriculum

Co-analgesics/Adjuvants

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Medications developed and marketed for another medical condition (e.g., depression) but found also to be effective for pain

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Many co-analgesics target neuropathic pain E L N E C Geriatric Curriculum

Anticonvulsants

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Act by reducing conduction of pain signals along damaged nerves Gabapentin (Neurontin ® ) is commonly used for burning, shooting pains

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Other anticonvulsants used for neuropathic pain: Levetiracetam (Keppra ® ), Tiagibine (Gabatril ® ), Lamotrigine (Lamictal ® ), and the newest one Pregabalin (Lyrica ® ) E L N E C Geriatric Curriculum

Anticonvulsants (cont.)

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All these agents can cause unclear thinking, forgetfulness, and other CNS side effects Slow initiation and taper up is essential – for example, start Neurontin ® at 100 mg q hs and move up by 100 mg per day in divided doses once a week E L N E C Geriatric Curriculum

Tricyclic Antidepressants (TCAs)

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Indicated in neuropathic pain Believed to work by blocking chemical neurotransmitters for pain in the spinal cord and the brain Significant anticholinergic effects Causes morning grogginess at higher doses Significant postural hypotension in elderly Patient education is important!

E L N E C Geriatric Curriculum

Tricyclic Antidepressants (con’t)

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Desipramine and nortiptyline are preferred over amitriptyline or doxepin in the older adult because they have less severe anticholinergic effects TCAs have significant interactions with other drugs that can cause blood levels to be much higher – if suspicious ask the pharmacist to review the resident’s med list E L N E C Geriatric Curriculum

Newer Antidepressants

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Greater potency, fewer side effects Not much data in older adults

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Expensive Particularly effective for residents with pain and depression Examples: duloxetine (Cymbalta ® ) - FDA approved for neuropathic pain; venlafaxine (Effexor ® ) E L N E C Geriatric Curriculum

Topical Agents

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Local action with minimal systemic side effects Indicated for neuropathic pain but can be effective in musculoskeletal pain as well E L N E C Geriatric Curriculum

Topical Agents: Lidocaine

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Lidocaine 5% patch, ointment FDA-approved for post-herpetic neuralgia Clinical trials show effectiveness in other neuropathic pain syndromes Effective adjuvant for osteoarthritis and back pain Local side effects: redness, edema, abnormal sensations at site N E C Geriatric Curriculum

Topical Agents: Capsaicin

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Active ingredient of hot chili peppers Clinical trials show effectiveness for diabetic neuropathy, osteoarthritis, and rheumatoid arthritis Common adverse effects: burning pain at application site, sneezing and coughing Dosed q 6h, usually takes 2—4 weeks to achieve therapeutic effect E L N E C Geriatric Curriculum

Other Adjuvants/Coanalgesics

May be effective in special cases

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Use cautiously in older adults Corticosteroids, e.g., prednisone, dexamethasone (Decadron ® ) Muscle relaxants, e.g., baclofen (Lioresal ® ) E L N E C Geriatric Curriculum

Interventional Therapies

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Intra-articular steroid injections Epidural steroid injections Neurolytic blocks Neuroablative procedures Eisenberg, 1995; Furlan, 2001; Wong et al, 2004 E L N E C Geriatric Curriculum

Cancer Therapies to Relieve Pain

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Radiation Surgery Chemotherapy Hormonal Therapy Others Doyle et al., 2001; Dunn et al., 2002; Janjan et al., 2003; Jeremic, 2001 E L N E C Geriatric Curriculum

Part II B: Opioid Medications

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Objectives Describe the role of opioids in pain management Discuss the advantages and disadvantages of opioids Address barriers to opioid use Describe opioid options E L N E C Geriatric Curriculum

Key Opioid Issues

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Natural or synthetic drugs with morphine-like actions; activate opioid receptors Indicated for moderate to severe pain Effective for pain regardless of pathophysiology Safe for older adults when carefully initiated & titrated E L N E C Geriatric Curriculum

Advantages of Opioids

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Many choices Can be delivered by all routes Immediate-release (IR) and sustained-release (SR) formulations

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No end organ toxicity E L N E C Geriatric Curriculum

Addressing Barriers to Opioid Use

E L N E C Geriatric Curriculum

Addiction

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Primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. Characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

AAPM, 2001; APS, 2003; AMDA, 2003 E L N E C Geriatric Curriculum

Tolerance

A state of adaptation in which exposure to a drug induces changes that result in a decrease in one or more of the drug’s effects over time AAPM, 2001 E L N E C Geriatric Curriculum

Physical Dependence

A state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist AAPM, 2001 E L N E C Geriatric Curriculum

Side Effects

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Sedation Nausea and vomiting Constipation Urinary retention Confusion Dysphoria, hallucinations Myoclonus (rare, on low doses) Respiratory depression (rare) E L N E C Geriatric Curriculum

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Opioids

Older adults already on daily opioids are considered “opioid tolerant” - will require higher or more frequent doses to obtain relief Older adults requiring multiple doses of SAO/day should have LAO Older adults with “predictable” pain should have scheduled doses of SAO PRN not effective approach with cognitively impaired E L N E C Geriatric Curriculum

Equianalgesic Dosing

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Methods for switching from one opioid to another or administration routes Use of equianalgesic tables is necessary but use the data cautiously Keep in mind the issue of “incomplete cross-tolerance” Reduce by 30-50% when changing drugs N E C Geriatric Curriculum

Opioid Choices: The Long and the Short of It

E L N E C Geriatric Curriculum

Short Acting Opioids

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Hydrocodone/APAP (e.g., Vicodin ® , Lortab ® ) Oxycodone/APAP (Percocet ® ) Oxycodone as a single agent (Roxicodone ®) Morphine Sulfate (MSIR ® , Roxal ® ) Hydromorphone (e.g., Dilaudid ® ) Tramadol (Ultram ® ) Oxymorphone (Opana ® ) Fentanyl transmucosal (Actiq ® , Fentora ® ) E L N E C Geriatric Curriculum

Long Acting Opioids

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Morphine Sustained Release (MS Contin ® , Kadian ® , Avinza ® ) Oxycodone Sustained Release Transdermal Fentanyl (Oxycontin (Duragesic Methadone Tramadol (Ultram ER ® ) Oxymorphone (Opana ER ® ) ® ) ® ) E L N E C Geriatric Curriculum

Low Dose Opioid Options

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Hydrocodone 2.5 mg / 325 mg APAP

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can be split to give a 1.25 mg dose Tramadol 37.5 mg / 325 mg APAP

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Can be split to give 18.75 mg dose Morphine 10 mg / 5 ml solution

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Can give 2 mg in one ml of solution Duragesic 12 mcg patch Kadian 20 mg per 24 hour dose E L N E C Geriatric Curriculum

Opioids to Avoid

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Codeine Propoxyphene (Darvon ® , Darvocet ® ) Meperidine (Demerol ® ) Mixed opioid receptor agonist antagonists:

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Buprenorphine (Buprenex ® ) Butorphanol (Stadol ® ) Nalbuphine (Nubain ® ) Pentazocine (Talwin ® ) E L N E C Geriatric Curriculum

Myths Regarding Nebulized and Sublingual Opioids E

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L Nebulized opioids provide no advantage over other routes of administration for dyspnea or pain Sublingual morphine – only 18% absorbed through sublingual mucosa N

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Fentanyl Buprenorphine Methadone E Oxycodone C Geriatric Curriculum 51% 55% 34% 16% Coluzzi, 1998; Coyne, 2003; Dudgeon & Lertzman, 1998

Part II C: Management of Analgesic Side Effects

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Objective: Review the prevention, assessment, and treatment of analgesic side effects E L N E C Geriatric Curriculum

Analgesic Side Effects

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More common in older persons More common with hepatic or renal insufficiency

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Commonly occurs:

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With initiation of a new analgesic

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Following an increase in analgesic dose

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When non-analgesic is introduced that interacts with existing analgesic E L N E C Geriatric Curriculum

Side Effect Management: General Approaches

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Decrease dose of analgesic Lower the dose and add an analgesic from a different class

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Switch to different analgesic in the same class

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Add a medication to treat side effect E L N E C Geriatric Curriculum

CNS Side Effects

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Drowsiness Respiratory Depression

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Delirium E L N E C Geriatric Curriculum

Drowsiness

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Very common during initiation or up titration Generally resolves within 72 hours Most sensitive indicator of too much drug Mild drowsiness may not be particularly bothersome E L N E C Geriatric Curriculum

Drowsiness

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For persistent, bothersome drowsiness

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Down titrate the analgesic

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Switch to a different analgesic or

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Start low dose caffeine, methylphenidate, or modafinil E L N E C Geriatric Curriculum

Opioid-induced Respiratory Depression

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Very rare in opioid tolerant resident Higher risk in older adults and those with pulmonary compromise and sleep apnea Clinically significant respiratory depression does not occur in older adults who are awake, so must combine respiratory with sedation assessment E L N E C Geriatric Curriculum

E

Respiratory Depression

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RR < 8/min w/ marked sedation (sluggish response to vigorous stimuli or unresponsive to painful stimuli) Naloxone: after dilution (0.4 mg in 10 ml saline)- Slowly administer 1.0 ml IV push, repeat q 3 – 4 minutes until adequate LOC is achieved Monitor resident q15 min for at least 2 h Naloxone duration of action (~ 1 h)

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may need to be repeated WI Pain Patient Care Team, 2006 L N E C Geriatric Curriculum

Delirium

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Acute time limited episode most often related to disease or drug effect Emphasis is on determining etiology; organ system failure versus drug effect Most often requires drastic reduction or discontinuation of suspected drug and re evaluation of symptoms May require treatment with antipsychotic drugs or geropsych consult E L N E C Geriatric Curriculum

Opioid Side Effects

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GI Side Effects

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Nausea

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Constipation

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Dry Mouth E L N E C Geriatric Curriculum

Nausea

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Common side effect during initiation or up titration of opioids; generally resolves within 72 hrs Persistent bothersome nausea may be treated by decreasing the opioid, switching opioids, or adding an antiemetic Treat severe analgesic-induced nausea with antiemetic therapy; this situation will likely require switching to a different agent E L N E C Geriatric Curriculum

Constipation

E

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Nearly universal side effect of opioids and other analgesics

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Does not go away Must be aggressively treated prophylactically

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L Assess for frequency, quantity, and quality of stool N E C Geriatric Curriculum

Constipation

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For decreased amount encourage fruits, vegetables; avoid bulking agents

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For hard stool add softeners and emollients For decreased frequency of stools add laxatives or motility stimulants E L N E C Geriatric Curriculum

Constipation

ALWAYS consider stool softeners and laxatives when on opioids E L N E C Geriatric Curriculum

Dry Mouth

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Can be very bothersome Access to water Mouth swabs Sucking on hard lemon drops or other candy

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Artificial saliva E L N E C Geriatric Curriculum

E

Adjuvant Drug Side Effects

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Gabapentin

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Slowed thinking

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Feeling of “low” energy

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Drowsiness Start very low and titrate very slowly Pregabalin (Lyrica ® ) - may have fewer side effects & allow faster titration N E C Geriatric Curriculum

Adjuvant Drug Side Effects

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Tricylic antidepressants

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Morning “hangover”

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Daytime drowsiness

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Postural hypotension Again, key is start low and go slow Despramine / nortriptyline preferred Switch to alternate agents (venlafaxine or duloxetine) if side effects persist E L N E C Geriatric Curriculum

Summary

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Prevention and prompt treatment of side effects is critical to ensuring effective pain relief. E L N E C Geriatric Curriculum

E L N E C Geriatric Curriculum