Lecture 13

Question 1

Are patients with pain usually under or overtreated?

Answer 1

Undertreated

Question 2

Are the pathophysiologic mechanisms for pain well understood?

Answer 2

No, they are complex and usually do not translate into necessary skills for managing pain in most patients.

Question 3

Marks & Sachar

Answer 3

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

Question 4

Brescia et al

Answer 4

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

Question 5

Anand et al

Answer 5

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

Question 6

Cleveland et al

Answer 6

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

Question 7

Reasons for Undertreatment (5)

Answer 7

1. Lack of routine assessment
2. Lack of Advocacy
3. Lack of prescriber and patient education
4. Lack of multidisciplinary team-based care
5. Lack of availability

Question 8

Lack of Assessment

Answer 8

• 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

Question 9

Lack of Advocacy

Answer 9

• 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

Question 10

Lack of Multidisciplinary Teams

Answer 10

-Critical for patients with more complex chronic pain syndromes

Question 11

Lack of Availability

Answer 11

• 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

Question 12

Bastian et al, Psychological Science

Answer 12

• 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

Question 13

Regulatory Concerns (2)

Answer 13

1. Growing fear of prosecution among providers

2. Concerns of addiction, tolerance, and toxicity

Question 14

Fear of Prosecution

Answer 14

• 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

Question 15

Concerns of Addiction/Tolerance/Toxicity

Answer 15

• 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

Question 16

Respiratory Depression

Answer 16

Possible side effect of using opioids. Doesn’t occur when using opioids that are doses and titrated appropriately

Question 17

Types of Pain (3)

Answer 17

1. Acute
2. Malignant
3. Chronic/Non-malignant

Question 18

Acute Pain

Answer 18

• Immediate pain due to an obvious injury
• Managable with various analgesics
• Mild - Moderate: NSAID possible with opioids as well
• Severe: Opioids

Question 19

Malignant Pain

Answer 19

• 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

Question 20

Chronic/Non-Malignant

Answer 20

• 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

Question 21

Factors that Influence Pain Perception

Answer 21

• 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

Question 22

Appropriate Management of Pain

Answer 22

• 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

Question 23

Opioid

Answer 23

Morphine or other agonist of mu receptor

Question 24

Non-opioid

Answer 24

Non-morphine like analgesic (NSAID)

Question 25

Adjuvant

Answer 25

Usually antidepressants or anticonvulsants

Question 26

Bone Pain

Answer 26

- 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)

Question 27

Neurogenic

Answer 27

- 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

Question 28

Tolerance

Answer 28

- 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)

Question 29

Goals of Pain Control (3)

Answer 29

1. Pain free at night 2. Pain free at rest 3. Pain free upon movement

Question 30

Use of Analgesics

Answer 30

- 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

Question 31

Opioids Properties (3)

Answer 31

1. Titratability 2. Tolerability 3. Tolerance

Question 32

Titratability

Answer 32

- Choose an agent with a short half-life to allow for rapid titration - Opioids with long half-lives should be reserved for special situations

Question 33

Tolerability

Answer 33

- 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

Question 34

Tolerance

Answer 34

- 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

Question 35

Approaching a Patient (2)

Answer 35

1. Be familiar with patient, their type and degree of pain, and their analgesic needs (to validate orders). 2. Pharmacists can provide valuable assistance but are often unengaged.

Question 36

Services Pharmacists can Provide

Answer 36

1. Educating patients about opioids – what to do, what not to do, how to manage adverse effects, medication storage/security, etc. 2. Titrating analgesics 3. Simplifying analgesic regimens (eliminating duplicative medications) 4. Managing adverse effects 5. Dispelling myths 6. Following up with patients to optimize use