1	Managing Chronic Pain Palliative Care Institute of Southeast Louisiana Hospice of St. Tammany Covington, LA
2	Introduction 50 million people suffer from chronic pain Treatment with opioids is safe and effective New understanding of CNS changes in chronic pain provides rationale for treatment Relief from suffering is our goal
3	How to Manage Pain Effectively and Efficiently Assessing Pain Difference between Acute and Chronic Treatment of Pain Specific Opioids Adjuvants for Pain Side-effects Importance of Teamwork
4	Assessing Pain Detailed description of pain What makes it better or worse Effect on emotional, social status Do a physical assessment Review diagnostic and lab data Reassess often to adjust treatment
5	Acute Pain Pathway for acute pain perception is conventional Duration is short Endorphins and enkephalins are released by CNS to block pain perception Opioids are effective for acute pain
6	Chronic Pain Prolonged pain impulses cause “burn-out” of the AMPA receptors involved in pain transmission in the spinal cord Endorphins become less effective NMDA receptors, normally quiescient, are activated, causing changes in pain transmission and behavior
7	NMDA Effects in Chronic Pain Windup Neural remodeling Activation of NK-1 receptors Afferent becomes efferent Neurogenic inflammation
8	Treating Pain with Opioids Nociceptive(Somatic and Visceral) and Neuropathic Pain WHO 3-step analgesic ladder Step 1: Mild analgesics: APAP, Propoxyphene, NSAIDS Step 2: Moderate analgesics: Codeine, Hydrocodone/APAP, Oxycodone/APAP, Tramadol Step 3: Strong Opioids
9	Prescribing Opioids for Chronic Pain- General Principles Use WHO pain ladder to select analgesic Around-the-clock, q. 3-4 hr. Assess frequently, adjust dose Add up total opioid taken q. 24hr. Select long-acting opioid q. 12 hr. Use short-acting opioid for breakthrough pain prn. Use one short- and one long-acting Reassess to titrate dose
10	Equianalgesic Doses if Morphine = 10 mg p.o. Dilaudid(hydromorphone= 2mg Oxycodone = 5-10 mg Hydrocodone =15 mg Codeine = 60mg Ultram(tramadol) =50 mg Demerol(merperidine) =50 mg Fentanyl(duragesic)=see slide 13 Levorphanol = 1-2 mg
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12	Step 3 Strong Opioids Morphine Oxycodone Dilaudid (Hydromorphone) Fentanyl Methadone Levorphanol
13	Morphine Usual 1^st. choice for moderate, severe pain. Begin low, 15mg q 3-4 hr. Titrate ,reassess often. No ceiling Resp. depression rare in chronic pain patients. High doses: metabolites = nausea,dysphoria, muscle jerks
14	Dilaudid- hydromorphone Beginning dose 2-4 mg q 3-4 hr. Very effective, similar to MS. Less nausea. No ceiling. Often used orally for breakthrough pain and i.v. No sustained-release form. 2 mg = 10 mg MS
15	Oxycodone Starting oral dose 5-10 mg q 3-4 hr. Very effective Less nausea, less troublesome metabolites.Combined with ASA and APAP (Percocet,etc.), limits ceiling. Expensive sustained-release form (Oxycontin), no ceiling. Watch for illegal diversion. Oxycontin 10,20,40,80mg. Liquid concentrate 20mg/ml useful buccally in the dying, as is MS(Roxanol).
16	Duragesic (Fentanyl) Duragesic patch: use care in opioid- naïve patient-use 25 mcg/hr first, after pain controlled by short-acting opioid. To calculate dose, convert any and all opioids to their morphine-equivalent/24 hr first. 12 hr delay in onset and offset due to skin reservoir absorption.
17	Duragesic (cont’d) Fever increases absorption rate. Avoid skin with scant subcut. fat. 25mcg patch= 50 mg MS /24 hrs 50 ‘ ‘ = 100 mg “ 75 “ “ = 150 mg “ 100 “ “ = 200mg “ (approx.)
18	Methadone and Levorphanol Under-used, not marketed NMDA receptor-blocking activity makes these, especially methadone, the best choice for neuropathic and complex chronic pain Levorphanol is 4-8x stronger than MS: longer ½ life (q 6 hrs)
19	Advantages of Methadone Long duration of action Short initial distribution half-life No active metabolites No ceiling dose NMDA receptor-blocker action in spinal cord (important in neuropathic and chronic pain) Cost: approx. $20-25/month( vs. $200-500/mo. for hydromorphone,sust.act. morphine,oxycodone,fentanyl patch.
20	Advantages (cont’d) Potency at least equal to morphine Oral, rectal absorption excellent Low incidence of side-effects Less constipating Lower incidence of tolerance Available for iv infusion use Most important,methadone is both a mu opioid agonist and an NMDA receptor antagonist as it relates to pain relief
21	Disadvantages Stigma and association with substance-abuse Accumulation due to long and variable elimination half-life in some persons Said to be hard to convert to and from other opioids Fear of regulators Lack of education and experience
22	Cost Comparison of Opioids ( 30 day supply) Duragesic Patch 25mcg/hr $ 140 Duragesic Patch 100 mcg/hr $ 430 Oxycontin 40 mg q 12 hr $ 250 MS contin 60 mg q 12 hr $ 210 Dilaudid 4 mg q 4 hr ATC $ 118 Percocet 5 mg q 4 hr ATC $ 210 Levorphanol 2 mg q 6 hr $ 120 Methadone 10 mg q 8 hr $ 20
23	From the literature: 108 outpatients with cancer pain on opioids 103 successfully switched to methadone- oral q 8 hrs with significant reduction of pain Bruera,E. et al, proceedings of the 9^th World Congress on Pain,2000, p.957.
24	From the literature: 52 prospective, consecutive patients with either uncontrolled cancer pain on opioids or intolerable side-effects switched to methadone. All had significant reduction of pain and significantly less nausea, vomiting, constipation, and drowsiness. Mercandante, S. et al, J. of Clinical Oncology. 2001; 19:2898-2904
25	Personal experience: Prescribing Methadone 2001-2003 Palliative Care Consults(total) 140: Methadone for Chronic pain: 88 Excellent relief( pain reduced from 7-10 to 0-3) : 50 Fair relief (pain reduced to 4-6): 18 No benefit or side-effects: 20 ( Nausea 6, Sedation 12, Depression 2)
26	Adjuvants for Pain For Neuropathic pain: Tricyclic antidepressants-desipramine, nortriptyline preferred Anticonvulsants- valproic acid, gabapentin preferred For bone and soft-tissue pain: NSAIDs,corticosteroids,palliative radiation,biphosphonates For visceral pain: corticosteroids,H-2 blockers,metoclopropamide
27	Side-effects of Treatment Opioid adverse effects: nausea,constipation,somnolence, dysphoria, muscle jerks, itching, respiratory depression Neuropathic adjuvant side-effects: dizziness ,sleepiness, low BP, liver toxicity(uncommon) NSAID side-effects: nausea, GI ulcer or bleeding, edema,decreased renal function
28	Importance of Teamwork Complex chronic pain, especially if caused by life-threatening disease, is best treated by a team. The diverse talents of physician, nurse, social worker, chaplain, working together offers comprehensive control of physical, emotional, and spiritual pain. Palliative care is for ALL patients who are suffering.