Chronic Pain Medications: Introduction

Katy Trinkley, PharmD Angie Thompson, PharmD

Outline

Opioid risks and risk prevention strategies

Medication treatment by pain type

Fundamental principles of opioid therapy

Opioid risks

Opioid prescribing is on the rise

Benefit of opioids after 1 year

Opioid dose is directly related to mortality

Ann Intern Med. 2015; 162:276 Arch Intern Med. 2011;171:686

Opioid risks

Opioid prescribing is on the rise

Benefit of opioids after 1 yearNo evidence!

Opioid dose is directly related to mortality

Ann Intern Med. 2015; 162:276 Arch Intern Med. 2011;171:686

Risk prevention strategies

Opioids Avoid Minimize Prolong initiation

Only indicated when safer alternatives are exhausted

Pain types

Nat Rev Drug Discov. 2010;9:589

Pain types

Nat Rev Drug Discov. 2010;9:589

Guided prescribing by pain type

Visceral Highly variable by specific condition

Neuropathic or fibromyalgia Many opioid alternatives

Nociceptive Some opioid alternatives

Guided prescribing

Neuropathic or fibromyalgia pain Topicals

Lidocaine cream/patch, capsaicin Gabapentin SNRI

Venlafaxine, duloxetine TCA

Nortriptyline Pregabalin

Guided prescribing

Nociceptive pain Acetaminophen

4 grams/d Topicals

Lidocaine cream/patch, diclofenac gel, capsaicin SNRI for low back pain NSAIDs

Aspirin, naproxen Tramadol IR/ER Opioids

Ann Intern Med. 2015;163:JC10. Circulation. 2007; 115:1634. BMJ. 2011;342:c7086

Opioid principles

Goals of therapy Selection of opioid Initiation Monitoring Titration Breakthrough pain

Goals of therapy

Dependent on type of pain Discussion of patient and provider expectations Set realistic goals

Acute pain – rapid pain relief Chronic pain – improve or maintain level of day to day

functioning, overall well being, relationships, reduce drug dependency

Selection of opioid

Route of administrationConstant pain vs. intermittent painRenal/hepatic functionPrevious exposure to opioids

Initiation of opioids

Short term trial No evidence supporting one opioid over another No evidence supporting short acting vs. long acting

Generally considered safer to use short-acting opioids for initial therapy

Choice of opioid, starting dose, and titration schedule will be very patient specific

Initiation of opioids

In general start with: Typical starting dose Immediate release formulations Insufficient evidence to recommend around the

clock or scheduled opioids Titrate up slowly▪ Especially true for geriatric patients

Monitoring patient on opioids

Monitor for effectiveness and adverse effects 4 A’s ▪ Analgesia▪ Activity ▪ Aberrant drug behavior▪ Adverse effects

Assessment frequency will vary based on patient’s pain

Titration of opioids

Dose decreases: Slow titration : 10% per week Rapid titration: 25-50% every few days

Dose increases: 20-50% increases in daily dose Equivalent to “breakthrough” dosing needed if on sustained

release products Transition to equivalent dose of sustained released

product, once pain control is achieved Maintain immediate release product for breakthrough pain Goal: Maximize sustained release/minimize immediate release

Breakthrough pain

Brief, transitory, exacerbation of moderate to severe pain while on stable doses of long acting opioid therapy or around the clock parenteral therapy

May be due to underlying condition or new/unrelated pain Typically treated with as need immediate release opioid

therapy 10-20% of total daily opioid dose

Rescue doses for breakthrough pain should be dosed frequently Outpatient setting: Every 4-6 hours is typical

Titration based on rescue dosing

If using rescue doses consistently, consider titrating long acting opioids

Recalculate dose of rescue therapy every time dose of long acting opioids is adjusted

Typically use same drug for both rescue and long acting therapy

Max opioid doses

In theory, there is no maximum ceiling dose for opioid therapy

Best evidence indicates 120 mg/day of morphine or morphine equivalent Maximum studied doses in randomized controlled trials

Higher doses may indicate substance abuse/diversion and/or need for opioid rotation or taper

Questions