Taking Control: Emerging Issues in Pain ... - Pharmacy Times

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The Problem Is Pain Aging population = increased need for pain relief Appropriate use of opioid therapy for pain management increased in recent years 90% of chronic pain patients receive opioids Borowitz SM et al. Pediatrics. 2005;115:873-877; Tassinari D et al. J Palliat Med. 2008;11:492-501;Benyamin R et al. Pain Physician. 2008;11:S105-S120; Bell TJ et al. Pain Med. 2009;10:35-42; Background and Significance • Prevalence of chronic pain among general population believed to be high: • 56 million (~1 in 6) Americans suffer from chronic pain • Recent large survey 1 • Examined general populations (N=18,980) across several European countries • Prevalence of chronic, painful physical conditions estimated at 17.1% • World Health Organization study 2 • Examined 26,000 primary care patients across 15 countries • Prevalence of chronic pain estimated at 22% • Prevalence of pain in US sites (Seattle, Washington) estimated at 17% 1. Ohayon MM et al. Arch Gen Psychiatry. 2003 ;60(1):39-47. 2. Gureje O et al. JAMA. 1998;280(2):147-151. Undertreatment of Pain: Impact • Economic impact • $61.2 billion/year in lost productivity 1 • Quality of life • Persistent pain reduces quality of life 2 • Pain associated with psychological disorders (eg, depression, anxiety) 3,4 • Health outcomes • Pain is predictor of poor health and depression 5 • Families with 1 migraineur experience 6 • 70% higher total unadjusted medical costs • 80% higher outpatient costs Prevalence of Pain Associated With Medical Conditions HRS (1996) 1 Age 54-64 y N=6837 AHEAD (1993) 2 Age 70 y N=5807 Overall prevalence (%) 27 33 Condition (%) Lung disease Stroke Heart disease Arthritis Diabetes Cancer Hypertension 50 44 41 40 39 35 33 44 41 41 60 39 34 37 1. Stewart WF et al. JAMA. 2003;290:2443-2454. 2. Skevington SM. Pain. 1998;76:395-406. 3. Elliott TE et al. Pain Med. 2003;4:331-339. 4. McWilliams LA et al. Pain. 2004;111:77-83. 5. Reyes-Gibby CC et al. Pain. 2002;95:75-82. 6. Stang PE et al. Am J Manag Care. 2004;10:313-320. HRS = Health and Retirement Study; AHEAD = Asset and Health Dynamics Study Among the Oldest Old. 1. Data from HRS. Analyses courtesy of C. Reyes-Gibby, MD, Houston, Texas, 2005. 2. Reyes-Gibby CC et al. Pain. 2002;95:75-82. APS Survey: Reason for Changing Providers Disparities in Pain Management Age Ethnicity Older nursing home patients received appropriate pain assessment 3.9% of time 1 26% of older patients with daily pain did not receive any analgesic agents 2 Emergency department study • Black patients: 57% received analgesics 3 • White patients: 74% received analgesics 3 • Hispanic patients: half as likely as non-Hispanic white patients to receive analgesics 4 APS = American Pain Society. Persistent pain Clinician not knowledgeable APS. Chronic pain in America: roadblocks to relief. Available at: http://www.ampainsoc.org/whatsnew/summary2_road.htm. Accessed Jan 15, 2011. Did not take patient’s pain seriously Unwilling to treat aggressively Gender Women received less medication for cancer pain than men 5 Women received more sedatives than men (men received analgesics instead) 6 1. Baier RR et al. J Am Geriatr Soc. 2004;52:1988-1995. 2. Bernabei R et al. JAMA. 1998;279:1877-1882. 3. Todd KH et al. Ann Emerg Med. 2000;35:11-16. 4. Todd KH et al. JAMA. 1993;269:1537-1539. 5. Cleeland CS et al. N Engl J Med. 1994;330:592-596. 6. Unruh AM. Pain. 1996;65:123-167.
Barriers to Pain Management • Hearing patients, but not listening • Low priority given to pain treatment • Lack of consistent documentation • Abuse concerns by clinicians, patients, family • Enforcement: laws and regulation constraints • Judgment issues • Meaning of pain to patient • Need to follow up • Financial implications • Fear of not being viewed as “good” patient • Hesitation to seek medical attention • Dangers: adverse effects, management, awareness Differences Between Acute and Chronic Pain Acute (Nociceptive) Pain Has biologic function 1 Chronic Pain No biologic value 1-3 Acts as warning system Detrimental effects 1-3 indicating tissue injury 1 Persists beyond usual course Recent onset 2 of acute illness or injury Finite duration (days (months to years) 1-3 to weeks) 2 Chronic pathologic process; Remits when underlying may recur at intervals 1-3 pathology resolves 1 1. Brookoff D. Hosp Pract. 2000;35:45-52,59. 2. Portenoy RK, Kanner RM, eds. Pain Management: Theory and Practice. Philadelphia, PA: FA Davis Co; 1996:248-276. 3. Turk DC, Melzack R, eds. Handbook of Pain Assessment. 2nd ed. New York, The Guilford Press; 2001:3-11. Pain classification Diagnostic classification A. Nociceptive pain I. Somatic: well localized; e.g. skin, bones II. Visceral: poorly localized; e.g. organs B. Neuropathic pain I. Central: Localized and diffused; burning, stabbing pain e.g. CNS II. Peripheral: localized neuropathies Pain Management Guidelines World Health Organization’s Pain Relief Ladder C. Idiopathic pain usually in head, shoulders, or pelvic areas Cancer Pain Relief and Palliative Care. Geneva, Switzerland; World Health Organization; 1990. Therapeutic Strategies in Pain Management Equianalgesic Dose Table • Lifestyle changes • Rehabilitative • Psychological • Complementary and integrative medicine • Educational • Pharmacotherapy • Injection, surgical, neuromodulation • Googling “Equianalgesic Dose Table” yields 27,400 citations • Many different versions • Based on short-term trials of acute post-op pain or low doses in cancer patients • Patient-specific variables • Unidirectional vs bidirectional equivalencies Fine PG, Portenoy RK. A Clinical Guide to Opioid Analgesia. Minneapolis, MN: McGraw-Hill; 2004.
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