Yale 20: Non-Opioid Pain Management

Transcript

• 00:00Hi everyone, my name is Julia Joseph.
• 00:04I'm a current third year internal medicine
• 00:06resident at Yale New Haven Hospital.
• 00:08I created this video with the help
• 00:09of our palliative faculty member,
• 00:11Doctor Persik in order to
• 00:13discuss non opioid pain options,
• 00:15especially from an inpatient perspective.
• 00:17I remember being an intern,
• 00:19especially on nights, and not having
• 00:21an idea of what the options were to
• 00:23treat pain before reaching for opioids.
• 00:25So hopefully this will
• 00:27help build a framework.
• 00:29We will first start with a case,
• 00:31then go over basic principles,
• 00:33dive into the non opioid pain options before
• 00:37concluding with our case and learning points.
• 00:39So we'll start off with a familiar situation.
• 00:42Imagine you're the overnight intern
• 00:44and you get woken up with a page.
• 00:46Hey doc patient in room 5 two
• 00:48O 8 is having a lot of pain.
• 00:50Can you give him something?
• 00:52What do you do?
• 00:55One acronym that can be helpful
• 00:57to assess pain is OPQRST,
• 00:59which many of you may have
• 01:01been taught in medical school.
• 01:03It will remind you to ask about the onset,
• 01:05the provoking factors,
• 01:07the quality of the pain,
• 01:09whether the pain radiates anywhere,
• 01:11the severity of the pain,
• 01:13and the timing and duration of the pain.
• 01:19As you gather this information,
• 01:21it's helpful to classify the type of pain.
• 01:23There are several types of pain syndromes,
• 01:26but I've included three major types
• 01:28of syndromes that you may encounter.
• 01:30No sceptive pain is pain that arises
• 01:32from the activation of no sceptors due
• 01:35to a pain impulse that was detected
• 01:37as demonstrated here. For example,
• 01:39when you stick your hand on a nail,
• 01:41the no sceptors transduce the
• 01:43signal back to your brain which
• 01:45registers the painful impulse.
• 01:47Neuropathic pain is actual damage to
• 01:50the somatosensory nervous system.
• 01:51You will commonly see this in patients
• 01:53with long standing diabetes and have
• 01:55sustained nerve damage in their feet,
• 01:57for example.
• 01:58Finally, nosey plastic pain arises
• 02:01from altered perception of pain.
• 02:03While there's no evidence of tissue damage
• 02:05as you might see a nociceptive pain,
• 02:07they are experiencing pain from
• 02:10dysregulated sensory processing.
• 02:12You may see this in conditions
• 02:15like fibromyalgia.
• 02:16All right, so let's dive into
• 02:18our non opioid pain modalities.
• 02:21So the first medication we'll
• 02:23discuss is acetaminophen.
• 02:24Acetaminophen is very effective
• 02:26for mild to moderate pain,
• 02:28but can also help with severe
• 02:30pain when combined with opioids.
• 02:31It works by inhibiting prostaglandins,
• 02:34which decreases pain signaling
• 02:36and tamps down fevers.
• 02:37IV Tylenol has the same efficacy
• 02:39as rectal and oral Tylenol,
• 02:41but works quicker.
• 02:42It can be hard to get approved
• 02:44though because of the higher cost.
• 02:46Rectal and IV administration can
• 02:48especially be useful for patients
• 02:51at end of life or patients who
• 02:53can't take oral Tylenol safely.
• 02:54The absolute Max that's recommended
• 02:57is 4G a day,
• 02:58but for those patients who have a history
• 03:01of cirrhosis or chronically used Tylenol,
• 03:03you should really consider a reduced
• 03:06maximum of two to three grams per day.
• 03:10You should be careful when keeping
• 03:12a patient on scheduled acetaminophen
• 03:14when you want to avoid masking fevers,
• 03:16such as when you are taking
• 03:18care of neutropenic patients.
• 03:19You should also be careful prescribing
• 03:21too much acetaminophen and patients
• 03:23who are at risk of accumulating
• 03:26the toxic metabolite nap Qi.
• 03:27These include patients with low glutathione
• 03:30stores like malnourished patients,
• 03:32patients with ongoing alcohol use,
• 03:35or patients who are on medications
• 03:37that are CYP 450 inducers.
• 03:41Acetaminophen,
• 03:42as you can see here, gets metabolized
• 03:44to nap Qi by the CYP 450 enzyme.
• 03:47So you can imagine that if you
• 03:49have medications that Rev up the
• 03:51activity of the CYP 450 enzyme,
• 03:53you will then accumulate more nap Qi.
• 03:56You also need glutathione in
• 03:59order to inactivate nap Qi.
• 04:00So in patients who are malnourished
• 04:02or don't have enough glutathione
• 04:04stores you can imagine then you will
• 04:06have more accumulated nap Qi that
• 04:08will lead to toxic liver damage.
• 04:12ENASAS are the next class of medications
• 04:15which have anti-inflammatory
• 04:16properties unlike acetaminophen.
• 04:18They work by inhibiting Cox enzymes in both
• 04:21the peripheral and central nervous system.
• 04:23Toradol is an example of a non selective
• 04:26NSAID while selecoxib is a Cox two
• 04:29selective NSAID by inhibiting Cox two.
• 04:31Selecoxib confers a degree of
• 04:35gastric protection by only
• 04:38working on the Cox 2 enzyme.
• 04:41Unfortunately,
• 04:41NSAID's overall have an increased risk of
• 04:44MIS and strokes as well as risk of AKI.
• 04:47The risk of AKI is particularly
• 04:49high in the 1st 30 days.
• 04:51Cox two inhibitors do have more GI
• 04:54protective effects but unfortunately still
• 04:55have the other serious side effects noted.
• 04:58In general,
• 04:58you should avoid in patients who
• 05:00are at risk of bleed,
• 05:01significant cardiac history or
• 05:03renal impairment.
• 05:07This is an NSAID reference table that you
• 05:09can pause if you'd like to learn more.
• 05:11The ones pointed out are some
• 05:12common NSAID that you may come
• 05:14across such as Motrin and Toradol,
• 05:16which you could see in the hospital,
• 05:17especially Toradol because it's
• 05:19a non selective NSAID that comes
• 05:21in IV or IM formulation. There's
• 05:23Meloxicam which is a relatively
• 05:25Cox two selective NSAID,
• 05:27although it has some Cox one activity.
• 05:29And then there's Sela Coxib which
• 05:31is a Cox two selective NSAID.
• 05:33Next, let's talk about some topical options.
• 05:36Diclofenac is a topical NSAID that
• 05:38can be used up to four times a day.
• 05:40You can use 2G for each upper extremity
• 05:42joint and 4G for each lower extremity joint.
• 05:45You should not use more
• 05:46than 32 grams in one day.
• 05:48The systemic exposure from gel form
• 05:50is on average 6% of the oral form.
• 05:53It carries the same risk profiles oral
• 05:55NSAID's, but it overall is better tolerated.
• 05:58Capsaicin cream is derived from
• 05:59Hot Chili Peppers and works by
• 06:01desensitizing no seceptive fibers.
• 06:03It can also be useful in neuropathic pain.
• 06:05You can dose up to four times a day,
• 06:07but it may take several weeks
• 06:08before you see an effect.
• 06:10Stinging and burning at the site of
• 06:12application has also been reported.
• 06:14Finally, lidocaine is an anaesthetic
• 06:16agent that comes in several forms.
• 06:18You can dose 3 patches of 5% lidocaine
• 06:21in one setting with a 12 hour on
• 06:23period and 12 hour off period.
• 06:25Systemic exposure is approximately
• 06:27less than 5% with this regimen,
• 06:29so systemic side effects are
• 06:31overall relatively rare.
• 06:34Gabapentinoids are the next class of
• 06:36medications that we'll talk about.
• 06:38They were initially developed as
• 06:40anti seizure agents because they
• 06:41suppress neuronal excitability by
• 06:43working on voltage gated calcium
• 06:45channels as shown in this diagram.
• 06:47They can also be used to
• 06:50treat neuropathic pain.
• 06:51These are both commonly used gabapentinoids.
• 06:54Pregabalin is more potent and more
• 06:57predictably absorbed than gabapentin.
• 06:59Peak blood concentration occurs
• 07:01within an hour of taking pregabalin,
• 07:03but can take approximately
• 07:053 hours with gabapentin.
• 07:07Due to being a scheduled
• 07:09class 5 controlled substance,
• 07:10Pregabalin is not as easy to
• 07:14prescribe as gabapentin.
• 07:15When prescribing pregabalin,
• 07:16you can start at 50 to 150 milligrams a day,
• 07:20usually in two to three divided doses.
• 07:23From there,
• 07:24you can up titrate every week
• 07:25to a maximum of 300 to 600
• 07:28milligrams per day in two to three
• 07:30divided doses to reach effect.
• 07:32With gabapentin,
• 07:33you can start at 300 milligrams every day,
• 07:36usually in three divided doses.
• 07:38You can up titrate to a maximum of 3600
• 07:42milligrams every day to reach effect
• 07:46CNS. Depression is a common
• 07:49problem with gabapentinoids,
• 07:50especially when used alongside opioids.
• 07:53Toxicity can especially be seen
• 07:55in patients with renal impairment,
• 07:57so be cautious in those with Akis or
• 07:59history of CKD if stopped suddenly.
• 08:02Withdrawal syndromes have been
• 08:03described with gabapentinoids similar
• 08:05to alcohol and benzo withdrawal,
• 08:07including seizures.
• 08:08So in admitting a patient on
• 08:10high doses of these medications,
• 08:12be careful not to stop them immediately
• 08:15to avoid precipitating withdrawal,
• 08:16which can occur within 12 hours to
• 08:19seven days after discontinuing.
• 08:22The last
• 08:23non opioid medication we will discuss
• 08:26is duloxetine, a type of SNRI.
• 08:29Of all antidepressants,
• 08:30duloxetine has the largest evidence
• 08:32base to support its use in pain relief.
• 08:35It has been FDA approved for several
• 08:37types of pain syndromes but unfortunately
• 08:39comes with several noted side effects.
• 08:41As listed here.
• 08:42You can start duloxetine at 20 to 30
• 08:45milligrams a day for one week and then
• 08:47from their up titrate until receiving
• 08:49a maximum of 60 to 120 milligrams.
• 08:51You should see pain improvement as early
• 08:54as the first week of implementation.
• 08:56You can especially consider SNR is
• 08:58like duloxetine for those patients
• 09:00who have comorbid depression and pain.
• 09:05Easy measures that can be implemented
• 09:07and that are often forgotten in the
• 09:09inpatient setting include using heater ice,
• 09:11physical therapy to help with mobility,
• 09:14and using foam support or
• 09:16pillows to help with elevation.
• 09:18Now let's get back to our case.
• 09:20You were the overnight intern
• 09:22paged about a patient's pain.
• 09:24You do a quick chart review and note
• 09:26your patient has a history of type 2
• 09:27diabetes and is on a blood thinner.
• 09:29Their labs are otherwise unremarkable.
• 09:32Your sign out says that he
• 09:34responds to Oxy at bedside.
• 09:35Your patient tells you that he is
• 09:37having burning pain in his feet that
• 09:39is making it hard for him to sleep.
• 09:41He already received 650
• 09:42milligrams of acetaminophen.
• 09:44That didn't seem to help.
• 09:46So what can you do?
• 09:48You determine that this is a
• 09:50neuropathic pain syndrome based
• 09:51on the patient's description.
• 09:52You can give additional acetaminophen
• 09:55or trial topical agents,
• 09:57but given that this is likely
• 09:59underlying peripheral neuropathy,
• 10:00you could consider trialing a low dose
• 10:02gabapentinoid or switching to duloxetine,
• 10:04especially if he's already on an SSRI.
• 10:07In this case you should avoid ENSAES,
• 10:09especially because he's on a blood
• 10:11thinner and opioids would not be
• 10:14first line in this pain syndrome.
• 10:16So to summarize,
• 10:17we discussed 3 pain syndromes
• 10:20including nociceptive,
• 10:21neuropathic and NOC plastic pain.
• 10:24OPQRST is an approach to assess pain.
• 10:27Acetaminophen should cautiously be used
• 10:29in patients with low glutathione stores
• 10:32and if they're taking CYP 450 inducers.
• 10:36NSAID's can be non selective
• 10:38or Cox two selective,
• 10:39but overall their use can still be
• 10:41limited by several side effects.
• 10:43Topical options that we talked
• 10:45through include diclofenac,
• 10:46capsaicin and lidocaine.
• 10:47Gabapentinoids including
• 10:48pregabalin and gabapentin can
• 10:51be useful for neuropathic pain,
• 10:53and duloxetine is an SNRI that
• 10:56also has pain relieving properties.
• 10:59And if you're interested,
• 11:00here are the many sources
• 11:02that I used for this talk.