February 2007
In
this issue…
Pain
Management in Geriatric Patients Lags Behind
Polyanalgesic
Consensus Panel Issues New Guidelines for Pain Management via Intraspinal
Infusion
Excessive
Use of Topical Anesthetics Can Be Fatal
Pain
Management in Geriatric Patients Lags Behind
Health
Progress, the “official journal of
the Catholic Health Association of the United States,” includes an
article that examines the problems of relieving the pain of the elderly.
Author Carolyn Louise Robinson, MSN, who is a gerontological and adult
nurse practitioner, cites estimates of pain of 45%–85% in the elderly
population and says that much of this pain is undertreated. Additionally,
the elderly often get less aggressive treatment than younger patients and
both elderly patients with dementia and those in long-term care facilities
are “at increased risk for untreated pain.”
Many
barriers remain to successful pain management in older adults, says
Robinson, in spite of efforts such as the campaign to label pain as the
fifth vital sign. Among them are:
-
Health care professionals’ lack of knowledge about assessment and management of pain in the elderly;
-
The “regulatory scrutiny of prescribing practices for opioids” and concerns about this scrutiny;
-
The attitude and biases of health professionals about both pain and the elderly;
-
A lack of standardized psychometric instruments to evaluate pain in the elderly;
-
A lack of training of both physicians and nurses to treat pain in the senior population;
-
The changing physiology of the aging human body;
-
The financial straits of some of the elderly which prevent them from filling prescriptions;
-
The multiple chronic diseases that many elderly have, with many daily medications that may adversely react with each other and the “dominant curative medical model” that is at odds with those chronic, incurable disease;
-
Patient intimidation by the healthcare provider’s “education, status, occupation and income,” and the failure of many older adults to report pain because of fear of hospitalization or invasive procedures; and
-
A typical presentation of pain in the elderly.
In
examining opiophobia—”a failure to use opioid drugs due to
overestimation of the risks, resulting in undertreatment of pain,”
Robinson says that there is little fear that older persons will become
addicted to opioids. Fewer than one in 20,000 patients who are prescribed
opioids become addicted and the danger of addiction exists primarily in
those who have problems with substance abuse.
Tom
J. Hicks’ describes the problem of managing pain as a “nurse-patient
pact” and Robinson sees this description as “wonderful and
appropriate.” She emphasizes the need for “individualized,
comprehensive pain assessment” and says it should include “the
patient’s method of coping with pain.” She insists on frankness,
saying, “Older patients need straightforward information about their
analgesics’ side effects, benefits and interactions.” “Being
truthful with patients is a respectful duty, one that, when carried out,
strengthens the provider-patient pact,” she adds.
To
address the problem, Robinson makes the following recommendations:
-
Friends and family members should be taught to recognize symptoms of pain in the elderly.
-
Elderly patients in pain should be referred to available community and medical resources.
-
Elderly patients should be educated about pain, which should include teaching about “self-management and coping strategies.”
-
There should be better coordination and communication about the work of regulatory agencies with regard to opioids.
-
Geriatric patients, as well as others, should be cared for by multidisciplinary teams to avoid the fragmentation of health care that is so common today. (Health Progress, 1-2/2007)
Reprinted
from The Carolinas Center Weekly Updates 1/07
Polyanalgesic
Consensus Panel Issues New Guidelines for Pain Management via Intraspinal
Infusion
CHARLESTON,
W. Va.--(HSMN NewsFeed)--A panel of experts has recommended major changes
to the guidelines used to determine treatment via intraspinal infusion for
patients suffering from severe chronic pain. The 2007 Polyanalgesic
Consensus Panel brought together a group of national leaders in chronic
pain management for the purpose of updating their current algorithm. In
making their new recommendations, the expert panel reviewed data published
since its last meeting, as well as considered changes in FDA status and
the clinical experience of the consensus panel members.
“Treating chronic pain via intraspinal drug
delivery is a practice that is changing rapidly,” said Timothy Deer, MD,
of the Center for Pain Relief in Charleston, West Virginia. The group of
nearly 20 experts was led by Deer and Samuel Hassenbusch, MD, PhD, of the
University of Texas M.D. Anderson Cancer Center in Houston. The conference
was held January 20 in Miami, FL.
Physicians treating patients with severe pain can
now turn to increasingly sophisticated pump-and-catheter drug delivery
systems. But they must choose from a growing number of novel drugs created
for these systems, as well as existing drugs newly approved for
intraspinal infusion. “The updated algorithm aids physicians by
providing a foundation for clinical practice,” Deer said.
The new algorithm includes ziconotide (PRIALT,
Elan Corp.) as an alternative to first-line opioids, morphine and
hydromorphone and as a second-line treatment in combination with one of
the two first-line opioids. Additionally, fentanyl was moved from a
fourth-line treatment option to a second-line option and clonidine was
recommended for neuropathic pain as second-line single agent option.
Lastly, several drugs were removed from line-four classificat ion and
designated as options only for patients receiving end-of-life care.
In previous years, the panel determined that
preclinical and clinical trial data should include evidence of safety,
efficacy, stability and compatibility with drug delivery systems, and, in
the case of drug combinations, drug-drug stability. “The new guidelines
reflect the most current and best available evidence for each of the drugs
included in the algorithm—informed, as always, by our own collective
experience of their use,” Deer said.
The panel’s conclusions are expected to be
published later this year in a peer-reviewed journal. The original
guidelines were published in 2000 in the Journal of Pain and Symptom
Management. The guidelines were updated in 2003 and the panel’s
recommendations published the next year in the same journal.
At the time of the panel’s 2003 meeting,
ziconotide had not received FDA approval. It became commercially available
in early 2005. Ziconotide, a non-narcotic synthetic based on a conopeptide
found in neurotoxic marine snails, is an important addition to the list of
options physicians have to treat severe chronic pain. Unlike intraspinal
opioids, ziconotide is not associated with granuloma formation. “This is
a real concern because granuloma formation means you have to stop therapy
and evaluate the need for catheter removal and replacement,” Deer said.
The panel did, however, recognize some
variability in the recommended and observed effective dosages of
ziconotide. Among its recommendations will be a 0.5 to 2.4 micrograms per
day starting dosage range, with a maximum of 19.2 micrograms per day. Slow
dosage titration was recommended to reduce the risk for toxicities. In
addition, ziconotide can be combined with other line-three treatment
options (morphine or hydromorphone, bupivacaine and clonidine).
The panel removed midazolam and baclofen from
line-four and neostigmine, adenosine and ketorolac from line-five due to
lack of adequate clinical evidence to support their general use for
chronic pain. Four drugs, midazolam, ketamine,
tetracaine and droperidol were recommended only for treating patients
whose prognosis is four weeks or less. Baclofen was designated for use
only in patients with spasticity.
The drug options for intraspinal drug delivery to
treat severe pain are increasing rapidly. Periodic update of the
guidelines for their selection is therefore necessary if physicians are to
make treatment decisions that will most benefit their patients, Deer said.
“We must evaluate new data as it becomes available and change our
selection criteria accordingly,” he added.
The Polyanalgesic Consensus Panel is an expert
panel of leading pain management physicians from throughout the United
States who meet periodically to evaluate the efficiency of various
treatments. For more information about the members of the 2007
Polyanalgesic Consensus Panel visit the The
Healthcare Sales & Marketing Network Web site.
Reprinted from The Healthcare and Sales Marketing Network Press Release Feb 8, 2007
Excessive
Use of Topical Anesthetics Can Be Fatal
Antibiotic
Treatment for Many Outpatient and Inpatient Bacterial Infections
Information from Industry
Yael
Waknine
Learn
more about high-dose, short-course therapy, including PK/PD parameters,
clinical benefits, and doctor and patient benefits.
February
8, 2007—The US Food and Drug Administration (FDA) has warned healthcare
professionals regarding potential risks associated with unsupervised
patient use of topical anesthetic products for cosmetic procedures.
Although topical anesthetic creams, ointments, and gels containing
lidocaine, tetracaine, benzocaine, and prilocaine are usually applied in a
physician’s office prior to medical procedures, their use for cosmetic
procedures may be unsupervised by a healthcare professional.
As a result, patients may apply excessive amounts of the topical product
to their skin, leading to systemic absorption of the active ingredient and
life-threatening adverse events such as arrhythmias and seizures,
according to an alert sent this week from MedWatch, the FDA’s safety
information and adverse event reporting program.
Two cases cited by the FDA in a public health advisory include young women
aged 22 and 25 years who applied topical anesthetics with high doses of
lidocaine and tetracaine to their legs prior to laser hair removal. As
instructed, the women wrapped their legs in plastic wrap to increase the
creams’ numbing effect. Both women had seizures, fell into comas, and
subsequently died from the toxic effects of systemic absorption.
The FDA has also received reports of serious and potentially fatal adverse
events such as arrhythmia, seizures, coma, and slowed or stopped breathing
after use of anesthetic topical products in children and adults when used
for approved and unapproved indications.
Healthcare professionals are advised to prescribe FDA-approved topical
anesthetics in the lowest concentration consistent with pain relief goals,
and to advise patients regarding their safe use.
Adverse events potentially related to use of topical anesthetic products
should be reported to the FDA’s MedWatch reporting program by phone at
1-800-FDA-1088, by fax at 1-800-FDA-0178, online,
or by mail to 5600 Fishers Lane, Rockville, MD 20852-9787.
Pain
Surveys and Studies
-
In the last 10 years, says one recent survey, “Persistent, chronic pain has risen dramatically among full-time US workers.” Workers today practice “presenteeism”—going to work rather than taking a sick day, which has “a negative impact on work despite being physically present at the job.” The information is the result of a 2006 survey, just released, which is profiled on Ortho-McNeil’s “Pain in the Workplace” Web site. (PR Newswire US, 1/30, The Carolinas Center Weekly Updates, Feb 8, 2007)
-
JAMA reports that the FDA “has issued an alert about reports of death and respiratory depression, cardiac arrhythmias, and other life-threatening adverse events in patients receiving methadone for chronic pain. Fatalities have been reported in patients who were switched from chronic, high-dose treatment with other opioids to methadone and in patients initiating treatment with methadone.” Methadone dosing recommendations for the treatment of chronic pain are online, and the alert is posted here. (JAMA, 2007;297:354; FDA Web site, The Carolinas Center Weekly Update, Feb 2, 2007)
-
A study originally reported in the Journal of Pain & Symptom Management (2006;32(6):519-31) says, “Pain in persons who receive hospice care is not fully understood.” At least one pain score was reported by 45.1% of over 347,000 respondents, with an average of 2.9 times per person. The average intensity was mild, but 20.3% reported severe pain and 73.9% of those had a cancer diagnosis. (Pharma Investments, Ventures & Law Weekly, 1/28, The Carolinas Center Weekly Update, Feb 2, 2007)
RFP Now Available for Community Program/CBPR Grants
The
LAF announced that the 2007 Request for Proposals (RFP) is now available.
The application process will open and they will begin accepting Letters of
Intent (LOI) on March 1, 2007. They will hold
three Q&A sessions on the LAF grant process for interested applicants.
Please review the RFP for dates and times. If you have any questions,
please send an email to research.grants@laf.org
or communityprogram@laf.org.
Access the RFP on the LAF
Web site
.
Spotlight
on Shingles Webcast
If you missed (or would like to hear/see it again), the American Pain Foundation’s January 25th Spotlight on Shingles Webcast, you can view here. This 32 minute presentation will orient you to the new Spotlight on Shingles Public Education Toolkit and provide you with information on how you can take this information to the public. To order a free toolkit, please call (202) 729-4103. The toolkits will be mailed the week of February 12th, 2007.
March
Educational Event
The Carolinas Center’s 2007 Annual
Clinical Conference
The
2007 Annual Clinical Conference is being held at the Hilton Oceanfront
Resort in Hilton Head, SC on March 18-21! Join us in Hilton Head for a
wonderful meeting, featuring “Final Gifts” author, Patricia Kelley;
Marcia Lattanzi Licht and Judi Lund-Person from NHPCO; Robert Jackson,
Director of AARP-NC; Maureen Carling, pain and symptom management
consultant and speaker; just to name a few! Special features of this
meeting include a doll making workshop on Sunday afternoon, the Sacred
Space Salon (open throughout the meeting), Welcome Reception and Awards
Celebration, outstanding Trade Show, “drive-in” day for CNAs
(featuring special workshops for CNAs), and the return of our “Boot
Camp” series for those new to Hospice. For more information and to
register online, visit the Carolinas Center for Hospice and End of Life
Care Web
site.
Reprinted from The Carolinas Center Weekly Updates Feb 2007
SAVE
THE DATE!
April
24–27
Las
Vegas, Nevada
20
contact hours
May
11
Columbia,
SC
May
16
Washington,
DC
(Celebration
plans for South Carolina: TBA)
Alliance
of State Pain Initiative Annual Conference
June
21–23
Boston,
MA
The
Carolinas Center Annual Pain Congress
September
27–28
Charlotte,
NC
Pain
Assessment and the Vulnerable Adult
February
is recognized
as the Month for Vulnerable Adult Awareness in South Carolina.
An
article titled “Using State Elder Abuse Laws in Pain Treatment Cases—available
at painlaw.org—highlights
a case where an elderly man’s family was awarded 1.5 million dollars after
proving that healthcare providers failed to provide adequate pain management
as he died of metastatic lung and bone cancer. According to the article, “This
case was the first in which undertreatment of pain was framed as an elder
abuse claim.”
An
abstract from Intensive
Critical Care Nursing titled “Developing
a pain assessment tool for use by nurses in an adult intensive care unit.”
It addresses the difficulties of pain assessment for patients who are “unable
to communicate verbally due to the presence of endotracheal/tracheostomy
tubes, sedation and paralysing agents.” It goes on to say that “nurses
therefore rely on behavioural and physiological indicators in establishing
the presence of pain. However, as these also occur in situations and
conditions not associated with pain there is a need for a systematic,
objective assessment tool. Such a tool, consisting of a numerical and verbal
rating scale to facilitate documentation and audit, was developed as a
result of ongoing adjustment and evaluation. The tool scores the patient’s
pain by incorporating behavioural and physiological indicators and is used
in conjunction with the Glasgow Coma Score and the modified Sheffield
Sedation Scale to achieve a comprehensive neurological assessment.”
|
Glasgow
Coma Score |
||
|
Eye
Opening (E) |
Verbal
Response (V) |
Motor
Response (M) |
|
4=Spontaneous |
5=Normal
conversation |
6=Normal |
|
|
Total
= E+V+M |
|
The
Glasgow Coma Scale is the most widely used scoring system used in
quantifying level of consciousness following traumatic brain injury. It is
used primarily because it is simple, has a relatively high degree of
interobserver reliability and because it correlates well with outcome
following severe brain injury.
It
is easy to use, particularly if a form is used with a table similar to the
one above. One determines the best eye opening response, the best verbal
response, and the best motor response. The score represents the sum of the
numeric scores of each of the categories. There are limitations to its use.
If the patient has an endotracheal tube in place, they cannot talk. For this
reason, many prefer to document the score by its individual components; so a
patient with a Glasgow Coma Score of 15 would be documented as follows: E4
V5 M6. An intubated patient would be scored as E4 Vintubated M6. Of these
individual factors, the best motor response is probably the most
significant.
Other
factors which alter the patients level of consciousness interfere with the
scale’s ability to acurately reflect the severity of a traumatic brain
injury. So, shock, hypoxemia, drug use, alcohol intoxication, metabolic
disturbances may alter the GCS independently of the brain injury. Obviously,
a patient with a spinal cord injury will make the motor scale invalid, and
severe orbital trauma may make eye opening impossible to assess. The GCS
also has limited utility in children, particularly those less than 36
months. In spite of these limitations, it is quite useful and is far and
away the most widely used scoring system used today to assess patients with
traumatic brain injury.
Reprinted
from http://www.ssgfx.com/CP2020/medtech/glossary/glasgow.htm
The
New Sheffield Sedation Scale
1
awake
2
agitation
3
optimal level (i)
4
optimal level (ii)
5
sluggish level
6
flat level
Reprinted from Intensive Care Nursing: A Framework for Practice, Philip Woodrow, page 64, published by Routledge (UK)
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