aware
WELL Duquesne University Mylan School of Pharmacy
UPDATE from the Center for Pharmacy Care
March-April 2005
Chronic Pain
An Ongoing Problem Impacting Quality of Life
C
hronic pain is a serious and often overlooked condition that burdens many people with disabling physical and emotional symptoms that can drastically affect their quality of life. It is estimated that more than 25 million Americans suffer from chronic pain. This affliction knows no boundaries of age, race, or social status. Consequently, chronic pain often leads to isolation, depression and anxiety. The American Chronic Pain Association defines chronic pain as “pain that continues a month or more beyond the usual recovery period for an injury or illness or that goes on for months or years due to a chronic condition. The pain is usually not constant, but can interfere with daily life at all levels.”
T
he Chronic Pain Initiative utilizes the resources of Duquesne University to improve the quality of life for people suffering with pain and for their family members through an interdisciplinary effort focusing on healing of mind, body and spirit. The Chronic Pain Initiative serves those people in pain by: • Providing continuing education for professionals dedicated to improving the quality of life for those individuals suffering from pain.
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Upcoming Events
Chronic Pain Initiative—Mission & Goals • Providing support and informational resources for families and caregivers of those suffering from pain thereby reintroducing hope into their lives. • Advancing educational opportunities for our students of all disciplines relative to pain and pain management through interdisciplinary models of care. If you have questions about chronic pain, please call x5874 for a confidential referral to one of the members of this initiative.
Mark Your Calendar MARCH – American Diabetes Alert DayMarch 22, 2005
All events will be held in the Center for Pharmacy Care, Room 320 Bayer Learning Center, unless otherwise noted.
APRIL – National Alcohol Screening DayApril 7, 2005
• March 7 & 14, 2005, 9:00 a.m.-1:00 p.m. Center for Pharmacy Care Wellness Mondays
• April 4, 18 & 25, 2005, 9:00 a.m.-1:00 p.m. Center for Pharmacy Care Wellness Mondays
• March 16, 2005, 9:00 a.m.-1:00 p.m. Cholesterol & Diabetes Screening Please call 412-396-5874 for an appointment.
• April 6, 2005, 11:00 a.m.-1:00 p.m. Blood Pressure Screening Alcohol Awareness Information Locations: Union Concourse, 3rd Floor
• March 2 & 16, 2005, 11:00 a.m.-1:00 p.m. Blood Pressure Screening Locations: Union Concourse, 3rd Floor
• April 20, 2005, 10:00 a.m.-2:00 p.m. Chronic Pain Awareness Table Duquesne University Benefits Fair Locations: Union Ballroom, 4th Floor
TOBACCO CESSATION PROGRAM
CENTER FOR PHARMACY CARE – Wellness Mondays
The Center for Pharmacy Care offers a five-week tobacco cessation program. Any employee or student interested in joining a group to quit tobacco should call x5874. Dates will be determined after sign-up.
The Center offers the following complimentary screenings on Mondays by appointment: bone density, body composition analysis, facial skin analysis & cholesterol screening. Please call 412-396-5874 for an appointment.
www.duq.edu
Chronic Pain–impacting quality of life Frequently Asked Questions About Chronic Pain Q. What causes chronic pain? A. Chronic pain can originate from these acute injuries or infections: • Dental infection • Ear infection • Carpal tunnel syndrome
• “Whiplash” • Pinched sciatic nerve • Temporomandibular joint dysfunction (TMJ)
It also may result from diseases such as: • • • • •
Arthritis Cancer Diabetes Fibromyalgia/fibrosis Pelvic inflammatory disease
• • • • •
Osteoporosis Lupus erythematosus Scoliosis Endometriosis Neuralgia/ neuropathy
Additionally, chronic pain can be related to back injury, headache, phantom limb pain, or it may occur with no apparent cause. Q. What drug treatments are available for chronic pain? A. Treatment of chronic pain typically consists of several components, including education, medication and physical therapy. Patients and their family and friends must understand the disease itself, the importance of rehabilitation and the expected goals of treatment. Medication is only one piece of the management puzzle, which can encompass a variety of options. Due to the fast-paced changes occurring in the world of medicine, there are a wide variety of medications available for treatment. Over-thecounter (OTC) pain relievers may be adequate in many cases. However, physicians may be required to prescribe stronger medication depending on the level of pain. It is important to remember not to mix OTC pain relievers and prescription drugs without consulting your pharmacist or physician. More severe pain may require the use of prescription analgesics such as propoxyphene (Darvon, Darvocet-N, etc.) and tramadol (Ultram, Ultracet, etc.). Derivatives of opium (“opioids”) such as morphine, codeine, oxycodone (Percocet, etc.),
and hydrocodone (Vicodin, etc.) are reserved for treating more severe forms of constant or nearconstant pain. Some types of pain may respond to antidepressants such as amitriptyline or anticonvulsant drugs such as gabapentin (Neurontin). Please see the electronic version of this newsletter for a more extensive discussion of the drugs used to treat chronic pain. Q. Do I need to be concerned with addiction to my pain medication? A. Drug addiction may be defined as a strong physiological and psychological dependence on a drug or other psychoactive substance. It is usually characterized by compulsive drug use, despite harm to the user. Physical dependence occurs when withdrawal signs and symptoms are present after a chemical substance is abruptly stopped. Tolerance occurs when increased dosages of a drug are needed to produce the same level of pain relief or when a reduced effect is seen with a constant dose. If you become physically dependent, your doctor can slowly decrease your dose until your body no longer “needs” the drug. If you are psychologically addicted, your doctor may gradually decrease the dosage, change your drug, or decrease the dosage prior to completely stopping the medication. OTC pain relievers are not addictive and will not produce physical dependence. These products should be used only as directed on the package or
Newsletter Contributors John G. Lech, Pharm.D. Michelle L. Rosko, Pharm.D. Candidate Tracy L. Zilka, Pharm.D. Candidate
Additional information regarding chronic pain may be obtained by visiting the following Web sites: • www.nlm.nih.gov/medlineplus/pain.html
• www.theacpa.org
• www.asahq.org/patienEducation/managepain.htm
• www.familydoctor.org
by a physician because they have the potential to produce serious side effects if misused. Although studies report drug abuse/dependence in three to 19 percent of chronic pain patients, true addiction and tolerance are uncommon. The risks can be further reduced by adhering to the dosage regimen prescribed by your physician. Q. Are there any alternatives to drug therapy? A. There are several types of non-pharmacologic therapies being used to treat pain. • Physical and aquatic therapy can help improve daily function, decrease pain and enhance quality of life. • The application of heat or cold may be particularly useful in some situations. • Trans-cutaneous electrical nerve stimulation (TENS) is electrical stimulation that does not require needles or medication and often provides significant relief. • Acupuncture is an ancient Chinese practice that requires placement of very thin needles at specific points on the skin to reduce pain. • Psychological support is an essential component of chronic pain management. Support and counseling from a psychiatrist or psychologist combined with a comprehensive pain treatment program may be beneficial for patients suffering from chronic pain. • Surgery may be considered as an alternative in some conditions not responding to medical and alternative therapies.
A publication of the Duquesne University Mylan School of Pharmacy Center for Pharmacy Care & Pharmaceutical Information Center (PIC) Additional information on any of the topics discussed may be obtained from the Pharmaceutical Information Center by calling 412-396-4600 or sending an e-mail to pic@duq.edu. Questions about screenings or programs: Christine O’Neil, Pharm.D, B.C.P.S. 412-396-6417 3/05 303619 CG
Chronic Pain–Drug Administration Appropriate drug selection
for the management of chronic pain is dependent on many factors. Probably the most significant of these is the intensity of pain. Several assessment tools are now available for evaluating the severity of pain. Most experts use a numeric scale of 0–10 where 0 = no pain, 5 = moderate pain and 10 = worst possible pain. The American Chronic Pain Association provides a useful “Quality of Life Scale” for patients with pain. It can be accessed on their Web site (www.theacpa.org).
Mild pain can generally be relieved with
simple analgesics such as acetaminophen (Tylenol, etc.), aspirin (Anacin, Ascriptin, etc.), and non-steroidal anti-inflammatory drugs (NSAIDs) including ibuprofen (Advil, Motrin, etc.) and naproxen (Aleve, etc.). These medications relieve pain and can reduce fever. Aspirin and the NSAIDs also decrease inflammation. Acetaminophen is still considered the drug of choice for osteoarthritis and is often combined with opioids (Percocet, Vicodin, etc.) for moderate to severe pain. Although considered relatively safe, these products must still be used according to the instructions on the label, otherwise the risk of adverse reactions will increase. NSAIDs should not be used for more than ten consecutive days without the advice of a physician.
Non-narcotic analgesics such
as propoxyphene (Darvon, Darvocet, etc.), pentazocine (Talwin) and tramadol (Ultram, Ultracet) may be useful when simple analgesics are no longer effective. Propoxyphene and pentazocine are associated with a number of adverse events, especially in the elderly, and are generally not considered the drug of choice for chronic pain. Adjuvants such as gabapentin (Neurontin) and antidepressants (amitriptyline, nortriptyline, etc.) may be combined with simple analgesics in some types of pain. These medications are used to relieve what is described as “shooting pain” and they work by decreasing abnormal sensations caused by damaged nerves.
opioids
Rarely are (morphine, hydrocodone, etc.) necessary in those suffering minor pain. In cases of moderate or severe pain, simple analgesics and adjuvant therapy may be sufficient. However, many patients with moderate to severe pain will require opioids. Patients suffering from severe pain may benefit if simple analgesics are included in their pain regimen, although they usually require opioids for optimal pain relief. Opioids are often prescribed for acute, short-term pain, but they remain the cornerstone of treatment for the severe, chronic pain associated with cancer, back injury, etc.
opioid drug group
The includes natural components of opium (morphine and codeine); semi-synthetic derivatives such as oxycodone, hydrocodone, and hydromorphone; and synthetic analogues like methadone and fentanyl. Many of these drugs are available in short- and long-acting oral forms as well by injection. Drugs like morphine may be administered rectally or by subcutaneous, intramuscular, or intravenous injection. In cases of severe, intractable pain, morphine is often given as a continuous intravenous infusion. Fentanyl also is produced in a patch formulation (Duragesic) that can be applied every three days and as a lozenge (Actiq) that is placed inside the cheek. The dosage and frequency of use of these products is highly variable. Meperidine (Demerol) is a relatively weak opioid. It can cause a number of adverse effects and accumulates in patients with kidney disease. For these reasons, it is no longer recommended for the treatment of chronic pain. Patients and caregivers must be particularly careful to follow the instructions on the current prescription for any opioid. They should verify these guidelines with their doctor and pharmacist.
most common
The adverse effects of opioids are constipation, nausea and vomiting, and pruritus (itching). Constipation can be easily treated or prevented by the use of laxatives such as Senokot-S. Nausea and vomiting can be managed with medications like Phenergan, Reglan, Zofran, etc. Itching is often resolved by the addition of antihistamines such as Allegra, Claritin, Benadryl, etc.
Chronic pain management
includes not only treatment, but prevention as well. This goal can often be achieved by adherence to the basic guidelines for the drug therapy of pain as well as to the nonpharmacologic measures that reduce pain and improve the quality of life. Physicians, nurses and pharmacists caring for those with chronic pain recognize the burden of this symptom and the role of drug therapy. Their primary objective is to use all available drug and non-drug measures to reduce and, hopefully, prevent pain. The reader is encouraged to review the Web sites included in this newsletter for more information on the drug therapy of chronic pain.