Quieting Down Opioid Prescribing Maria Foy,

Transcript:Quieting Down Opioid Prescribing Maria Foy,:
Quieting Down Opioid Prescribing Maria Foy, PharmD, BCPS, CPE Pharmacy Care Coordinator/Palliative Care Abington Hospital Jefferson Health Tanya J. Uritsky, PharmD, BCPS, CPE Clinical Pharmacy Specialist, Pain Management and Palliative Care Hospital of the University of Pennsylvania Disclosures Tanya Uritsky has nothing to disclose Maria Foy is on the speaker’s bureau for Astra Zeneca Goals and Objectives At the completion of this activity, the participant should be able to: Recommend an opioid de-escalation protocol based on current opioid dosage and length of therapy Provide dosing for inpatient ketamine during the de-escalation process Utilize co-analgesics for the treatment of chronic pain Question Symptoms of central sensitization may include (select all that apply): Allodynia Hyperalgesia Swelling Bradycardia Pain System Changes and Opioids Tanya J. Uritsky, PharmD, BCPS, CPE The Pain Pathway Bingham B, et al. , Nature Clinical Practice, 2009; 5(1):1-37. Accessed at: www.nature.com/clinicalpractice/rheum “Inflammatory Soup” Lower threshold for activation Increased rate of firing Plays a role in allodynia, hyperalgesia and in central sensitization Peripheral Sensitization Central Sensitization Amplification of neural signaling that elicits pain hypersensitivity An uncoupling of the clear stimulus-response relationship that defines nociceptive pain Manifests as: Hyperalgesia/secondary hyperalgesia Allodynia Prolonged pain after transient stimulus Can persist long after healing of the injury Woolf CJ. Pain, 2011;152(3 Suppl):S2-S15. Taking A Closer Look Pain afferents - Glutamate, Substance P, Calcium Central -NMDA activation, reduced endogenous opioid, reduced serotonin/5HT2A up-regulation, norepinephrine changes, dopamine changes Microglial Cells/Astrocytes -glutamate, cytokines, K/Ca channel dysregulation Raouf, et al. 2010 Glial Cell Activation Adapted from: https://www.practicalpainmanagement.com/pain/other/glial-cell-activation-neuroinflammation-how-they-cause-centralized-pain, online May 2015; accessed September 21, 2017 Neuroinflammation Chronic Fatigue Depression Centralized Pain Insomnia Overstimulation of sympathetic nervous system Intellectual Decline Pituitary Over-Stimulation Activated Glial Cells Pain Memory Adapted from: https://www.practicalpainmanagement.com/pain/other/glial-cell-activation-neuroinflammation-how-they-cause-centralized-pain, online May 2015; accessed September 21, 2017 What You See Major Symptoms Constant pain Insomnia, depression, fatigue Secondary Symptoms Anxiety, anorexia, hopelessness, allodynia Behavior Reclusiveness, immobility Becoming house/bed bound Sympathetic Nervous System Excitation Hypertension, tachycardia, hyperthermia, hyperhidrosis, mydriasis, etc. https://www.practicalpainmanagement.com/pain/other/glial-cell-activation-neuroinflammation-how-they-cause-centralized-pain, online May 2015; accessed September 21, 2017 But Why? Lowers pain threshold Stress Poor sleep Operant learning Individual beliefs and expectations Predictors of chronic pain Anxiety disorder Physical, psychological, emotional trauma or abuse Depression The Common Denominator Treatments of Central Sensitization Ketamine Gabapentin Pregabalin Duloxetine, milnacipran, lamotrigine Cox-2 inhibitors Cognitive Behavioral Therapy Aerobic exercise/physical therapy Chronic pain rehabilitation Massage therapy Relaxation Acupuncture Question Common attributes of both central sensitization and addiction are: A. Confusion B. Allodynia C. Hyperalgesia D. Environmental