2/27/2015

Pediatric Pain Management Victoria Chadwick, PharmD PGY1 Pharmacy Resident Seattle Children’s Hospital [email protected]

Overview o Background o Pediatric pain assessment o The Pain Scale o Identifying the signs and symptoms in children o Initiating appropriate therapy o WHO Pain Ladder o Stepwise approach o Commonly used medications/formulations o Tapers and withdrawal o Complicating factors of pain regimens o Chronic pain, palliative and end-of-life care

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Cases: • 2 year old female in Urgent Care with 2 day history of fever, fussiness and pulling on right ear. Diagnosed with AOM and discharged. • 17 year old male inpatient post surgical drainage of left thigh abscess and concurrent osteomyelitis. • 12 year old male inpatient for pneumonia. History of spine fracture 2 years prior with ongoing dependence on pain medications. • 7 year old female transferred from outside hospital post sepsis with recent bilateral amputations. Three wound-vacs in place and scheduled for twice weekly surgical debridement. •

3 day old female in NICU ventilated and on ECMO for respiratory collapse secondary to meconium aspiration.

Background

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Pain • The perception of central nervous system’s response to noxious stimulation • “The Fifth Vital Sign” • Incorporated into standard medical assessments • Healthcare Resource Implications • Billions spent annually on treatment of acute and chronic pain • Prescription analgesics ~$750 million/year • Over-The-Counter analgesics ~ $3 billion/year • Major impact on quality of life • Key word = PERCEPTION • Reports of pain are qualitative and subjective

Assessment

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Assessment: The Pain scale

SO… WHAT IS THEIR PAIN SCALE?

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Assessment: signs & symptoms of pain • Extremely difficult to assess young patients – Non-verbal, difficulty appropriately expressing pain

• Common signs & symptoms of pain in kids – – – – – – – – – –

Fussiness Mood changes/frustration Crying/inconsolable Tachycardia Elevated BP Sweating Wincing/guarding Withdrawn, isolation Decreased oral intake Decreased mobility

Assessment: Objective tools

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Assessment: Objective tools

• Others: Observational visual analog scale, COMFORT scale

Types of pain • Somatic: typically associated with acute injury

– Persistent activation of pain receptors on somatic structures like bone, tissue – Quality: sharp, stabbing, throbbing, aching – Meds: anti-inflammatory, opioids

• Visceral: visceral organ pain receptor activation and signal transduction via autonomic nervous system – Tends to be ill-defined pain – Quality: diffuse, cramping, referred outside of location of injury – Meds: anti-inflammatory, opioids

• Neuropathic: directly associated with damaged and/or malfunctioning of nervous system

– Can originate both centrally and peripherally; can radiate to areas innervated by nerve; can persist after nerve damage is repaired – Quality: burning, tingling, electric shock-like around area of nerve damage, hypersensitivity – Meds: anti-depressants, anti-convulsants

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Goals of pain control • Maximize pain relief • Minimize side effects • Use the least number and lowest dose(s) of drug(s) to achieve desired results • Continue therapy for appropriate duration to manage painful situation • Continual assessment of drug therapy – Efficacy- Are we achieving our pain control goal with the current regimen (i.e. Pain score improvement? Breakthrough pain episodes?) – Toxicities- Is the patient experiencing side effects associated with the treatment regimen? – Tolerance- Is the patient developing signs of drug tolerance? – Addiction- Is the patient at risk or showing risk signs of substance abuse?

Initiating therapy

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Initiating therapy • World Health Organization PAIN LADDER – Initially developed for cancer pain management – Adopted and widely accepted as a general guideline for pain management

• IMPORTANT: SET REALISTIC PAIN CONTROL GOALS!

A stepwise approach to pain STEP ONE: MILD PAIN • Pain scale score range ~1-3, typically intermittent, minimal impact on activity and/or quality of life • Preferred agents: non-opioid analgesics, anti-inflammatories – Can be prescribed/taken scheduled for a defined period of time, or as needed – Acetaminophen: liver toxicity – NSAIDS: renal function, GI toxicity, anti-platelet effects – Aspirin: Reye’s Syndrome, anti-platelet effects, GI toxicity

• Non-pharmacological therapies – – – –

Rest, removal of causative agent Physical therapy Altered functioning and/or mobility Topical compresses, ice, heat

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A stepwise approach to pain STEP TWO: MODERATE PAIN

• Pain scale score ~ 4-6, some impact on activity and/or quality of life • Preferred agents: opioid analgesics + anti-inflammatories + nonopioid analgesics – Immediate-release narcotics, typical dosing frequency every 4 to 6 hours; can be prescribed/taken scheduled for a defined period of time, or as needed – Single agent or combination opioid/non-opioid products – Combined use of opioid and non-opioid medications can decrease overall opioid requirement – CLINICAL CONSIDERATION: combo products are FIXED ratios • • • •

Not all formulations are appropriate for pediatric use Amount of non-opioid drug may not be considered when prescribed May exceed total daily dose if additional non-opioid drug administered Prescribing single-agents to be given simultaneously is a reasonable, SAFER alternative for ALL patients

A stepwise approach to pain STEP THREE: SEVERE PAIN • Pain score ~ 7-10, typically more persistent, major impact on activity and quality of life • Preferred agents: potent opioid analgesics + anti-inflammatories + non-opioid analgesics – Typically scheduled dosing; oral, intravenous, long-acting or controlled release formulation use possible – Oral agents: morphine, oxycodone, hydromorphone – IV agents: morphine, hydromorphone, fentanyl – Long-acting oral agents: MS Contin, OxyContin – Goal is adequate basal pain control with minimal breakthrough painful episodes – Route of administration determined by acuity and severity of pain, ability of patient to tolerate oral therapy, access

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Case

Case STEP THREE: SEVERE PAIN • 9 year old, 26 kg patient status-post open lung biopsy for suspicious lesions found on CT, returns from the PACU, where she received 2 doses of morphine 0.05 mg/kg= 1.3 mg IV for acute post-op pain. The surgical team clears the patient for regular diet and advancing activity as tolerated, but warns the primary care team that the incision site and chest wall may be extremely tender for the next several days. During examination, the patient reports pain equivalent to an 8 out of 10 via the faces scale. She is visibly uncomfortable, winces when the doctor examines the incision site closely, and guards the area. • The team asks their [awesome] clinical pharmacist to recommend an appropriate pain regimen to make their patient more comfortable.

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Case STEP THREE: SEVERE PAIN • ONE APPROACH (because it’s not the only one) – Oxycodone 0.1 mg/kg = 2.6 mg PO Q6H for 24 hours – Acetaminophen 12.5 mg/kg = 325 mg PO Q6H for 24 hours • Mimics combination analgesic, can decrease need for opioid

– Include morphine 0.05 mg/kg = 1.3 mg IV Q2H PRN SEVERE/Breakthrough pain – After 24 hours, if patient’s pain is controlled and clinical situation is improving, change oxycodone to Q6H PRN SEVERE pain and acetaminophen to Q6H PRN MODERATE pain • Will encourage APAP use for less severe pain • Can still be used around-the-clock if pain worsens • Can also include morphine 0.05 mg/kg = 1.3 mg IV Q2H PRN SEVERE pain and unable to tolerate PO order

Case ASSESSING TREATMENT REGIMEN • 24 hours later, our post-op patient has worsening pain (pain scale ranging from a 7 to a 10), with a decrease in both ambulation and oral intake. She has continued the around the clock oxycodone and APAP, RN reports that she vomited within 30 minutes after 2 of the scheduled doses, and has used a total of 6 PRN morphine IV doses in the past 24 hours. The team is concerned that her oral regimen is not adequate and asks for an appropriate IV regimen to ease her pain.

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Opioid Analgesia conversion chart

• Dose reduction when converting patient from one narcotic to another – 0-25% decrease depending on prior narcotic exposure, pain score

Case MAKING ADJUSTMENTS • Assess total analgesia used during 24 hour period – Oxycodone 2.6 mg x 4 doses = 10.4 mg – Morphine IV 1.3 mg x 8 doses (6 PRN, 2 in PACU) = 10.4 mg

• Convert everything to IV analgesic – Opioid analgesia conversion chart – Convert all PO analgesics to equivalent PO morphine, then convert PO morphine total to IV morphine • Oxycodone 10.4 mg PO = morphine 15.6 mg PO – 2 mg PO oxycodone = 3 mg PO morphine

• Morphine 15.6 mg PO = morphine 5.2 mg IV – 3 mg PO morphine = 1 mg IV morphine

– Total IV morphine = 5.2 mg + 10.4 mg = 15.6 mg IV mophine – Intermittent IV Bolus dosing vs. continuous infusion • IV boluses = increased risk of breakthrough pain, shorter duration of activity, less basal pain control, multiple line-access, risk of infection • Continuous infusion = easier to achieve good basal pain control, less line accesses, titrateable • PCA= patient-controlled analgesia; may not always be appropriate in pediatric patients

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Case INTRAVENOUS INFUSION PAIN REGIMEN • Morphine 15.6 mg IV / 24 hours • Morphine infusion 0.65 mg/hour – Divide total daily usage by 24 hours to get mg/hr – 25 mcg/kg/hr (usual range = 10-50 mcg/kg/hr) • Most IV pumps are programmable via mcg/kg/hr

• If morphine drip concentration is 0.2 mg/mL, what is the infusion rate in terms of mL/hr? – 3.25 mL/hr – PRN bolus dose for breakthrough pain • Can give ~20-50% of hourly rate every 20 minutes PRN OR 0.05 mg/kg = 1.3 mg IV Q2H PRN severe/breakthrough pain • Use the PRN bolus data to assess pain relief and adjust rate up (or down)

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As pain improves, titrate drip rate down prior to converting to PO

Case ASSESSING TREATMENT REGIMEN • Our patient was on the continuous morphine drip at 25 mcg/kg/hr for 24 hours. Her pain is improved, and the team decreases her drip rate by 5 mcg/kg/hr every 4 hours as tolerated, continuing to monitor pain scores and providing PRN analgesia. • Her drip rate is currently 10 mcg/kg/hr, she has only used IV morphine 1 x 1.3 mg PRN dose in 24 hours, and is eating and drinking well. • The team asks their [awesome] clinical pharmacist to devise an oral pain management plan for their patient.

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Case CONVERTING TO ORAL REGIMEN • Add total daily IV morphine usage – Continuous infusion and any PRNs used • •

10 mcg/kg/hr x 26 kg x 24 hr = 6.24 mg IV + 1.3 mg PRN dose = ~7.5 mg IV Can use the average of several days to get better overall picture of pain needs

• Convert IV morphine to PO morphine – 1 mg IV morphine = 3 mg PO morphine – 7.5 mg IV morphine = 22.5 mg PO morphine

• Convert PO morphine to whatever PO analgesic you are using – 3 mg PO morphine = 2 mg PO oxycodone – 22.5 mg PO morphine = 15 mg PO oxycodone (total per day)

• Divide into appropriate mg doses based on dosing frequency – 15 mg PO oxycodone / Q6H = ~3.75 mg PO Q6H •

Verify against standard dosing (~0.14 mg/kg/dose; typical range 0.1-0.2 mg/kg/dose)

– Provide morphine 0.05 mg/kg = 1.3 mg IV Q2H PRN severe/breakthrough pain

• Devise taper plan!!!

Tapers

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Tapers • Stopping acute or short-term pain regimen – Typically on pain meds