Title: Pain and Symptom Management in End Stage Renal Disease
1Pain and Symptom Management in End Stage Renal
Disease
CARING THROUGH THE END Palliative Care Along
the Continuum of CKD
- Sara Davison
- MD, MHSc (Bioethics)John Dosseter Health Ethics
Centre, University of Alberta
2Objectives
- Discuss the magnitude and scope of chronic pain
and other symptoms in the ESRD population - Prevalence, severity, etiology
- Discuss the impact of chronic pain in ESRD
patients - Global HRQOL
- Psychological distress, insomnia, functional
status - Discuss the potential barriers to adequate pain
and symptom management - Outline potential strategies to enhance pain and
symptom management
3ESRD Population
- The elderly represent a steadily increasing
proportion of new patients - 50 patients starting dialysis gt 65 years old
- Significant co-morbidity
4- As the dialysis population ages and experiences
multiple co-morbidities, it is increasingly
important and challenging to maintain a
reasonable HRQOL. - Symptoms, especially pain, are important
determinants of HRQOL - Kimmel PL, AJKD 2003
- Effective pain management is an integral
component of quality patient care
5Burden of Symptoms in HD Patients
42.5
26.8
28.8
51.1
63.8
Davison, 2002
6Most Common Symptoms Reported by Symptomatic HD
Patients
with Symptoms
Symptoms
Kimmel PL, AJKD 2003
7Pain in Hemodialysis Patients
- Although dialysis sustains life, underlying
systemic disease persist - Ischemic limbs, peripheral neuropathies
- Numerous painful syndromes unique to chronic
kidney disease - Calciphylaxis, renal bone disease
- Prospective cohort study of 205 HD patients (UAH)
- 103 (50) reported a current problem with pain
- 55 of these patients reported their pain as
severe - Causes of pain were diverse
- 18 had multiple causes for their pain
Davison, AJKD 2003
8Etiology of Pain
Davison, AJKD 2003
9Severity of Pain Brief Pain Inventory Scores
82.5
58.3
Davison, AJKD 2003
10Pain Management
11Point Prevalence of Analgesic Use DOPPS
¾ of patients reporting moderate to severe pain
were not prescribed analgesics
12Impact of Pain on HRQOL
Total Score
Scales
Kimmel PL, AJKD 2003
13The Impact of Pain
- Symptoms, especially pain, are important
determinants of HRQOL of patients with ESRD - Symptoms may be more important than objective
clinical assessments in determining HRQOL for
these patients - Pain is a multidimensional phenomenon with
physical, psychological and social components - Failure to treat pain adequately could be
expected to lead to disruption in many aspects of
life such as functional status, mood, sleep, and
global HRQOL
14Brief Pain Inventory Interference Items
55.3
62.1
Davison, 2004
15The Impact of Pain Depression and Insomnia
- Prevalence of Depression (BDI)
- 18 in patients with no-mild pain v. 34 in
patients with moderate-severe pain (OR 2.31,
p0.01) - Pain was the only significant predictor in
multivariate analyses - Prevalence of insomnia
- 53 in patients with no-mild pain v. 75 in
patients with moderate-severe pain (OR 2.32,
p0.02) - Pain and younger age were the only significant
predictors
16Impact of Pain on QOL, Depression and Sleep
Scores
Scales
Davison, 2004
17The Impact of Pain
- Pain contributed significantly to psychological
distress anxiety, irritability, ability to cope
with stress in addition to depression - Pain had a significant adverse effect on
recreational activities, relationships, physical
functioning, emotional functioning (P lt 0.001),
and sexual functioning (P 0.034) in patients with
pain compared to those without pain - Pain had a significant impact on all measured
activities of daily living
18Spirituality
- The ways in which chronic pain patients cope or
adjust to their illness is likely central to
understanding the great variability across
patients in their ability to function with their
pain. - Issues of spirituality and social support are
likely very important for many patients in this
equation although were not studied here. - The concept of Total Pain (Cicely Saunders)
emphasizes the contribution of psychological,
spiritual and social factors to the experience of
pain. - These factors need to be taken into consideration
when caring for our patients
19Consideration of Withdrawal from Dialysis
- Patients with more likely to have considered or
be considering withdrawal of dialysis if they
suffered from moderate-severe pain - 59 patients with pain were considering stopping
dialysis - 46 of patients with moderate-severe pain
- 17 of patients with no-mild pain (P lt 0.001)
- Pain was NOT the most common reason for
considering withdrawal of dialysis
20Reasons for Consideration of Withdrawal
Davison, 2004
21End-of-Life Pain Management
- Pain control is an essential component of EOL
care, especially in patients with ESRD - Adequate pain control is central to a patients
perception of a high quality death - Pain is present in 42 of patients discontinuing
dialysis during the last 24 hrs of life (Cohen
LM, Arch Int Med, 1995) - Patients with cognitive impairment may have
difficulty communicating pain
22Interim Conclusions
- Pain and other symptoms are common, often severe,
and are suboptimally treated - Pain is associated with depression, anxiety,
insomnia, decreased functional status and
decreased global HRQOL - Need to focus more on pain and symptom management
if we are to improve HRQOL - Effective pain management will likely require
attention to issues relating to psychological
status, sleep, functional ability, spirituality
and social support
23Barriers to Effective Pain Management
- Patient reluctance to report pain
- Lack of staff time and training in the basic
principles of pain management
24Barriers to Effective Pain Management
- ESRD Specific
- Lack of recognition of the problem therefore not
a clinical or research focus - Lack of education, training and dedicated
resources - Complicated pharmacokinetics and pharmacodynamics
- Uremic symptoms may mimic opioid toxicity
- Treatment algorithms for cancer patients may not
apply to ESRD patients - Objective data on appropriate and effective
management strategies for ESRD patients are still
required
25Barriers to Effective Pain Management
- Limb preservation, defer high risk surgery
- Pain is often experienced in the context of
multiple, complex symptoms and EOL issues which
may interfere markedly with psychological, social
and physical coping skills
26Barriers to Effective Pain Management
- ELDERLY
- More sensitive to the effects of many analgesics
- More susceptible to adverse effects
- Polypharmacy
- High number of comorbid conditions
- Pharmacokinetic and pharmacodynamic changes occur
with aging - Analgesics associated with falls in the elderly
27Pain Management
- Pharmacological and non-pharmacological
interventions! - Appropriate investigations and diagnosis re
cause - An understanding of the type of pain is useful in
tailoring analgesic therapy - Regular assessment and recording of pain
severity, effects on functioning and HRQOL etc,
and adverse effects of current management - This can be largely protocol driven
- Possible role for advanced nurse practionner
28Freedom from pain
OPIOID FOR MODERATE TO SEVERE PAIN
NON-OPIOID ADJUVANT
3
Pain persisting or increasing
WEAK OPIOID FOR MILD TO MODERATE PAIN
NON-OPIOID ADJUVANT
2
Pain persisting or increasing
NON-OPIOID ADJUVANT
1
PAIN
29Non-Narcotic Analgesics
- Acetaminophen
- Does not require dose adjustment in ESRD
- Non-narcotic of choice for mild-moderate pain in
CKD/ESRD - Numerous OTC meds contain acetaminophen
hepatotoxicity - Potential cause of CKD/loss of GFR
- NSAIDS
- Can be used in conjunction with acetaminophen
- Increased risk of bleeding with CKD/ESRD
- Potential cardiovascular risks associated with
COX-2 inhibitors - Renal side effects hypertension, hyponatremia,
loss of RRF, hyperkalemia (CKD)
30Narcotics
- Can be used in combination with non-narcotics or
alone for moderate-severe pain - Active metabolites are renally excreted
- Side Effects
- Constipation
- Nausea and vomiting
- Pruritus
- Hypotension
- CNS and respiratory depression
ESRD
Co-Morbidity
Prevention
31- Codeine
- Elimination ½ life is significantly increased in
dialysis patients - Reports of neurotoxicity
- Should be used with caution but tolerated
relatively well if carefully monitored - Oxycodone
- Elimination significantly increased in ESRD
- Fibrillary GN
- Growing popularity as a drug of abuse and is now
considered one of the most desirable of
prescription drugs - Should be used with caution but tolerated
relatively well if carefully monitored
32- Morphine
- Active metabolite M6G is renally excreted and
accumulates in ESRD - Increased side effects
- No data regarding dose adjustments for
sustained-release preparations of morphine - Hydromorphone
- 10 times more potent than morphine, shorter
duration of action - Case reports of adverse effects, essentially no
PK data - Published and clinical experience indicates that
it may be administered safely in ESRD may be
particularly useful in patients who have
intolerable side effects from other narcotics
Lee MA, Palliat Med 2001
33- Methadone
- Opioid commonly used for treatment of severe pain
or withdrawal in narcotic addicts - High oral bioavailability and a long ½ life
- Essentially no PK data in ESRD single report
suggesting normal levels in ESRD - Anecdotal experience suggests a relatively good
safety profile - Fentanyl
- Transdermal formulation
- When patients are on a stable narcotic dose
- Essentially no PK data of transdermal formulation
or effect of dialysis on levels (one report
stated poor removal) - Toxicity has been reported but anecdotal
experience suggests a reasonable safety profile
if monitored carefully
34Propoxyphene
- Related to Methadone
- Active metabolite, norpropoxyphene is renally
excreted - Local anesthetic properties similar to quinidine
- Predispose patients to risk of cardiac conduction
abnormalities - Neither proppoxyphene or norpropoxyphene are
removed with dialysis - Cardiotoxicity cannot be reversed by naloxone
- Use with extreme caution
- Never use
35Adjuvants
- Anticonvulsants
- Gabapentin effective for neuropathic pain and
restless legs - Accumulation with toxicity in ESRD Max dose
300mg/day - Carbamazepine neuropathic pain
- Does not require dose adjustment in ESRD
- Less adverse effects start _at_ 200mg BID
- Antidepressants
- Tricyclic antidepressants neuropathic pain,
synergistic with opioids - Anticholinergic effects dry mouth sedation,
weight gain caution in patients with cardiac
conduction abnormalities - Despiramine may have less side effects than
amitriptyline
36Narcotic Drug Abuse Myths and Fears
- Tolerance the need for increasing doses of a
drug in order to achieve the same pharmacological
action - Unwanted effects (nausea) desired pain relief
- Dose escalation may be required
- Incomplete cross tolerance to unwanted effects is
the basis for switching from one opioid to
another aim to maintain analgesia while reducing
adverse effects - Physical dependence characterized by withdrawal
symptoms if treatment is stopped abruptly or an
antagonist is given. - Does not prevent dose reduction if pain is
relieved - Does not prevent the effective use of opioids
- Tolerance and physical dependence are expected
consequences and should NOT lead to a reduction
of therapy
37Narcotic Drug Abuse Myths and Fears
- Addiction (psychological dependence) a
behavioral pattern characterized by craving for
the drug and an overwhelming preoccupation with
obtaining it - Extensive clinical experience has shown that it
occurs rarely in patients receiving opioids for
pain relief!
38Dosing of Analgesics
- by mouth
- When ever possible, drugs should be given orally
(transdermal) - by the clock
- Drugs should be given regularly PRN
breakthrough - by the ladder
- Use the sequence of the WHO analgesic ladder
- for the individual
- There is no standard (ceiling) dose for strong
opioids. The right dose is the dose that
relieves pain without unacceptable side effects - Every patient is different
- attention to detail
- Pain changes over time assessment and
reassessment - Actively prevent adverse effects
39Dosing
- Ineffective medications should be tapered and
discontinued and REPLACED with another agent - Clear communication ensure patients understand
the regimen, the goals of therapy, adverse
effects and what to do if control inadequate. - Dosing should be as simple as possible
40Conclusions
- ESRD patients have a high burden of symptoms
throughout their illness (not just at the EOL) - Pain in ESRD is common, often severe and poorly
managed - Symptoms, especially pain, have a tremendous
negative impact on all aspects of HRQOL - Effective pain and symptom management is an
integral component of quality ESRD patient care - For management of pain to be effective, issues
relating to psychological status, sleep,
functional ability and HRQOL must be addressed
along with the pain
41Conclusions
- Multidisciplinary nephrology teams must focus on
pain and symptom management (clinical and
research) - Enhanced training for residents, CME for staff,
training for nursing staff and allied HCP - Culture of the dialysis unit must change to
support this new focus on pain and symptom
management - Infrastructure must reflect these new priorities
dedicated resources
42Conclusions
- Concerns about analgesics (especially opioids)
has lead to a more cautious use of analgesics in
ESRD patients and has resulted in potential under
prescription - Must optimize BOTH pharmacological and
non-pharmacological interventions for effective
pain management