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Clinical Pharmacology Considerations in Pain Management in Patients with Advanced Kidney Failure

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Clinical Pharmacology Considerations in Pain Management in Patients with Advanced Kidney Failure NephropharmacologyCJASN ePress. Published on March 4, 2019 as doi: 10.2215/CJN.05180418 for the Clinician Clinical Pharmacology Considerations in Pain Management in Patients with Advanced Kidney Failure Sara N. Davison Abstract Pain is common and poorly managed in patients with advanced CKD, likely due to both under and over prescription ofappropriate analgesics. Poorlymanaged paincontributes topatients’ poorqualityof life andexcessive health care Division of use. There is tremendous variability within and between countries in prescribing patterns of analgesics, suggesting Nephrology and that factors other than patient characteristics account for these differences. This article discusses the Immunology, Department of pharmacologic management of acute and chronic pain in patients with advanced CKD, and the role analgesics, Medicine, University including opioids, play in the overall approach to pain management. of Alberta, Edmonton, Clin J Am Soc Nephrol 14: ccc–ccc, 2019. doi: https://doi.org/10.2215/CJN.05180418 Alberta, Canada Correspondence: Introduction with advanced CKD, including patients with ESKD Dr. Sara N. Davison, Division of Pain is common in patients with advanced CKD. treated with dialysis or conservative kidney manage- Nephrology and Over 58% of patients experience pain and approxi- ment. The role analgesics play in the overall approach Immunology, mately 49% of patients report moderate or severe to pain management will be discussed, with the Department of pain, whether they are treated with dialysis or understanding that analgesics should not be the Medicine, University managed conservatively (1). It is widely recognized of Alberta, 11-107 sole focus of treatment and should only be used Clinical Sciences that pain, in particular chronic pain, is associated when needed, in conjunction with other treatment Building, Edmonton, with psychologic distress; depressive disorders; lim- modalities, to meet patient-specific treatment goals. AB T6G 2G3, Canada. itations in work, family, and social life; decreased life Email: sara.davison@ satisfaction and quality of life (QOL); and increased ualberta.ca hospitalizations and emergency department visits Key Considerations in the Evaluation of Pain to (2–5). For patients receiving hemodialysis (HD), Guide Pharmacologic Management uncontrolled pain leads to shortened or missed Evaluation of pain requires a comprehensive pa- treatments (6). Chronic pain in the United States tient assessment and physical examination that in- ’ costs hundreds of billions of dollars annually (7). cludes understanding the patient s diagnosis and Pain is defined by the International Association medical history in addition to determining the effects ’ for the Study of Pain as “an unpleasant sensory ofthepainonthepatients psychologic status, social and emotional experience associated with actual functioning, functional status, and QOL. Four as- or potential tissue damage, or described in terms pects of the evaluation essential to determining a of such damage” (8). This definition recognizes pharmacologic approach will be discussed here. pain as a multidimensional phenomenon with Theyconsistofdetermining(1)painintensity;(2) physical and psychosocial components. A unidi- chronicityandpossiblereversiblecausesforthepain; — mensional approach to pain management, espe- (3)thetypeofpain nociceptive, neuropathic, or cially one that relies exclusively on analgesics, is combined; and (4) treatment goals. unlikely to be successful.Nonpharmacologic therapies that address the whole person in the Pain Intensity context of their disease and personal life are vital Determining pain intensity helps establish the in managing chronic pain and should augment need for treatment. The experience of pain is unique pharmacologic treatments (i.e.,multimodalther- to each individual and can only be measured by that apy). These may include physical therapies such individual. Listening to the patient validates the as aerobic exercise, stretching, massage, acupres- significance of their pain and their suffering and is an sure, and acupuncture; behavioral therapies such importantpartofthetherapeuticintervention.Sev- as cognitive behavioral therapy, biofeedback, eral global symptom assessment tools have been relaxation techniques, counseling, guided imag- validated for use in patients with CKD. These have ery, and mindfulness-based stress reduction; as recently been reviewed elsewhere (1). These tools well as interventions such as nerve blocks and differ in format, such as numeric, visual, or verbal trigger point injections. scales. Although each has evidence for validity, The focus of this article is the pharmacologic patients interpret them differently, making it difficult management of acute and chronic pain in patients to compare between studies. Substantial data exist www.cjasn.org Vol 14 June, 2019 Copyright © 2019 by the American Society of Nephrology 1 2 Clinical Journal of the American Society of Nephrology around what constitutes clinically significant pain. Most to ensure long-term resolution. One should initiate anal- of these data are on the basis of 0–10 scales and consensus gesics promptly with moderate or severe pain because from the Initiative on Methods, Measurement and Pain pain is more difficult to treat once the pain cycle becomes Assessment in Clinical Trials was to recommend using a established. Although we still do not fully understand the 0–10 numeric rating scale, at least in pain studies (9). This development of chronic pain, lessons learned from pa- also helps compare findings across patient populations tients undergoing surgery have taught us that good pain and studies. A score of 0–3 generally reflects mild pain, control reduces the likelihood of experiencing chronic pain which does not usually require initiation of or change in after surgery. We also know that the risk of abuse is low in pain management. Moderate pain with a score of 4–6 patients receiving opioids for acute pain after surgery if the generally means therapy has to be initiated or changed opioids are used in a controlled manner. because pain is managed inadequately. A score of 7–10 is Patients with chronic pain often do not have a treatable described as severe pain and typically requires immediate underlying cause for their pain and the somatosensory attention to treatment. component of the pain assumes greater prominence than The Edmonton Symptom Assessment System–revised: in acute (and, some say, cancer) pain. As the disorder Renal is a quick, simple, and widely used global symp- progresses, the original triggers become less important and tom assessment tool that can be used successfully in psychologic mechanisms gain importance. Pharmacologic patients, even as they approach death (2). The most recent therapy alone is unlikely to be sufficient and pain scores version consists of a 0–10 numeric rating scale for 12 have not been shown to correlate with analgesic therapy, commonly experienced symptoms, including pain (10). including opioid use. For patients with chronic pain, nonpharmacologic assessment and support is essential. Chronicity of Pain and Reversible Factors The management of recurrent pain, such as pain from Determining the chronicity of pain is important in needling fistulas, intradialytic steal syndrome, intradia- determining appropriate management strategies (Table 1). lytic headaches, and cramps (Table 1), is more in keeping With acute pain it is important to treat underlying causes with acute pain. It focuses on strategies to minimize tissue Table 1. Chronicity and type of pain Pain Details Chronicity of pain Acute pain c Typically persists for ,3 mo. c Associated with tissue damage. c Usually episodic with periods without pain. c Tends to last a predictable period, have no progressive pattern and subsides as healing occurs. c Tends to respond well to pharmacologic therapy: titrating analgesics against pain intensity usually works well. Chronic pain c Often defined as any painful condition that persists for .3mo(8). c Usually initiated by tissue injury but is perpetuated by neurophysiologic changes, which take place within the peripheral and central nervous system leading to continuation of pain once healing has occurred. c Severity is often out of proportion with the extent of the originating injury. c More likely to result in functional impairment and disability, psychologic distress, sleep deprivation, and poor QOL than acute pain. c The pain experience may be affected substantially by mood, stress, and social circumstances. c May not respond well to analgesics, including opioids, except early in the course of treatment. Recurrent pain c Acute pain from tissue injury, which may occur over long periods of time (e.g., pain from needling fistulas, intradialytic steal syndrome, intradialytic headaches, and cramps). c Patient will also be free from pain for long periods. c More intrusive on everyday life than “acute pain.” Type of pain Nociceptive c Results from tissue damage in the skin, muscle, and other tissues, causing stimulation of sensory receptors. pain c May be described as sharp or like a knife and often felt at the site of damage (e.g., joint pain from dialysis-related arthropathy). c With stimulation of visceral nociceptors, may be experienced as dull, aching, and poorly localized (e.g., gut ischemia). c Tends to respond to analgesics. Neuropathic c Results from damage to the nervous system resulting in either dysfunction or pathologic change. pain c May be felt at a site distant from its cause (e.g., in the distribution
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