Smertebehandling B. Husebø

WHO’s smertebehandlingstrapp Tilleggsmedisin Antidepressiva Antiepileptika Kortison Laksansien Antiemetikum ”STERKE” OPIOIDER I KOMBINASJON MED I III + tilleggs-medikasjon! ”SVAKE” OPIOIDER I KOMBINASJON MED I II IKKE-OPIOIDER I 2 2

bettina.husebo@isf.uib.no Analgesic drugs Acetaminophen Table 1 Systematic review of short - and long-term completed clinical trials in patients with dementia Analgesic drugs Acetaminophen NSAIDs Acetaminophen Acetaminophen Propoxyphene Darvocet Nonopioids Opioids Oxycodone Morphine Lidocaine, local Not mentioned Acetaminophen Morphine Buprenorphine Pregabaline Author Douzjian M Stein CM Kovach CR Allen RS Manfredi PL Buffum MD Chibnall Benedetti F Husebo BS Year 1998 2001 2003 2004 2005 2006 2011 Setting 1 NH 20 NHs 6 NHs 5 NHs 3 NHS 2 NHs Laboratory 14 NHs 18 NHs Study design Observational study Cluster randomized controlled study Cross-sectional study Randomized, double-blind, placebo-controlled trial Randomized, double-blind, placebo-controlled, cross-over trial Placebo controlled, open/hidden paradigme Randomized, double-blind, control group trial Multicenter, cluster randomized controlled trial Daily dose 1950mg acetaminonophen Substitution of NSAIDs with 1950mg acetaminophen Individual dosage 20mg oxycodone or 20mg morphine 2600mg regularly scheduled (qid) or as-needed (prn) acetaminophen 3000mg acetaminophen 1% solution of lidocaine Stepwise protocol of pain treatment Trial duration 24 weeks 12 weeks About 8 weeks 4 weeks 8 weeks (4 weeks long-acting opioid, 4 weeks placebo) 4 weeks total (2 weeks scheduled and 2 weeks as-needed medication 8 weeks (4 weeks acetaminophen, 4 weeks placebo) One time application, repeated after one year 8 weeks with follow-up 4 weeks after treatment Enrolment criteria NH patients with ongoing psychotropic medication NH patients; ≥65 years; taking NSAIDs regularly; osteoarthitis NH patients with dementia unable to verbalize their needs Patients with and without speach abilities CMAI≥40, pain questionnaire with 4 questions NH patients NH patients, FAST stage 5 or 6 AD patients vs mental unimpaired people NH patients, moderate to severe dementia, FAST 5 or 6 NH patients; ≥65 years; MMSE ≤ 20; CMAI≥39 No of subjects 10 147 76, about 48 received analgesics 92 47 42 25 44 (AD n=28, control n=16) 114 (n=26 received analgesics) 352 Mean (range) age (years) > 70 81 (65-101) 86.7 (56-100) 83.9 (61-105) 86.7 85.7 (67-101) 85.9 ± 7.4 73.5 ± 6.8 86.6 85.7 (65-104) Female NA 80 % 81 % 89.6 61 % 87 % 75 % MMSE 19 5.5 ± (0-20) 14±6 (1-29) 6.0 ± 7.2 4 ±5 15.6 ± 1.9 (13-20) 7.8 ±6.2 (0-20) 7.5 (0-20) Primary outcome Psychotropic Summery Sheet Number of NSAIDs and acetaminophen used ADD Philadephia Geriatric Center Pain Measure, MMSE, Charlson Comorbidity Index, Functunal Independence Measure CMAI DIS-DAT DCM NRS DIS-DAT BEHAVE-AD Secondary outcome VRS, NRS, MHAQ, SIP-NH, MMSE, change in GI symptoms FBP, MMSE MMSE, pain questionnaire with 4 questions MMSE, GDS CMAI, FAST, GMBH, BPRS, use of psychotropic medication MMSE, FAB MOBID-2 Pain Scale, NPI-NH MMSE, ADL, FAST bettina.husebo@isf.uib.no

Systematisk review om analgetisk effekt hos pasienter med demens (PubMed, EMBASE, Cochrane) 1 cross-sectional, 2 observational, 7 RCT RCT-studiene 3 for paracetamol (Stein 2001, Buffum 2004, Chibnall 2005) 1 for lidocain, localt (Benedetti 2006) 1 for morfin, oxycodone (Manfredi 2003) 1 med stepwise pain treatment (Husebø et al. 2011) 1 ukjent medikasjon (Kovach 2006) Ingen med NSAIDs, antiepileptika, svake opioider, plaster 2 studier i Europa Primary/secondary outcome measures? Svært varierende resultater Stort behov for ”mer” bettina.husebo@isf.uib.no

Balanse mellom effekt og bivirkning II Start med det minst toksiske Paracetamol, Novalgin: regelmessig 1gx3 NSAIDs, ASA kun over kort tid Unngå: svake opioider, TCA, neuroleptika Antiepileptika: ved nevropatisk smerte Forsiktig dosejustering Opioider Ved moderat og alvorlig smerte Forsiktig dosejustering, etter hvert depotpreparat Forbigående lett sedasjon er å forvente Evt. kombinasjon med paracetamol Profylakse: kvalme og obstipasjon AGS Panel Persistent Pain Older Persons. JAGS 2002 5