Pain Management in Home Dialysis

A recent study examined opioid medication prescription patterns from claims data in the United States Renal Data System between 2006-2010. The authors found that 60%+ of dialysis patients were prescribed one or more opioids each year, and 20% had at least one 90-day prescription each year. Most of the prescriptions in the study were for hydrocodone, oxycodone or tramadol. Among the 2010 patient cohort, even those with 1-89 days of opioid medications had higher rates of hospitalization, death, and withdrawal from dialysis. Reading that study led to this blog.

The History of Pain Management

For years, pain was largely ignored and not routinely assessed in any patients, much less those on dialysis. Starting in 1990, an effort was made to bring more attention to acute and chronic pain. Pharmacy manufacturers marketing newer pain medications reportedly led doctors to believe the drugs were not addictive. In 1996, the American Pain Society called for pain to be the 5th vital sign. In 1997, the Food & Drug Administration started to allow direct-to-consumer marketing. Patients in pain began asking their doctors for medications to relieve their pain.

In 2001, the Joint Commission established standards recommending that providers assess adult patients for pain. Since 2006, patients discharged from a hospital have received the HCAHPS, a patient satisfaction survey that includes three pain questions. According to the Agency for Healthcare Research and Quality, 73% of discharged patients (not all on dialysis) reported on that survey that they had pain in the hospital that required medication.

Identifying Pain in Dialysis

Starting in 2008, the ESRD Conditions for Coverage required dialysis facilities to offer patients a health-related quality of life survey. That survey, the KDQOL-36, asks home and in-center dialysis patients “During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?” Staff began to identify how many dialysis patients had pain and to recognize how much their pain interfered with their lives. Pain can affect sleep and cause depression, both of which can lead to bad outcomes.

In 2009 the Mid-Atlantic Renal Coalition and the Kidney End of Life Coalition (now called the Kidney Supportive Care Coalition) developed a brochure called Clinical Algorithm & Preferred Medications to Treat Pain in Dialysis Patients. At the same time, there are risks to the use of opioids in dialysis. A recent study found a link between opioid use and a higher risk of hospitalization, death, and withdrawal from dialysis.¹ Are these negative outcomes the result of the use of opioids—or of the underlying pain that led the doctor to prescribe and the patient to take opioids? We don’t know.

Home dialysis may reduce some pain symptoms. However, there are conditions that cause both in-center and home dialysis patients to want relief from diabetic nerve pain, arthritis, osteomyelitis, access and other surgery, etc.²

Pain Severity & Types of Pain

The Clinical Algorithm brochure suggested that pain can be assessed using a numeric 10-point scale or with a screening tool showing a series of 10 faces. Levels of pain range from no pain (0), to mild pain (1-4), to moderate pain (5-6) and finally to severe pain (7-10).

The brochure noted that pain may be acute (short-term) e.g., following an accident or surgery, or chronic (long-term), and outlined two types of pain:

• Nociceptive—dull, aching, cramping, and throbbing
• Neuropathic—numbness, stabbing, burning or tingling

Finally, the brochure suggested that doctors consider the type of pain when deciding which drugs or other treatments to prescribe. A ladder for different levels of pain medications and which ones were preferred for dialysis patients at that time was included. The use of some of these drugs is being called into question today. One bullet said, “Refer for non-pharmacological interventions as appropriate.” Yet, no options for these were included.

Center for Disease Control & Prevention Recommendations

In 2016, the CDC published its CDC Guideline for Prescribing Opioids for Chronic Pain and a fact sheet based on that guideline. It The guideline includes 12 recommendations in these 3 areas:

1. “Determining when to initiate or continue opioids for chronic pain.
2. Opioid selection, dosage, duration, follow-up, and discontinuation.
3. Assessing risk and addressing harms of opioid use.”

The CDC guideline offers cautions for use of opioids and nonopioid medications in people age 65 and older and those with decreased kidney function. It includes a section on the effectiveness of nonopioid and nonpharmacological treatments for pain.

Opioid Drug Use Statistics

Today almost daily you read or hear about the “opioid crisis” or “opioid epidemic” in the U.S. There is no denying that a growing number of people die from opioid misuse/abuse. According to the National Institute on Drug Abuse (NIDA), more than 90 people die every day from abuse of prescription opioids, the synthetic opioid Fentanyl and heroin. In 2015, more than 2 million people abused prescribed opioids and almost 600,000 were addicted to heroin.

NIDA quoted these statistics:

• 21-29% of those prescribed opioids for chronic pain misuse them.³
• 8-12% of those prescribed opioids for chronic pain develop an opioid use disorder.⁴,⁵,⁶
• 4-6% of those who misuse prescribed opioids move on to heroin.2-4
• 80% of those who use heroin had previously misused prescribed opioids.2

According to the CDC’s U.S. Prescribing Rate Maps, from 2006-2012, there was a steady increase in the rate of prescriptions dispensed by retail pharmacies for opioids per 100 patients from 72.4 in 2006 to 81.3 in 2012. However, as the opioid crisis has grown, there has been greater scrutiny on physician prescribing patterns and a decrease in the number of prescriptions dispensed for opioid medications. This rate declined from 78.1 in 2013 to 66.5 in 2016. The number of prescriptions for opioids dispensed by retail pharmacies in 2016 was almost 215,000. In 2016, CNN did a story describing how patients who are initially prescribed opioids can develop a tolerance to the drug requiring them to take more for the same effect, then they develop an addiction to the opioid and if cut off, too many start taking heroin. Opioids cost $1 per milligram—while heroin costs about 1/10 that price.

U.S. State Opioid Prescribing Rates, 2016

Dosing and Dialyzability of Opioids

Some opioids are removed from the body through the kidneys. When kidneys are damaged, the dose of some drugs should be reduced. Some drugs are known to be removed by HD or PD—and more frequent and/or longer HD treatments might remove more of the drugs. Whether dialysis removes other drugs is unknown.⁷

Alternatives to Opioids in Pain Management

Some over-the-counter (OTC) medications are unsafe for people with kidney disease and kidney failure. According to the NKF, people over 65 and those with high blood pressure, kidney, heart, or liver disease should avoid non-steroidal anti-inflammatories (Advil, Aleve, Motrin, etc.) unless doctor ordered. The most commonly recommended OTC pain medication is acetaminophen (Tylenol®) when taken according to package instructions.

In addition to recommending various non-opioid pharmacological treatments, the CDC recommends these nonpharmacological treatments for these kinds of pain:

• Low back pain – exercise, physical therapy, and cognitive behavioral therapy.
• Osteoarthritis – exercise, weight loss, patient education
• Fibromyalgia - low-impact aerobic exercise (e.g., brisk walking, swimming, water aerobics, or bicycling), cognitive behavioral therapy, biofeedback, interdisciplinary rehabilitation

According to the National Center for Complementary and Integrative Medicine, one of the National Institute of Health provides on its website information on Chronic Pain: In Depth where they review the evidence for other pain management approaches:

General chronic pain – yoga, tai chi, music, mindfulness/meditation-based interventions, relaxation techniques, qi gong, hypnosis, and cannabinoids (especially for neuropathic pain or cancer) may help, while hypnosis’ effects vary from person-to-person;

Low back pain – acupuncture, massage (short-term relief), spinal manipulation, yoga, herbals (devil’s claw, white willow bark taken orally; cayenne, comfrey, Brazilian arnica, lavender essential oil applied topically) help;

Osteoarthritis – massage, for knees tai chi has helped; glucosamine, chondroitin and SAMe have mixed results

Rheumatoid arthritis – omega-3 fatty acids, gamma-linolenic acid (GLA) or the herb Thunder God Vine may help;

Headache – acupuncture has the most evidence of effectiveness; others that have limited or inconsistent results include biofeedback, massage, relaxation techniques, spinal manipulation, and tai chi; the American Headache Society says Butterbur is effective and Co-Q-10 may be effective in preventing migraines

Neck pain – acupuncture, frequent and long neck massage, and spinal manipulation may help

Fibromyalgia - tai chi, yoga, mindfulness, and biofeedback show promising results and Vitamin D may help those deficient in Vitamin D, but there is no convincing evidence that homeopathy helps

Irritable bowel syndrome – hypnotherapy and probiotics show promise, but there is only weak evidence that peppermint oil helps

Conclusion

Many people, including those on dialysis, suffer from pain. A growing number of people are addicted to and dying from misuse/abuse of opioid drugs. We can’t stop assessing for and treating pain but we need to do more to avoid setting people up for addiction. There are many other ways to help CKD and dialysis patients manage pain and even some over-the-counter pain medications are safe when taken as prescribed. However, nonpharmacological treatments described above may provide benefit without many of the risks of pharmacological treatments.

More needs to be done. Medicare Part D covers medications, including opioids. However, Medicare doesn’t cover such nonpharmacological treatments as acupuncture, massage, exercise, and yoga. It’s time that state and federal policymakers looked at these effective nonpharmacological treatments and change policies that would allow Medicare and other insurance plans cover them. Doing this could improve patients’ physical and mental health, help them maintain their jobs, and save lives and dollars. We must do more than launch another advertising campaign that tells people to “Just Say No.” We tried that before and it didn’t work.

1. Kimmel PL, Fwu CW, Abbott KC, Eggers AW, Kline PP, Eggers PW. Opioid Prescription, Morbidity, and Mortality in United States Dialysis Patients. J Am Soc Nephrol. 2017 Dec;28(12):3658-3670. https://www.ncbi.nlm.nih.gov/pubmed/28935654 (Accessed February 2018) ↩︎
2. Olivo RE, Hensley RL, Lewis JB, Saha S. Opioid Use in Hemodialysis Patients. Am J Kidney Dis. 2015 Dec;66(6):1103-5. http://linkinghub.elsevier.com/retrieve/pii/S0272638615010665 (Accessed February 2018) ↩︎
3. Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156(4):569-576. https://www.ncbi.nlm.nih.gov/pubmed/25785523 (Accessed February 2018) ↩︎
4. Muhuri PK, Gfroerer JC, Davies MC. Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Rev. August 2013. https://www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-use-2013.htm (Accessed February 2018) ↩︎
5. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The Changing Face of Heroin Use in the United States: A Retrospective Analysis of the Past 50 Years. JAMA Psychiatry. 2014;71(7):821-826. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1874575 (Accessed February 2018) ↩︎
6. Carlson RG, Nahhas RW, Martins SS, Daniulaityte R. Predictors of transition to heroin use among initially non-opioid dependent illicit pharmaceutical opioid users: A natural history study. Drug Alcohol Depend. 2016;160:127-134. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4767561/pdf/nihms752582.pdf (Accessed February 2018) ↩︎
7. Pham PC, Khaing K, Sievers TM, Pham PM, Miller JM, Pham SV, Pham PA, Pham PT. 2017 update on pain management in patients with chronic kidney disease. Clin Kidney J. 2017 Oct;10(5):688-697. https://academic.oup.com/ckj/article/10/5/688/4085328 (Accessed February 2018) ↩︎