Pain Management: Practicing the Art

Pain Management: Practicing the ArtM. Rachel McDowell, RN, MSN, ACNP-BCCancer Supportive Care Nurse PractitionerVanderbilt-Ingram Cancer CenterGoals of presentationProvide steps for developing treatment planApproach to titration (upward and downward)Patient educationConsent for treatmentUtilization of controlled substance databasesUrine drug screens use and interpretation

Benefits of pain controlEarlier mobilizationShortened hospitalizationReduced costImproved QOLDecrease in patient sufferingPain AssessmentLocationCharacterAchy SharpJabbingDeep or SuperficialBurning, tingling, numbnessDuration: when did this begin?Frequency: constant, intermittent, am, pm?

Intensity: Pain ScaleLorne B. Yudcovitch, OD, MS, FAAO; College of Optometry, Pacific University; 2043 College Way; Forest Grove, OR 97116 The Use of Anesthetics, Steroids, Non-Steroidals, and Central-Acting Analgesics in the Management of Ocular Pain Retrieved from http://www.google.com/imgres?imgurl=http://pacificu.edu/optometry/ce/courses/22746/images/clip_image002.jpg&imgrefurl=http://www.pacificu.edu/optometry/ce/courses/22746/ocularpainpg1.cfm&h=274&w=564&sz=37&tbnid=BdvVnqYJnZHq3M:&tbnh=65&tbnw=134&prev=/images%3Fq%3DPain%2BAssessment%2Bscales&hl=en&usg=__TdhB-pWbp_ouIYHvwQ4FJ1dHzgw=&ei=BBR2S6T_IMGXtgeCnqSlCg&sa=X&oi=image_result&resnum=7&ct=image&ved=0CCEQ9QEwBg

Treatment PlanGoal of Therapy:Decrease pain levelPain is mostly controlled, most of the timeIncrease level of functionMinimal side effects from regimenTime frame acute or chronic

Treatment Plan:After Assessment, and you have decided pt needs to be on opioids:Goal of therapy: decrease in pain level, increase in function, minimal side effects from regimen.What is their current regimen? On opioids or notDefinition of opioid nave/tolerant, weighing in clinical presentation of clinic. Differences in agesIs it working? Continue if working,If not then change meds or approach opioid appropriate or different modalityMedication regimenStarting opioid nave: low and slowTitration Long acting, short acting dosingConversionAdjuvant meds Non-pharm measuresNew patient information packet: Consent for treatment with controlled substance.Pain diaryPt education: Side effects: constipation, sedation, GI upset Information about prescribed opioid How to take opioid properly Adherence to dosing regimen Risk from breaking, chewing, crushing certain products Concomitant use of other CNS depressants, alcohol, or illegal drugsEstablishment of goals of treatmentRe-evaluation: Tolerance, missed doses, not following treatment planTN PMP utilization (Utilization of prescription monitoring programs to identify potential abuse) and UDS use; UDS interpretation.Understanding the role of drug testing Monitoring patients for misuse and abuse Concomitant use of other CNS depressants, alcohol, or illegal drugs Discontinuation: why and when and how

6Important FactorsEtiology of pain, prognosisStage of disease how aggressive do you want to be?What kind of pain or combo do they have?What have they been tried on in the past?How did it work for them, side effects, adverse events?Age, performance statusHistory or current issue with drug misuse/abuseWhat kind of insurance do they have or not?How capable is the patient in understanding plan? Treatment OptionsTreat underlying causeNon-pharmacological measuresPharmacological measures

No single modality done in isolation will be effective for most patients with chronic noncancer pain (CNCP) (Ashburn, Staats, Lancet 1999)

8Nonpharmacologic OptionsBiofeedbackRelaxation therapyPhysical and occupational therapyCognitive/behavioral strategies Guided imageryAcupunctureTranscutaneous electrical nerve stimulationPositioningRest, activityMassageHeat and cold

9Treatment for painIdentify the cause of the painPrimary treatment if indicated

RadiationSurgeryHyperbaric treatmentInterventions: Nerve Block, KyphoplastyMedications

Interventional TechniquesInterventional TherapiesTrigger pointsAcupunctureNerve blocksFacet denervationIntrathecal pumps

MedicationsSomatic/Nociceptive PainOpioidsNSAIDSNeuropathic PainAnticonvulsantsAntidepressants - SNRIsBony PainNSAIDSSteroids Pharmacotherapeutics and the Nervous SystemPNSSpinal CordBrainPeripheral SensitizationLocal AnalgesicsTopical AnalgesicsAnticonvulsantsAntidepressantsOpioidsDescending ModulationAnticonvulsantsTricyclics, SNRIOpioidsCentral Sensitization AnticonvulsantsOpioidsNMDS-Receptor AntagonistsTricyclic/SNRI AntidepressantsCNSGuidelines for opioidsWHO ladder combined with etiology-specific therapies for syndromes

pharmacologic and nonpharmacologic interventions long-acting + short-acting opioids adjuvant medications for neuropathic painNSAIDs and steroids can be helpful when there is an inflammatory component to pain

WHO Guidelines for Cancer Pain Step 3: Opioids for moderate-to-severe pain +/- non-opioid +/-adjuvant therapy

Step 2: Opioids for mild- to-moderate pain +/- non-opioid +/- adjuvant therapy

Step 1: Non-opioid +/- adjuvant therapy

STEP 1STEP 2STEP 3GOAL:Freedom From PainPain PersistsPain Persists(Adapted from Portenoy et al, 1997) 15Opioid SelectionNo perfect opioid

Pre-treat likely side effects

Must recognize individual responses to opioids may varyResponse and side effectsHydrocodone vx. Oxycodone

Sequential trials of different opioids alone or in combination may be necessary to optimize therapy

16Common AnalgesicsDemerolMorphine Sulfate IRPercocetDilaudidLortabOpana IROxycodoneTramadol

ButransMorphine Sulfate EROxyContinExalgoFentanyl patchesOpana ERMethadone

Pure Opioid AgonistsPure Opioid agonistNo ceiling effect for analgesiaSingle-entity for moderate to severe painMay be a role for combined opioids in certain subsets of patientsCurrent RegimenOpioid Nave: Never been on opioids beforeOnly been on opioids for a short time period or intermittently

Opioid Tolerant Taking pain medications on a regular basis Dependent on amount of pain medicationDifferences in older adultExperience higher peak and longer duration of drug actionAge-related changes in drug distribution and elimination make more sensitive to sedation and respiratory distressPain perceived differentlyPhysiologic PsychologicalCultural changesAltered presentationsAging does NOT increase Pain thresholdOlder adults (esp frail and old-old) at risk for too little or too much

General ApproachStart pt on short acting

Titrate up for pain relief

Once stable convert to long actingAdd amount of short acting for 24 hoursConvert to long acting

Continue short acting for breakthrough pain10-15 % of 24 hour total narcoticAdvantages of Long-Acting OpioidsMore predictable serum levelsMore predictable pain reliefAvoids mini-withdrawalsEasier to use; improved complianceGreater Patient satisfactionLess reinforcement of drug-taking behavior22Titration of OpioidsTitrate to adequate pain control. Appropriate dose adjustments are critical to adequate pain control. Adjustments are indicated under the following circumstancesIf the patient has been taking more than 4 rescue doses per day If the patient rates pain as greater than 4/10If the patient complains the pain is inadequately controlled

23Narcotic total= Fixed Dose + Rescue

Dose TitrationBased on two pieces of information:Calculation of the 24-hour narcotic total (this should be averaged over several days unless the patient has had a marked increase in pain in the prior 24-hour period of time)The stated average pain level (this should be averaged over several days unless the patient has had a marked increase in pain in the prior 24-hour period of time)24-hour narcotic total:= 24o fixed dose + 24o rescue doses

a patient is taking MSER 60 mg po bid with MSIR 15 mg po q1-2hrs prn for breakthrough. On history, he indicates that he is taking the sustained-release formulation as directed and 8 rescue doses in a 24-hour period of time. The 24-hour narcotic total is: (60 mg x 2 doses) + (15 mg x 8 doses) =

120 mg + 120 mg = 240 mg.Dose TitrationDose titration by a fixed percentageModerate pain (5/6): increase 24 hour narcotic total by 25%Severe pain (7+): increase narcotic total by 50%Rescue dose: 10-15% of total dose offered Q 1-2 hours PRNAccommodate increase if pt frail, sick, or elderly2727Case Study Pt reports 6/10 pain, therefore he requires a 25 % increase in medication.

2. Pts 24 hour narcotic total = ___ mg morphine

Step 1:Increase dose by 25%

24 NT mg + (24 NT x .25) =

New long acting dose

Step 2:Determine the new fixed dose

New fixed dose / 2 doses per day = X mg bid

Step 3Calculate the rescue dose10% of NT mg = X mg

New rescue order = MSIR X mg q2h prn

Old regimenMSER 60 mg bidMSIR 15 mg q 2 prn

New regimenMSER 150 mg bidMSIR 30 mg q 2 prnCase StudyPt reports 8/10 pain.

What do you do?

33Pt reports 8/10 pain, therefore he requires a 50 % increase in his medication.

Pts 24 hour narcotic total = 240 mg morphine3434Step 1:Increase dose by 50%

24 NT mg + (24 NT x .50) =

240 mg + ___ = ___ mg3535Step 2:Determine the new fixed dose

? mg / 2 doses per day = ? mg

3636Step 3: Calculate the rescue dose

10% of new 24 NT = ___ mg

New rescue order = MSIR ___ mg q2h prn

3737Old regimenMSER 60 mg bidMSIR 15 mg q 2 prn

New regimen MSER 180 mg bidMSIR 30 mg q 2 prnEquianalgesiaOpioidEquianalgesic DoseMorphine30 mg poDilaudid4-6 mg poHydrocodone30 mg poOxycodone30 mg poCodeine180 mg poOpanaUse conversion calculator3939Fentanyl Doses based on Daily Oral Morphine Dosage OrThe ratio is 2:1 2 mg oral morphine per DAY ~ 1 mcq fentanyl patch24-hour oral morphine dose (mg/day)Transdermal fentanyl dose (mcq/hour)30-902591-15050151-21075211-270100Every additional 60 mg per dayAn additional 25 mcq per hourFentanyl PatchIn pts currently on opioids, conversion factor for Morphine to Fentanyl is 2:1Fentanyl patch is 2X more potent than morphine POIf the 24 hr narcotic total= 180 mg morphineFentanyl dose= ___ mg (use nearest fentanyl patch size)4141IV to PO conversionNow your patient is ready to go home but need to be converted to PO medication.

Pt is on a morphine pain pump at a continuous infusion of 7.5 mg/hour and uses the bolus of 1 mg 6 times in the past 24 hours.

4242Case Study7.5 mg/hr X 24 = 180 mg morphine IV/24IV Narcotic total = 186 mg IVPO Narcotic total = 558

Opioid nave: IV is 6X more potent than PO (1:6)Currently on opioid: IV is 3X more potent than PO (1:3)

43434. Rescue dose is 10% = 60 mg morphine q 2 hours prn

5. Long acting dose = 280 mg morphine bid4444Old regimen:7.5 mg/hour CIV, with 1 mg q 10 minutes prn

New Regimen:MSER 280 mg bidMSIR 60 mg q 2 prn

Case StudyA patient with a pathologic fracture had satisfactory relief of pain with an IV dilaudid infusion of 3 mg per hour. You want to send her home on an equianalgesic dose of sustained release oral morphine (MS Contin or OraMorph SR given q12h, or Kadian q day).What is the correct dose?Calculations1. 3 mg/hr dilaudid = 72 mg IV dilaudid/24 hrs

2. Convert from dilaudid to morphine:

72 mg dilaudid IV X 5 = 360 mg IV morphine

3. Narcotic total = 360 mg IV morphine/24 hours

3. Narcotic total = 360 mg IV morphine/24 hours

4. Multiply IV by 3 to obtain PO dose360 x 3 = 1080 mg morphine in 24 hours PO

5. Breakthrough dose = 10 % of 24 hour narcotic totalMSIR 30 mg, 3 tabs po q 2 prnDilaudid 8 mg, 2 tab po q 2 prn6. The q12h dose = 500 mg morphine SR PO q12h

MS Contin 100 mg, 5 tabs po BIDMS Contin 100 mg, 3 tabs po TID

Old regimen: 3 mg/hr dilaudid IV

New regimen:MS Contin 100 mg, 5 tabs po BIDMS Contin 100 mg, 3 tabs po TID

Rescue dosingMSIR 30 mg, 3 tabs po q 2 prn orDilaudid 8 mg, 2 tabs po q 2 prn

NARCAN !!!!!Narcan is a narcotic antagonist that works by blocking opiate receptor sites, which reverses or prevents toxic effects of narcotic (opioid) analgesics.DANGER: if given too quickly or if too much is given severe life-threatening side effects can occur5151Cardiovascular: Hyper-/hypotension, tachycardia, ventricular arrhythmia, cardiac arrestCNS: Irritability, anxiety, narcotic withdrawal, restlessness, seizureGastrointestinal: Nausea, vomiting, diarrheaNeuromuscular & skeletal: TremulousnessRespiratory: Dyspnea, pulmonary edema5252Use of Narcan in Narcotic overdose:I.V. (preferred), I.M., intratracheal, SubQ: 0.4-2 mg every 2-3 minutes as needed; may need to repeat doses every 20-60 minutes. If no response is observed after 10 mg, question the diagnosis. Note: Use 0.1-0.2 mg increments in patients who are opioid dependent and in postoperative patients to avoid large cardiovascular changes.

5353

Adjuvant AnalgesicsTCAsDesipramineElavilSNRIsCymbaltaSavellaAnticonvulsantsNeurontin/GabapentinLyricaJoint/Bone pain: NSAIDS potentiate opioids MethadoneLidoderm patches

TCAs and SNRIsDesipramine: 25 mg at bedtime, increase weekly to max dose of 150 mg daily

Elavil: 25 mg at bedtime, max of 150 mg daily

Cymbalta: 20 mg at bedtime, max dose 120 mgAnticonvulsantsNeurontin/GabapentinMaximum daily dose: 3600 mgStart low and titrate up to max dose100 mg qidLyricaMaximum daily dose: 300 mgStart at 25 or 50 mg tid

Problematic Side Effect: sedation

Bony or Metastatic painNSAIDSIbuprofen 800 mg tidNaproxen 600 mg bidDiclofenac 100 mg bidSteroidsMedral Dose PakMethadonePossible duel mechanism of actionSomatic and neuropathic pain reliefRelatively inexpensiveAvailable as a liquidLong half-lifeAccumulates with repeat doses with limited analgesic effectComplex pharmacokineticsNo known active metabolitesConversion tables underestimate potencyCardiac ToxicityRecommend specialized training before prescribing as NP Lidoderm PatchLidocaine 5% in dermal patchOn 12 hours, off 12 hoursFDA approved for shinglesDrug interaction and side effects are unlikely most common is skin sensitivity Mechanical barrier decreases allodynia

Patient EducationHow the medication will impact their painHow to take medication.What the medication is treatingPotential side effects, like constipation.When to call doctors office.

6262Patient EducationHow to store/protect their medication.Lock box or safeHow to travel with their medication.What to do if/when medication is stolen or is lost/missing CALL POLICE, FILE REPORTConsent for treatmenthttps://tnm.rxportal.sxc.com/rxclaim/TNM/PtMedMngtAgrmt.pdf

http://www.painmed.org/Workarea/DownloadAsset.aspx?id=3211Consent for Treatment SourcesPatient educationPatients responsibility

Clinicians responsibility

Urine Drug Screen

Use of drugs other than prescribed, and consequencesRe-evaluationChanges in pain (level, location, frequency, character)Level of functionAverage pain levelWorst pain levelSide effectsBenefitsAdherence to medication regimen (missed or extra doses)

Titrating off OpioidsIndicated if pt unable to take medications safelyIf pts level of function is decliningIf medication is not effectively decreasing or controlling their level of pain

Dose reduce in increments of 25% at a time No faster than 48-72 hours.State Controlled Substance Database ReportsFrequent evaluations, with good documentationLost or stolen drugs: Must report to police departmentCheck for placement of fentanyl patchesUrine Drug Screens random, or when there is aberrant behavior

Monitoring for abuseInterpretation of UDS ResultsImportant to understand what the results meanIf question, call lab to check resultsDrugMajor CmpdsMinor CmpdsCodeineCodeineMorphineMorphineMorphineCodeineDihydrocodeineDihydrocodeineHydrocodoneHydromorphoneHydrocodoneHydrocodoneHydromorphoneDihydrocodeineHydromorphoneHydromorphoneOxycodoneOxycodoneOxymorphoneOxymorphoneOxymorphoneFentanylFentanyl**may not be picked in opiate screenHeroin/diamorphineMorphine6MAM by specific assayMarijuanaCarboxy-THC**many false +screenCocaineBenzoylecgonineResultsCANNABINOIDS (SCREEN) Positive Immunoassay(cut-off 20 ng/mL); confirmation to follow THC CONFIRMATION Positive for Carboxy-THCCannabis metabolite cut-off 15 ng/mL COCAINE METAB (SCREEN) Positive Immunoassay(cut-off 300 ng/mL); confirmation to follow BEG CONFIRMATION Positive for BenzoylecgonineCocaine metabolite cut-off 150 ng/mL

METHADONE (SCREEN) Negative Immunoassay(cut-off 300 ng/mL)OPIATE (SCREEN) Positive Immunoassay(cut-off 300 ng/mL); confirmation to follow GC/MS OPIATE CONFIRM Positive DIHYDROCODEINE Negative CODEINE Negative MORPHINE Negative HYDROCODONE Negative HYDROMORPHONE Negative OXYCODONE Positive OXYMORPHONE Positive OXYCODONE (SCREEN) Positive Immunoassay(cut-off 300 ng/mL); confirmation to follow

TRICYCLICS (SCREEN) Negative Immunoassay(cut-off 300 ng/mL) ACETAMINOPHEN METABS Negative SALICYLATES Negative PHENOTHIAZINES Negative PROPOXYPHENE Negative Immunoassay(cut-off 300 ng/mL) METHANOL Negative ETHANOL Negative ACETONE Negative ISO-PROPANOL Negative

How to protect yourselfDocumentationUDSConsent for treatmentControlled Substance Database ReportFrequent re-evaluationCommunication (with your team and other providers)Patient EducationConsistency

Addressing AberrantDrug-Related BehaviorGeneral Management Principlesknow laws and regulationsstructure therapy to match perceived riskProactive Strategiescommunicate goals of therapy provide written guidelines (treatment contract)assess oftenReactive Strategiesrequire frequent visits and small quantities of druguse of urine toxicologieslong-acting drugs with no rescue dosesrefer to addiction-medicine community (sponsor, program, addiction-medicine specialist, psychotherapist)(Mironer et al, 2000; Portenoy et al, 1997; Passik et al, 2000)7676 Promoting Pain Relief and Preventing Abuse of Pain Medications: A Critical Balancing ActA joint statement from 21 health care organizations and the Drug Enforcement Agency, October 23, 2001Undertreatment of pain is a serious problem in the US, including pain among patients with chronic conditions and those who are critically ill or near deathEffective pain management is an integral and important aspect of quality medical care, and pain should be treated aggressivelyFor many patients, opioid analgesics, when used as recommended by established pain management guidelines, are the most effective way to treat their pain, and often the only treatment option that provides significant relief

http://www.usdoj.gov/dea/presrel/pr102301.html7777Considerations for the Nurse PractitionerRegulations State law, Boards of Nursing and Medicine

Safe Practice

Requirements by the State Board of Nursing and Board of Medicine

PrescriptionsEvaluation of Quantity and ChronicityDocumented appropriate diagnosis Treatment of recognized medical indicationDocumented persistence of recognized medical indicationProperly documented follow-up evaluation with appropriate continuing care Writing Prescriptions Prescriptive authority varies state by stateNPs denied any prescriptive authorityLimited prescriptive authority i.e. NP can only write 72 hours worth of pain medicationFull prescriptive authority granted to NPs. For specifics visit: http://www.medscape.com/viewarticle/439917http://www.bartonassociates.com/nurse-practitioners/nurse-practitioner-scope-of-practice-laws/

Safe Prescription WritingPts Name, DOB, Current date

Medication name Dose (mg, mcg)

SIG: instructions about how medication is to be taken, how often, how many tablets, what route, frequency.

DISP: amount of tablets or liquid to be dispensed. Should write it both as number and spelled out.82Vanderbilt University Medical CenterBarbara Murphy, M.D.M. Rachel McDowell, APRN-BC1956 The Vanderbilt ClinicNashville, TN 37232(615) 322-3677

Name: John DoeDOB: 01-01-01Date: 10-10-05

RX:Morphine Sulfate Immediate Release 30 mgSIG: One tab PO Q 2 hours prn painDisp: #56 (fifty six) (2 week supply)Max of 4 tabs in a 24 hour period0 (ZERO) refillsSignature: Mary Rachel McDowell, APRN-BCDEA #: MMM111111111Helpful WebsitesAmerican Pain Societyhttp://www.ampainsoc.org/Partners against Painhttp://www.partnersagainstpain.com/index.aspx?sid=27International Association for the Study of Painhttp://www.iasp-pain.org//AM/Template.cfm?Section=HomeThe Joint Commissionhttp://www.jointcommission.org/American Academy of Pain http://www.aapainmanage.org/ManagementThe following resources can provide important information on prescription pain medications, such as DEA schedule, appropriate prescribing and use, and information on how to prevent drug abuse and diversion:The American Pain Society (APS) http://www.ampainsoc.org American Academy of Pain Medicine (AAPM) http://www.painmed.org American Society of Addiction Medicine (ASAM) http://www.asam.org Pain and Policy Studies Group for the University of Wisconsin Comprehensive Cancer Center http://www.medsch.wisc.edu/painpolicy United States Drug Enforcement Administration http://www.dea.gov

Taken from Partners Against Pain Web siteFood and Drug Administration http://www.fda.gov The Substance Abuse and Mental Health Services Administration (SAMHSA) http://www.samhsa.gov The National Association of Drug Diversion Investigators (NADDI) http://www.NADDI.org Local law enforcement Local addiction treatment specialists/centersTaken from Partners Against Pain Web site

ReferencesKatz, Warren, Rothenberg, Russell, 2005, Section 3: The Nature of Pain: Pathophysiology, JCR: Journal of Clinical Rheumatology, volume 11 (2) Supplement, April 2005, pp S11-S15, http://gateway.ut.ovid.com/gw1/ovidweb.cgi, (Oct. 3, 2005)Cancer: principles and practice of oncology [edited by] Vincent T. DeVita, Jr., SamuelHellman, Steven A. Rosenberg; 319 contributors.6thNicholson, B.D., Neuropathic Pain: New Strategies to Improve Clinical Outcome, January 31, 2005 http://www.medscape.com/viewprogram/3765_pnt, (Sept. 30, 2005)

Passik SD, Portenoy RK. Substance abuse issues in palliative care. In Berger A, Portenoy RK, Weissman D, eds. Principles and Practice of Supportive Oncology. 2nd ed. Philadelphia, PA: Lippincott-Raven Publishers; 1998.Passik SD, Portenoy RK: Substance abuse issues in psycho-oncology. In Holland J, et al. Handbook of Psycho-oncology. 2nd ed. Oxford: Oxford University Press; 1998:576-586.Loeser et al, 2001; Portenoy et al, 1996)Besson, JM. The neurobiology of pain. Lancet. 1999;353:1610-1615 .

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