Chronic Pain in Primary Care: Designing and Implementing a Management Plan Module 3 Paula Worley, MSN, RN, FNP-BC Diane Tyler, PhD, RN, FNP-BC, FNP-C, FAAN Mary Lou Adams, PhD, RN, FNP-BC, FAAN Frances Sonstein, MSN, RN, FNP, CNS Stephanie Key, MSN, RN, CPNP-PC The University of Texas at Austin School of Nursing Consultants: Yvonne D’Arcy, MSN, RN and JoEllen Wynne, MSN, RN, FNP-BC, FAANP
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Chronic Pain in Primary Care: Designing and Implementing a Management Plan Module 3 Paula Worley, MSN, RN, FNP-BC Diane Tyler, PhD, RN, FNP-BC, FNP-C,
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Chronic Pain in Primary Care: Designing and Implementing a Management Plan
Module 3Paula Worley, MSN, RN, FNP-BC
Diane Tyler, PhD, RN, FNP-BC, FNP-C, FAAN
Mary Lou Adams, PhD, RN, FNP-BC, FAAN
Frances Sonstein, MSN, RN, FNP, CNS
Stephanie Key, MSN, RN, CPNP-PC
The University of Texas at Austin School of Nursing
2. Goals for functional improvement3. Pain management agreement4. Informed consent for treatment5. Assessments at regular intervals6. Pharmaceutical Modalities 7. Non-pharmaceutical Modalities8. Documentation
Eight Point Treatment Plan: 1. Comprehensive Assessment
Complete physical exam Diagnostic testing Medication and supplemental
historyBenefit to harm analysis
Eight Point Treatment Plan:2. Goals for Functional Improvement
Measurable and realistic
Agreed upon by prescriber and patient
Based on improvement in function
Improvement in tolerance to exercise
Eight Point Treatment Plan:3. Pain Management Agreement
Purpose ◦Reduce the risk of prescribing
◦Assist in compliance with legal requirements
◦Prevent misunderstandings about certain medications
◦Document consequences of breaking agreement
Eight Point Treatment Plan:3. Pain Management Agreement (Continued)
Patient agrees:◦ To communicate fully about pain experience◦ Not to use recreational drugs◦ Not to share, sell or trade medications◦ To use one pharmacy◦ Not to request narcotics outside of business
hours◦ That “lost prescriptions” will not be replaced◦ To have random drug screenings◦ Not to go to the ER without prescriber’s
Eight Point Treatment Plan:6. Pharmaceuticals – Adjunctants
Antidepressants
Anxiolytics
Muscle relaxers Steroids
Eight Point Treatment Plan:6. Pharmaceuticals – Adjuctants
Anti-depressantsDepression is a component of
chronic pain for more than 80% of patients
Suicide rate for patients with chronic pain is higher than other patients in the same age group without chronic pain (D’Arcy, April 2009)
Eight Point Treatment Plan:6. Pharmaceuticals – Adjunctants
Anxiolytics
Antidepressants are effective anxiolytics, and some classes provide pain relief
Benzodiazepines:◦Helpful in short term management as
anti-depressants take affect◦Potentially can disrupt sleep
architecture and worsen depression
Eight Point Treatment Plan: 6. Pharmaceuticals – Adjunctants
Muscle RelaxersLower the level of pain experiencedIncrease flexibility and range of
motionReducing spasms and involuntary
muscle contractionsExamples: carisoprodol,
cyclobenzaprineSide effect: sedation
Eight Point Treatment Plan: 6. Pharmaceuticals – Adjunctants
Corticosteroids
Anti-inflammatory for chronic swelling of joints and tendons
Often reserved for flare-ups or episodes of acute pain associated with long term conditions
Side effects: ◦short term – emotional lability◦long term – osteoporosis, adrenal
suppression.
Eight Point Treatment Plan: 6. Pharmaceuticals – Weak Opioids
Opioid agonist – binding with the mu (CNS opioid) receptors and are weak reuptake inhibitors of norepinephrine and serotonin.◦Caution for serotonin syndrome◦May be habit forming◦Cardiac and respiratory depression
Eight Point Treatment Plan: 6. Pharmaceuticals – Weak Opioids
Tramadol
Dosage 50 – 100 mg/4 – 6 hours
Max 400 mg/day, 300 mg/day in elderly
CKD reduce dosage by half and frequency increased to every 12 hours
Hydrocodone 2.5 – 10 mg (max 1 gm/4 hours) + acetaminophen 300 mg or 7.5 mg with 200 mg ibuprofen
Adverse effects:◦ Nausea/vomiting (give with food) ◦ Constipation◦ Cardiac and respiratory depression & sedation
Eight Point Treatment Plan:6. Pharmaceuticals – Strong Opioids
Morphine 5 – 10 mg per hourFentanyl 25 mcg per hourDilaudid 1 – 4 mg per hourOxycodone - 10 – 80 mg tabletsMerperdine – Prolonged use may increase the risk
of toxicity (e.g., seizures) from the accumulation of metabolite, normeperidine
Most stronger opioids – titrated dose to desired effect
Great caution needs to be exercised to avoid life threatening respiratory depression, sedation, weakness, seizures and confusion
Implications of a Comprehensive Treatment PlanEffectively managing chronic pain using a comprehensive plan can safely and powerfully impact patients’ lives…
Allowing patients to participate more fully in the activities that give them enjoyment a sense of worth, purpose & fulfillment.
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