Pain Management Laura Bergs FNP. Definition of Chronic Pain Anyone with pain greater than 3 months Anyone with pain greater than 3 months Pain An unpleasant.

Pain Pain ManagementManagement

Laura Bergs FNPLaura Bergs FNP

Definition of Chronic Definition of Chronic PainPain

Anyone with pain greater than 3 monthsAnyone with pain greater than 3 months

PainPainAn unpleasant sensory and emotional An unpleasant sensory and emotional experience associated with actual or experience associated with actual or potential tissue damage, or described in potential tissue damage, or described in terms of such damage terms of such damage

Allodynia*Allodynia*Pain due to a stimulus that does not Pain due to a stimulus that does not normally provoke pain.normally provoke pain.

Regulations for Regulations for monitoringmonitoring

Will do urine drug screenWill do urine drug screen Will not give narcotics unless off Will not give narcotics unless off

all illegal drugsall illegal drugs Must follow pain management Must follow pain management

patient agreements and be patient agreements and be consistentconsistent

Urine Drug ScreenUrine Drug Screen

Metabolic PathwaysMetabolic Pathways

Morphine

Heroin

6-MAM

Metabolic PathwaysMetabolic Pathways

Morphine

Hydromorphone Hydromorphone

Metabolic PathwayMetabolic Pathway

Codeine

Hydrocodone Hydromorphone

Urine drug testingUrine drug testing Perform at initial visit, then random Perform at initial visit, then random Drug screen results are black and Drug screen results are black and

whitewhite False positives can occur in some False positives can occur in some

instancesinstances Talk with toxicology if not sure of Talk with toxicology if not sure of

resultsresults All patients usually deny illegal drug All patients usually deny illegal drug

useuse Don’t have to treat patient, you did Don’t have to treat patient, you did

not decide to do the illegal drug, they not decide to do the illegal drug, they diddid

Tools assist to determine if Tools assist to determine if narcotics needednarcotics needed

COAT (chronic opioid analgesic therapy)COAT (chronic opioid analgesic therapy)

pathway is a tool to be used by every pathway is a tool to be used by every

provider prior to long term opioid provider prior to long term opioid therapytherapy

Dire Score is used to determine if they Dire Score is used to determine if they are a candidate for opioid therapy are a candidate for opioid therapy

Risk stratification-medium is the default Risk stratification-medium is the default riskrisk

Inclusion Criteria COATInclusion Criteria COAT

Group A not currently on opioid Group A not currently on opioid and considering opioid trialand considering opioid trial

Group B on opioid < 3 months, Group B on opioid < 3 months, consideringconsidering

continuing opioidcontinuing opioid

Group C patient already on COATGroup C patient already on COAT

1st step in pathway1st step in pathwayDIRE ScoreDIRE Score

Scoring based onScoring based on DIRRRRE DIRRRRE (Diagnosis, intractability, Risk, (psychological, (Diagnosis, intractability, Risk, (psychological,

chemical health, reliability, Social Support) Efficacy Score)chemical health, reliability, Social Support) Efficacy Score)

Add D+I+4R+E=rangeAdd D+I+4R+E=range

Score 7-13 not suitable for COATScore 7-13 not suitable for COAT

Score 14-21 may be suitableScore 14-21 may be suitableThe Journal of Pain, Vol 7, No 9 September, 2006 PP671-681The Journal of Pain, Vol 7, No 9 September, 2006 PP671-681

Step 2:Step 2: Risk Stratification Risk Stratification

Medium default riskMedium default risk Move to low risk ifMove to low risk if

Age > 65 yearsAge > 65 years Morphine equivalents <=10mg/dMorphine equivalents <=10mg/d

Move to high risk ifMove to high risk if Age<=35Age<=35 Morphine equivalents >80mg/dayMorphine equivalents >80mg/day Past substance use disorderPast substance use disorder Aberrant drug related behaviorAberrant drug related behavior Mental IllnessMental Illness Provider judgmentProvider judgment

33rdrd step monitoring step monitoring Office visits based on risk, must see Office visits based on risk, must see

every three monthsevery three months Must have opioid agreement and Must have opioid agreement and

informed consentinformed consent Check state monitoring program Check state monitoring program

before initiating COATbefore initiating COAT Lab 7767 urine drug screen initial Lab 7767 urine drug screen initial

then randomizedthen randomized Pill counts, I do with every visit, you Pill counts, I do with every visit, you

may use your discretionmay use your discretion

Risk stratificationRisk stratification

May keep in medium rather than May keep in medium rather than move based on provider judgmentmove based on provider judgment

Must document rational if meets high Must document rational if meets high risk yet keep on medrisk yet keep on med

Tapering of OpioidTapering of Opioid

Decrease 10-20 percent each Decrease 10-20 percent each weekweek

Round off the dose to the next Round off the dose to the next available formulationavailable formulation

Symptoms can be managed with Symptoms can be managed with clonidineclonidine

Consider adjunctsConsider adjuncts

Opioid agreementOpioid agreement

Random drug screensRandom drug screens If found to have illegal's, If found to have illegal's, Can treat with adjuncts instead Can treat with adjuncts instead

of narcoticsof narcotics Chronic use of narcotic Chronic use of narcotic

medication discouragedmedication discouraged Wean off narcotics if not Wean off narcotics if not

dependent/addicteddependent/addicted

Drugs of Abuse reference Drugs of Abuse reference GuideGuide

Amphetamine

speed Dexedrine Benzadrine

Drugs of Abuse Drugs of Abuse Reference GuideReference Guide

MDMA

Ecstasy, XTC, ADAM Lover’s speed methylenedioxymethamphetamine

Drugs of Abuse Drugs of Abuse Reference GuideReference Guide

Methamphetamine

Speed, ice, crystal, crank Desoxym Methadrine

Deciding to take off OpioidDeciding to take off Opioid

At discretion of provider At discretion of provider If failed drug screen or If failed drug screen or

documented drug diversiondocumented drug diversion DIRE score <14DIRE score <14 may continue with no opioidsmay continue with no opioids

Weaning scheduleWeaning schedule 10 percent per week unless weaning 10 percent per week unless weaning

off Methadoneoff Methadone Manage withdrawal symptomsManage withdrawal symptoms May need to be inpatientMay need to be inpatient Most can come off without any Most can come off without any

difficulty difficulty If you discharge related to breach of If you discharge related to breach of

contract do have legal obligation to contract do have legal obligation to follow for 30 days (this does not follow for 30 days (this does not mean you have to prescribe narcotic)mean you have to prescribe narcotic)

Section YSection YDIRE Score <14DIRE Score <14

If harm greater than benefit educate If harm greater than benefit educate and taperand taper

Provider judgment that COAT benefits Provider judgment that COAT benefits greater than harm-review at each visitgreater than harm-review at each visit

Review with each visit: Review with each visit:

4A’s: analgesia4A’s: analgesia

activityactivity

adverse effectsadverse effects

aberrant behavioraberrant behavior

Provider benefit greater Provider benefit greater than harmthan harm

Documentation for effectivenessDocumentation for effectiveness 4As plus 2As4As plus 2As

AnalgesiaAnalgesia ActivityActivity Adverse effectsAdverse effects Aberrant behaviorAberrant behavior AssessmentAssessment ActionAction

.bpismartform brief pain questionnaire.bpismartform brief pain questionnaire

Illegal drug useIllegal drug use

Talk face to face with patientTalk face to face with patient Determine if they have an addictionDetermine if they have an addiction You treat without narcoticsYou treat without narcotics Usually these patients self dischargeUsually these patients self discharge High risk if you continue with narcotic High risk if you continue with narcotic

and there is documentation of patient and there is documentation of patient continuing with illegal drug usecontinuing with illegal drug use

Taper off opioidTaper off opioid

Decrease 10-20 percent per weekDecrease 10-20 percent per week Symptoms of abstinence Symptoms of abstinence

syndrome, clonidine 0.1 mg every syndrome, clonidine 0.1 mg every six hours or clonidine transdermal six hours or clonidine transdermal patchpatch

May safely wean Methadone May safely wean Methadone requires slower wean schedule 3% requires slower wean schedule 3% TAPERTAPER

Weekly visit with weaningWeekly visit with weaning

Weaning protocolsWeaning protocols

Those that do not follow the rulesThose that do not follow the rulesCan use clonidine for withdrawalCan use clonidine for withdrawalRefer to inpatient if able to find bed if on Refer to inpatient if able to find bed if on

MethadoneMethadoneAll other narcotics follow DIRE weaning All other narcotics follow DIRE weaning

protocolprotocolThose with no drug in urine are not taking the Those with no drug in urine are not taking the

drug and do not need to be weaneddrug and do not need to be weaned

Weaning scheduleWeaning schedule

If patient agrees to wean offIf patient agrees to wean off

Advantage-can try different drug Advantage-can try different drug once off all narcotics for two weeksonce off all narcotics for two weeks

Can tell if narcotic really did help Can tell if narcotic really did help with the pain, after several months with the pain, after several months of narcotic use they are not of narcotic use they are not beneficialbeneficial

Continue to monitor urine drug Continue to monitor urine drug screens even after weaned offscreens even after weaned off

Patient and provider Patient and provider goalsgoals

Need to set realistic goals with the Need to set realistic goals with the patientpatient

Most want all of their pain gone Most want all of their pain gone completely this is unrealistic if they completely this is unrealistic if they have had pain for several years, some have had pain for several years, some have just been discharged from have just been discharged from another pain clinicanother pain clinic

Review agreements with the patient Review agreements with the patient often to prevent misunderstandingoften to prevent misunderstanding

Functional assessmentFunctional assessment

Do not always go by pain level as Do not always go by pain level as statedstated

Look at how dressedLook at how dressed How they are able to perform How they are able to perform

daily functionsdaily functions Are they sedatedAre they sedated Are they able to answer direct Are they able to answer direct

questionsquestions When in doubt refer to meWhen in doubt refer to me

Adjunctive treatmentAdjunctive treatment

Expect them to participate in therapyExpect them to participate in therapy Expect them to participate in daily Expect them to participate in daily

exerciseexercise Expect them to participate in Expect them to participate in

psychotherapypsychotherapy Hope to start program for cognitive Hope to start program for cognitive

behavioral therapy for chronic painbehavioral therapy for chronic pain State surveillance program for State surveillance program for

medications check thismedications check this

Stable chronic opioid Stable chronic opioid patientpatient

No aberrant episodes and No aberrant episodes and warrants continued therapywarrants continued therapy

Once stable prefer that PCP take Once stable prefer that PCP take over prescribingover prescribing

Monitor monthly of every three Monitor monthly of every three monthsmonths

Happy to see them back if they Happy to see them back if they become unstable or wish to become unstable or wish to discontinue opioid therapydiscontinue opioid therapy

Any QuestionsAny Questions

ReferencesReferences

http://www.iasp-pain.org/Content/http://www.iasp-pain.org/Content/NavigationMenu/NavigationMenu/GeneralResourceLinks/GeneralResourceLinks/PainDefinitions/default.htmPainDefinitions/default.htm