Transcript Pain Management

Pain Management
Laura Bergs FNP
Definition of Chronic Pain
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Anyone with pain greater than 3
months
Pain
An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described
in terms of such damage
Allodynia*
Pain due to a stimulus that does not
normally provoke pain.
Regulations for monitoring
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Will do urine drug screen
Will not give narcotics unless off
all illegal drugs
Must follow pain management
patient agreements and be
consistent
Urine Drug Screen
Metabolic Pathways
Heroin
6-MAM
Morphine
Metabolic Pathways
Morphine
Hydromorphone
Hydromorphone
Metabolic Pathway
Codeine
Hydrocodone
Hydromorphone
Urine drug testing
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Perform at initial visit, then random
Drug screen results are black and
white
False positives can occur in some
instances
Talk with toxicology if not sure of
results
All patients usually deny illegal drug
use
Don’t have to treat patient, you did not
decide to do the illegal drug, they did
Tools assist to determine if
narcotics needed
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COAT (chronic opioid analgesic
therapy)
pathway is a tool to be used by every
provider prior to long term opioid
therapy
Dire Score is used to determine if they
are a candidate for opioid therapy
Risk stratification-medium is the
default risk
Inclusion Criteria COAT
Group A not currently on opioid and
considering opioid trial
Group B on opioid < 3 months,
considering
continuing opioid
Group C patient already on COAT
1st step in pathway
DIRE Score
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Scoring based on
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DIRRRRE
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Add D+I+4R+E=range
(Diagnosis, intractability, Risk, (psychological,
chemical health, reliability, Social Support) Efficacy Score)
Score 7-13 not suitable for COAT
Score 14-21 may be suitable
The Journal of Pain, Vol 7, No 9 September, 2006 PP671-681
Step 2:
Risk Stratification
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Medium default risk
Move to low risk if
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Age > 65 years
Morphine equivalents <=10mg/d
Move to high risk if
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Age<=35
Morphine equivalents >80mg/day
Past substance use disorder
Aberrant drug related behavior
Mental Illness
Provider judgment
rd
3
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step monitoring
Office visits based on risk, must see
every three months
Must have opioid agreement and
informed consent
Check state monitoring program before
initiating COAT
Lab 7767 urine drug screen initial then
randomized
Pill counts, I do with every visit, you
may use your discretion
Risk stratification
May keep in medium rather than move
based on provider judgment
Must document rational if meets high
risk yet keep on med
Tapering of Opioid
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Decrease 10-20 percent each
week
Round off the dose to the next
available formulation
Symptoms can be managed with
clonidine
Consider adjuncts
Opioid agreement
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Random drug screens
If found to have illegal's,
Can treat with adjuncts instead of
narcotics
Chronic use of narcotic
medication discouraged
Wean off narcotics if not
dependent/addicted
Drugs of Abuse reference Guide
Amphetamine
speed
Dexedrine
Benzadrine
Drugs of Abuse Reference Guide
MDMA
Ecstasy, XTC, ADAM
Lover’s speed
methylenedioxymethamphetamine
Drugs of Abuse Reference Guide
Methamphetamine
Speed, ice, crystal, crank
Desoxym
Methadrine
Deciding to take off Opioid
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At discretion of provider
If failed drug screen or
documented drug diversion
DIRE score <14
may continue with no opioids
Weaning schedule
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10 percent per week unless weaning
off Methadone
Manage withdrawal symptoms
May need to be inpatient
Most can come off without any
difficulty
If you discharge related to breach of
contract do have legal obligation to
follow for 30 days (this does not mean
you have to prescribe narcotic)
Section Y
DIRE Score <14
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If harm greater than benefit educate and
taper
Provider judgment that COAT benefits
greater than harm-review at each visit
Review with each visit:
4A’s: analgesia
activity
adverse effects
aberrant behavior
Provider benefit greater than
harm
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Documentation for effectiveness
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4As plus 2As
Analgesia
 Activity
 Adverse effects
 Aberrant behavior
 Assessment
 Action
.bpismartform brief pain questionnaire
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Illegal drug use
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Talk face to face with patient
Determine if they have an addiction
You treat without narcotics
Usually these patients self discharge
High risk if you continue with narcotic
and there is documentation of patient
continuing with illegal drug use
Taper off opioid
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Decrease 10-20 percent per week
Symptoms of abstinence
syndrome, clonidine 0.1 mg every
six hours or clonidine transdermal
patch
May safely wean Methadone
requires slower wean schedule
3% TAPER
Weekly visit with weaning
Weaning protocols
Those that do not follow the rules
Can use clonidine for withdrawal
Refer to inpatient if able to find bed if on
Methadone
All other narcotics follow DIRE weaning
protocol
Those with no drug in urine are not taking the
drug and do not need to be weaned
Weaning schedule
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If patient agrees to wean off
Advantage-can try different drug
once off all narcotics for two weeks
 Can tell if narcotic really did help
with the pain, after several months of
narcotic use they are not beneficial
 Continue to monitor urine drug
screens even after weaned off
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Patient and provider goals
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Need to set realistic goals with the
patient
Most want all of their pain gone
completely this is unrealistic if they
have had pain for several years, some
have just been discharged from
another pain clinic
Review agreements with the patient
often to prevent misunderstanding
Functional assessment
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Do not always go by pain level as
stated
Look at how dressed
How they are able to perform daily
functions
Are they sedated
Are they able to answer direct
questions
When in doubt refer to me
Adjunctive treatment
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Expect them to participate in therapy
Expect them to participate in daily
exercise
Expect them to participate in
psychotherapy
Hope to start program for cognitive
behavioral therapy for chronic pain
State surveillance program for
medications check this
Stable chronic opioid patient
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No aberrant episodes and
warrants continued therapy
Once stable prefer that PCP take
over prescribing
Monitor monthly of every three
months
Happy to see them back if they
become unstable or wish to
discontinue opioid therapy
Any Questions
References
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http://www.iasppain.org/Content/NavigationMenu/GeneralRes
ourceLinks/PainDefinitions/default.htm