Transcript Pain Management: Practicing the Art

M. Rachel McDowell, RN, MSN, ACNP-BC
Cancer Supportive Care Nurse Practitioner
Vanderbilt-Ingram Cancer Center
Goals of presentation
 Provide steps for developing treatment plan
 Approach to titration (upward and downward)
 Patient education
 Consent for treatment
 Utilization of controlled substance databases
 Urine drug screens use and interpretation
Benefits of pain control
 Earlier mobilization
 Shortened hospitalization
 Reduced cost
 Improved QOL
 Decrease in patient suffering
Pain Assessment
 Location
 Character
 Achy
 Sharp
 Jabbing
 Deep or Superficial
 Burning, tingling, numbness
 Duration: when did this begin?
 Frequency: constant, intermittent, am, pm?
Intensity: Pain Scale

Lorne 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_imag
e002.jpg&imgrefurl=http://www.pacificu.edu/optometry/ce/courses/22746/ocularpainpg1.cfm&h=274&w=5
64&sz=37&tbnid=BdvVnqYJnZHq3M:&tbnh=65&tbnw=134&prev=/images%3Fq%3DPain%2BAssessment%2Bscal
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ved=0CCEQ9QEwBg
Treatment Plan
 Goal of Therapy:
 Decrease pain level

Pain is mostly controlled, most of the time
 Increase level of function
 Minimal side effects from regimen
 Time frame – acute or chronic
Important Factors
 Etiology of pain, prognosis
 Stage 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 status
 History or current issue with drug misuse/abuse
 What kind of insurance do they have or not?
 How capable is the patient in understanding plan?
Treatment Options
 Treat underlying cause
 Non-pharmacological measures
 Pharmacological measures
 No single modality done in
isolation will be effective for most
patients with chronic noncancer
pain (CNCP) (Ashburn, Staats, Lancet 1999)
Nonpharmacologic Options
 Biofeedback
 Relaxation therapy
 Physical and occupational therapy
 Cognitive/behavioral strategies
 Guided imagery
 Acupuncture
 Transcutaneous electrical nerve stimulation
 Positioning
 Rest, activity
 Massage
 Heat and cold
Treatment for pain
 Identify the cause of the pain
 Primary treatment if indicated
 Radiation
 Surgery
 Hyperbaric treatment
 Interventions: Nerve Block, Kyphoplasty
 Medications
Interventional Techniques
 Interventional Therapies
 Trigger points
 Acupuncture
 Nerve blocks
 Facet denervation
 Intrathecal pumps
Medications
 Somatic/Nociceptive Pain
 Opioids
 NSAIDS
 Neuropathic Pain
 Anticonvulsants
 Antidepressants - SNRIs
 Bony Pain
 NSAIDS
 Steroids
Pharmacotherapeutics and the
Nervous System
Brain
Guidelines for opioids
 WHO ladder combined with etiology-specific
therapies for syndromes
 pharmacologic and nonpharmacologic
interventions
 long-acting + short-acting opioids
 adjuvant medications for neuropathic pain
 NSAIDs and steroids can be helpful when there is
an inflammatory component to pain
WHO Guidelines for Cancer Pain
GOAL:
Freedom From Pain
 Step 3: Opioids for
STEP 3
moderate-to-severe pain
+/- non-opioid +/-adjuvant
therapy
Pain Persists  Step 2: Opioids for mild- tomoderate pain +/- nonopioid +/- adjuvant therapy
STEP 2
 Step 1: Non-opioid +/adjuvant therapy
Pain Persists
STEP 1
(Adapted from Portenoy et al, 1997)
Opioid Selection
 No perfect opioid
 Pre-treat likely side effects
 Must recognize individual responses to
opioids may vary
 Response and side effects
 Hydrocodone vx. Oxycodone
 Sequential trials of different opioids –
alone or in combination – may be
necessary to optimize therapy
Common Analgesics
 Demerol
 Morphine Sulfate IR
 Percocet
 Dilaudid
 Lortab
 Opana IR
 Oxycodone
 Tramadol
 Butrans
 Morphine Sulfate ER
 OxyContin
 Exalgo
 Fentanyl patches
 Opana ER
 Methadone
Pure Opioid Agonists
 Pure Opioid agonist
 No ceiling effect for analgesia
 Single-entity for moderate to severe pain
 May be a role for combined opioids in certain
subsets of patients
Current Regimen
 Opioid Naïve:
 Never been on opioids before
 Only been on opioids for a short time period or
intermittently
 Opioid Tolerant
 Taking pain medications on a regular basis
 Dependent on amount of pain medication
Differences in older adult
 Experience higher peak and longer duration of drug
action
 Age-related changes in drug distribution and elimination
make more sensitive to sedation and respiratory distress
 Pain perceived differently
 Physiologic
 Psychological
 Cultural changes
 Altered presentations
 Aging does NOT increase Pain threshold
 Older adults (esp frail and old-old) at risk for too little
or too much
General Approach
 Start pt on short acting
 Titrate up for pain relief
 Once stable convert to long acting
 Add amount of short acting for 24 hours
 Convert to long acting
 Continue short acting for breakthrough pain
 10-15 % of 24 hour total narcotic
Advantages of Long-Acting Opioids
 More predictable serum levels
 More predictable pain relief
 Avoids mini-withdrawals
 Easier to use; improved compliance
 Greater Patient satisfaction
 Less reinforcement of drug-taking behavior
Titration of Opioids
 Titrate to adequate pain control.
Appropriate dose adjustments are
critical to adequate pain control.
Adjustments are indicated under the
following circumstances
 If the patient has been taking more than 4
rescue doses per day
 If the patient rates pain as greater than 4/10
 If the patient complains the pain is
inadequately controlled
Dose Titration
 Based 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 Titration
 Dose titration by a fixed percentage
 Moderate 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 PRN
 Accommodate increase if pt frail, sick,
or elderly
Case Study
1. Pt reports 6/10 pain, therefore he requires
a 25 % increase in medication.
2. Pt’s 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 3
Calculate the rescue dose
10% of NT mg = X mg
New rescue order =
MSIR X mg q2h prn
Old regimen
MSER 60 mg bid
MSIR 15 mg q 2 prn
New regimen
MSER 150 mg bid
MSIR 30 mg q 2 prn
Case Study
Pt reports 8/10 pain.
What do you do?
Pt reports 8/10 pain, therefore he
requires a 50 % increase in his
medication.
Pt’s 24 hour narcotic total =
240 mg morphine
Step 1:
Increase dose by 50%
24 NT mg + (24 NT x .50) =
240 mg + ___ = ___ mg
Step 2:
Determine the new fixed dose
? mg / 2 doses per day = ? mg
Step 3:
Calculate the rescue dose
10% of new 24 NT = ___ mg
New rescue order =
MSIR ___ mg q2h prn
 Old regimen
 MSER 60 mg bid
 MSIR 15 mg q 2 prn
New regimen
MSER 180 mg bid
MSIR 30 mg q 2 prn
Equianalgesia
Opioid
Equianalgesic Dose
Morphine
30 mg po
Dilaudid
4-6 mg po
Hydrocodone
30 mg po
Oxycodone
30 mg po
Codeine
180 mg po
Opana
Use conversion calculator
24-hour oral morphine dose (mg/day) Transdermal fentanyl dose (mcq/hour)
30-90
25
91-150
50
151-210
75
211-270
100
Every additional 60 mg per day
An additional 25 mcq per hour
Or
The ratio is 2:1
2 mg oral morphine per DAY ~ 1 mcq fentanyl patch
Fentanyl Patch
 In pts currently on opioids, conversion factor for
Morphine to Fentanyl is 2:1
 Fentanyl patch is 2X more potent than morphine
PO
 If the 24 hr narcotic total= 180 mg morphine
 Fentanyl dose= ___ mg (use nearest fentanyl
patch size)
IV to PO conversion
 Now 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.
Case Study
1.
2.
3.
7.5 mg/hr X 24 = 180 mg morphine IV/24
IV Narcotic total = 186 mg IV
PO Narcotic total = 558
 Opioid naïve: IV is 6X more potent than PO (1:6)
 Currently on opioid: IV is 3X more potent than
PO (1:3)
4. Rescue dose is 10% = 60 mg morphine q 2 hours
prn
5. Long acting dose = 280 mg morphine bid
 Old regimen:
 7.5 mg/hour CIV, with 1 mg q 10
minutes prn
 New Regimen:
 MSER 280 mg bid
 MSIR 60 mg q 2 prn
Case Study
 A 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?
Calculations
1. 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 dose
360 x 3 = 1080 mg morphine in 24 hours PO
5. Breakthrough dose = 10 % of 24 hour narcotic
total
MSIR 30 mg, 3 tabs po q 2 prn
Dilaudid 8 mg, 2 tab po q 2 prn
6. The q12h dose = 500 mg morphine SR PO q12h
MS Contin 100 mg, 5 tabs po BID
MS Contin 100 mg, 3 tabs po TID
 Old regimen:
 3 mg/hr dilaudid IV
 New regimen:
MS Contin 100 mg, 5 tabs po BID
MS Contin 100 mg, 3 tabs po TID
 Rescue dosing
MSIR 30 mg, 3 tabs po q 2 prn
or
Dilaudid 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
occur
 Cardiovascular: Hyper-/hypotension, tachycardia,




ventricular arrhythmia, cardiac arrest
CNS: Irritability, anxiety, narcotic withdrawal,
restlessness, seizure
Gastrointestinal: Nausea, vomiting, diarrhea
Neuromuscular & skeletal: Tremulousness
Respiratory: Dyspnea, pulmonary edema
Use 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.
Adjuvant Analgesics
 TCAs
 Desipramine
 Elavil
 SNRIs
 Cymbalta
 Savella
 Anticonvulsants
 Neurontin/Gabapentin
 Lyrica
 Joint/Bone pain: NSAIDS – potentiate opioids
 Methadone
 Lidoderm patches
TCAs and SNRIs
 Desipramine: 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 mg
Anticonvulsants
 Neurontin/Gabapentin
 Maximum daily dose: 3600 mg
 Start low and titrate up to max dose

100 mg qid
 Lyrica
 Maximum daily dose: 300 mg
 Start at 25 or 50 mg tid
 Problematic Side Effect: sedation
Bony or Metastatic pain
 NSAIDS
 Ibuprofen 800 mg tid
 Naproxen 600 mg bid
 Diclofenac 100 mg bid
 Steroids
 Medral Dose Pak
Methadone
 Possible duel mechanism of action
 Somatic and neuropathic pain relief
 Relatively inexpensive
 Available as a liquid
 Long half-life
 Accumulates with repeat doses with limited analgesic effect





Complex pharmacokinetics
No known active metabolites
Conversion tables underestimate potency
Cardiac Toxicity
Recommend specialized training before prescribing as
NP
Lidoderm Patch
 Lidocaine 5% in dermal patch
 On 12 hours, off 12 hours
 FDA approved for shingles
 Drug interaction and side effects are unlikely –
most common is skin sensitivity
 Mechanical barrier decreases allodynia
Patient Education
 How the medication will impact their
pain
 How to take medication.
 What the medication is treating
 Potential side effects, like constipation.
 When to call doctor’s office.
Patient Education
 How to store/protect their medication.
 Lock box or safe
 How to travel with their medication.
 What to do if/when medication is
stolen or is lost/missing – CALL POLICE,
FILE REPORT
 Consent for treatment
Consent for Treatment
Sources
https://tnm.rxportal.sxc.com/rxclaim/TNM/PtMedMngtAgrmt.pdf
http://www.painmed.org/Workarea/DownloadAsset.aspx?id=3211
Patient education
 Patient’s responsibility
 Clinician’s responsibility
 Urine Drug Screen
 Use of drugs other than prescribed,
and consequences
Re-evaluation
 Changes in pain (level, location, frequency,






character)
Level of function
Average pain level
Worst pain level
Side effects
Benefits
Adherence to medication regimen (missed or
extra doses)
Titrating off Opioids
 Indicated if pt unable to take medications
safely
 If pt’s level of function is declining
 If 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.
Monitoring for abuse
 State Controlled Substance Database Reports
 Frequent evaluations, with good
documentation
 Lost or stolen drugs: Must report to police
department
 Check for placement of fentanyl patches
 Urine Drug Screens – random, or when there is
aberrant behavior
Interpretation of UDS Results
 Important to understand what the results mean
 If question, call lab to check results
Drug
Major Cmpds
Minor Cmpds
Codeine
Codeine
Morphine
Morphine
Morphine
Codeine
Dihydrocodeine
Dihydrocodeine
Hydrocodone
Hydromorphone
Hydrocodone
Hydrocodone
Hydromorphone
Dihydrocodeine
Hydromorphone
Hydromorphone
Oxycodone
Oxycodone
Oxymorphone
Oxymorphone
Fentanyl
Fentanyl
**may not be picked in opiate
screen
Heroin/diamorphine
Morphine
6MAM by specific assay
Marijuana
Carboxy-THC
**many false +screen
Cocaine
Benzoylecgonine
Oxymorphone
Results
CANNABINOIDS (SCREEN) Positive
Immunoassay(cut-off 20 ng/mL); confirmation to
follow
THC CONFIRMATION Positive for Carboxy-THC
Cannabis metabolite cut-off 15 ng/mL
COCAINE METAB (SCREEN) Positive
Immunoassay(cut-off 300 ng/mL); confirmation to
follow
BEG CONFIRMATION Positive for Benzoylecgonine
Cocaine metabolite cut-off 150 ng/mL
METHADONE (SCREEN) Negative Immunoassay(cutoff 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(cutoff 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 yourself
Documentation
UDS
Consent for treatment
Controlled Substance Database Report
Frequent re-evaluation
Communication (with your team and other
providers)
 Patient Education
 Consistency
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
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Addressing Aberrant
Drug-Related Behavior
 General Management Principles
–
–
know laws and regulations
structure therapy to match perceived risk
 Proactive Strategies
–
–
–
communicate goals of therapy
provide written guidelines (treatment contract)
assess often
 Reactive Strategies
–
–
–
–
require frequent visits and small quantities of drug
use of urine toxicologies
long-acting drugs with no rescue doses
refer to addiction-medicine community (sponsor,
program, addiction-medicine specialist, psychotherapist)
(Mironer et al, 2000; Portenoy et al, 1997; Passik et al, 2000)
Promoting Pain Relief and Preventing Abuse
of Pain Medications: A Critical Balancing Act
A joint statement from 21 health care organizations and the
Drug Enforcement Agency, October 23, 2001
 Undertreatment of pain is a serious problem in the US,
including pain among patients with chronic conditions and
those who are critically ill or near death
 Effective pain management is an integral and important
aspect of quality medical care, and pain should be
treated aggressively
 For 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.html
Considerations for the
Nurse Practitioner
 Regulations – State law, Boards of Nursing and
Medicine
 Safe Practice
 Requirements by the State Board of Nursing and
Board of Medicine
 Prescriptions
Evaluation of
Quantity and Chronicity
 Documented appropriate diagnosis
 Treatment of recognized medical indication
 Documented persistence of recognized
medical indication
 Properly documented follow-up evaluation with
appropriate continuing care
Writing Prescriptions
 Prescriptive authority varies state by state
 NPs denied any prescriptive authority
 Limited prescriptive authority – i.e. NP can only write 72
hours worth of pain medication
 Full prescriptive authority granted to NPs.
 For specifics visit:
http://www.medscape.com/viewarticle/439917
 http://www.bartonassociates.com/nursepractitioners/nurse-practitioner-scope-of-practicelaws/
Safe Prescription Writing
Pt’s 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.
Vanderbilt University Medical Center
Barbara Murphy, M.D.
M. Rachel McDowell, APRN-BC
1956 The Vanderbilt Clinic
Nashville, TN 37232
(615) 322-3677
Name: John Doe
Date: 10-10-05
DOB: 01-01-01
RX:
Morphine Sulfate Immediate Release 30 mg
SIG: One tab PO Q 2 hours prn pain
Disp: #56 (fifty six) (2 week supply)
Max of 4 tabs in a 24 hour period
0 (ZERO) refills
Signature: Mary Rachel McDowell, APRN-BC
DEA #: MMM111111111
Helpful Websites
 American Pain Society

http://www.ampainsoc.org/
 Partners against Pain
 http://www.partnersagainstpain.com/index.aspx?sid=27
 International Association for the Study of Pain
 http://www.iasp-pain.org//AM/Template.cfm?Section=Home
 The Joint Commission
 http://www.jointcommission.org/
 American Academy of Pain
 http://www.aapainmanage.org/Management
The 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 site
 Food 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/centers
 Taken from Partners Against Pain Web site
References
 Katz, 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., Samuel
Hellman, Steven A. Rosenberg; 319 contributors.—
6th
 Nicholson, 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 .