Transcript Opioid and - Michigan State University College of Nursing

The 2017 Conference on Pain
February 7, 2017
Leslie Simons, DNP, ANP-BC
Assistant Professor
Michigan State University College of Nursing
Michigan State University
East Lansing, MI
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 Authors
 Leslie
Conflicts of Interest;
Simons: No Conflict of
Interest.
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
Participants will acquire knowledge of
physical assessment techniques and
opioid medication management to
improve prescribing of pain
medication for older adults.
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 Letters
to 2.3 million healthcare
practitioners.
 Address the opioid crisis.
 Past education/Aggressive Pain
Treatment
 Since 1999 opioid overdose
deaths have quadrupled.
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 ANCC
Leadership Role
 Educating
America’s Nurses
on Opioid Use
 Schools
of Nursing Pledging
to Teach CDC Guidelines
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 Older
Adults over age 75
 7 million in the U.S.
 Making the need to improve
pain management in older
adults an important
national concern.
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 Essential
◦ Pain May Go Unrecognized.
◦ Inadequate Pain
Treatment.
◦ Competent Health Care
Providers.
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 Focused
History
 Depression
 Physical
 Functional
Screening
Exam
Assessment
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 Assessment
of functional status is
essential.
 Functional limitations predict
◦ Decreased physical function.
◦ Increased risk of dementia.
◦ Loss of independence.
◦ Institutionalization.
◦ Increased mortality.
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◦ Decreased density of myelinated /
unmyelinated nerve fibers.
◦ Slower transduction/transmission of
pain signals.
◦ Lower density of pain inhibiting nerve
fibers.
◦ Slower recovery from hyperalgesic
states.
◦ Development of persistent pain.
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 Effective
pain management
requires a multidisciplinary
approach to assessment,
treatment and goal setting,
including pathophysiologic and
social aspects of the pain
condition.
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 PT/OT/CBT
 Massage
 Chiropractic
 Acupuncture
 Aquatic
 TENS
Therapy
Therapy
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 Acetaminophen
 Gabapentin/Pregabalin
 Duloxetine
 Muscle
Relaxants
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 Standards
 Older
of Care
Patients as a Special
Population
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 Obtaining
a level of
anesthesia so that ADLs can
be obtained or advanced.
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 Appropriate
selection and
dosing of medications is
essential
 Opioids must be used with
caution.
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 Consider
Opioids Only if
Benefits for Pain/Function
Outweigh Patient Risk.
 Guidelines
CDC 2016 Guideline
Beers Criteria
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 Prescribing
Opioids for chronic pain
 Recommendations
◦ When to initiate/continue.
◦ Selection/follow up
◦ Discontinuation
◦ Risks and Harm.
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 Prior
to Prescribing
• Review Patient Prescription
History
• MAPS
• Urine Drug Screening
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 Selection
 Dosage
• Lowest Effective Dosage
• < 50 morphine mg equivalents/day
• Long Term Use
 Follow
Up
 When to Discontinue
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 Potentially
Inappropriate
Medication Use (PIMS) in
Older adults.
 Not Meant to Override Clinical
Judgement.
 Educate Clinicians/Patients.
 Reduce Adverse Drug Events.
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 Drug
– Disease
• Benzodiazepines/Cognitive
Impairment
Short, Intermediate & Long Acting
Non Benzodiazepine / Benzodiazepine
Receptor Agonist Hypnotics
Increased Risk
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 Drugs
– Disease
 Opioids,
Tramadol/CNS
Disorders
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 Drugs
– Disease
NSAIDS/HTN/GI BLEEDING
• Avoid Chronic Use
• Increased Risk Peptic Ulcer
Disease
• Avoid with Anticoagulants
• High Risk Group > 75 years
•
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 Drug
•
– Drug
Taking > 3 CNS Active Drugs
Decreased
Cognition/Respiratory
Depression/Delirium/Falls
•
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Mild Pain
◦ Treat with acetaminophen/Others
 Moderate Pain
◦ Treat with Tramadol/Adjuvant
Therapy
 Severe Pain
◦ Treat with strong opioid
◦ If opioids must be used/reduce
other CNS-active medications.

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 Half
Life 2 -4 hours.
 Opioid Naïve.
 Dose Adjustment every 2-3
days.
◦ Pain Control
Achieved/Functional Goals Met.
◦ Steady State Maintained
 Consider Dose Reduction.
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

Half Life 8-12 hours.
Long-term use.
◦ Do not prescribe 2 long-acting opioids
together.
◦ Use Extended Release in the same family.
◦ Examples:
 Oxycodone ER 10 mg BID supplemented with
 Oxy IR 5 mg BID as needed for breakthrough
pain.
 Morphine ER & MSIR
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St. Marie, B. (2010) (Ed.). Core Curriculum for Pain
Management Nursing. American Society for Pain
Management Nursing: W.B. Sanders Company.
Dowel D, Haegerich T. M., Chou R. CDC Guideline for
Prescribing Opioids for Chronic Pain-United States,
2016. MMWR Recomm Rep 2016;65:1-49.
DOI: http://doi.org/10.1588/mmwr.rr6501e1
American Geriatrics Society 2015 Updated Beers
Criteria for Potentially Inappropriate Medication Use
in Older Adults. (2015). Journal of the American
Geriatrics Society, 63(11):2227-22246
doi: 10.1111/jgs. 13702.Epub2015Oct8
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
Stizlein-Davis, P. Opioids for pain management in older
adults: Strategies for safe prescribing. (2017). The Nurse
Practitioner, 42(2):21-26
doi: 10.1097/01.NPR 0000511772.62176.10
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