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