Pain Management &

Analgesic PrescribingSpecial Geriatric Focus Included

FOR ADVANCED PRACTICE NURSES

Linh My Thi Nguyen, MD, Med | Assistant Professor | UTHealth Medical School

Department of Internal Medicine | Division of Geriatric and Palliative Medicine

Michelle Peck, MSN, MPH, ANP-BC, GNP-BC, CLNC | Faculty | UTHealth School of Nursing

Department of Nursing Systems

Let’s Discuss… Benefits & side effects of common analgesics

Impact of patient-related factors on drug selection & dose based on knowledge of patient related changes

Medications to avoid, use with caution, explain why

Management of pain based on client care goals

Realityhttp://www.consumerreports.org/cro/video-hub/3705124027001

/

The Dangers of Painkillers: A Special Report.

Published: July 2014

Critical Techniques

My primary area of work is…

Ambulatory Care Facility

Community Health Agency

Doctor’s Office/Clinic

Home Health

Hospital

Nursing Facility/Rehab

Nursing School/Education

Surgical Center

Other

My primary specialty area is…

Adult /Geriatric

Pediatric/Neonatal

Family

Women’s Health

Psychiatric

Acute Critical Care

Education

Hospice

Other

Follow the Guidelines

Follow the GuidelinesAmerican Academy of Pain Medicine (AAPM)“Pain is one of the most common reasons people consult a physician. Yet it frequently is inappropriately treated.”

AAPM believes pain should be diagnosed and treated in a comprehensive, systematic, collaborative, patient-centered fashion

http://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf

Physiologic

Psychologic

Behavioral

Social

Cultural

Religious

PAIN is a Multifacete

d Experience

Agency for Healthcare Research & Quality (AHRQ)Practice guidelines for chronic pain management. An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine.

Optimize pain control, recognizing that a pain-free state may not be attainable

Enhance functional abilities and physical and psychological well-being

Enhance the quality of life of patients

Minimize adverse outcomes

Target population

http://www.guideline.gov/content.aspx?id=23845

Agency for Healthcare Research & Quality (AHRQ)Practice guidelines for chronic pain management. Pharmacologic interventions

Anticonvulsants Alpha-2-delta calcium channel antagonists Sodium channel blockers Membrane-stabilizing drugs Antidepressants Tricyclic antidepressants Selective serotonin–norepi reuptake inhibitors Selective serotonin reuptake inhibitors Benzodiazepines

N-methyl-D-aspartate (NMDA) receptor antagonistsNonsteroidal anti-inflammatory drugs (NSAIDs) Opioid therapy Sustained or controlled-release opioids Tramadol Skeletal muscle relaxants Topical agents Capsaicin Lidocaine Ketamine

Which statement about pharmacologic management IS TRUE according to AHRQ

Practice Guidelines?A.For selected patients, nonsteroidal anti-inflammatory drugs, and topical

agents may be used.

B.Anticonvulsants should be used as part of a multimodal strategy for patients with visceral pain.

C.Selective serotonin reuptake inhibitors should be avoided for patients with diabetic neuropathy.

D.A strategy for monitoring and managing side effects, adverse effects, and compliance should be considered for selected patients undergoing any long-term pharmacologic therapy.

The American Geriatrics Society (AGS)Clinical Practice Guideline: Pharmacological Management of Persistent Pain in Older PersonsConsider Acetaminophen initial & ongoing pharmacotherapy mild to moderate musculoskeletal NSAIDs & COX-2 selective inhibitors considered rarely, with caution, in highly selected individuals

Consider for opioid therapy:

Moderate to severe pain

Pain-related functional impairment

Diminished quality of life due to pain

http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/persistent_pain_executive_summary

Client Selection, Risk Stratification

Prior to initiating COT:

Conduct an H&P and assessment of risk of substance abuse, misuse, or addiction

Perform and document a benefit-to-harm evaluation

Informed Consent & Management Plans

Obtain informed consent: goals, expectations,

potential risks, and alternatives

Written opioid management plans/agreements:

obtaining opioids from one prescriber

filling opioids prescriptions at one pharmacy

urine drug screens, pill counts, limited prescriptions

Initiation & Titration of COT

Therapeutic trial to determine if opioid is appropriate

Individualize opioid selection, initial dosing, and titration

MonitoringDocumentation of pain intensity & level of function

assessments & progress towards achieving

Monitor for aberrant drug‑related behaviors

Periodic urine drug screens:Low risk: 1-2; Moderate risk:3-4

High risk:>=4, every month, office visit, or every drug refill

High-Risk ClientsRestructure therapy if needed

Consider consultation:

Mental health

Addiction specialist

Discontinuation of COT

Follow WHO Pain Ladder

Follow WHO pain ladder

World Health Organization Stepwise Analgesic Ladder, Focus on

Proper selection, dosing, titration, and administration of analgesics

Five concepts: by mouth, by the clock, by the ladder, for the individual, with attention to detail

Mild pain 1 - 3 on a 10 point scale

Analgesics include:

Aspirin

Acetaminophen (Tylenol)

Nonsteroidal anti-inflammatory drugs (Elderly need to be cautious)

Coanalgesics

Step 1

Moderate pain 4 - 6 on 10 point scale

Analgesics include:

Codeine

Hydrocodone

Oxycodone

Nonopioid analgesic

CoanalgesicsStep 2

Severe Pain 7 - 10 on a 10 point scale

Analgesics include:Morphine

Oxycodone

Hydromorphone

Fentanyl

Nonopioid analgesics

CoanalgesicsStep 3

Which of the following is TRUE regarding the WHO pain ladder?

1.Five concepts include by mouth, by the clock, by the ladder, for the individual, with attention to detail

2.Mild pain 1 - 5 on a 10 point scale analgesics include Aspirin

3.Severe pain 7 - 10 on a 10 point scale analgesics include Oxycodone

Notable Fame: Comedian, ActorCause of Death: Overdose, Combination of Morphine and Cocaine Drug Category: MixedWhen: 1997Age: 33

Name this Celebrity - Chris Farley

Select the Best

Intervention

http://www.consumerreports.org/cro/video-hub/37401615890

01/

Pain Management

Goals:Prevention of acute painControl of chronic painOptimizing functionImproving quality of lifeInterdisciplinary team

Effective Management

Requires the health care providers to be aware of personal biases surrounding pain

and its management

CHOOSE WISELY

AND CONSIDER

COST

Pain Considerations

Older Adults

Rate your knowledge level of Beer’s Criteria…

1.Expert 2.Moderate 3.Minimal4.None5.I prefer wine over Beer’s

BEER’S CRITERIAExpert Panel from around the worldDeveloped list of Medications to Avoid if you are over 65

Recently Updated in 2012Severity ratings of medications on High to Low ScaleProblems grouped based on DiseaseConcerns listed independent of Disease

Beer’s List - Pain Rx DecisionsDrug Rationale Recommend Quality of

EvidenceStrength

Recommend

NSAIDs oralAspirin > 325 mg/d

GI bleeding;Protection

with PPIs or misoprostol

Avoid chronic use

Moderate Strong

Skeletal Muscle

Relaxants

Ineffective at tolerated

doses, antichol,

falls

Avoid Moderate Strong

Tertiary TCAs, alone

or incombination

:Amitriptylin

e

Highly antichol, sedating,and cause orthostatic hypotension

Avoid High Strong

Notable Fame: Singer, ActressCause of Death: Drowning, Complications of Cocaine, Heart Disease

Flexeril, Marijuana, Xanax and Benadryl found in her bodyDrug Category: MixedWhen: 2012Age: 48

Name this Celebrity - Whitney Houston

Topical Agents Local Anesthetics

Lidocaine and Bupivacaine Block Na+ influx of voltage-gated ion channels in afferent neuron terminals

Inhibiting depolarization and generation of action potentials

Resulting in the transmission of fewer nociceptive impulses to the spinal cord

Topical lidocaine is used for neuropathic pain

Blocks hyperactive sodium ions in damaged peripheral nerves

Inhibit transmission of ectopic impulses to the dorsal horn

Notable Fame: SingerCause of Death: Cardiac arrest, Lidocaine, Propofol, Midazolam, Diazepam, Lorazepam Drug Category: Prescription drug overdoseWhen: 2009Age: 50

Name this Celebrity - Michael Jackson

Topical Agents Analgesic Creams, Rubs, and SpraysCounterirritants - Ingredients such as menthol, methylsalicylate, and camphor create a burning or cooling sensation -distracts your mind from the pain (Icy Hot and Biofreeze)

Salicylates - Same ingredients that give aspirin its pain-relieving quality , when absorbed into the skin, they may help with pain (Aspercreme and Bengay) appear to be more effective for muscle aches

Capsaicin - Main ingredient of hot chili peppers, one of the most effective ingredients for topical pain relief (Capzasin and Zostrix) more often used for pain associated with damaged nerves

Topical Agents

Capsaicin Defunctionalizes nerve fiber terminals through multiple mechanisms

Initial reduction in neuronal excitability and responsiveness

Inactivation voltage-gated Na channels

Direct desensitization of plasma membrane TRPV1 receptors

Followed by extracellular Ca2+ entry TRPV1, release from intracellular stores overwhelm TRPV1 receptor

May initially cause pain -substance P released from nociceptive terminals, gets better over time

May need to apply for a few days to a couple of weeks before pain relief noticed

Topical Prescription Pain Products

FDA has approved several topical products (Voltaren, Pennsaid, others)

Contain the prescription NSAID diclofenac, OA in joints close to the skin's surface

Patches containing a numbing medication, such as lidocaine (Lidoderm)

Approved in the U.S. to treat a painful complication of shingles

May be used for other pain types, insurance may not pay off-label costs

NSAIDsInhibit conversion of arachidonic acid to prostaglandins catalyzed by COX isozymes

Nonselective NSAIDs inhibit COX-1 & 2 and include ibuprofen, aspirin, and naproxen

Nonselective action inhibits the formation of gastroprotective mediating prostaglandins and pain-promoting prostaglandins increasing the risk of serious GI complications

Selective COX-2 inhibitors, fewer GI side effects, increased risk of cardio-renal morbidities

Disease Drug Rationale Recommendation Quality of Evidence

Strength

Chronic kidneydisease StagesIV and V

NSAIDs May increase risk ofkidney injury

Avoid Moderate Strong

Hx of gastric, duodenalulcers

Aspirin (>325)Non–COX-2 selective NSAIDs

May exacerbate existingulcers or cause newor additional ulcers

Avoid unless otheralternatives are noteffective & can take gastroprotective agent

Moderate Strong

Heart Failure NSAIDs and COX-2 inhibitors

Potential for fluid retention and exacerbating HF

Avoid Moderate Strong

AcetaminophenIncluded in combination with many prescription opioids

Analgesia is achieved through central inhibition of prostaglandin

Not anti-inflammatory

Side-effect profile is relatively benign with intermittent

Long-term or high-dose use can be hepatotoxic

Daily dose should never exceed 4000mg

Recommended over NSAIDs in patients with GI, renal, or cardiovascular comorbidity

http://www.consumerreports.org/cro/video-hub/3907633633001/

Anticonvulsant Drugs Gabapentinoids Gabapentin, Pregabalin effective wide neuropathic pain

Selective binding/blockade voltage-gated Ca channels brain, dorsal spine

Inhibits the release of glutamate, norepinephrine, substance P

Decreases spinal cord levels of neurotransmitters, neuropeptides

Binding affinity of pregabalin is 6 times greater than gabapentin

Gabapentin possesses a shorter half-life and nonlinear absorption

Pregabalin is easier to titrate and better tolerated

Anticonvulsant Drugs LacosamideModulation collapsin-response mediator protein 2

Inhibits the NMDA receptor subunit NR2B

Topiramate Suppression of action potentials Na & Ca channel blockade

GABA receptor & AMPA receptor antagonism and kainate inhibition

Also a glutamate antagonist

Antidepressants Tricyclic Antidepressants Widely used in neuropathic pain, blocking pre-synaptic reuptake norepinephrine/serotonin

Reducing neuronal influx of Ca of Na ions and activity with adenosine and NMDA

Secondary amines nortriptyline and desipramine are favored over the tertiary amines amitriptyline and imipramine due to more benign side effect

Disease Drug Rationale Recommendation

Quality of Evidence

Strength

ChronicConstipation

Tertiary TCAs

Can worsen constipation Avoid unless noother alternatives

Moderate Weak

Syncope Tertiary TCAs Increases risk of orthostatic hypotension or bradycardia

Avoid Moderate Strong

Delirium All TCAs Avoid in older adults with or at high risk of delirium, taper off

Avoid Moderate Strong

Hx falls orfractures

TCAsSSRIs

Ability to produce ataxia, impairedpsychomotor function, syncope, falls

Avoid unless saferNot available

High Strong

Antidepressants Serotonin-Norepinephrine Reuptake Inhibitors

Duloxetine, Venlafaxine, and Milnacipran Duloxetine is used in painful diabetic neuropathy efficacy at 60 to 120 mg/day

Venlafaxine behaves like a SSRI at doses of ≤150 mg/day and like an SNRI at doses >150 mg/day, dose ≥150 mg/day is often necessary to achieve pain control

Milnacipran has the greatest affinity for norepinephrine

Duloxetine has the greatest potency in blocking serotonin

Venlafaxine selectively binds to the serotonin but not the norepinephrine transporter

SNRIs are better tolerated than TCAs because they lack affinity for cholinergic, histaminic, and adrenergic receptors

Antidepressants Mirtazapine Atypical tetracyclic antidepressant

Inhibition of 5HT-2, 5HT3, H1-a2-hetero, and alpha-2-adrenergic receptors

Beneficial effect in the adjuvant treatment of migraine headache, anxiety, agitation, depression, insomnia, and low appetite

H1-receptor antagonism is most prominent at low doses (≤30 mg)

Drug Rationale Recommend

Quality of Evidence

Strength

MirtazapineSerotonin–norepinephrinereuptake inhibitorSelective serotoninreuptake inhibitorTricyclic antidepressants

May exacerbate or cause syndrome ofinappropriate antidiuretic hormonesecretion or hyponatremia; need tomonitor sodium level closely whenstarting or changing dosages in olderadults due to increased risk

Use with caution

Moderate Strong

Glutamate Antagonists

Dextromethorphan Oral cough suppressant, NMDA receptor antagonist, a sigma-1 receptor agonist, an

N-type calcium channel antagonist, and a serotonin reuptake transporter antagonist

Rapid hepatic metabolism interferes with maintaining plasma concentrations sufficient for analgesia

Co-administration of quinidine has been found to maintain therapeutic levels

FDA approved dextromethorphan for use in the treatment of pseudobulbar palsy

Also used in painful diabetic polyneuropathy

Avoiding drugs with strong anticholinergic properties is imperative in the elderly with cognitive impairment. Which drug combination would you NOT prescribe?

1.Skeletal muscle relaxants & Acetylcholinesterase inhibitors

2.Acetylcholinesterase inhibitors & some antidepressants

3.Skeletal muscle relaxants & some antidepressants

Glutamate Antagonists Ketamine Phencyclidine anesthetic given parenterally, neuraxially, nasally, transdermally or orally

in subanesthetic doses to alleviate a variety of pain conditions, including severe acute pain, chronic or neuropathic pain, and opioid tolerance by NMDA receptor antagonism.

Also has activity on nicotinic, muscarinic, and opioid receptors and exerts both anti-nociceptive and anti-hyperalgesic effects

Potentially distressing adverse reactions (psychotomimetic side effects) and unwanted changes in mood, perception, and intellectual performance limit its use in pain control

Notable Fame: American golfer (LPGA)Cause of Death: Asphyxia, Butalbital,

Temazepam, Alprazolam, Codeine, Hydrocodone, TramadolDrug Category: Prescription drug overdoseWhen: 2010Age: 25

Name this Celebrity - Erica Blasberg

Opioids Tramadol Centrally acting, weak mu opioid receptor agonist

Inhibits norepinephrine and serotonin reuptake

Promotes serotonin release

Peripheral activity absent - no effects on blood pressure, ulcer, heart failure

Disease Drug Rationale Recommendation

Quality of Evidence

Strength

Chronicseizuresor epilepsy

Tramadol Lowers seizure threshold; may beacceptable in patients with well-controlledseizures in whom alternative agents havenot been effective

Avoid Moderate Strong

Notable Fame: Actor, Musician, SingerCause of Death: Heart arrhythmia, possibly aggravated by multiple prescriptions - Methadone, Codeine, Barbiturates, CocaineDrug Category: MixedWhen: 1977Age: 42

Name this Celebrity - Elvis Presley

Morphine & Other Mu Opioid Receptor Agonists Analgesia through opioid receptor binding on cell membranes, producing simultaneous activity at multiple

presynaptic, postsynaptic, and nervous system sites

Each opioid produces a unique spectrum of effects - analgesia, somnolence, respiratory depression, dysphoria, euphoria, decreased GI motility, altered circulatory dynamics, histamine release, physical dependence

Morphine, Codeine, Hydrocodone, and Oxymorphone, have greatest affinity for the mu opioid receptor

Presynaptic opioid receptor activation inhibits release of nociceptive neurotransmitters, substance P, glutamate

Postsynaptic activation inhibits pain by opening K or Cl channels, hyperpolarize and inhibit neuronal firing

Inhibits pain signal transmission from peripheral afferents to ascending spinal cord neurons, activates descending pathway inhibition, and will alter limbic activity, decreasing pain awareness

Start with immediate-release

around the clock

Convert long acting sustained

released ONLY AFTER pain is

controlled

Titrating to Comfort

Notable Fame: ActorCause of Death: Combined Toxicity

Oxycodone, Hydrocodone, Alprazolam, Diazepam, Temazepam, Doxylamine

Drug Category: Prescription drug overdoseWhen: 2008Age: 28

Name this Celebrity - Heath Ledger

Alpha-2 Adrenoceptor Agonists

Clonidine and Tizanidine Antinociceptive activity

Modulating dorsal horn neuron function, norepinephrine and 5-HT release

Potentiating mu-opioid receptors, decreasing neuron excitability - calcium channel modulation

Clonidine, transdermal, local use enhances release of endogenous encephalin-like substances

Tizanidine is used as a muscle relaxant and antispasticity agent

Other Agents Baclofen Muscle relaxant that induces analgesia

Agonist action on inhibitory GABA-B receptors

Efficacious for trigeminal neuralgia

Anti-spasticity properties of baclofen may induce analgesia

Botulinum Toxin Neurotoxic protein synthesized by the bacterium Clostridium botulinum

Produces analgesia, blocking neurotransmitter release and TRPV1 receptor signaling in C-fibers

Inhibits substance P and CGRP release

Reduces neurogenic inflammation

Increases heat pain threshold

Other Agents Sulfasalazine Tetrahydrobiopterin

Essential co-factor in producing nitric oxide and monoamines

FDA-approved anti-inflammatory agent that inhibits sepiapterin reductase

May represent an effective therapy for neuropathic pain

Ondansetron 5-HT3 receptor antagonist

Anti-nociceptive effects

Blocking descending serotonergic facilitatory drive to the dorsal horn laminae

Monitor for Toxicity

and Red Flags

Signs & Symptoms of ToxicityClassic signs of opioid intoxication

Depressed mental status

Decreased tidal volume

Decreased bowel sounds

Decreased respiratory rate:

best predictor RR < 12

Miotic pupils:

normal exam does NOT exclude opioid intoxication

Signs & Symptoms of ToxicityOpioid-Induced Neurotoxicity

A syndrome of neuropsychiatric consequences of opioid administration

Occurs when active opioid metabolites build up (could be due to dehydration and/or decreasing kidney function)

Commonly occurs in response to rapid escalation of opioid medicines

Features include cognitive impairment, severe sedation, hallucinosis, delirium, myoclonus, seizure, hyperalgesia, and allodynia

Suspect Opioid-Induced Neurotoxicity:1. Painful experience from a source that is

not normally painful.2. Complaints of :all over” body pain, or a

pain that becomes generalized.3. Worsening pain, but no worsening of

disease.4. Involuntary muscle twitching.5. Confusion, hallucinations,

disorientation, decreased LOC.6. Seizures.

Treatment:

If caused by dehydration giving IVF will reverse.

If caused by decrease in kidney function reducing the opioid dose usually will reverse.

If caused by rapid escalation of opioid medicine, reducing the dose or rotating to a different opioid will usually reverse.

Risk Assessment Patient reported history

Psychology interview

Risk screening tools: Screener and Opioid Assessment for Patients with Pain(SOAPP)

Opioid Risk Tool(ORT)

Pain Medication Questionnaire (PMQ)

CAGE Questionnaire

Clinical impression

Risk MonitoringPrescription monitoring programs

Pain medication diaries

Pill counts

Urine drug testing (UDT)

Risk monitoring tools: Current Opioid Misuse Measure (COMM)

The Addiction Behavior Checklist (ABC)

Behavior patterns “Red Flags”

Red FlagsMedication loss

Frequent telephone calls

Frequent ER visits

Drug hoarding

Doctor shopping

Aggressive demand for more drugs

Drug seeking

Clinging to specific drugs

Use for non-prescribed indications (ex. Anxiety, insomnia)

Which of the following clinical interventions can increase risk of diversion?

1. Attention to patterns of prescription requests

2. Annual review in the prescription monitoring program database

3. Urine and/or blood drug screening & pill counts

4. Frequent follow up and client contact

Amphetamines

Barbiturates

Benzodiazepines

Cocaine

Methadone

Opiates

Phencyclidine

Propoxyphene

Tetrahydrocannbinol

UDS 9 UDS 12

Amphetamines

Barbiturates

Benzodiazepines

Cocaine

Methadone

Methaqualone

Opiates - confirms if Codeine, Hydrocodone, Hydromorphone, Morphine, or Oxycodone

Phencyclidine

Propoxyphene

Tetrahydrocannabinol

For Tramadol, Fentanyl, or Buprenorphine:A separate order is needed

How Many Times Have You Looked Up a Client on the Prescription Access in Texas

(PAT) System?1.Never

2.1-5 times

3.5-10 times

4.More than 10 times

Texas Department of

Public Safety

Prescription Access in

Texas (PAT)

https://

www.texaspatx.com/login.aspx

When to Consult a Specialist

Consultation & ReferralBe willing to refer:

When pain problems remain intractable, unremitting

To obtain other approaches to assessment or management

To determine if interventional procedures would help relieve pain

Psychosocial indications for consultation:

History of substance abuse

Interpersonal dynamics that seem to complicate the treatment

Give special attention to clients risk for Rx misuse, abuse, diversion

May be required for psychiatric disorders

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