m. rachel mcdowell, rn, msn, acnp-bc cancer supportive care nurse practitioner vanderbilt-ingram...
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Pain Management: Practicing the Art
M. Rachel McDowell, RN, MSN, ACNP-BCCancer Supportive Care Nurse PractitionerVanderbilt-Ingram Cancer Center
Goals of presentation
Provide steps for developing treatment planApproach to titration (upward and downward)Patient educationConsent for treatmentUtilization of controlled substance databasesUrine drug screens use and interpretation
Benefits of pain control
Earlier mobilizationShortened hospitalizationReduced costImproved QOLDecrease in patient suffering
Pain AssessmentLocationCharacter
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_image002.jpg&imgrefurl=http://www.pacificu.edu/optometry/ce/courses/22746/ocularpainpg1.cfm&h=274&w=564&sz=37&tbnid=BdvVnqYJnZHq3M:&tbnh=65&tbnw=134&prev=/images%3Fq%3DPain%2BAssessment%2Bscales&hl=en&usg=__TdhB-pWbp_ouIYHvwQ4FJ1dHzgw=&ei=BBR2S6T_IMGXtgeCnqSlCg&sa=X&oi=image_result&resnum=7&ct=image&ved=0CCEQ9QEwBg
Treatment PlanGoal of Therapy:
Decrease pain level Pain is mostly controlled, most of the time
Increase level of functionMinimal side effects from regimenTime frame – acute or chronic
Important FactorsEtiology of pain, prognosisStage 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 statusHistory or current issue with drug misuse/abuseWhat kind of insurance do they have or not?How capable is the patient in understanding
plan?
Treatment OptionsTreat underlying causeNon-pharmacological measuresPharmacological measures
No single modality done in isolation will be effective for most patients with chronic noncancer pain (CNCP) (Ashburn, Staats, Lancet 1999)
Nonpharmacologic OptionsBiofeedbackRelaxation therapyPhysical and occupational therapyCognitive/behavioral strategies
Guided imageryAcupunctureTranscutaneous electrical nerve stimulationPositioningRest, activityMassageHeat and cold
Treatment for painIdentify the cause of the painPrimary treatment if indicated
RadiationSurgeryHyperbaric treatmentInterventions: Nerve Block, KyphoplastyMedications
Interventional TechniquesInterventional Therapies
Trigger pointsAcupunctureNerve blocksFacet denervationIntrathecal pumps
MedicationsSomatic/Nociceptive Pain
OpioidsNSAIDS
Neuropathic PainAnticonvulsantsAntidepressants - SNRIs
Bony PainNSAIDSSteroids
Pharmacotherapeutics and the Nervous System
PNS
Spinal Cord
Brain
Peripheral Sensitization Local Analgesics
Topical AnalgesicsAnticonvulsantsAntidepressantsOpioids
Descending Modulation
AnticonvulsantsTricyclics, SNRI
Opioids
Central Sensitization AnticonvulsantsOpioidsNMDS-Receptor AntagonistsTricyclic/SNRI Antidepressants
CN
S
Guidelines for opioidsWHO ladder combined with etiology-specific
therapies for syndromes
pharmacologic and nonpharmacologic interventions
long-acting + short-acting opioids adjuvant medications for neuropathic painNSAIDs and steroids can be helpful when there
is an inflammatory component to pain
WHO Guidelines for Cancer Pain
Step 3: Opioids for moderate-to-severe pain +/- non-opioid +/-adjuvant therapy
Step 2: Opioids for mild- to-moderate pain +/- non-opioid +/- adjuvant therapy
Step 1: Non-opioid +/- adjuvant therapy
STEP 1
STEP 2
STEP 3
GOAL:Freedom From Pain
Pain Persists
Pain Persists
(Adapted from Portenoy et al, 1997)
Opioid SelectionNo perfect opioid
Pre-treat likely side effects
Must recognize individual responses to opioids may varyResponse and side effectsHydrocodone vx. Oxycodone
Sequential trials of different opioids – alone or in combination – may be necessary to optimize therapy
Common AnalgesicsDemerolMorphine Sulfate IRPercocetDilaudidLortabOpana IROxycodoneTramadol
ButransMorphine Sulfate EROxyContinExalgoFentanyl patchesOpana ERMethadone
Pure Opioid Agonists
Pure Opioid agonistNo ceiling effect for analgesiaSingle-entity for moderate to severe painMay be a role for combined opioids in certain
subsets of patients
Current RegimenOpioid Naïve:
Never been on opioids beforeOnly 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 adultExperience higher peak and longer duration of drug
actionAge-related changes in drug distribution and
elimination make more sensitive to sedation and respiratory distress
Pain perceived differently Physiologic Psychological Cultural changes
Altered presentationsAging does NOT increase Pain thresholdOlder adults (esp frail and old-old) at risk for too
little or too much
General ApproachStart pt on short acting
Titrate up for pain relief
Once stable convert to long actingAdd amount of short acting for 24 hoursConvert to long acting
Continue short acting for breakthrough pain10-15 % of 24 hour total narcotic
Advantages of Long-Acting Opioids
More predictable serum levelsMore predictable pain reliefAvoids mini-withdrawals
Easier to use; improved complianceGreater Patient satisfactionLess reinforcement of drug-taking behavior
Titration of OpioidsTitrate to adequate pain control.
Appropriate dose adjustments are critical to adequate pain control. Adjustments are indicated under the following circumstancesIf the patient has been taking more than 4
rescue doses per day If the patient rates pain as greater than
4/10If the patient complains the pain is
inadequately controlled
Dose TitrationBased 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 TitrationDose 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
PRNAccommodate 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 3Calculate the rescue dose
10% of NT mg = X mg
New rescue order = MSIR X mg q2h prn
Old regimenMSER 60 mg bidMSIR 15 mg q 2 prn
New regimenMSER 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 regimenMSER 60 mg bidMSIR 15 mg q 2 prn
New regimen MSER 180 mg bid
MSIR 30 mg q 2 prn
EquianalgesiaOpioid 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
Fentanyl Doses based on Daily Oral Morphine
Dosage
OrThe ratio is 2:1
2 mg oral morphine per DAY ~ 1 mcq fentanyl patch
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
Fentanyl PatchIn pts currently on opioids, conversion factor
for Morphine to Fentanyl is 2:1Fentanyl patch is 2X more potent than
morphine POIf the 24 hr narcotic total= 180 mg morphineFentanyl 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 Study1. 7.5 mg/hr X 24 = 180 mg morphine IV/242. IV Narcotic total = 186 mg IV3. 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 bidMSIR 60 mg q 2 prn
Case StudyA 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 dose360 x 3 = 1080 mg morphine in 24 hours
PO
5. Breakthrough dose = 10 % of 24 hour narcotic totalMSIR 30 mg, 3 tabs po q 2 prnDilaudid 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 BIDMS Contin 100 mg, 3 tabs po TID
Old regimen: 3 mg/hr dilaudid IV
New regimen:MS Contin 100 mg, 5 tabs po BIDMS Contin 100 mg, 3 tabs po TID
Rescue dosingMSIR 30 mg, 3 tabs po q 2 prn
orDilaudid 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, diarrheaNeuromuscular & skeletal: TremulousnessRespiratory: 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 AnalgesicsTCAs
DesipramineElavil
SNRIsCymbaltaSavella
AnticonvulsantsNeurontin/GabapentinLyrica
Joint/Bone pain: NSAIDS – potentiate opioids
MethadoneLidoderm patches
TCAs and SNRIsDesipramine: 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
AnticonvulsantsNeurontin/Gabapentin
Maximum daily dose: 3600 mgStart low and titrate up to max dose
100 mg qidLyrica
Maximum daily dose: 300 mgStart at 25 or 50 mg tid
Problematic Side Effect: sedation
Bony or Metastatic painNSAIDS
Ibuprofen 800 mg tidNaproxen 600 mg bidDiclofenac 100 mg bid
SteroidsMedral Dose Pak
MethadonePossible duel mechanism of action
Somatic and neuropathic pain reliefRelatively inexpensiveAvailable as a liquidLong half-life
Accumulates with repeat doses with limited analgesic effectComplex pharmacokineticsNo known active metabolitesConversion tables underestimate potencyCardiac ToxicityRecommend specialized training before prescribing
as NP
Lidoderm PatchLidocaine 5% in dermal patchOn 12 hours, off 12 hoursFDA approved for shinglesDrug interaction and side effects are unlikely –
most common is skin sensitivity Mechanical barrier decreases allodynia
Patient EducationHow the medication will impact their pain
How to take medication.What the medication is treatingPotential side effects, like constipation.
When to call doctor’s office.
Patient EducationHow 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
https://tnm.rxportal.sxc.com/rxclaim/TNM/PtMedMngtAgrmt.pdf
http://www.painmed.org/Workarea/DownloadAsset.aspx?id=3211
Consent for Treatment Sources
Patient educationPatient’s responsibility
Clinician’s responsibility
Urine Drug Screen
Use of drugs other than prescribed, and consequences
Re-evaluationChanges in pain (level, location, frequency,
character)Level of functionAverage pain levelWorst pain levelSide effectsBenefitsAdherence to medication regimen (missed or
extra doses)
Titrating off OpioidsIndicated if pt unable to take medications
safelyIf pt’s level of function is decliningIf 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.
State Controlled Substance Database ReportsFrequent evaluations, with good
documentationLost or stolen drugs: Must report to police
departmentCheck for placement of fentanyl patchesUrine Drug Screens – random, or when there
is aberrant behavior
Monitoring for abuse
Interpretation of UDS ResultsImportant to understand what the results
meanIf question, call lab to check results
Drug Major Cmpds Minor Cmpds
Codeine Codeine Morphine
Morphine Morphine Codeine
Dihydrocodeine DihydrocodeineHydrocodone
Hydromorphone
Hydrocodone Hydrocodone HydromorphoneDihydrocodeine
Hydromorphone Hydromorphone
Oxycodone Oxycodone Oxymorphone
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
Results
CANNABINOIDS (SCREEN) Positive Immunoassay(cut-off 20 ng/mL); confirmation to follow
THC CONFIRMATION Positive for Carboxy-THCCannabis metabolite cut-off 15 ng/mL
COCAINE METAB (SCREEN) Positive Immunoassay(cut-off 300 ng/mL); confirmation to follow
BEG CONFIRMATION Positive for BenzoylecgonineCocaine metabolite cut-off 150 ng/mL
METHADONE (SCREEN) Negative Immunoassay(cut-off 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(cut-
off 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 yourselfDocumentationUDSConsent for treatmentControlled Substance Database ReportFrequent re-evaluationCommunication (with your team and other
providers)Patient EducationConsistency
Addressing AberrantDrug-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 PractitionerRegulations – 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 indicationDocumented persistence of recognized
medical indicationProperly documented follow-up evaluation
with appropriate continuing care
Writing Prescriptions Prescriptive authority varies state by state
NPs denied any prescriptive authorityLimited prescriptive authority – i.e. NP can only write
72 hours worth of pain medicationFull prescriptive authority granted to NPs.
For specifics visit: http://www.medscape.com/viewarticle/439917
http://www.bartonassociates.com/nurse-practitioners/nurse-practitioner-scope-of-practice-laws/
Safe Prescription WritingPt’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 CenterBarbara Murphy, M.D.M. Rachel McDowell, APRN-BC1956 The Vanderbilt ClinicNashville, TN 37232(615) 322-3677
Name: John Doe DOB: 01-01-01Date: 10-10-05
RX:Morphine Sulfate Immediate Release 30 mgSIG: One tab PO Q 2 hours prn painDisp: #56 (fifty six) (2 week supply)Max of 4 tabs in a 24 hour period
0 (ZERO) refillsSignature: Mary Rachel McDowell, APRN-BCDEA #: MMM111111111
Helpful WebsitesAmerican 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
ReferencesKatz, 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 .
Questions