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  1. Chronic Pain in Primary Care: Designing and Implementing a Management PlanModule 3

    Paula Worley, MSN, RN, FNP-BC Diane Tyler, PhD, RN, FNP-BC, FNP-C, FAAN Mary Lou Adams, PhD, RN, FNP-BC, FAAN Frances Sonstein, MSN, RN, FNP, CNS Stephanie Key, MSN, RN, CPNP-PC The University of Texas at Austin School of Nursing Consultants: Yvonne D’Arcy, MSN, RN and JoEllen Wynne, MSN, RN, FNP-BC, FAANP
  2. Objectives: Describe elements of a comprehensive treatment plan for chronic pain in primary care. Discuss documentation of the treatment plan that will include pharmacologic and non-pharmacologic interventions. Identify resources for the effective use of pharmacologic modalities. Identify resources for the effective use of non-pharmacologic modalities.
  3. Significance of Chronic Pain Common reason for primary care visits Expectation of patient? Pain medication Prescribers’ fear Patient addiction, misuse or diversion Causing harm Legal ramifications
  4. Prescription Drug Abuse CDC reported 76% of the 12 million Americans abusing prescription drugs are consuming drugs that were prescribed to someone else(Horswell, 2012). Prescribers’ concerns are real.
  5. Prescription Drug Monitoring ProjectPDMP PDMP is a federal initiative providing a forum for information sharing on prescription drug use among state and federal agencies. Goal is to curtail drug diversion and abuse while ensuring patient care. http://www.pmpalliance.org
  6. Eight Point Treatment Plan Based on comprehensive assessment Goals for functional improvement Pain management agreement Informed consent for treatment Assessments at regular intervals Pharmaceutical Modalities Non-pharmaceutical Modalities Documentation
  7. Eight Point Treatment Plan: 1. Comprehensive Assessment Complete physical exam Diagnostic testing Medication and supplemental history Benefit to harm analysis
  8. Eight Point Treatment Plan:2. Goals for Functional Improvement Measurableand realistic Agreed upon by prescriber and patient Based on improvement in function Improvement in tolerance to exercise
  9. Eight Point Treatment Plan:3. Pain Management Agreement Purpose Reduce the risk of prescribing Assist in compliance with legal requirements Prevent misunderstandings about certain medications Document consequences of breaking agreement
  10. Eight Point Treatment Plan:3. Pain Management Agreement (Continued) Patient agrees: To communicate fully about pain experience Not to use recreational drugs Not to share, sell or trade medications To use one pharmacy Not to request narcotics outside of business hours That “lost prescriptions” will not be replaced To have random drug screenings Not to go to the ER without prescriber’s permission www.aapainmanage.org
  11. Eight Point Treatment Plan:4. Informed Consent for Treatment Pain management agreement Disclosure of risk and benefits Frequency of assessment
  12. Eight Point Treatment Plan:5. Assessment at Regular Intervals Frequency varies by state but at least every 3 months Assess Pain intensity Progress toward functional goals Adverse effects Screening for abuse and misuse
  13. Eight Point Treatment Plan:5. Assessment at Regular Intervals Screening Tools for abuse/misuse Current Opioid Misuse Measure (COMM) Pain Assessment and Documentation Tool (PADT) – 4 “A”s Analgesia Activities of daily living Adverse events Potential Aberrant drug-related behavior
  14. Eight Point Treatment Plan:6. Pharmaceutical Modalities Analgesic Ladder World Health Organization
  15. Analgesic Ladder: Levels of Pain Severity (rating scale) Mild (1 – 3/10) Moderate (4 – 6/10) Severe (7 – 10/10)
  16. Eight Point Treatment Plan:6. Pharmaceuticals Simple analgesics Adjunctants Weak opioids Strong opioids
  17. Eight Point Treatment Plan:6. Pharmaceuticals – Simple Analgesics Acetaminophen NSAIDS Selective cox 2 inhibitors – celecoxib and meloxicam Non-selective – ibuprofen and naproxen
  18. Eight Point Treatment Plan:6. Pharmaceuticals – Simple Analgesics Acetaminophen Dosage 325 – 1000 mg every 4 – 6 hours. Maximum daily dose reduced from 4,000 to 3,000 mg/day - aimed at reducing accidently overdose Black Box warning – associated with acute liver failure Contained in multiple cold/allergy products; daily dose can be exceeded without patient awareness
  19. Eight Point Treatment Plan:6. Pharmaceuticals – Simple Analgesics NSAIDs Action is inhibiting cox, an enzyme responsible for inflammation and pain Weigh benefits versus increased risk of Increased CV events –Black Box Warning Erosive gastritis and small bowel ulcerations (Goldstein, et al, 2005) Blood pressure elevation Worsening renal insufficiency
  20. Eight Point Treatment Plan:6. Pharmaceuticals – Adjunctants Antidepressants Anxiolytics Muscle relaxers Steroids
  21. Eight Point Treatment Plan:6. Pharmaceuticals – Adjuctants Anti-depressants Depression is a component of chronic pain for more than 80% of patients Suicide rate for patients with chronic pain is higher than other patients in the same age group without chronic pain (D’Arcy, April 2009)
  22. Eight Point Treatment Plan:6. Pharmaceuticals – Adjunctants Anxiolytics Antidepressants are effective anxiolytics, and some classes provide pain relief Benzodiazepines: Helpful in short term management as anti-depressants take affect Potentially can disrupt sleep architecture and worsen depression
  23. Eight Point Treatment Plan:6. Pharmaceuticals – Adjunctants Muscle Relaxers Lower the level of pain experienced Increase flexibility and range of motion Reducing spasms and involuntary muscle contractions Examples: carisoprodol, cyclobenzaprine Side effect: sedation
  24. Eight Point Treatment Plan: 6. Pharmaceuticals – Adjunctants Corticosteroids Anti-inflammatory for chronic swelling of joints and tendons Often reserved for flare-ups or episodes of acute pain associated with long term conditions Side effects: short term – emotional lability long term – osteoporosis, adrenal suppression.
  25. Eight Point Treatment Plan: 6. Pharmaceuticals – Weak Opioids Opioid agonist – binding with the mu (CNS opioid) receptors and are weak reuptake inhibitors of norepinephrine and serotonin. Caution for serotonin syndrome May be habit forming Cardiac and respiratory depression
  26. Eight Point Treatment Plan: 6. Pharmaceuticals – Weak Opioids Tramadol Dosage 50 – 100 mg/4 – 6 hours Max 400 mg/day, 300 mg/day in elderly CKD reduce dosage by half and frequency increased to every 12 hours
  27. Eight Point Treatment Plan:6. Pharmaceuticals – Weak Opioids + Simple Analgesics Codeine 15 – 60 mg every 4 – 6 hours (max 360 mg/day) + 300 mg acetaminophen Hydrocodone 2.5 – 10 mg (max 1 gm/4 hours) + acetaminophen 300 mg or 7.5 mg with 200 mg ibuprofen Adverse effects: Nausea/vomiting (give with food) Constipation Cardiac and respiratory depression & sedation
  28. Eight Point Treatment Plan:6. Pharmaceuticals – Strong Opioids Morphine 5 – 10 mg per hour Fentanyl 25 mcg per hour Dilaudid 1 – 4 mg per hour Oxycodone - 10 – 80 mg tablets Merperdine – Prolonged use may increase the risk of toxicity (e.g., seizures) from the accumulation of metabolite, normeperidine Most stronger opioids – titrated dose to desired effect Great caution needs to be exercised to avoid life threatening respiratory depression, sedation, weakness, seizures and confusion
  29. Eight Point Treatment Plan:7. Non-Pharmaceuticals Acupuncture Manual therapy Exercise TENS Thermal Therapy
  30. Eight Point Treatment Plan: 7. Non-Pharmaceuticals Acupuncture Most widely used Complimentary & Alternative Therapy in the US Thin needles are inserted into the skin Needles are stimulated to release neurotransmitters Shown to improve function in Osteoarthritis Fibromyalgia Back pain
  31. Eight Point Treatment Plan7. Non-Pharmaceuticals: Manual Therapy Massage - NIH defines as pressing, rubbing on soft tissues Deep tissue or lighter technique Applied near site of pain thought to activate inhibitory neurons to close the gate on painful impulses
  32. Eight Point Treatment Plan7. Non-Pharmaceuticals Exercise Moving, stretching, low impact aerobics, pool & physical therapy, yoga Endorphin release to reduce pain Increase flexibility Muscle strengthening Improve mood
  33. Eight Point Treatment Plan:7. Non-Pharmaceuticals TENS Transcutaneous Electrical Nerve Stimulation Release of endorphins Block deep sensations of pain Portable machines are available at very affordable prices
  34. Application of Heat Increase circulation to affected area reducing Stiffness Pain Muscle spasms Caution Short periods of time To avoid burns, never use over: Areas of poor circulation Mentholated creams or medication patches
  35. Eight Point Treatment Plan:Non-Pharmaceuticals – Application of Cold Decreased nerve conduction Vasoconstriction Caution Short periods of time Frequently monitor skin condition With patients with diabetes and CV disease
  36. Eight Point Treatment Plan: 8. Documentation in Medical Record Clear Detailed Systematic Consistent with evidence Therapies offered, accepted and declined Comprehensive assessment of Analgesic, ADL, Adverse events, screening for Aberrancy
  37. Consider Referral If not progressing toward functional goals Side effects are unacceptable Experience of pain is not improving Violation of pain management agreement
  38. Consider Consult To share responsibility and liability To confirm or adjust pain management treatment plan
  39. Where to Refer Pain management Drug rehab Resources for further information: Responsible Opioid Prescribing: A Clinician’s Guide by Scott M. Fishman, MD American Academy of Pain Management American Pain Society www.PainEDU.org
  40. Implications of a Comprehensive Treatment Plan Effectively managing chronic pain using a comprehensive plan can safely and powerfully impact patients’ lives… Allowing patients to participate more fully in the activities that give them enjoyment a sense of worth, purpose & fulfillment.
  41. References Bennett, J. S., Daugherty, A., Herrington, D., Greenland, P., Roberts, H., & Taubert, K. A. (2005). The use of non-steroid inflammatory drugs (NSAIDs): A science advisory from the American Heart Association. Journal of the American Heart Association, 111, 1713-1716. D’Arcy, Y. (2009, April). Be in the know about pain management. Nurse Practitioner, 34(4), 43-47. Retrieved from http://journals.lww.com/tnpj/toc/2009/04000 D’Arcy, Y. (2009). Chronic opioid therapy clinical guidelines. The Nurse Practitioner, 34(10), 13-15. DOI: 10.1097/01.NPR.0000361298.80778.10 D’Arcy, Y. (2011). Compact clinical guide to acute pain management: An evidence-based approach for nurses (pp. 171-194). New York, NY: Springer. Fine, P., & Portenoy, R. (2004). A clinical guide to opioid analgesia. New York: McGraw Hill. Goldstein, J. L., Eisen, G. M., Lewis, B., Gralnek, I. M., Zlotnick, S., & Fort, J. G. (2005).Video capsule endoscopy to prospectively assess small bowel injury with celecoxib, naproxen plus omeprazole, and placebo.Clinical Gastroenterology and Hepatology, 3, 133–141. Horswell, C. (2012, March 20). New law puts heat on 'doctor shoppers.' The Houston Chronicle. Retrieved fromhttp://www.chron.com/news/houston-texas/article/New-law-puts-heat-on-doctor-shoppers-3416651.php Macias, A. (2011). State legislatures attempt to shut down the pill mills. Bulletin of the American College of Surgeons, 96(11), 38-39. Sullivan, M. D. & Robinson, J. P. (2006). Antidepressants and anticonvulsants medication for chronic pain. Physical Medicine and Rehabilitation Clinics of North America. 2006 May;17(2):381-400, vi-vii.
  42. Post Test Questions 1. The majority of prescription drug abuse in the US is with medications: That are prescribed to the patient/offender. That were purchased on the street. That were prescribed to someone else. That were stolen.
  43. True/False: All states in the US have a fully functioning Prescription Drug Monitoring Project for prescribers of opioids. 3. Which of the following is not usually found in a pain management agreement? The patient agrees to one pharmacy The patient agrees to not use recreational drugs The patient designates one person that may pick up their medications. The patient agrees that lost prescriptions will not be replaced.
  44. Additionally, which of the following are not included in a pain management treatment plan: To communicate fully about pain experience. Not to request narcotics outside of business hours. c. That “lost prescriptions” will not be replaced d. To go to the ER after hours for breakthrough pain.
  45. 5. Assessment at regular intervals should always include: Functional goals achieved. Intensity of pain Drug screening Screening for abuse/diversion 6. True/False: When moving from mild opioids to strong opioids and calculating dosage, prescribers should decrease dosage by 10%.
  46. 7. Reasons to refer to pain management are all of the following except: Patient is requiring an increase in pain medication. Side effects are unacceptable. The prescriber desires consult with specialist. Patient is not able to progress toward functional goals. Patient’s medications were lost or stolen. 8. Documentation should include all of the following except: Intensity of pain Functional goals Adverse events Patient’s mode of transportation Screen for abuse/diversion
  47. 9. Resources for the prescriber are available through all of the following except: Pain management specialist Pain.edu website The American Academy of Pain Management The Department of Public Safety 10. What class of pharmaceutical is thought to interfere with sleep architecture? Muscle relaxers NSAIDs Benzodiazepines Hydrocodone