Chronic Pain in Primary Care: Designing and Implementing a Management Plan Module 3

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