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