chronic pain in primary care: designing and implementing a management plan module 3 paula worley,...
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Chronic Pain in Primary Care: Designing and Implementing a Management Plan
Module 3Paula 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
Objectives:1. Describe elements of a comprehensive
treatment plan for chronic pain in primary care.
2. Discuss documentation of the treatment plan that will include pharmacologic and non-pharmacologic interventions.
3. Identify resources for the effective use of pharmacologic modalities.
4. Identify resources for the effective use of non-pharmacologic modalities.
Significance of Chronic PainCommon reason for primary care
visits
Expectation of patient? Pain medication
Prescribers’ fear ◦Patient addiction, misuse or diversion◦Causing harm◦Legal ramifications
Prescription Drug AbuseCDC 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.
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
Eight Point Treatment Plan
1. Based on comprehensive assessment
2. Goals for functional improvement3. Pain management agreement4. Informed consent for treatment5. Assessments at regular intervals6. Pharmaceutical Modalities 7. Non-pharmaceutical Modalities8. Documentation
Eight Point Treatment Plan: 1. Comprehensive Assessment
Complete physical exam Diagnostic testing Medication and supplemental
historyBenefit to harm analysis
Eight Point Treatment Plan:2. Goals for Functional Improvement
Measurable and realistic
Agreed upon by prescriber and patient
Based on improvement in function
Improvement in tolerance to exercise
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
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
permissionwww.aapainmanage.org
Eight Point Treatment Plan:4. Informed Consent for TreatmentPain management agreement
Disclosure of risk and benefits
Frequency of assessment
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
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
Eight Point Treatment Plan:6. Pharmaceutical Modalities
Analgesic Ladder
World Health Organization
Analgesic Ladder: Levels of Pain Severity (rating scale)
Mild (1 – 3/10)
Moderate (4 – 6/10)
Severe (7 – 10/10)
Eight Point Treatment Plan:6. Pharmaceuticals
Simple analgesics
Adjunctants
Weak opioids
Strong opioids
Eight Point Treatment Plan:6. Pharmaceuticals – Simple Analgesics
Acetaminophen
NSAIDS
◦Selective cox 2 inhibitors – celecoxib and meloxicam
◦Non-selective – ibuprofen and naproxen
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
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
Eight Point Treatment Plan:6. Pharmaceuticals – Adjunctants
Antidepressants
Anxiolytics
Muscle relaxers Steroids
Eight Point Treatment Plan:6. Pharmaceuticals – Adjuctants
Anti-depressantsDepression 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)
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
Eight Point Treatment Plan: 6. Pharmaceuticals – Adjunctants
Muscle RelaxersLower the level of pain experiencedIncrease flexibility and range of
motionReducing spasms and involuntary
muscle contractionsExamples: carisoprodol,
cyclobenzaprineSide effect: sedation
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.
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
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
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
Eight Point Treatment Plan:6. Pharmaceuticals – Strong Opioids
Morphine 5 – 10 mg per hourFentanyl 25 mcg per hourDilaudid 1 – 4 mg per hourOxycodone - 10 – 80 mg tabletsMerperdine – 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
Eight Point Treatment Plan:7. Non-Pharmaceuticals
AcupunctureManual therapyExerciseTENSThermal Therapy
Eight Point Treatment Plan: 7. Non-Pharmaceuticals
Acupuncture
Most widely used Complimentary & Alternative Therapy in the US
Thin needles are inserted into the skinNeedles are stimulated to release
neurotransmittersShown to improve function in
◦ Osteoarthritis◦ Fibromyalgia ◦ Back pain
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
Eight Point Treatment Plan7. Non-Pharmaceuticals
ExerciseMoving, stretching, low impact
aerobics, pool & physical therapy, yoga
◦Endorphin release to reduce pain◦Increase flexibility◦Muscle strengthening◦Improve mood
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
Application of HeatIncrease 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
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
Eight Point Treatment Plan: 8. Documentation in Medical RecordClearDetailedSystematicConsistent with evidenceTherapies offered, accepted and
declinedComprehensive assessment of
Analgesic, ADL, Adverse events, screening for Aberrancy
Consider Referral If not progressing toward
functional goals
Side effects are unacceptable
Experience of pain is not improving
Violation of pain management agreement
Consider ConsultTo share responsibility and
liability
To confirm or adjust pain management treatment plan
Where to ReferPain managementDrug rehabResources 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
Implications of a Comprehensive Treatment PlanEffectively 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.
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 from http://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.
1. The majority of prescription drug abuse in the US is with medications:
a. That are prescribed to the patient/offender.
b. That were purchased on the street.
c. That were prescribed to someone else.
d. That were stolen.
Post Test Questions
2. 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?
a.The patient agrees to one pharmacyb.The patient agrees to not use
recreational drugsc.The patient designates one person
that may pick up their medications.d.The patient agrees that lost
prescriptions will not be replaced.
4. Additionally, which of the following are not included in a pain management treatment plan:a. To communicate fully about pain
experience.b. Not to request narcotics outside
of business hours.c. That “lost prescriptions” will not be replacedd. To go to the ER after hours for breakthrough pain.
5. Assessment at regular intervals should always include:
a. Functional goals achieved.b. Intensity of painc. Drug screeningd. Screening for abuse/diversion
6. True/False: When moving from mild opioids to strong opioids and calculating dosage, prescribers should decrease dosage by 10%.
7. Reasons to refer to pain management are all of the following except:
a. Patient is requiring an increase in pain medication.
b. Side effects are unacceptable.c. The prescriber desires consult with
specialist.d. Patient is not able to progress toward
functional goals.e. Patient’s medications were lost or stolen.
8. Documentation should include all of the following except:
f. Intensity of paing. Functional goalsh. Adverse eventsi. Patient’s mode of transportationj. Screen for abuse/diversion
9. Resources for the prescriber are available through all of the following except:
a. Pain management specialistb. Pain.edu websitec. The American Academy of Pain
Managementd. The Department of Public Safety
10. What class of pharmaceutical is thought to interfere with sleep architecture?
e. Muscle relaxersf. NSAIDsg. Benzodiazepinesh. Hydrocodone