Pain Management Laura Bergs FNP Definition of Chronic

Pain Management Laura Bergs FNP

Definition of Chronic Pain n Anyone with pain greater than 3 months Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage Allodynia* Pain due to a stimulus that does not normally provoke pain.

Regulations for monitoring Will do urine drug screen n Will not give narcotics unless off all illegal drugs n Must follow pain management patient agreements and be consistent n

Urine Drug Screen

Metabolic Pathways Heroin 6 -MAM Morphine

Metabolic Pathways Morphine Hydromorphone

Metabolic Pathway Codeine Hydrocodone Hydromorphone

Urine drug testing n n n Perform at initial visit, then random Drug screen results are black and white False positives can occur in some instances Talk with toxicology if not sure of results All patients usually deny illegal drug use Don’t have to treat patient, you did not decide to do the illegal drug, they did

Tools assist to determine if narcotics needed n n n COAT (chronic opioid analgesic therapy) pathway is a tool to be used by every provider prior to long term opioid therapy Dire Score is used to determine if they are a candidate for opioid therapy Risk stratification-medium is the default risk

Inclusion Criteria COAT Group A not currently on opioid and considering opioid trial Group B on opioid < 3 months, considering continuing opioid Group C patient already on COAT

1 st step in pathway DIRE Score n Scoring based on n DIRRRRE (Diagnosis, intractability, Risk, (psychological, chemical health, reliability, Social Support) Efficacy Score) n Add D+I+4 R+E=range Score 7 -13 not suitable for COAT Score 14 -21 may be suitable The Journal of Pain, Vol 7, No 9 September, 2006 PP 671 -681

Step 2: Risk Stratification n n Medium default risk Move to low risk if n n n Age > 65 years Morphine equivalents <=10 mg/d Move to high risk if n n n Age<=35 Morphine equivalents >80 mg/day Past substance use disorder Aberrant drug related behavior Mental Illness Provider judgment

3 rd step monitoring n n n Office visits based on risk, must see every three months Must have opioid agreement and informed consent Check state monitoring program before initiating COAT Lab 7767 urine drug screen initial then randomized Pill counts, I do with every visit, you may use your discretion

Risk stratification May keep in medium rather than move based on provider judgment Must document rational if meets high risk yet keep on med

Tapering of Opioid Decrease 10 -20 percent each week n Round off the dose to the next available formulation n Symptoms can be managed with clonidine n Consider adjuncts n

Opioid agreement Random drug screens n If found to have illegal's, n Can treat with adjuncts instead of narcotics n Chronic use of narcotic medication discouraged n Wean off narcotics if not dependent/addicted n

Drugs of Abuse reference Guide Amphetamine speed Dexedrine Benzadrine

Drugs of Abuse Reference Guide MDMA Ecstasy, XTC, ADAM Lover’s speed methylenedioxymethamphetamine

Drugs of Abuse Reference Guide Methamphetamine Speed, ice, crystal, crank Desoxym Methadrine

Deciding to take off Opioid At discretion of provider n If failed drug screen or documented drug diversion n DIRE score <14 n may continue with no opioids n

Weaning schedule n n n 10 percent per week unless weaning off Methadone Manage withdrawal symptoms May need to be inpatient Most can come off without any difficulty If you discharge related to breach of contract do have legal obligation to follow for 30 days (this does not mean you have to prescribe narcotic)

Section Y DIRE Score <14 n n If harm greater than benefit educate and taper Provider judgment that COAT benefits greater than harm-review at each visit Review with each visit: 4 A’s: analgesia activity adverse effects aberrant behavior

Provider benefit greater than harm n Documentation for effectiveness n 4 As plus 2 As n Analgesia n Activity n Adverse effects n Aberrant behavior n Assessment n Action. bpismartform brief pain questionnaire

Illegal drug use n n n Talk face to face with patient Determine if they have an addiction You treat without narcotics Usually these patients self discharge High risk if you continue with narcotic and there is documentation of patient continuing with illegal drug use

Taper off opioid Decrease 10 -20 percent per week n Symptoms of abstinence syndrome, clonidine 0. 1 mg every six hours or clonidine transdermal patch n May safely wean Methadone requires slower wean schedule 3% TAPER n Weekly visit with weaning n

Weaning protocols Those that do not follow the rules Can use clonidine for withdrawal Refer to inpatient if able to find bed if on Methadone All other narcotics follow DIRE weaning protocol Those with no drug in urine are not taking the drug and do not need to be weaned

Weaning schedule n If patient agrees to wean off Advantage-can try different drug once off all narcotics for two weeks n Can tell if narcotic really did help with the pain, after several months of narcotic use they are not beneficial n Continue to monitor urine drug screens even after weaned off n

Patient and provider goals n n n Need to set realistic goals with the patient Most want all of their pain gone completely this is unrealistic if they have had pain for several years, some have just been discharged from another pain clinic Review agreements with the patient often to prevent misunderstanding

Functional assessment Do not always go by pain level as stated n Look at how dressed n How they are able to perform daily functions n Are they sedated n Are they able to answer direct questions n When in doubt refer to me n

Adjunctive treatment n n n Expect them to participate in therapy Expect them to participate in daily exercise Expect them to participate in psychotherapy Hope to start program for cognitive behavioral therapy for chronic pain State surveillance program for medications check this

Stable chronic opioid patient No aberrant episodes and warrants continued therapy n Once stable prefer that PCP take over prescribing n Monitor monthly of every three months n Happy to see them back if they become unstable or wish to discontinue opioid therapy n

Any Questions

References n http: //www. iasppain. org/Content/Navigation. Menu/General Resource. Links/Pain. Definitions/default. htm