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A lecture given to nurse practitioners, physician assistants and others on pain management. The aim of the talk is to review:
1- the principles of effective pain management;
2- the knowledge and/or resources to assist in indentifying patients at high risk for substance abuse, and
3- the importance of counseling patients about the side effects, addictive nature and proper storage and disposal of prescription medications.

*Disclaimer: Case presentation is made up of a combination of cases, and does not reflect the case of any one particular patient.

Published in: Health & Medicine
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  1. 1. Effective Pain Management<br />Ann Connolly, ACNP<br />Jennifer Reidy, MD<br />Suzana Makowski, MD May 19, 2011<br />
  2. 2. Declarations<br />There has been no commercial sponsorship or support for this program.<br />The planners and presenters have declared that no conflict of interest exists.<br />The MARN CE Committee does not endorse any products in conjunction with any educational activity.<br />
  3. 3. Overview<br />
  4. 4. Objectives<br />Participants will:<br />Gain an understanding of the principles of effective pain management<br />Have the knowledge and/or resources to assist in indentifying patients at high risk for substance abuse, and<br />Gain an awareness of the importance of counseling patients about the side effects, addictive nature and proper storage and disposal of prescription medications. <br />
  5. 5. The challenge<br />It is true that untreated and undertreated pain is a major public health issue, so is addiction.<br />
  6. 6. Approach<br />Pain Policy #2012 <br />Ask (screen)<br />Assess (comprehensively)<br />Manage (treat)<br />Re-assess (modify plan prn)<br />Educate (patient/family)<br />Educate (clinicians) <br />Monitor (effectiveness)<br />Pain Web Site (OurNet)<br />PAIN<br />
  7. 7. Case Presentation<br />59 y.o. man presents to his primary care physician for chronic foot pain <br />
  8. 8. Types of pain<br />
  9. 9. Pain<br />It is common<br />It is often undertreated<br />There are many barriers to treating pain<br />Clinical,<br />Patient-related<br />System-related<br />Racial and ethnic barriers exist<br />Language<br />Perceptions<br />
  10. 10. Is his pain real?<br />Woolf CJ. Lancet 1999<br />
  11. 11. Treatment of pain<br />Pharmacotherapy<br />Rehabilitative Approaches<br />Psychologic Interventions<br />Anesthesia/Interventional Pain Approaches<br />Neurostimulatory Techniques<br />Radiotherapy<br />Surgery<br />Complementary/Alternative Approaches<br />Lifestyle Changes<br />
  12. 12. Overview of Pharmacology<br />
  13. 13. Opioid Pharmacology<br />
  14. 14. Opioid pharmacology<br />Conjugated by liver<br />90-95% excreted in urine<br />Dehydration, renal failure, severe hepatic failure<br />Decrease interval/dosing size<br />If oliguria/anuria<br />STOP routine dosing (basal rate) of morphine<br />Use ONLY PRN<br />
  15. 15. Opioid Pharmacology<br />What is the half life (range) for opioids?<br />2-4 hours<br />How many half lives to get to steady state? <br />4-5<br />What do you base your scheduled dosing on: Cmax or T1/2?<br />T1/2<br />What do you base your breakthrough dosing on: Cmaxor T1/2? <br />Cmax<br />
  16. 16. A few words on methadone<br />Methadone Rises as a Painkiller With Big Risks<br />By ERIK ECKHOLM and OLGA PIERCE<br />Published: August 16, 2008<br />[Methadone] is implicated in more than twice as many deaths as heroin, and is rivaling or surpassing the tolls of painkillers like OxyContin and Vicodin.<br />“This is a wonderful medicine used appropriately, but an unforgiving medicine used inappropriately,” said Dr. Howard A. Heit, a pain specialist at Georgetown University. <br /> - find a mentor on use of methadone in pain management<br />
  17. 17. Case continued<br />Patient comes into the hospital ….<br />Pain meds on admission:<br /><ul><li>Oxycontin 40mg PO BID
  18. 18. OxyIR 10mg PO q2 hours PRN– up to 6 per day
  19. 19. Gabapentin 600mg PO TID</li></li></ul><li>PCAs with chronic pain<br />Pain meds on admission:<br /><ul><li>Oxycontin 40mg PO BID OxyIR10mg PO q2 hours PRN
  20. 20. Gabapentin 600mg PO TID</li></ul>Oxycodone 80mg+60mg = 140mg/day<br />140mg PO oxy x (5mg IV morphine/10mg PO oxy) = 60 mg IV morphine/day<br />60mg IV morphine ÷ 24 hours = 2.5 mg/hour<br />PCA basal rate 2mg/hour, bolus 0.5 or 1mg with 15 minute lockout<br />
  21. 21. Case: In the ER<br />Patient goes to the ER …<br />He has been doubling his oxycodone dose on his own at home – “my foot pain is terrible!”<br />“I’m out of my medication and I need more – help me!”<br />
  22. 22. Slides adapted from: <br />“Safe and effective opioid prescribing for chronic pain”<br />Boston University School of Medicine<br />Free online CME<br /><br />
  23. 23. Prescription Drug Abuse<br />Major public health problem<br />Abuse and misuse of opioids more than doubled during 1990s to present<br />Most nonmedical users obtain drug from family or friend (medicine cabinet)<br />Source where family/friend obtained drug: one clinician<br />Source: SAMHSA, OAS, NSDUH data, July 2007<br />
  24. 24. From 1997-2006, opioid prescriptions increased sevenfold<br />Unintentional overdoses more than doubled<br />Overall risk of opioid overdose remains very low (0.04%)<br />Sources: 2007 National Vital Statistics System; JAMA 2011;305(13):1315-21<br />Deaths from prescription drug abuse<br />
  25. 25. Is your patient’s chronic pain real?<br /><ul><li>No objective way to measure
  26. 26. Difficult to know the difference between inappropriate drug-seeking and appropriate pain-relief seeking behavior
  27. 27. You need time and a relationship to discover the difference</li></li></ul><li>General Principles<br /><ul><li>Maintain risk-benefit model, not a police-offender model
  28. 28. Reassure patient that you understand pain severity
  29. 29. Reflect on patient strengths (self-efficacy)
  30. 30. Partner with patient by sharing control</li></li></ul><li>When are opioids indicated?<br /><ul><li>Pain is moderate to severe
  31. 31. Pain has significant impact on function
  32. 32. Pain has significant impact on quality of life
  33. 33. Non-opioid pharmacotherapy has failed
  34. 34. Patient agreeable to have opioid use closely monitored</li></li></ul><li><ul><li>Published rates of abuse and/or addiction in chronic pain patients are 3-19%
  35. 35. Known risk factors:
  36. 36. Past cocaine use, hx alcohol or cannabis use
  37. 37. Lifetime hx of substance abuse
  38. 38. Family hx of substance abuse
  39. 39. Tobacco addiction
  40. 40. Hx of severe depression or anxiety</li></ul>Ives T et al BMC Health Services Research 2006, Reid MC et al JGIM 2002, <br />Michna E et al JPSM 2004, Akbik H et al JPSM 2006<br />What is the risk of addiction?<br />
  41. 41. What is addiction?<br /><ul><li>Loss of control
  42. 42. Compulsive use
  43. 43. Continued use despite harm
  44. 44. Craving
  45. 45. It is NOT physical dependence
  46. 46. Biological adaptation with signs & symptoms of withdrawal if opioid is abruptly stopped</li></li></ul><li>Aberrant medication-taking behavior: Yellow flags<br /><ul><li>Less likely to be predictive of addiction
  47. 47. Complaints about need for medication
  48. 48. Drug hoarding
  49. 49. Requesting specific pain medication
  50. 50. Openly acquiring similar medications from other providers
  51. 51. Occasional unsanctioned dose escalation
  52. 52. Nonadherence to other recommendations for pain therapy</li></ul>Passik SD Mayo Clin Proc 2009<br />
  53. 53. Aberrant medication-taking behavior: Red flags<br /><ul><li>More likely to be predictive of addiction
  54. 54. Deterioration in functioning at work or socially
  55. 55. Illegal activities – selling, forging, buying
  56. 56. Injecting or snorting medication
  57. 57. Multiple episodes of “lost” or “stolen” scripts
  58. 58. Resistance to change therapy despite adverse effects
  59. 59. Refusal to comply with random drug screens
  60. 60. Concurrent abuse of alcohol or illicit drugs
  61. 61. Use of multiple physicians and pharmacies</li></li></ul><li>Aberrant medication-taking behaviors: differential diagnosis<br /><ul><li>Opioid-analgesic tolerance
  62. 62. Self-medication of psychiatric & physical symptoms other than pain
  63. 63. Criminal intent - diversion
  64. 64. Inadequate analgesia “pseudoaddiction”
  65. 65. Disease progression
  66. 66. Opioid-resistant pain
  67. 67. Opioid-induced hyperalgesia
  68. 68. Addiction</li></li></ul><li><ul><li>Assess for benefit
  69. 69. Pain, function and quality of life
  70. 70. Assess for harm – use “universal precautions”
  71. 71. Agreements/contracts
  72. 72. Informed consent
  73. 73. Monitor for aberrant medication-taking behavior
  74. 74. Urine drug testing, pill/patch counts
  75. 75. Monitor for adherence, addiction & diversion
  76. 76. Initially small quantities & frequent visits
  77. 77. Establish a refill & cross-coverage system</li></ul>Assessing & monitoring<br />
  78. 78. Assessment tool<br />PEG (Pain, Enjoyment, General activity) scale (0-10)<br /><ul><li>What number best describes your pain on average in the past week? (no pain – worst pain you can imagine)
  79. 79. What number best describes how, during the past week, pain has interfered with your enjoyment of life? (does not interfere – completely interferes)
  80. 80. What number best describes how, during the past week, pain has interfered with your general activity? (does not interfere – completely interferes)</li></li></ul><li>Standard urine test detects only natural opiates reliably<br />33<br />* Converts to morphine, so can be detected in standard opioid immunoassay<br />
  81. 81. Should opioids be continued?<br /><ul><li>You must convince yourself that there is benefit
  82. 82. Benefit must outweigh observed harms
  83. 83. If small benefit, consider increasing dose as a “test”
  84. 84. If no effect = no benefit, can stop opioids (taper and reassess)
  85. 85. You DO NOT have to prove addiction or diversion – only assess risk-benefit ratio</li></li></ul><li><ul><li>Show admiration for overcoming addiction
  86. 86. Acknowledge patient’s desire to “never go there” again
  87. 87. Openly discuss higher risk
  88. 88. Consider using ASA-GI bleed analogy
  89. 89. Partner with patient to monitor for risk </li></ul>Patients w/ past substance abuse<br />
  90. 90. <ul><li>Stress how much you believe/empathize with pt’s pain and impact on life
  91. 91. Give feedback: explain why pt’s behaviors raises your concern for possible addiction
  92. 92. Benefits no longer exceed risks
  93. 93. “I cannot responsibly continue prescribing opioids as I feel it would cause you more harm than good.”
  94. 94. Avoid judging the person
  95. 95. Show commitment to continue caring about pt and pain, even without opioids
  96. 96. Always offer referral to addiction treatment</li></ul>Exit strategy: discussing lack of benefit<br />
  97. 97. MA Online Prescription Monitoring Program<br />Online database of prescriptions filled in MA<br />Oct 2009-Dec 2010: Schedule II<br />January 2011 onward: Schedule II-V<br />Pharmacies report data weekly<br />Up to 4 week lag in uploading data<br />Registered providers may access online <br />Requires patient first and last names, birthday<br />Only provider may access (not nurse, MA)<br />Only for patients for whom you are prescribing<br />
  98. 98. Safe Disposal<br />Federal: FDA, White House Office of National Drug Control Policy; US Environmental Protection Agency<br />State: MA DCR; Mass DEP; MA Water Resources Authority<br />Local: Take back programs<br />When no longer needed<br />
  99. 99. Summary<br /><ul><li>Pain management is a core competency of medicine
  100. 100. Use whole-person approach, w/focus on wellness
  101. 101. Understand pathophysiology of pain, pharmacology of medications
  102. 102. With opioids for chronic pain, use consistent approach but set level of monitoring to match risk
  103. 103. If there is benefit in the absence of harm, continue opioids
  104. 104. If there is no benefit or if there is harm, stop opioids</li></li></ul><li>In conclusion<br />It is true that untreated and undertreated pain is a major public health issue, so is addiction.<br />
  105. 105. Prevalence & Impact<br />Chronic pain is one of the most common conditions for which people seek medical treatment <br />35% of Americans suffer from chronic pain<br />>50 million Americans are partially or totally disabled by chronic pain<br />50 million workdays are lost per year <br />$100 billion is the estimated annual cost in lost productivity, medical costs, and lost income<br />
  106. 106. >40% to 50% of patients in routine practice settings fail to achieve adequate pain relief<br />In a recent study of 805 chronic pain sufferers, >50% had to change physicians to achieve relief because the physician:<br /><ul><li>was unwilling to treat pain aggressively
  107. 107. did not take the patient’s pain seriously
  108. 108. had inadequate knowledge about pain treatment</li></ul>Undertreatment of chronic pain<br />
  109. 109. Barriers to treating pain<br />Clinician-Related<br />Limited knowledge of pain pathophysiology and assessment skills<br />Biases against opioid therapy and overestimation of risks<br />Fear of regulatory scrutiny/action<br />Patient-Related<br />Exaggerated fear of addiction, tolerance, side effects<br />Reluctance to report pain: stoicism, desire to “please”clinician<br />Concerns about “meaning” of pain (associate increased pain with worsening disease)<br />System-Related<br />Low priority given to pain and symptom control<br />Limits on number of Rxs filled per month & number of refills allowed<br />Reimbursement policies <br />
  110. 110. Racial & ethnic barriers<br />Language or cultural differences make pain assessment more difficult<br />Clinicians’ perceptions and misconceptions:<br />minority-group patients have fewer financial resources to pay for prescriptions<br />higher drug-abuse potential among minority groups<br />Patients’ lack of assertiveness in seeking treatment<br />Lack of treatment expertise at many sites at which minority-group patients are treated<br />Relative unavailability of opioids in some communities<br />
  111. 111. Un- & undertreated pain can lead to worse chronic pain<br />In chronic pain, the nervous system remodels continuously in response to repeated pain signals<br /><ul><li>nerves become hypersensitive to pain
  112. 112. nerves become resistant to anti-nociceptive system</li></ul>If untreated, pain signals will continue even after injury resolves<br />Chronic pain signals become embedded in the central nervous system<br />
  113. 113. Common causes of chronic pain<br />
  114. 114. Clinician issues<br />Over-prescribing<br />Pts expect medication to solve problems<br />Fear of confrontation and saying “no” to pt<br />Under-prescribing<br />Poor education about opioids<br />Overestimate potency and duration of action<br />Fear of being duped<br />Exaggerated fear of addiction potential<br />
  115. 115. Should opioids be continued?<br /><ul><li>You must convince yourself that there is benefit
  116. 116. Benefit must outweigh observed harms
  117. 117. If small benefit, consider increasing dose as a “test”
  118. 118. If no effect = no benefit, can stop opioids (taper and reassess)
  119. 119. You DO NOT have to prove addiction or diversion – only assess risk-benefit ratio</li></li></ul><li>Are opioids effective in chronic pain?<br /><ul><li>Most studies are uncontrolled case series
  120. 120. RCTs are short duration (<4 months) and small sample sizes (<300 pts)
  121. 121. Mostly industry-sponsored
  122. 122. Pain relief modest
  123. 123. Limited or no improvement in functioning</li></ul>Balantyne JC, Mao J NEJM 2003, Kalso E et al Pain 2004, <br />Eisenberg E et al JAMA 2005, Martell BA et al Ann Intern Med 2007<br />
  124. 124. Patients vary in response to opioids<br /><ul><li>>100 polymorphisms in the human mu receptor gene
  125. 125. Mu receptor subtypes
  126. 126. Not everyone responds to same opioid in same way
  127. 127. Not all pain responds to same opioid in same way
  128. 128. Incomplete cross-tolerance between opioids</li></li></ul><li>Can long-term opioid use worsen chronic pain?<br /><ul><li>Methadone maintenance patients with increased pain sensitivity
  129. 129. ? Neuroadapation to chronic opioids
  130. 130. Opioid-induced hyperalgesia</li></ul>Doverty M et al Pain 2001, Angst MS Clark JD Anesthesiology 2006<br />