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The Nurse Practitioner Role in Increasing Access to Pain Care


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The Nurse Practitioner Role in Increasing Access to Pain Care

  1. 1. The Nurse Practitioner Role in Increasing Access to Pain Care An introduction to Strategies and Tools for Safe and Effective Practice With thanks to Purdue Pharma for the use of their accredited slides, part of Purdue Pharma’s “Pain and Symptom Management” series. Celina Dara RPh, ACPR, PharmD
  2. 2. ObjectivesObjectives  A review of current and future Ontario legislation to enable Nurse Practitioner prescribing of opioids  A review of how prescriptions for opioids should be written in Ontario.  A review of assessment tools, screening tools and documentation necessary to assist in the management of chronic non-cancer pain (CNCP).  Understand how to use Universal Precautions to prescribe and manage opioids safely
  3. 3. Expanding the NP scope ofExpanding the NP scope of practicepractice  Controlled Drugs and Substances Act (CDSA) “Addition of New Practitioner Regulations”, 2007 ◦ allow nurse practitioners to possess, administer, sell or provide, prescribe, and/or transport certain controlled substances, only if the authorization to prescribe controlled substances within the scope of their practice is permitted by provincial/ territorial law where they practice.  Bill 179, the Regulated Health Professions Statute Law Amendment Act, 2009 ◦ considering the NP authority of open prescribing of pharmaceuticals and other substances, ie, to prescribe, dispense, mix and sell drugs without restrictions.  Bill 101, the Narcotics Safety and Awareness Act 2010 ◦ In May 2010, the Government of Ontario developed a strategy to address the health and safety concerns related to the use of narcotics and other controlled substances  Barriers ◦ understanding of the role and scope for a NP ◦ Licensing authority to address the core competencies of the regulated profession
  4. 4. Legal requirements for a narcotic prescriptionLegal requirements for a narcotic prescription  The registration number on the certificate of registration issued to the prescriber by the College, as defined in the Regulated Health Professions Act, 1991, of which he or she is a member (Bill 101).  The name of the person for whom the monitored drug is prescribed.  The name, strength (where applicable) and quantity of the monitored drug.  The directions for use of the monitored drug.  The name and address of the prescriber.  The date on which the monitored drug is prescribed.  Any other information, including personal information, required by the regulations  Narcotic refills are specifically forbidden by the Narcotic Control Regulations, Section 37  Part-fills are legal for both Narcotics and Controlled drugs if the total quantity dispensed does not exceed that originally authorized.  The doctor must authorize the total quantity involved as a single figure and not as a smaller figure multiplied by the number of times the medication is to be dispensed.
  5. 5. 1 2. 1.The prescription is valid for 20 tablets only, after which a new prescription is required. 2. The prescription shown is valid for 60 tablets only. The total quantity could be interpreted as either 60 + 3 repeats (240 tab), or 60 x 3 repeats (180 tabs). Thus, the quantity is not stated as a single figure and the “x 3” cannot be accepted 3 3. A legal part-fill. The pharmacist may dispense 20 tablets at weekly intervals until 100 have been dispensed. He/she should not dispense more than 20 per week, without documented prescriber authority. Each dispensing requires the record to reference to this original authority (Rx number), not the last-filled number. Once all 100 have been dispensed, the prescription is expired. Any new authorization becomes a new prescription authority. All subsequent part-fills dispensed must then cross-reference to the new authorization number. Prescription Part-fills -- An Update. Ontario College of Pharmacists. 4 4. The pharmacist may dispense 60 tablets on three occasions at intervals of no less than 28 days.
  6. 6. Pain Management GoalsPain Management Goals  Decrease pain  Improve function ◦ physical ◦ psychosocial  Minimize adverse effects ◦ for the patient ◦ for the health care provider ◦ for society 6 Treat Pain Prevent Misuse Maintaining the Balance
  7. 7. Elements of a Good Pain History:Elements of a Good Pain History: CNCPCNCP 1. Current pain descriptions (including pain scoring) 2. Previous pain history (including treatments & results) 3. Other concurrent medical / psych problems 4. Current treatments, effectiveness and adverse effects 5. Social history (family, work, income, relationships) 6. Addiction screening 7. Current functioning and patient future goals
  8. 8. Descriptive, Numeric,AnalogueDescriptive, Numeric,Analogue Pain Rating ScalesPain Rating Scales Williamson A and Hoggart B, 2005 No Pain Pain as Bad as it Could Possibly Be 10 cm Visual Analog Scale No Pain Unbearable Pain 0 1 2 3 4 5 6 7 8 9 10 0-10 Numeric Rating Scale (NRS) No Pain Mild Pain Moderate Pain Severe Pain Very Severe Pain Worst Possible Pain Simple Descriptive Pain Intensity Scale
  9. 9. Brief Pain Inventory – BPIBrief Pain Inventory – BPI 9
  10. 10. Codeine Oxycodone Tramadol (+/- nonopioid) (+/- adjuvants) Acetaminophen ASA NSAIDs/COXIBs (+/- adjuvants) The Analgesic Stepped ApproachThe Analgesic Stepped Approach World Health Organization. Cancer Pain Relief, with a Guide to Opioid Availability. Geneva, Switzerland: WHO, 1996. Leppert W, Luczak J. The role of tramadol in cancer pain management – a review. Support Care Cancer 2005;13:5-17. Mild Pain Moderate Pain Severe Pain Increasing Pain Fentanyl Hydromorphone Methadone Morphine Oxycodone (+/- nonopioid) (+/- adjuvants)
  11. 11. Pharmacological:Pharmacological: Non-OpioidNon-Opioid  Topical  Non-Opioid Analgesics ◦ Acetaminophen ◦ Anti-inflammatory medications  NSAIDs / COXIBs  Adjuvants (Co-analgesics) ◦ Anticonvulsants ◦ Antidepressants ◦ Others
  12. 12. Initiating Opioid TherapyInitiating Opioid Therapy Basic Considerations:  Patient opioid exposure and experience  Patient fears (stigma)  Caregiver and physician attitudes, preferences & biases  Compliance  Convenience  Cost Pharmaco-clinical Considerations: Patient sensitivities/allergies  Administration and absorption limitations  Metabolism and clearance  Opioid profile Fine PG. Journal of Pain, Aug. 2001
  13. 13. Starting Long Term Opioid TherapyStarting Long Term Opioid Therapy - Options- Options 1. Start with an IR opioid and titrate to effect. When dose stable  CR opioid ◦ Fastest method for pain relief 1. Start with CR opioid baseline dose and use IR opioid to titrate ◦ Once weekly add the total daily dose of IR to the CR dose and repeat weekly until dose stable 1. Start with oral CR opioid and titrate dose q3 days (or when adverse effects stable) ◦ For stable, chronic pain Patient Educational Material
  14. 14. Titrating Opioids - PrecautionsTitrating Opioids - Precautions  During titration, temporary drowsiness can occur  Patients should be advised not to drive or perform potentially hazardous activities while titrating the opioid dose – until tolerance to drowsiness occurs
  15. 15. Rational PolypharmacyRational Polypharmacy  Taper off of sedating medications ◦ i.e. sedatives, muscle relaxants, sleeping meds  For sleep try: tricyclics (amitriptyline, doxepin), trazodone, gabapentin, pregabalin, mirtazepine, quetiapine or olanzapine INSTEAD OF BENZODIAZEPINES  Optimize anti-depressant therapy (TCAs, venlafaxine, bupropion, duloxetine)  For anxiety and pain try SNRIs, SSRIs, gabapentin or pregabalin before resorting to benzodiazepines 15
  16. 16. Change the Dose or Dosing Interval ?Change the Dose or Dosing Interval ?  Start CR oral opioids on a q12h schedule  For end of dose failure, first try increasing the dose before changing schedule (most frequent q8h)  Move up to the next agent in the analgesic stepped approach  Initiate transdermal patch on a q72 hr (3-day) dosing schedule  Options for end of dose failure on the third day ◦ Increase the dosage of the q72 hr patch  A “pharmacologically stable dose” when the total daily dose is fixed for at least two weeks and frequency is scheduled and spread throughout the day AND/OR at least 70% of the prescribed opioid is CR
  17. 17. Switching Opioids – How ?Switching Opioids – How ? Relative Opioid PotencyRelative Opioid Potency  Approximate dose ratio of two opioids required to produce a similar degree of analgesia ◦ “equianalgesic tables”  Differs between acute and chronic dosing  Influenced by a number of variables ◦ Age, prior opioid exposure, route of administration, metabolism, and clearance abnormalities
  18. 18. Opioid Equianalgesic DosesOpioid Equianalgesic Doses OpioidOpioid OralOral ParenteralParenteral morphine 30 mg 10 mg codeine 200 mg 120 mg hydromorphone 4-6 mg 2 mg meperidine 300 mg 75 mg oxycodone 30 mg N/A in Canada 60-134mg oral morphine /day = 25 mcg/hr transdermal fentanyl Duragesic Product Monograph 2010
  19. 19. Switching Opioids – HowSwitching Opioids – How 1. Use opioid tables to calculate a total daily equianalgesic dose of the new opioid 2. Switch to 50-60% of the predicted dose of the new opioid and titrate to effect again • Decision to cut dose and by what percentage may depend on the reason for switch OR 1. Start the new opioid and titrate while decreasing the dose of the old opioid -SR morphine 15mg ~ CR oxycodone 10mg ~CR hydromorphone 3mg Jovey R. et al. Managing Pain. p. 94
  20. 20. Cytochrome P450 DrugCytochrome P450 Drug Interaction TableInteraction Table University of Indiana Department of Medicine  Most opioids metabolized by 2D6  Fentanyl and methadone metabolized by 3A4
  21. 21. Acute Adverse Effects of OpioidsAcute Adverse Effects of Opioids COMMON LESS COMMON RARE Side effect • Nausea and vomiting • Constipation • Sedation and drowsiness • Confusion • Myoclonus • Dry mouth • Urinary retention • Sweats • GE reflux • Pruritus • Respiratory depression (very rare in properly titrated patients)
  22. 22. Treatment of Common Acute OpioidTreatment of Common Acute Opioid Side EffectsSide Effects TREATMENT Nausea and vomiting • First line agents – Prochlorperazine 5-10 mg po q4-6h prn – Dimenhydrinate 12.5-50 mg po q4-6h prn (often too sedating) – Haloperidol 0.5-1 mg po daily-tid • If motility is an issue – Metoclopramide 10-20 mg po qid – Domperidone 10-20 mg po qid Constipation • Use dietary measures first (bran, flax, prunes) – Osmotics-MOM, lactulose – Stool softeners - docusate – Stimulants-senna, bisacodyl – Suppositories-dulcolax – Enemas
  23. 23. Long-term Effects of OpioidLong-term Effects of Opioid TherapyTherapy  Apparent opioid “tolerance” can be due to: ◦ Worsening underlying condition ◦ Pharmacological tolerance ◦ Opioid-induced abnormal pain sensitivity (hyperalgesia) ◦ Opioid addiction / diversion  Endocrine effects  effects on hypothalamic pituitary axis ◦ Decreased serum testosterone, estrogen  Opioid adverse effects on immune function? ◦ 2 studies in rats, 1 small study in humans with AIDs ◦ But unrelieved pain also impairs immune function** Ballantyne & Mao, NEJM 2003; 349(20): 1943-53 **Page GG, Adv Exp Med Biol. 2003;521:117-25.
  24. 24. Discontinuing Long-term OpioidsDiscontinuing Long-term Opioids  Why? ◦ Resolution of underlying problem  Dramatic decrease in pain ◦ Persistent unacceptable adverse effects in spite of careful titration and switching ◦ Repeated behaviours consistent with addiction / diversion ◦ Opioid hyperalgesia in spite of switching ◦ Patient wants to discontinue
  25. 25. Opioid Tapering ProtocolsOpioid Tapering Protocols 1. 50% of the previous daily dose x 2 days, then reduce the dose by 25% q2 days until the equivalent of 30mg/day of oral morphine, then D/C 2. 10% reduction per day, daily dispensing 3. 10% of total daily dose q1-2 weeks  Once one third of the original dose is reached, slow the taper to one half or less of the previous rate  Explain withdrawal symptoms to the patient !!  Manage withdrawal effects with clonidine, NSAIDs, loperamide HCI
  26. 26. Essential Follow-up DocumentationEssential Follow-up Documentation – the “6 A s”– the “6 A s” 1. Analgesia (pain relief) 2. Activities (physical and psychosocial functioning) 3. Adverse Effects (and your advice) 4. Ambiguous Drug Taking Behaviour (and your response) 5. Accurate medication record 6. Affect Jovey R. et al. Managing Pain. 2002 p. 121 Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Medicine 2005;6:107-112.
  27. 27. Appendix B-7: Example of documenting opioid therapy * Date Jan 13, 2008 Mar 23, 2008 Opioid type Oxycodone Oxycodone Opioid dose 20 tid 30 tid Pain worst 8 6 Pain least 3 3 Pain average 6 5 Pain right now 6 4 BPI functional improvement Sleep improved Back to work Adverse effects Nil Nil Medical complications UDS clear No concerns Compliance Increase to 30 tid Keep this dose Affect Other comments *The Canadian Guideline for Safe and Effective Use of Opioids For Chronic Non-Cancer Pain. May 2010.
  28. 28. Screening for AddictionScreening for Addiction RiskRisk
  29. 29. Concurrent Pain & AddictionConcurrent Pain & Addiction  Both pain and addiction can co-exist in the same patient  This does not necessarily preclude the use of opioid therapy, but…  …does require more attention (and time): ◦ More initial assessment ◦ More careful prescribing ◦ More behavioural monitoring ◦ More documentation
  30. 30. DefinitionsDefinitions Addiction:  Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations  It is characterized by behaviours that include one or more of the following: ◦ Impaired control over drug use, compulsive use, continued use despite harm, and craving 30 Douglas Gourlay, MD, FRCPC Liaison Committee for Pain and Addiction
  31. 31. DefinitionsDefinitions Physical Dependence:  Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. 31 Douglas Gourlay, MD, FRCPC Liaison Committee for Pain and Addiction
  32. 32. DefinitionsDefinitions Tolerance:  Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time  Tolerance develops at different rates, in different people, to different effects 32 Douglas Gourlay, MD, FRCPC
  33. 33. Primary Care Triage ofPrimary Care Triage of CNCP PatientsCNCP Patients 33 Group 1: Primary Care Patients – Low Risk No past, current, or family history of substance use disorders Represents the majority of patients who will present to the GP/FM Gourlay D. Pain Med 2005;6:107
  34. 34. Screening for Addiction / MisuseScreening for Addiction / Misuse RiskRisk  Previous history of substance abuse / addiction  Family history of substance abuse / addiction  Previous “chemical coping” with life stresses  Significant psychiatric diagnoses ◦ Bipolar ◦ Psychotic disorders ◦ Borderline, anti-social or psychopathic personality disorders  Previous high risk, impulsive behaviours (esp. criminal activity)  High risk home environment
  35. 35. Screening for Opioid Misuse RiskScreening for Opioid Misuse Risk  More detailed assessment: ◦ Take a history around drug and alcohol use  Age of first use, routes of use, current use EtOH and other drugs ◦ History of adverse consequences of EtOH/drug use  DWI,“black outs”, medical / social / legal complications ◦ Previous Treatment History  Residential v outpatient, mutual support (i.e.AA,NA) ◦ 3rd party corroboration (old charts, doctors, spouse)
  36. 36. Assessing Addiction Risk:Assessing Addiction Risk: C.A.G.E. – AIDC.A.G.E. – AID  Cut down on drinking or drug use  Annoyed or angered by others complaining about drinking or drug use  Guilty about consequences of drinking or drug use  Eye-opener drink or drug in the morning to decrease withdrawal effects • 1 point should raise concern in women • 2 or more means further assessment required Brown R. J Fam Pract 1997;44:151
  37. 37. Opioid Risk ToolOpioid Risk Tool  5 questions  5 minutes  Specific to pain & opioid use  Quantifies risk level  Non-confrontational  Easy to use Webster LR. Pain Med 2005
  38. 38. 38
  39. 39. Opioids for the Higher Risk PatientOpioids for the Higher Risk Patient  Generally younger age and/or Hx of substance abuse1  Confirm the diagnosis (addiction consult if available)  Try other (non-opioid) options first  Assess and document function up front  Written prescribing agreement  Collateral information / supportive network  Short dispensing intervals (part-fills)  Little or no use of IR/SA opioids for breakthrough pain  Urine drug screening  Document follow-up carefully 1. Reid MC et al. J Gen Intern Med 2002;17:173-9.
  40. 40. Initiating Opioid Therapy: OpioidInitiating Opioid Therapy: Opioid Prescribing AgreementsPrescribing Agreements  Principle Goals: ◦ Promote adherence ◦ Attain informed consent ◦ Manage legal risk ◦ Improve practice efficiency  Exercise caution before implementing  Think about why using; is content appropriate?  May not effectively meet goals; lack of evidence  May lead to opiophobia; strain physician-patient relationship; ethical considerations
  41. 41. Written Treatment AgreementsWritten Treatment Agreements  Recommended in all guidelines  NOT a ‘contract’  May help to demonstrate informed consent  Used to clearly set out patient AND physician expectations/responsibilities  Effective boundary setting tool  Must be readable, reasonable and have some flexibility 41 Creating and Implementing Opioid Agreements by Howard A. Heit, MD, FACP, FASAM
  42. 42. Appendix B-5: Sample Opioid Medication Treatment Agreement I understand that I am receiving opioid medication from Dr. to treat my pain condition. I agree to the following: 1. I will not seek opioid medications from another physician. Only Dr. will prescribe opioids for me. 2. I will not take opioid medications in larger amounts or more frequently than is prescribed by Dr.. 3. I will not give or sell my medication to anyone else, including family members; nor will I accept any opioid medication from anyone else. 4. I will not use over-the-counter opioid medications such as 222’s and Tylenol® No. 1. 5. I understand that if my prescription runs out early for any reason (for example, if I lose the medication, or take more than prescribed), Dr. will not prescribe extra medications for me; I will have to wait until the next prescription is due. 6. I will fill my prescriptions at one pharmacy of my choice; pharmacy name: ______________________________________________________________ 7. I will store my medication in a secured location. I understand that if I break these conditions, Dr. may choose to cease writing opioid prescriptions for me. Source: Modified from Kahan 2006 The Canadian Guideline for Safe and Effective Use of Opioids For Chronic Non-Cancer Pain. May 2010.
  43. 43. Opioids for CNCP –Opioids for CNCP – SafeguardingYour PracticeSafeguardingYour Practice  Document an adequate initial assessment  Record a working diagnosis and DDx  Document pain severity and impact on QOL  Document trials of non-opioid treatments  Record a treatment plan  Screen for addiction risk and psychosocial factors
  44. 44. Opioids for CNCP –Opioids for CNCP – SafeguardingYour PracticeSafeguardingYour Practice  Document informed consent  Remember “a trial of opioid therapy”  Use a written agreement for high risk patients  Record caution to avoid driving, etc. during dose titration  One prescriber, one pharmacist
  45. 45. Opioids for CNCP –Opioids for CNCP – SafeguardingYour PracticeSafeguardingYour Practice  Start with short dispensing intervals initially (i.e. part fills for 1 wk at a time) until trust established  Schedule follow-up visits at appropriate intervals  Record the 6A’s at each visit  Periodically reassess the patient’s progress, physical findings and the need for opioids  Avoid sedatives in patients on opioids – use rational polypharmacy  Know your limits and when to ask for help
  46. 46. College of Physicians and Surgeons of OntarioCollege of Physicians and Surgeons of Ontario Evidence-BasedEvidence-Based Recommendations for Management of Chronic Non-Malignant Pain - 2000Recommendations for Management of Chronic Non-Malignant Pain - 2000  Do… ◦ Screen for current and past alcohol and drug problems ◦ Try non-opioid medications and adjuvant treatments first ◦ Focus on improving function, not complete pain relief ◦ Implement a treatment agreement with your patient ◦ Titrate opioids carefully, looking for analgesic effectiveness, functional status, and adverse effects ◦ Switch to long-acting opioids ◦ Use breakthrough doses sparingly ◦ Keep a narcotic prescription flow sheet on the patient’s chart ◦ Make prescriptions “tamper-proof” 46
  47. 47. College of Physicians and Surgeons of OntarioCollege of Physicians and Surgeons of Ontario Evidence-Based Recommendations for Management of Chronic Non-Malignant PainEvidence-Based Recommendations for Management of Chronic Non-Malignant Pain - 2000- 2000  Use care and monitoring especially when: ◦ prescribing short acting opioids ◦ a prescription for opioids requested earlier than the expected or agreed time ◦ prescribing two or more different opioids at the same time ◦ prescribing two or more drugs with abuse potential, ie, opioids and benzodiazepines 47
  48. 48.  Don’t: ◦ Prescribe large quantities of short acting opioids ◦ Continue to prescribe opioids when there is evidence of non- compliance, escalation, misrepresentation, or fraud, e.g. double-doctoring or forgery ◦ Feel compelled to prescribe opioid or any drug if it is against your honest judgment or if you feel uncomfortable prescribing the drug 48 College of Physicians and Surgeons of OntarioCollege of Physicians and Surgeons of Ontario Evidence-Based Recommendations for Management of Chronic Non-Malignant PainEvidence-Based Recommendations for Management of Chronic Non-Malignant Pain - 2000- 2000
  49. 49. Take Home MessagesTake Home Messages  Screen for addiction risk in all patients  Set boundaries around medication use (Rx agreement)  Identify drug misuse behaviours early and intervene  Introduce opioids as a “trial of therapy” with agreed upon goals  Taper opioids when goals not achieved  The Canadian Guideline for Safe and Effective Use of Opioids For Chronic Non-Cancer Pain. May 2010. Gourlay D.L. Pain Med. 2005 Mar;6(2):107-12.
  50. 50. QuestionsQuestions  The Canadian Guideline for Safe and Effective Use of Opioids For Chronic Non-Cancer Pain. May 2010. Gourlay D.L. Pain Med. 2005 Mar;6(2):107-12.