1. Pain Management: Practicing the Art
M. Rachel McDowell, RN, MSN, ACNP-BC
Cancer Supportive Care Nurse Practitioner
Vanderbilt-Ingram Cancer Center

2. Goals of presentation Provide steps for developing treatment plan
Approach to titration (upward and downward)
Patient education
Consent for treatment
Utilization of controlled substance databases
Urine drug screens use and interpretation

3. Benefits of pain control
Earlier mobilization
Shortened hospitalization
Reduced cost
Improved QOL
Decrease in patient suffering

4. Pain Assessment Location Character Duration: when did this begin?
Achy
Sharp
Jabbing
Deep or Superficial
Burning, tingling, numbness
Duration: when did this begin?
Frequency: constant, intermittent, am, pm?

5. Intensity: Pain Scale
Lorne B. Yudcovitch, OD, MS, FAAO; College of Optometry, Pacific University; 2043 College Way; Forest Grove, OR “The Use of Anesthetics, Steroids, Non-Steroidals, and Central-Acting Analgesics in the Management of Ocular Pain” Retrieved from

6. Treatment Plan Goal of Therapy: Decrease pain level
Pain is mostly controlled, most of the time
Increase level of function
Minimal side effects from regimen
Time frame – acute or chronic
Treatment Plan:
After Assessment, and you have decided pt needs to be on opioids:
Goal of therapy: decrease in pain level, increase in function, minimal side effects from regimen.
What is their current regimen? On opioids or not
Definition of opioid naïve/tolerant, weighing in clinical presentation of clinic.
Differences in ages
Is it working? Continue if working,
If not then change meds or approach – opioid appropriate or different modality
Medication regimen
Starting opioid naïve: low and slow
Titration Long acting, short acting dosing
Conversion
Adjuvant meds
Non-pharm measures
New patient information packet:
Consent for treatment with controlled substance.
Pain diary
Pt education:
Side effects: constipation, sedation, GI upset
Information about prescribed opioid
How to take opioid properly
Adherence to dosing regimen
Risk from breaking, chewing, crushing certain products
Concomitant use of other CNS depressants, alcohol, or illegal drugs
Establishment of goals of treatment
Re-evaluation:
Tolerance,
missed doses,
not following treatment plan
TN PMP utilization (Utilization of prescription monitoring programs to identify potential abuse) and UDS use; UDS interpretation.
Understanding the role of drug testing
Monitoring patients for misuse and abuse
Discontinuation: why and when and how

7. Important Factors Etiology of pain, prognosis
Stage 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 status
History or current issue with drug misuse/abuse
What kind of insurance do they have or not?
How capable is the patient in understanding plan?

8. Treatment Options Treat underlying cause Non-pharmacological measures
No single modality done in isolation will be effective for most patients with chronic noncancer pain (CNCP) (Ashburn, Staats, Lancet 1999)

9. Nonpharmacologic Options
Biofeedback
Relaxation therapy
Physical and occupational therapy
Cognitive/behavioral strategies
Guided imagery
Acupuncture
Transcutaneous electrical nerve stimulation
Positioning
Rest, activity
Massage
Heat and cold

10. Treatment for pain Identify the cause of the pain
Primary treatment if indicated
Radiation
Surgery
Hyperbaric treatment
Interventions: Nerve Block, Kyphoplasty
Medications

11. Interventional Techniques
Interventional Therapies
Trigger points
Acupuncture
Nerve blocks
Facet denervation
Intrathecal pumps

12. Medications Somatic/Nociceptive Pain Neuropathic Pain Bony Pain
Opioids
NSAIDS
Neuropathic Pain
Anticonvulsants
Antidepressants - SNRIs
Bony Pain
Steroids

13. Pharmacotherapeutics and the Nervous System
Brain
Descending Modulation
Anticonvulsants
Tricyclics, SNRI
Opioids
CNS
Central Sensitization
Anticonvulsants
Opioids
NMDS-Receptor Antagonists
Tricyclic/SNRI Antidepressants
PNS
Spinal Cord
Peripheral Sensitization
Local Analgesics
Topical Analgesics
Anticonvulsants
Antidepressants
Opioids

14. Guidelines for opioids
WHO ladder combined with etiology-specific therapies for syndromes
pharmacologic and nonpharmacologic interventions
long-acting + short-acting opioids
adjuvant medications for neuropathic pain
NSAIDs and steroids can be helpful when there is an inflammatory component to pain

15. WHO Guidelines for Cancer Pain
STEP 1
STEP 2
STEP 3
GOAL:
Freedom From Pain
Pain Persists
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
(Adapted from Portenoy et al, 1997)

16. Opioid Selection No perfect opioid Pre-treat likely side effects
Must recognize individual responses to opioids may vary
Response and side effects
Hydrocodone vx. Oxycodone
Sequential trials of different opioids – alone or in combination – may be necessary to optimize therapy

17. Common Analgesics Demerol Butrans Morphine Sulfate IR
Morphine Sulfate ER
Percocet
OxyContin
Dilaudid
Exalgo
Lortab
Fentanyl patches
Opana IR
Opana ER
Oxycodone
Methadone
Tramadol

18. Pure Opioid Agonists Pure Opioid agonist
No ceiling effect for analgesia
Single-entity for moderate to severe pain
May be a role for combined opioids in certain subsets of patients

19. Current Regimen Opioid Naïve: Opioid Tolerant
Never been on opioids before
Only 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

20. Differences in older adult
Experience higher peak and longer duration of drug action
Age-related changes in drug distribution and elimination make more sensitive to sedation and respiratory distress
Pain perceived differently
Physiologic
Psychological
Cultural changes
Altered presentations
Aging does NOT increase Pain threshold
Older adults (esp frail and old-old) at risk for too little or too much

21. General Approach Start pt on short acting Titrate up for pain relief
Once stable convert to long acting
Add amount of short acting for 24 hours
Convert to long acting
Continue short acting for breakthrough pain
10-15 % of 24 hour total narcotic

22. Advantages of Long-Acting Opioids
More predictable serum levels
More predictable pain relief
Avoids mini-withdrawals
Easier to use; improved compliance
Greater Patient satisfaction
Less reinforcement of drug-taking behavior

23. Titration of Opioids
Titrate to adequate pain control. Appropriate dose adjustments are critical to adequate pain control. Adjustments are indicated under the following circumstances
If the patient has been taking more than 4 rescue doses per day
If the patient rates pain as greater than 4/10
If the patient complains the pain is inadequately controlled
Narcotic total= Fixed Dose + Rescue

24. Dose Titration Based 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)

25. 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.

26. The 24-hour narcotic total is:
(60 mg x 2 doses)
+ (15 mg x 8 doses) =
120 mg mg = 240 mg.

27. Dose Titration Moderate pain (5/6): Severe pain (7+): Rescue dose:
Dose 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 PRN
Accommodate increase if pt frail, sick, or elderly 27

28. Case Study
Pt reports 6/10 pain, therefore he requires a 25 % increase in medication.
2. Pt’s 24 hour narcotic total = ___ mg morphine

29. Step 1: Increase dose by 25% 24 NT mg + (24 NT x .25) =
New long acting dose

30. Step 2: Determine the new fixed dose
New fixed dose / 2 doses per day =
X mg bid

31. Calculate the rescue dose
Step 3
Calculate the rescue dose
10% of NT mg = X mg
New rescue order =
MSIR X mg q2h prn

32. Old regimen
MSER 60 mg bid
MSIR 15 mg q 2 prn
New regimen
MSER 150 mg bid
MSIR 30 mg q 2 prn

33. Case Study
Pt reports 8/10 pain.
What do you do?

34. Pt’s 24 hour narcotic total = 240 mg morphine
Pt reports 8/10 pain, therefore he requires a 50 % increase in his medication.
Pt’s 24 hour narcotic total =
240 mg morphine 34

35. Step 1:
Increase dose by 50% 24 NT mg + (24 NT x .50) = 240 mg + ___ = ___ mg 35

36. Step 2:
Determine the new fixed dose
? mg / 2 doses per day = ? mg 36

37. Step 3: Calculate the rescue dose 10% of new 24 NT = ___ mg
New rescue order =
MSIR ___ mg q2h prn 37

38. Old regimen
MSER 60 mg bid
MSIR 15 mg q 2 prn
New regimen
MSER 180 mg bid
MSIR 30 mg q 2 prn

39. Equianalgesia Opioid Equianalgesic Dose Morphine 30 mg po Dilaudid
Hydrocodone
Oxycodone
Codeine
180 mg po
Opana
Use conversion calculator 39

40. Fentanyl Doses based on Daily Oral Morphine Dosage
24-hour oral morphine dose (mg/day)
Transdermal fentanyl dose (mcq/hour)
30-90 25
91-150 50 75
100
Every additional 60 mg per day
An additional 25 mcq per hour Or
The ratio is 2:1
2 mg oral morphine per DAY ~ 1 mcq fentanyl patch

41. Fentanyl Patch
In pts currently on opioids, conversion factor for Morphine to Fentanyl is 2:1
Fentanyl patch is 2X more potent than morphine PO
If the 24 hr narcotic total= 180 mg morphine
Fentanyl dose= ___ mg (use nearest fentanyl patch size) 41

42. 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. 42

43. Case Study 7.5 mg/hr X 24 = 180 mg morphine IV/24
IV Narcotic total = 186 mg IV
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) 43

44. 4. Rescue dose is 10% = 60 mg morphine q 2 hours prn
5. Long acting dose = 280 mg morphine bid 44

45. Old regimen:
7.5 mg/hour CIV, with 1 mg q 10 minutes prn
New Regimen:
MSER 280 mg bid
MSIR 60 mg q 2 prn

46. Case Study
A 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?

47. Calculations 72 mg dilaudid IV X 5 = 360 mg IV morphine
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

48. 3. Narcotic total = 360 mg IV morphine/24 hours
4. Multiply IV by 3 to obtain PO dose
360 x 3 = 1080 mg morphine in 24 hours PO
5. Breakthrough dose = 10 % of 24 hour narcotic total
MSIR 30 mg, 3 tabs po q 2 prn
Dilaudid 8 mg, 2 tab po q 2 prn

49. MS Contin 100 mg, 5 tabs po BID MS Contin 100 mg, 3 tabs po TID
6. The q12h dose = 500 mg morphine SR PO q12h
MS Contin 100 mg, 5 tabs po BID
MS Contin 100 mg, 3 tabs po TID

50. Dilaudid 8 mg, 2 tabs po q 2 prn
Old regimen:
3 mg/hr dilaudid IV
New regimen:
MS Contin 100 mg, 5 tabs po BID
MS Contin 100 mg, 3 tabs po TID
Rescue dosing
MSIR 30 mg, 3 tabs po q 2 prn or
Dilaudid 8 mg, 2 tabs po q 2 prn

51. 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 51

52. CNS: Irritability, anxiety, narcotic withdrawal, restlessness, seizure
Cardiovascular: Hyper-/hypotension, tachycardia, ventricular arrhythmia, cardiac arrest
CNS: Irritability, anxiety, narcotic withdrawal, restlessness, seizure
Gastrointestinal: Nausea, vomiting, diarrhea
Neuromuscular & skeletal: Tremulousness
Respiratory: Dyspnea, pulmonary edema 52

53. Use of Narcan in Narcotic overdose:
I.V. (preferred), I.M., intratracheal, SubQ: mg every 2-3 minutes as needed; may need to repeat doses every minutes.
If no response is observed after 10 mg, question the diagnosis.
Note: Use mg increments in patients who are opioid dependent and in postoperative patients to avoid large cardiovascular changes. 53

55. Adjuvant Analgesics TCAs SNRIs Anticonvulsants Desipramine Elavil
Cymbalta
Savella
Anticonvulsants
Neurontin/Gabapentin
Lyrica
Joint/Bone pain: NSAIDS – potentiate opioids
Methadone
Lidoderm patches

56. TCAs and SNRIs
Desipramine: 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

57. Anticonvulsants Neurontin/Gabapentin Lyrica
Maximum daily dose: 3600 mg
Start low and titrate up to max dose
100 mg qid
Lyrica
Maximum daily dose: 300 mg
Start at 25 or 50 mg tid
Problematic Side Effect: sedation

58. Bony or Metastatic pain
NSAIDS
Ibuprofen 800 mg tid
Naproxen 600 mg bid
Diclofenac 100 mg bid
Steroids
Medral Dose Pak

59. Methadone Possible duel mechanism of action Relatively inexpensive
Somatic and neuropathic pain relief
Relatively inexpensive
Available as a liquid
Long half-life
Accumulates with repeat doses with limited analgesic effect
Complex pharmacokinetics
No known active metabolites
Conversion tables underestimate potency
Cardiac Toxicity
Recommend specialized training before prescribing as NP

60. Lidoderm Patch Lidocaine 5% in dermal patch On 12 hours, off 12 hours
FDA approved for shingles
Drug interaction and side effects are unlikely – most common is skin sensitivity
Mechanical barrier decreases allodynia

62. Patient Education How the medication will impact their pain
How to take medication.
What the medication is treating
Potential side effects, like constipation.
When to call doctor’s office. 62

63. Patient Education How 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

64. Consent for Treatment Sources

65. Patient education Patient’s responsibility Clinician’s responsibility
Urine Drug Screen
Use of drugs other than prescribed, and consequences

66. Re-evaluation Changes in pain (level, location, frequency, character)
Level of function
Average pain level
Worst pain level
Side effects
Benefits
Adherence to medication regimen (missed or extra doses)

67. Titrating off Opioids
Indicated if pt unable to take medications safely
If pt’s level of function is declining
If medication is not effectively decreasing or controlling their level of pain
Dose reduce in increments of 25% at a time
No faster than hours.

69. Monitoring for abuse State Controlled Substance Database Reports
Frequent evaluations, with good documentation
Lost or stolen drugs: Must report to police department
Check for placement of fentanyl patches
Urine Drug Screens – random, or when there is aberrant behavior

70. Interpretation of UDS Results
Important to understand what the results mean
If question, call lab to check results

71. Drug
Major Cmpds
Minor Cmpds
Codeine
Morphine
Dihydrocodeine
Hydrocodone
Hydromorphone
Oxycodone
Oxymorphone
Fentanyl
**may not be picked in opiate screen
Heroin/diamorphine
6MAM by specific assay
Marijuana
Carboxy-THC
**many false +screen
Cocaine
Benzoylecgonine

72. Results
CANNABINOIDS (SCREEN) Positive Immunoassay(cut-off 20 ng/mL); confirmation to follow THC CONFIRMATION Positive for Carboxy-THC Cannabis metabolite cut-off 15 ng/mL COCAINE METAB (SCREEN) Positive Immunoassay(cut-off 300 ng/mL); confirmation to follow BEG CONFIRMATION Positive for Benzoylecgonine Cocaine metabolite cut-off 150 ng/mL

73. 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

74. 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

75. How to protect yourself
Documentation
UDS
Consent for treatment
Controlled Substance Database Report
Frequent re-evaluation
Communication (with your team and other providers)
Patient Education
Consistency

76. Addressing Aberrant Drug-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) 76

77. 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 77

79. Considerations for the Nurse Practitioner
Regulations – State law, Boards of Nursing and Medicine
Safe Practice
Requirements by the State Board of Nursing and Board of Medicine
Prescriptions

80. Evaluation of Quantity and Chronicity
Documented appropriate diagnosis
Treatment of recognized medical indication
Documented persistence of recognized medical indication
Properly documented follow-up evaluation with appropriate continuing care

81. Writing Prescriptions
Prescriptive authority varies state by state
NPs denied any prescriptive authority
Limited prescriptive authority – i.e. NP can only write 72 hours worth of pain medication
Full prescriptive authority granted to NPs.
For specifics visit:

82. Safe Prescription Writing
Pt’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.

83. Morphine Sulfate Immediate Release 30 mg
Vanderbilt University Medical Center Barbara Murphy, M.D. M. Rachel McDowell, APRN-BC 1956 The Vanderbilt Clinic Nashville, TN (615)
Name: John Doe DOB:
Date:
RX:
Morphine Sulfate Immediate Release 30 mg
SIG: One tab PO Q 2 hours prn pain
Disp: #56 (fifty six) (2 week supply)
Max of 4 tabs in a 24 hour period
0 (ZERO) refills
Signature: Mary Rachel McDowell, APRN-BC
DEA #: MMM

84. Helpful Websites American Pain Society Partners against Pain
Partners against Pain
International Association for the Study of Pain
The Joint Commission
American Academy of Pain

85. 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)
American Academy of Pain Medicine (AAPM)
American Society of Addiction Medicine (ASAM)
Pain and Policy Studies Group for the University of Wisconsin Comprehensive Cancer Center
United States Drug Enforcement Administration
Taken from Partners Against Pain Web site

86. Food and Drug Administration http://www.fda.gov
The Substance Abuse and Mental Health Services Administration (SAMHSA)
The National Association of Drug Diversion Investigators (NADDI)
Local law enforcement
Local addiction treatment specialists/centers
Taken from Partners Against Pain Web site

87. References
Katz, 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, (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, (Sept. 30, 2005)

88. Passik SD, Portenoy RK. Substance abuse issues in palliative care
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:
Loeser et al, 2001; Portenoy et al, 1996)
Besson, JM. The neurobiology of pain. Lancet ;353:

89. Questions