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

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

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

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?

Intensity: Pain Scale Lorne B. Yudcovitch, OD, MS, FAAO; College of Optometry, Pacific University; 2043 College Way; Forest Grove, OR 97116 “The Use of Anesthetics, Steroids, Non-Steroidals, and Central-Acting Analgesics in the Management of Ocular Pain” Retrieved from http://www.google.com/imgres?imgurl=http://pacificu.edu/optometry/ce/courses/22746/images/clip_image002.jpg&imgrefurl=http://www.pacificu.edu/optometry/ce/courses/22746/ocularpainpg1.cfm&h=274&w=564&sz=37&tbnid=BdvVnqYJnZHq3M:&tbnh=65&tbnw=134&prev=/images%3Fq%3DPain%2BAssessment%2Bscales&hl=en&usg=__TdhB-pWbp_ouIYHvwQ4FJ1dHzgw=&ei=BBR2S6T_IMGXtgeCnqSlCg&sa=X&oi=image_result&resnum=7&ct=image&ved=0CCEQ9QEwBg

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

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?

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)

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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)

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 50 151-210 75 211-270 100 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

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

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

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

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

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

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?

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

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

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

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

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

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

Use of Narcan in Narcotic overdose: I.V. (preferred), I.M., intratracheal, SubQ: 0.4-2 mg every 2-3 minutes as needed; may need to repeat doses every 20-60 minutes. If no response is observed after 10 mg, question the diagnosis. Note: Use 0.1-0.2 mg increments in patients who are opioid dependent and in postoperative patients to avoid large cardiovascular changes. 53

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

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

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

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

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

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

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

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

Consent for Treatment Sources https://tnm.rxportal.sxc.com/rxclaim/TNM/PtMedMngtAgrmt.pdf http://www.painmed.org/Workarea/DownloadAsset.aspx?id=3211

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

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)

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 48-72 hours.

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

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

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

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

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

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

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

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

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 http://www.usdoj.gov/dea/presrel/pr102301.html 77

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

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

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: http://www.medscape.com/viewarticle/439917 http://www.bartonassociates.com/nurse-practitioners/nurse-practitioner-scope-of-practice-laws/

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.

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 37232 (615) 322-3677 Name: John Doe DOB: 01-01-01 Date: 10-10-05 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 #: MMM111111111

Helpful Websites American Pain Society Partners against Pain http://www.ampainsoc.org/ Partners against Pain http://www.partnersagainstpain.com/index.aspx?sid=27 International Association for the Study of Pain http://www.iasp-pain.org//AM/Template.cfm?Section=Home The Joint Commission http://www.jointcommission.org/ American Academy of Pain http://www.aapainmanage.org/Management

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) http://www.ampainsoc.org American Academy of Pain Medicine (AAPM) http://www.painmed.org American Society of Addiction Medicine (ASAM) http://www.asam.org Pain and Policy Studies Group for the University of Wisconsin Comprehensive Cancer Center http://www.medsch.wisc.edu/painpolicy United States Drug Enforcement Administration http://www.dea.gov Taken from Partners Against Pain Web site

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

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, http://gateway.ut.ovid.com/gw1/ovidweb.cgi, (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, 2005 http://www.medscape.com/viewprogram/3765_pnt, (Sept. 30, 2005)

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; 1998:576-586. Loeser et al, 2001; Portenoy et al, 1996) Besson, JM. The neurobiology of pain. Lancet. 1999;353:1610-1615 .

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