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AMDA Guideline for Pain Management in LTC April 2015 CMDA Alan Miller RPh MS CGP How to Use Definition Recognition Assessment Treatment Monitoring Criteria Quality of Evidence – High: usually RCT – Moderate: room for uncertainty – Low: results doubtful Strength of Recommendation – Strong: benefit outweighs risk – Weak: benefits balanced – Insufficient: Hospice/Palliative Care AMDA Tool Kit Palliative Care in the Long Term Care Setting Persistent Pain Functional Impairment Falls Slow Rehabilitation Mood Changes Depression Anxiety Sleep and Appetite Disturbance Greater Healthcare Use Pain with Dementia Dementia Patients are often able to report pain PAIN-AD: Pain assessment in Advanced Dementia PACSLAC: Pain assessment check list for seniors with limited ability to communicate Barriers to Recognition and Treatment Patient Related Cultural and Social Provider related Facility related Facility Preparedness Communication Education Staffing Recognition Evaluate the patient for pain Have likely causes been defined Provide Appropriate Interim Treatment for Pain Assessment Perform a pertinent history and physical examination Assessment Are the causes of pain identified ? If Yes proceed to summarize Assessment If No Perform further diagnostic testing as indicated Assessment Have the probably causes of pain been identified? If yes proceed to Summarize Assessment Obtain additional evaluation or consultation as necessary Have the probably causes of pain been identified If no repeat the sections of assessment Assessment Summarize the characteristics and causes of the patient’s pain and assess the impact of pain on function and quality of life Treatment Review of nonpharmacologic options Treatment Adopt a patient centered interdisciplinary care plan Treatment Set goals for pain relief Treatment Implement the care plan Treatment Extensive discussion of: Principles of Analgesic Use Monitoring Re-evaluate the patient’s pain Adjust treatment as necessary Is pain controlled? Resolving Conflicts and Challenges in Pain Management Monitoring Monitor the facility’s performance in the management of pain Appendix Examples of Pain Scales Opioid Initiation and Titration Worksheet Model Transdermal Fentanyl Policy Methadone Use in LTC setting Appendix Adjuvant Analgesic Medications Algorithm of the Guideline Algorithm Two page algorithm of the guideline Add in this slide Principles of Analgesic Use General Principles for Prescribing WHO pain relief ladder Non Opioid Analgesics Recommendations for NSAID use Principles of Analgesic Use Topical Analgesics Opioid Analgesics Equianalgesic Dosing General Principles for prescribing and titrating opioids Opioid Titration Options Principles of Analgesic Use Treatment of Neuropathic Pain Table of Medications Principles of Analgesic Use Preventing and managing opioid induce bowel dysfunction and constipation Analgesics to Avoid in LTC NSAIDS: indomethacin, meclofenamate, piroxicam tolmetin due to GI and CNS side effects Meperidine: CNS and accumulation Analgesics to Avoid in LTC Partial opioid agonists butorphanol, nalbuphine, pentazocine due to ceiling effects associated with dysphoria and hallucinations May precipitate withdrawal in opioid dependent patients CAM Complementary and Alternative Medicine Therapies for Pain Opioid Induced Hyperalgesia Opioid Tolerance or Hyperalgesia? Key Symptoms Offer Clues. Medscape. Sep 16, 2013. Dr. Silverman is medical director of Comprehensive Pain Medicine in Pompano Beach, Florida. Findings of the clinical prevalence of OIH are not available "When a chronic pain patient isn't getting better, a clinician asks: is the patient developing a tolerance and needs more opioid or does he have opioid-induced hyperalgesia?" Key symptoms offer important clues Patients with opioid-induced hyperalgesia will develop an increased sensitization to pain that may be unlike their original pain. "The first thing to understand is this is a diffuse, spreading kind of pain," "Patients develop an acute insensitivity to pain even though they may be stable and functioning on their opiates." The distinction from the development of a tolerance should be clear. "This is not just a lack of efficacy of the pain medicine — that's tolerance, and everybody develops a tolerance to almost every exogenous thing. It's a defense mechanism your body engages in and is not hyperalgesia." A stabilizing of symptoms when opioids are increased should be a tip-off that the patient has in fact developed a tolerance to the drugs, and the response should help to disprove a diagnosis of hyperalgesia. Conversely, with hyperalgesia, there may also be an initial response, but the relief is typically fleeting Importantly, clinicians should rule out other factors, including the progression of a disease, such as cancer, or a new injury causing new pain. Additionally, hyperalgesia should not be mistaken for allodynia. Whereas hyperalgesia is characterized as a painful response to painful stimuli, allodynia involves oversensitized, increased pain in response to even nonpainful stimuli, such as just brushing against the skin. AMDA Elements of C-II Fax To expedite filling of a controlled substance prescription: Always carry a prescription pad that meets your state’s requirements. Know what information is required for a controlled substance prescription to be legal. C-II required elements: Date of issue Patient’s name and address (a nursing facility is the address for the resident) Practitioner’s name, address and DEA # Drug name Drug strength Dosage form Quantity prescribed Directions for use Number of refills (if any) authorized Manual signature of prescriber Colorado Regulation for Faxed C-II Must be faxed by the prescriber or their agent Must have “LCTF” or “Hospice” written on prescription when received by the pharmacy C-II Control Medications A Prescriber with a DEA license can request an emergency supply by calling the pharmacy and talking to a pharmacist Electronic Prescribing is possible EPCS (electron prescribing of control substances) Surescripts and OmniviewDr are current options
