Download Chronic Pain in Primary Care: Overview and Pathophysiology

Chronic Pain in Primary Care:
Designing and Implementing a
Management Plan
Module 3
Paula Worley, MSN, RN, FNP-BC
Diane Tyler, PhD, RN, FNP-BC, FNP-C, FAAN
Mary Lou Adams, PhD, RN, FNP-BC, FAAN
Frances Sonstein, MSN, RN, FNP, CNS
Stephanie Key, MSN, RN, CPNP-PC
The University of Texas at Austin School of Nursing
Consultants:
Yvonne D’Arcy, MSN, RN and JoEllen Wynne, MSN, RN, FNP-BC, FAANP
Objectives:
1.
Describe elements of a comprehensive
treatment plan for chronic pain in primary care.
2.
Discuss documentation of the treatment plan
that will include pharmacologic and nonpharmacologic interventions.
3.
Identify resources for the effective use of
pharmacologic modalities.
4.
Identify resources for the effective use of nonpharmacologic modalities.
Significance of Chronic Pain

Common reason for primary care visits

Expectation of patient? Pain medication

Prescribers’ fear
◦ Patient addiction, misuse or diversion
◦ Causing harm
◦ Legal ramifications
Prescription Drug Abuse

CDC reported 76% of the 12 million
Americans abusing prescription drugs are
consuming drugs that were prescribed to
someone else (Horswell, 2012).

Prescribers’ concerns are real.
Prescription Drug Monitoring Project
PDMP

PDMP is a federal initiative providing a
forum for information sharing on
prescription drug use among state and
federal agencies.

Goal is to curtail drug diversion and abuse
while ensuring patient care.
http://www.pmpalliance.org
Eight Point Treatment Plan
1.
2.
3.
4.
5.
6.
7.
8.
Based on comprehensive assessment
Goals for functional improvement
Pain management agreement
Informed consent for treatment
Assessments at regular intervals
Pharmaceutical Modalities
Non-pharmaceutical Modalities
Documentation
Eight Point Treatment Plan:
1. Comprehensive Assessment
Complete physical exam
 Diagnostic testing
 Medication and supplemental history
 Benefit to harm analysis

Eight Point Treatment Plan:
2. Goals for Functional Improvement

Measurable and realistic

Agreed upon by prescriber and patient

Based on improvement in function

Improvement in tolerance to exercise
Eight Point Treatment Plan:
3. Pain Management Agreement
 Purpose
◦ Reduce the risk of prescribing
◦ Assist in compliance with legal requirements
◦ Prevent misunderstandings about certain
medications
◦ Document consequences of breaking agreement
Eight Point Treatment Plan:
3. Pain Management Agreement (Continued)
 Patient agrees:
◦
◦
◦
◦
◦
◦
◦
◦
To communicate fully about pain experience
Not to use recreational drugs
Not to share, sell or trade medications
To use one pharmacy
Not to request narcotics outside of business hours
That “lost prescriptions” will not be replaced
To have random drug screenings
Not to go to the ER without prescriber’s permission
www.aapainmanage.org
Eight Point Treatment Plan:
4. Informed Consent for Treatment
 Pain management agreement

Disclosure of risk and benefits

Frequency of assessment
Eight Point Treatment Plan:
5. Assessment at Regular Intervals

Frequency varies by state but at least
every 3 months

Assess
◦
◦
◦
◦
Pain intensity
Progress toward functional goals
Adverse effects
Screening for abuse and misuse
Eight Point Treatment Plan:
5. Assessment at Regular Intervals
Screening Tools for abuse/misuse

Current Opioid Misuse Measure (COMM)

Pain Assessment and Documentation Tool
(PADT) – 4 “A”s
◦
◦
◦
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Analgesia
Activities of daily living
Adverse events
Potential Aberrant drug-related behavior
Eight Point Treatment Plan:
6. Pharmaceutical Modalities
Analgesic Ladder
World Health Organization
Analgesic Ladder:
Levels of Pain Severity (rating scale)

Mild (1 – 3/10)

Moderate (4 – 6/10)

Severe (7 – 10/10)
Eight Point Treatment Plan:
6. Pharmaceuticals
 Simple analgesics

Adjunctants

Weak opioids

Strong opioids
Eight Point Treatment Plan:
6. Pharmaceuticals – Simple Analgesics

Acetaminophen

NSAIDS
◦ Selective cox 2 inhibitors – celecoxib and
meloxicam
◦ Non-selective – ibuprofen and naproxen
Eight Point Treatment Plan:
6. Pharmaceuticals – Simple Analgesics
Acetaminophen
 Dosage 325 – 1000 mg every 4 – 6 hours.
 Maximum daily dose reduced from 4,000 to
3,000 mg/day - aimed at reducing accidently
overdose
 Black Box warning – associated with acute
liver failure
 Contained in multiple cold/allergy products;
daily dose can be exceeded without patient
awareness
Eight Point Treatment Plan:
6. Pharmaceuticals – Simple Analgesics
NSAIDs
 Action is inhibiting cox, an enzyme
responsible for inflammation and pain

Weigh benefits versus increased risk of
◦ Increased CV events –Black Box Warning
◦ Erosive gastritis and small bowel ulcerations
(Goldstein, et al, 2005)
◦ Blood pressure elevation
◦ Worsening renal insufficiency
Eight Point Treatment Plan:
6. Pharmaceuticals – Adjunctants

Antidepressants

Anxiolytics

Muscle relaxers

Steroids
Eight Point Treatment Plan:
6. Pharmaceuticals – Adjuctants
Anti-depressants
 Depression is a component of chronic pain
for more than 80% of patients

Suicide rate for patients with chronic pain is
higher than other patients in the same age
group without chronic pain (D’Arcy, April 2009)
Eight Point Treatment Plan:
6. Pharmaceuticals – Adjunctants
Anxiolytics

Antidepressants are effective anxiolytics,
and some classes provide pain relief

Benzodiazepines:
◦ Helpful in short term management as antidepressants take affect
◦ Potentially can disrupt sleep architecture and
worsen depression
Eight Point Treatment Plan:
6. Pharmaceuticals – Adjunctants
Muscle Relaxers
 Lower the level of pain experienced
 Increase flexibility and range of motion
 Reducing spasms and involuntary muscle
contractions
 Examples: carisoprodol, cyclobenzaprine
 Side effect: sedation
Eight Point Treatment Plan:
6. Pharmaceuticals – Adjunctants
Corticosteroids
Anti-inflammatory for chronic swelling of
joints and tendons
 Often reserved for flare-ups or episodes of
acute pain associated with long term
conditions
 Side effects:

◦ short term – emotional lability
◦ long term – osteoporosis, adrenal suppression.
Eight Point Treatment Plan:
6. Pharmaceuticals – Weak Opioids

Opioid agonist – binding with the mu
(CNS opioid) receptors and are weak
reuptake inhibitors of norepinephrine and
serotonin.
◦ Caution for serotonin syndrome
◦ May be habit forming
◦ Cardiac and respiratory depression
Eight Point Treatment Plan:
6. Pharmaceuticals – Weak Opioids
Tramadol

Dosage 50 – 100 mg/4 – 6 hours

Max 400 mg/day, 300 mg/day in elderly

CKD reduce dosage by half and frequency
increased to every 12 hours
Eight Point Treatment Plan:
6. Pharmaceuticals – Weak Opioids +
Simple Analgesics

Codeine 15 – 60 mg every 4 – 6 hours (max 360
mg/day) + 300 mg acetaminophen

Hydrocodone 2.5 – 10 mg (max 1 gm/4 hours) +
acetaminophen 300 mg or 7.5 mg with 200 mg
ibuprofen

Adverse effects:
◦ Nausea/vomiting (give with food)
◦ Constipation
◦ Cardiac and respiratory depression & sedation
Eight Point Treatment Plan:
6. Pharmaceuticals – Strong Opioids
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Morphine 5 – 10 mg per hour
Fentanyl 25 mcg per hour
Dilaudid 1 – 4 mg per hour
Oxycodone - 10 – 80 mg tablets
Merperdine – Prolonged use may increase the risk of
toxicity (e.g., seizures) from the accumulation of
metabolite, normeperidine
Most stronger opioids – titrated dose to desired effect
Great caution needs to be exercised to avoid life
threatening respiratory depression, sedation, weakness,
seizures and confusion
Eight Point Treatment Plan:
7. Non-Pharmaceuticals
 Acupuncture
 Manual
therapy
 Exercise
 TENS
 Thermal Therapy
Eight Point Treatment Plan:
7. Non-Pharmaceuticals
Acupuncture
 Most widely used Complimentary &
Alternative Therapy in the US
 Thin needles are inserted into the skin
 Needles are stimulated to release
neurotransmitters
 Shown to improve function in
◦ Osteoarthritis
◦ Fibromyalgia
◦ Back pain
Eight Point Treatment Plan
7. Non-Pharmaceuticals:
Manual Therapy

Massage - NIH defines as pressing, rubbing
on soft tissues

Deep tissue or lighter technique

Applied near site of pain thought to activate
inhibitory neurons to close the gate on
painful impulses
Eight Point Treatment Plan
7. Non-Pharmaceuticals
Exercise

Moving, stretching, low impact aerobics,
pool & physical therapy, yoga
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Endorphin release to reduce pain
Increase flexibility
Muscle strengthening
Improve mood
Eight Point Treatment Plan:
7. Non-Pharmaceuticals
TENS

Transcutaneous Electrical Nerve Stimulation
◦ Release of endorphins
◦ Block deep sensations of pain

Portable machines are available at very
affordable prices
Application of Heat

Increase circulation to affected area
reducing
◦ Stiffness
◦ Pain
◦ Muscle spasms

Caution
◦ Short periods of time
◦ To avoid burns, never use over:
 Areas of poor circulation
 Mentholated creams or medication patches
Eight Point Treatment Plan:
Non-Pharmaceuticals –
Application of Cold
Decreased nerve conduction
 Vasoconstriction


Caution
◦ Short periods of time
◦ Frequently monitor skin condition
◦ With patients with diabetes and CV disease
Eight Point Treatment Plan:
8. Documentation in Medical Record
 Clear
 Detailed
 Systematic
 Consistent with evidence
 Therapies offered, accepted and declined
 Comprehensive assessment of
Analgesic, ADL, Adverse events,
screening for Aberrancy
Consider Referral

If not progressing toward functional goals

Side effects are unacceptable

Experience of pain is not improving

Violation of pain management agreement
Consider Consult

To share responsibility and liability

To confirm or adjust pain management
treatment plan
Where to Refer
Pain management
 Drug rehab
 Resources for further information:

◦ Responsible Opioid Prescribing: A Clinician’s Guide
by Scott M. Fishman, MD
◦ American Academy of Pain Management
◦ American Pain Society
◦ www.PainEDU.org
Implications of a Comprehensive
Treatment Plan
Effectively managing chronic pain using a
comprehensive plan can safely and
powerfully impact patients’ lives…
Allowing patients to participate more fully
in the activities that give them enjoyment a
sense of worth, purpose & fulfillment.
References
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Bennett, J. S., Daugherty, A., Herrington, D., Greenland, P., Roberts, H., & Taubert, K. A.
(2005). The use of non-steroid inflammatory drugs (NSAIDs): A science advisory from the
American Heart Association. Journal of the American Heart Association, 111, 1713-1716.
D’Arcy, Y. (2009, April). Be in the know about pain management. Nurse Practitioner, 34(4), 4347. Retrieved from http://journals.lww.com/tnpj/toc/2009/04000
D’Arcy, Y. (2009). Chronic opioid therapy clinical guidelines. The Nurse Practitioner, 34(10), 1315. DOI: 10.1097/01.NPR.0000361298.80778.10
D’Arcy, Y. (2011). Compact clinical guide to acute pain management: An evidence-based approach
for nurses (pp. 171-194). New York, NY: Springer.
Fine, P., & Portenoy, R. (2004). A clinical guide to opioid analgesia. New York: McGraw Hill.
Goldstein, J. L., Eisen, G. M., Lewis, B., Gralnek, I. M., Zlotnick, S., & Fort, J. G. (2005).Video
capsule endoscopy to prospectively assess small bowel injury with celecoxib, naproxen plus
omeprazole, and placebo. Clinical Gastroenterology and Hepatology, 3, 133–141.
Horswell, C. (2012, March 20). New law puts heat on 'doctor shoppers.' The Houston
Chronicle. Retrieved from http://www.chron.com/news/houston-texas/article/New-law-putsheat-on-doctor-shoppers-3416651.php
Macias, A. (2011). State legislatures attempt to shut down the pill mills. Bulletin of the
American College of Surgeons, 96(11), 38-39.
Sullivan, M. D. & Robinson, J. P. (2006). Antidepressants and anticonvulsants medication for
chronic pain. Physical Medicine and Rehabilitation Clinics of North America. 2006 May;17(2):381400, vi-vii.
Post Test Questions
1. The majority of prescription drug abuse in
the US is with medications:
a. That are prescribed to the
patient/offender.
b. That were purchased on the street.
c. That were prescribed to someone else.
d. That were stolen.
2. True/False: All states in the US have a fully
functioning Prescription Drug Monitoring Project
for prescribers of opioids.
3. Which of the following is not usually found in a
pain management agreement?
a. The patient agrees to one pharmacy
b. The patient agrees to not use recreational
drugs
c. The patient designates one person that may
pick up their medications.
d. The patient agrees that lost prescriptions will
not be replaced.
4. Additionally, which of the following are not
included in a pain management treatment
plan:
a. To communicate fully about pain
experience.
b. Not to request narcotics outside of
business hours.
c. That “lost prescriptions” will not be
replaced
d. To go to the ER after hours for
breakthrough pain.
5. Assessment at regular intervals should always
include:
a. Functional goals achieved.
b. Intensity of pain
c. Drug screening
d. Screening for abuse/diversion
6. True/False: When moving from mild opioids
to strong opioids and calculating dosage,
prescribers should decrease dosage by 10%.
7. Reasons to refer to pain management are all of the
following except:
a. Patient is requiring an increase in pain medication.
b. Side effects are unacceptable.
c. The prescriber desires consult with specialist.
d. Patient is not able to progress toward functional
goals.
e. Patient’s medications were lost or stolen.
8. Documentation should include all of the following
except:
a. Intensity of pain
b. Functional goals
c. Adverse events
d. Patient’s mode of transportation
e. Screen for abuse/diversion
9. Resources for the prescriber are available through all of
the following except:
a. Pain management specialist
b. Pain.edu website
c. The American Academy of Pain Management
d. The Department of Public Safety
10. What class of pharmaceutical is thought to interfere
with sleep architecture?
a. Muscle relaxers
b. NSAIDs
c. Benzodiazepines
d. Hydrocodone