1. Pain Management Laura Bergs FNP

2. Definition of Chronic Pain Anyone with pain greater than 3 months Anyone with pain greater than 3 months Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage Allodynia* Pain due to a stimulus that does not normally provoke pain. Allodynia* Pain due to a stimulus that does not normally provoke pain.

3. Regulations for monitoring Will do urine drug screen Will do urine drug screen Will not give narcotics unless off all illegal drugs Will not give narcotics unless off all illegal drugs Must follow pain management patient agreements and be consistent Must follow pain management patient agreements and be consistent

4. Urine Drug Screen

5. Metabolic Pathways 6- MAM HeroinMorphine

6. Metabolic Pathways Morphine Hydromorphone

7. Metabolic Pathway Codeine HydrocodoneHydromorphone

8. Urine drug testing Perform at initial visit, then random Perform at initial visit, then random Drug screen results are black and white Drug screen results are black and white False positives can occur in some instances False positives can occur in some instances Talk with toxicology if not sure of results Talk with toxicology if not sure of results All patients usually deny illegal drug use All patients usually deny illegal drug use Don’t have to treat patient, you did not decide to do the illegal drug, they did Don’t have to treat patient, you did not decide to do the illegal drug, they did

9. Tools assist to determine if narcotics needed COAT (chronic opioid analgesic therapy) COAT (chronic opioid analgesic therapy) pathway is a tool to be used by every pathway is a tool to be used by every provider prior to long term opioid therapy provider prior to long term opioid therapy Dire Score is used to determine if they are a candidate for opioid therapy Dire Score is used to determine if they are a candidate for opioid therapy Risk stratification-medium is the default risk Risk stratification-medium is the default risk

10. Inclusion Criteria COAT Inclusion Criteria COAT Group A not currently on opioid and considering opioid trial Group B on opioid < 3 months, considering continuing opioid Group C patient already on COAT

11. 1st step in pathway DIRE Score Scoring based on Scoring based on DIRRRRE (Diagnosis, intractability, Risk, (psychological, chemical health, reliability, Social Support) Efficacy Score) DIRRRRE (Diagnosis, intractability, Risk, (psychological, chemical health, reliability, Social Support) Efficacy Score) Add D+I+4R+E=range Add D+I+4R+E=range Score 7-13 not suitable for COAT Score 14-21 may be suitable The Journal of Pain, Vol 7, No 9 September, 2006 PP671-681

12. Step 2: Risk Stratification Medium default risk Medium default risk Move to low risk if Move to low risk if Age > 65 years Age > 65 years Morphine equivalents <=10mg/d Morphine equivalents <=10mg/d Move to high risk if Move to high risk if Age<=35 Age<=35 Morphine equivalents >80mg/day Morphine equivalents >80mg/day Past substance use disorder Past substance use disorder Aberrant drug related behavior Aberrant drug related behavior Mental Illness Mental Illness Provider judgment Provider judgment

13. 3 rd step monitoring Office visits based on risk, must see every three months Office visits based on risk, must see every three months Must have opioid agreement and informed consent Must have opioid agreement and informed consent Check state monitoring program before initiating COAT Check state monitoring program before initiating COAT Lab 7767 urine drug screen initial then randomized Lab 7767 urine drug screen initial then randomized Pill counts, I do with every visit, you may use your discretion Pill counts, I do with every visit, you may use your discretion

14. Risk stratification May keep in medium rather than move based on provider judgment Must document rational if meets high risk yet keep on med

15. Tapering of Opioid Decrease 10-20 percent each week Decrease 10-20 percent each week Round off the dose to the next available formulation Round off the dose to the next available formulation Symptoms can be managed with clonidine Symptoms can be managed with clonidine Consider adjuncts Consider adjuncts

16. Opioid agreement Random drug screens Random drug screens If found to have illegal's, If found to have illegal's, Can treat with adjuncts instead of narcotics Can treat with adjuncts instead of narcotics Chronic use of narcotic medication discouraged Chronic use of narcotic medication discouraged Wean off narcotics if not dependent/addicted Wean off narcotics if not dependent/addicted

17. Drugs of Abuse reference Guide Amphetamine speedDexedrineBenzadrine

18. Drugs of Abuse Reference Guide MDMA Ecstasy, XTC, ADAMLover’s speedmethylenedioxymethamphetamine

19. Drugs of Abuse Reference Guide Methamphetamine Speed, ice, crystal, crank DesoxymMethadrine

20. Deciding to take off Opioid At discretion of provider At discretion of provider If failed drug screen or documented drug diversion If failed drug screen or documented drug diversion DIRE score <14 DIRE score <14 may continue with no opioids may continue with no opioids

21. Weaning schedule 10 percent per week unless weaning off Methadone 10 percent per week unless weaning off Methadone Manage withdrawal symptoms Manage withdrawal symptoms May need to be inpatient May need to be inpatient Most can come off without any difficulty Most can come off without any difficulty If you discharge related to breach of contract do have legal obligation to follow for 30 days (this does not mean you have to prescribe narcotic) If you discharge related to breach of contract do have legal obligation to follow for 30 days (this does not mean you have to prescribe narcotic)

22. Section Y DIRE Score <14 If harm greater than benefit educate and taper If harm greater than benefit educate and taper Provider judgment that COAT benefits greater than harm-review at each visit Provider judgment that COAT benefits greater than harm-review at each visit Review with each visit: 4A’s: analgesia activity activity adverse effects adverse effects aberrant behavior aberrant behavior

23. Provider benefit greater than harm Documentation for effectiveness Documentation for effectiveness 4As plus 2As 4As plus 2As Analgesia Analgesia Activity Activity Adverse effects Adverse effects Aberrant behavior Aberrant behavior Assessment Assessment Action Action.bpismartform brief pain questionnaire

24. Illegal drug use Talk face to face with patient Talk face to face with patient Determine if they have an addiction Determine if they have an addiction You treat without narcotics You treat without narcotics Usually these patients self discharge Usually these patients self discharge High risk if you continue with narcotic and there is documentation of patient continuing with illegal drug use High risk if you continue with narcotic and there is documentation of patient continuing with illegal drug use

25. Taper off opioid Decrease 10-20 percent per week Decrease 10-20 percent per week Symptoms of abstinence syndrome, clonidine 0.1 mg every six hours or clonidine transdermal patch Symptoms of abstinence syndrome, clonidine 0.1 mg every six hours or clonidine transdermal patch May safely wean Methadone requires slower wean schedule 3% TAPER May safely wean Methadone requires slower wean schedule 3% TAPER Weekly visit with weaning Weekly visit with weaning

26. Weaning protocols Those that do not follow the rules Can use clonidine for withdrawal Refer to inpatient if able to find bed if on Methadone All other narcotics follow DIRE weaning protocol Those with no drug in urine are not taking the drug and do not need to be weaned

27. Weaning schedule If patient agrees to wean off If patient agrees to wean off Advantage-can try different drug once off all narcotics for two weeks Advantage-can try different drug once off all narcotics for two weeks Can tell if narcotic really did help with the pain, after several months of narcotic use they are not beneficial Can tell if narcotic really did help with the pain, after several months of narcotic use they are not beneficial Continue to monitor urine drug screens even after weaned off Continue to monitor urine drug screens even after weaned off

28. Patient and provider goals Need to set realistic goals with the patient Need to set realistic goals with the patient Most want all of their pain gone completely this is unrealistic if they have had pain for several years, some have just been discharged from another pain clinic Most want all of their pain gone completely this is unrealistic if they have had pain for several years, some have just been discharged from another pain clinic Review agreements with the patient often to prevent misunderstanding Review agreements with the patient often to prevent misunderstanding

29. Functional assessment Do not always go by pain level as stated Do not always go by pain level as stated Look at how dressed Look at how dressed How they are able to perform daily functions How they are able to perform daily functions Are they sedated Are they sedated Are they able to answer direct questions Are they able to answer direct questions When in doubt refer to me When in doubt refer to me

30. Adjunctive treatment Expect them to participate in therapy Expect them to participate in therapy Expect them to participate in daily exercise Expect them to participate in daily exercise Expect them to participate in psychotherapy Expect them to participate in psychotherapy Hope to start program for cognitive behavioral therapy for chronic pain Hope to start program for cognitive behavioral therapy for chronic pain State surveillance program for medications check this State surveillance program for medications check this

31. Stable chronic opioid patient No aberrant episodes and warrants continued therapy No aberrant episodes and warrants continued therapy Once stable prefer that PCP take over prescribing Once stable prefer that PCP take over prescribing Monitor monthly of every three months Monitor monthly of every three months Happy to see them back if they become unstable or wish to discontinue opioid therapy Happy to see them back if they become unstable or wish to discontinue opioid therapy

32. Any Questions

33. References http://www.iasp- pain.org/Content/NavigationMenu/GeneralRes ourceLinks/PainDefinitions/default.htm http://www.iasp- pain.org/Content/NavigationMenu/GeneralRes ourceLinks/PainDefinitions/default.htm