Chronic Pain in Primary Care: Designing and Implementing a Management Plan

Module 3Paula 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 non-pharmacologic interventions.

3. Identify resources for the effective use of pharmacologic modalities.

4. Identify resources for the effective use of non-pharmacologic modalities.

Significance of Chronic PainCommon reason for primary care

visits

Expectation of patient? Pain medication

Prescribers’ fear ◦Patient addiction, misuse or diversion◦Causing harm◦Legal ramifications

Prescription Drug AbuseCDC 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 ProjectPDMP

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. Based on comprehensive assessment

2. Goals for functional improvement3. Pain management agreement4. Informed consent for treatment5. Assessments at regular intervals6. Pharmaceutical Modalities 7. Non-pharmaceutical Modalities8. Documentation

Eight Point Treatment Plan: 1. Comprehensive Assessment

Complete physical exam Diagnostic testing Medication and supplemental

historyBenefit 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

permissionwww.aapainmanage.org

Eight Point Treatment Plan:4. Informed Consent for TreatmentPain 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◦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-depressantsDepression 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

anti-depressants take affect◦Potentially can disrupt sleep

architecture and worsen depression

Eight Point Treatment Plan: 6. Pharmaceuticals – Adjunctants

Muscle RelaxersLower the level of pain experiencedIncrease flexibility and range of

motionReducing spasms and involuntary

muscle contractionsExamples: carisoprodol,

cyclobenzaprineSide 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

Morphine 5 – 10 mg per hourFentanyl 25 mcg per hourDilaudid 1 – 4 mg per hourOxycodone - 10 – 80 mg tabletsMerperdine – 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

AcupunctureManual therapyExerciseTENSThermal Therapy

Eight Point Treatment Plan: 7. Non-Pharmaceuticals

Acupuncture

Most widely used Complimentary & Alternative Therapy in the US

Thin needles are inserted into the skinNeedles are stimulated to release

neurotransmittersShown to improve function in

◦ Osteoarthritis◦ Fibromyalgia ◦ Back pain

Eight Point Treatment Plan7. 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 Plan7. Non-Pharmaceuticals

ExerciseMoving, stretching, low impact

aerobics, pool & physical therapy, yoga

◦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 HeatIncrease 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 RecordClearDetailedSystematicConsistent with evidenceTherapies offered, accepted and

declinedComprehensive 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 ConsultTo share responsibility and

liability

To confirm or adjust pain management treatment plan

Where to ReferPain managementDrug rehabResources 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 PlanEffectively 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• 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), 43-47. Retrieved from http://journals.lww.com/tnpj/toc/2009/04000

• D’Arcy, Y. (2009). Chronic opioid therapy clinical guidelines. The Nurse Practitioner, 34(10), 13-15. 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-puts-heat-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):381-400, vi-vii. 

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.

Post Test Questions

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 pharmacyb.The patient agrees to not use

recreational drugsc.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 replacedd. 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 painc. Drug screeningd. 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:

f. Intensity of paing. Functional goalsh. Adverse eventsi. Patient’s mode of transportationj. Screen for abuse/diversion

9. Resources for the prescriber are available through all of the following except:

a. Pain management specialistb. Pain.edu websitec. The American Academy of Pain

Managementd. The Department of Public Safety

10. What class of pharmaceutical is thought to interfere with sleep architecture?

e. Muscle relaxersf. NSAIDsg. Benzodiazepinesh. Hydrocodone