Jocelyn Ludlow, MN RN CHSE, CNE, CMSRN Clinical Educator

Valley Medical Center Nurse Residency Program

OBJECTIVES AND TOPICS

Learning Objectives

After this module, the nurse resident will…

• describe the causes of pain and the importance of managing pain

• perform a comprehensive pain assessment on a patient in their setting

• administer pain medications using opioid dose-range orders and multi-modal approaches

• evaluate the JC guidelines for pain management and apply them to practice

• contrast the challenges of the opioid epidemic with the needs of patients with OUD

Topics

• Brief overview of pain

• Why we need to treat it

• Assessment of pain

• Dose range medication

• Multi modal pain management

• New JC guidelines for pain management and why are they important?

• The “opioid epidemic” and OUD patients

CAUSES AND ASSESSMENT OF PAIN

What is pain? Why do we treat it?

How do we assess it?

Pain Scales

WHAT IS PAIN?!• Acute

• Chronic

• Acute-on-chronic

Loeser, J. D. (1982).

WHY DO WE TREAT IT?

• Untreated acute post-op pain can lead to chronic pain

• Unmanaged pain can lead to depression and anxiety

• Causes sleep disruption

• Managing pain speeds recovery

• Patient more likely to ambulate, CBD, use IS, etc

• Helps the patient discharge sooner

Wells, N., Pasero, C., & McCaffery, M. (2008), Glowacki, D. (2015).

PAIN ASSESSMENT

http://hyperboleandahalf.blogspot.com/2010/02/boyfriend-doesnt-have-ebola-probably.html

ASSESSING PAIN• Functional assessment

• Expectations and pain management plan

• Patient factors

• Functional goals

• functional ability and self-efficacy

• Sleep patterns?

• Mild vs moderate vs severe

• Description of pain

http://www.edmontonnervepain.ca/education/words_describe_pain.html, Pino, C. , Covington, M. (2018).

PAIN SCALES

• Wong-Baker FACES

• CIPS: Cognitively Impaired Pain Scale

• Face

• Vocal/verbal

• Body language

• Physiologic changes

• Expected pain

• NPASS: Neonatal Pain, Agitation, and Sedation Scale

• RIPS: Riley Infant Pain Scale

PAIN ASSESSMENT

PQRST

• Provoked

• Quality

• Region

• Radiation

• Severity

• Timing

• Treatment

OLDCART• Onset

• Location

• Duration

• Characteristic

• Aggravating factors

• Radiation

• Treatment

· Pain rating

· Onset

· Location

· Duration

· Characteristics

· Aggravating factors · Relieving factors

· Intervention

Valley Policy

MIKE FRAPPE

• Mike Frappe is a 36 year old male, admitted with cellulitis to his right foot. His only other history is back pain and seasonal allergies. Two weeks ago, he “laid down” his motorcycle and got some “wicked road rash” on his ankle and foot. It is now red, painful and he cannot put weight on that foot. He went to urgent care a week ago, they gave him some antibiotics and “pain pills”, but he says “nothing is working”.

What type of pain is he experiencing?

What questions would you ask him to assess his pain?

• He tells you he came to the hospital because he “wanted this pain to go away!”

Discuss pain management goals for Mr. Frappe.

PAIN TREATMENT

Opioid pharmacology

Multi-Modal pain treatment

Administering opioids using dose-range orders

Non-pharmacologic pain treatments

OPIOIDS• Not always the first or best option

• Short term use is ideal

• IV, oral- liquid and pill, transdermal

• Most common PO: Oxycodone, Norco (has acetaminophen)

• Most common IV: Hydromorphone, Morphine

• Should be tapered before discharge

• What about PCAs?

Pino, C. , Covington, M. (2018)

https://drugabuse.com/library/the-

effects-of-opiate-use/

MULTI-MODAL PAIN MANAGEMENT

• The use of two or more drugs that act by different mechanisms plus non-pharmacologic treatments

• For surgical patients, multi modal pain management begins before surgery and lasts throughout

• pre-op medication, local, nerve blocks, spinal etc

• For chronic pain patients: medications and non- drug treatments

• Non-pharmacologic treatments:

• Sleep hygiene, exercise, CBT, acupuncture, physical therapy, hydrotherapy, etc

• Oral Sucrose is the first option for pain control for neonates

MULTI-MODAL PAIN

MANAGEMENT

• Treat pain and inflammation

• Side effects: nausea/vomiting/diarrhea (best if taken with food), bleeding, stomach ulcers, kidney damage, increased risk of MI and stroke

• Ibuprofen, Naproxen, Aspirin, Diclofenac, Meloxicam, Celecoxib. IV: Ketorolac

NSAIDS

• Analgesic and antipyretic (anti-fever) effects, very little anti-inflammatory

• Minimal side effects, do not cause drowsiness or respiratory depression

• Can be hepatotoxic, must be used cautiously with impaired liver function

• Max daily dose 4 grams

• Comes in IV and oral route

Acetaminophen (Tylenol)

MULTI-MODAL PAIN

MANAGEMENT

•Baclofen, cyclobenzaprine, Zanaflex

•Relax skeletal muscle, cramping and spasms

•Cause drowsiness

Muscle relaxants

•Neurontin, Lyrica

•Neuropathic pain agent

•Can cause dizziness and sedation, use cautiously in renal failure patients

•Results in the use of less opioids and reduced opioid side effects

Antiepileptics

WHAT ABOUT MEDICAL MARIJUANA?

• Hill, et al (2017):

“A recent meta-analysis of clinical trials of cannabis and cannabinoids for pain found modest evidence supporting the use of cannabinoid pharmacotherapy for pain. Recent epidemiological studies have provided initial evidence for a possible reduction in opioid pharmacotherapy for pain as a result of increased implementation of medical cannabis regimens.”

• Hyperalgesic and potentially addictive properties

• Other side effects: cognitive impairment, mental health issues, hyperemesis syndrome, respiratory issues…

• From 1999-2010 states with medical cannabis laws had significantly lower annual opioid overdose mortality rates compared to states without medical cannabis

• Chemotherapy induced nausea, chronic pain, MS

• More research still needed

DOSE RANGINGTHE VALLEY WAY

• Range order interpretation is stated in the Medication and Order Management policy

• The lowest dose will be trialed for the first time

• Assess soon after

• If the initial dose was not effective, give an additional dose, total not to exceed maximum dose in range.

• Once the dosing is effective, the time frequency begins at the last dose

• Next dose should be the be the effective dose

• Document any significant clinical info (procedures, PT, etc)

• May dose from low pain scale options if clinically appropriate, cannot dose for higher than reported pain

MIKE FRAPPE

Mike Frappe is admitted with cellulitis of his right foot from a motorcycle accident

Order:

oxycodone 5-10mg PO q4h PRN moderate pain (4-7), severe pain (8-10)

1500: Pt c/o pain of 8/10, burning, cannot stand even the covers touching his foot

1515: 5 mg oxycodone

1545: pt c/o pain of 6/10, still burning, can barely cover his foot

1600: 5 mg oxycodone

1630: pt states pain is at a 3/10, is resting and able to cover his legs with blankets

When can he get his next dose of oxycodone?

How much should the nurse give?

What if he c/o pain 9/10 and also had a dressing change due at 1600?

MIKE FRAPPE

Mr. Frappe also has an order for Tylenol 325-650 mg every 4 hrs for mild pain (1-3)

1600: dressing change

What could you give him if he cannot have any oxycodone yet?

What other non- narcotic medications might you request?

2000: pt states pain is 4/10, but is able to nap and his feet are no longer burning, just sore. He says that the oxycodone really helped his pain, but made him too sleepy.

What would you administer? What other conversations would you have with Mr. Frappe about his plan?

CURRENT CHALLENGES IN PAIN MANAGEMENT

CDC and Joint Commission new guidelines for pain management

The opioid “epidemic”

Patients with Opioid Use Disorder

CDC Guidelines for Prescribing Opioids• MME= morphine milligram equivalent

• Nonopioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care

• The lowest possible effective dosage should be prescribed

JOINT COMMISSION GUIDELINES

FOR PAIN

• Develop a pain treatment plan based on evidence-based practices and the patient’s clinical condition, past medical history, and pain management goals

• Develop realistic expectations and measurable goals that are understood by the patient for the degree, duration, and reduction of pain

• Discuss the objectives used to evaluate treatment progress (for example, relief of pain and improved physical and psychosocial function)

• Provide education on pain management, treatment options, and safe use of opioid and non-opioid medications when prescribed

• Educate patients and family on the safe use, storage, and disposal of opioids when prescribed

MIKE FRAPPE

• Mr. Frappe may go home tomorrow

• His pain has been managed with Oxycodone 5mg/4hrs, plus 1000mg Tylenol every 8 hours.

• Occasional dose of Toradol for breakthrough pain or before dressing changes and PT.

Discuss what his pain management goals will be at home….

What should he expect as far as medication prescribed at home?

What discharge teaching will he need regarding his pain medications?

OPIOID USE DISORDERDSM 5:

“A problematic pattern of opioid use leading to clinically significant impairment or distress”

“compulsive, prolonged self-administration of opioid substances that are used for no legitimate medical purpose or, if another medical condition is present that requires opioid treatment, that are used in doses greatly in excess of the amount needed for that medical condition.”

American Psychiatric Association. (2013).

https://www.hhs.gov/opioids/

Paschkis, Z.; Potter, M. (2015).

CARING FOR PATIENTS WITH

OUD

Accept the patient’s experience of pain

Do not withhold opioids

Be aware of the effect of tolerance

Risk of respiratory depression is less than opioid naïve

HOWEVER: monitor for risk behaviors

Methadone/suboxone: treats addiction NOT pain

Treat patients with respect and compassion

MIKE FRAPPE

• It has been a month since Mr. Frappe discharged and he is now back on your unit. His cellulitis has turned into a chronic, non-healing ulcer. He also states his back pain is back from having to sit so much.

• Mr. Frappe tells you “My foot hurt so bad, I needed more of those pills. The doctor would not give me any more. That motrin made my stomach hurt, and I was afraid to take Tylenol, I hear on the news it’s bad for your liver. So I took some pills my mom had leftover from her hip replacement 2 years ago. Now those are not even helping. I ran out yesterday and I feel terrible. It hurt so bad, I even thought about drinking or smoking weed to make the pain go away, but I have been sober for 10 years now. I came to the ER because I need some help with this pain. It’s 9/10 right now, just throbbing!”

What kind of pain is he experiencing?

What questions do you have for Mr. Frappe?

What is the best way to manage his pain while in the hospital?

REFERENCESAmerican Pain Society (2016). Guidelines on the management of postoperative pain. The Journal of Pain, 17:2. pp131-

157.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). 5th ed.

Arlington, VA: The Association

Bachhuber, M. A., Saloner, B., Cunningham, C. O., & Barry, C. L. (2014). Medical Cannabis Laws and Opioid Analgesic

Overdose Mortality in the United States, 1999–2010. JAMA Internal Medicine, 174(10), 1668–1673.

http://doi.org/10.1001/jamainternmed.2014.4005

Centers for Disease Control. (2017). Opioids for Acute Pain: What you need to know.

https://www.cdc.gov/drugoverdose/pdf/patients/Opioids-for-Acute-Pain-a.pdf

Centers for Disease Control. (2017). Prescription Opioids: What you need to know.

https://www.cdc.gov/drugoverdose/pdf/AHA-Patient-Opioid-Factsheet-a.pdf

Centers for Disease Control. (2017). Opioid Prescribing: Where you live matters. CDC Vital Signs.

https://www.cdc.gov/vitalsigns/pdf/2017-07-vitalsigns.pdf

Centers for Disease Control. (2017). CDC Guidelines for prescribing opioids for chronic pain.

https://www.cdc.gov/drugoverdose/pdf/Guidelines_At-A-Glance-508.pdf

Glowacki, D. (2015). Effective pain management and improvements in patients’ outcomes and satisfaction. Crit Care

Nurse. 35:3

Hill, K. P., Palastro, M. D., Johnson, B., & Ditre, J. W. (2017). Cannabis and Pain: A Clinical Review. Cannabis and

Cannabinoid Research, 2(1), 96–104. http://doi.org/10.1089/can.2017.0017

Joint Commission. (2017). Joint Commission enhances pain assessment and management requirements for accredited

hospitals. The Joint Commission Perspectives.

https://www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_Pain_Assessment_and_Management_Requir

ements_for_Accredited_Hospitals1.PDF

Loeser, J. D. (1982). Concepts of pain. In J. Stanton-Hicks & R. Boaz (Eds.), Chronic low back pain (pp. 109 –142). New

York: Raven Press.

Loeser, J. D., & Melzack, R. (1999). Pain: an overview. Lancet (London, England), 353(9164), 1607-1609

National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population

Health and Public Health Practice; Committee on the Health Effects of Marijuana: An Evidence Review and Research

Agenda. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for

Research. Washington (DC): National Academies Press (US); 2017 Jan 12. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK423845/ doi: 10.17226/24625

Paschkis, Z.; Potter, M. (2015). Acute pain management for inpatients with opioid use disorder. JN The American Journal

of Nursing. 115: 9, - p 24–32.

doi: 10.1097/01.NAJ.0000471243.30951.92

Pino, C. , Covington, M. (2018). Prescription of opioids for acute pain in opioid naïve patients. In: UpToDate, Fishman, S.,

Crowley, M. (Eds), UpToDate, Waltham, MA.

Wells N, Pasero C, & McCaffery M. (2008). Chapter 17 : Improving the quality of care through pain assessment and

management. In: Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Hughes RG, editor. Agency for

Healthcare Research and Quality (US); Rockville (MD). https://www.ncbi.nlm.nih.gov/books/NBK2658/

Videos:

https://youtu.be/I7wfDenj6CQ

https://ed.ted.com/lessons/how-do-pain-relievers-work

https://youtu.be/NDVV_M__CSI

REFERENCES