Lecture 78 - Non-Malignant Pain Part 4 Flashcards
2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain
Includes 12 recommendations for clinicians providing pain care:
Includes - Outpatients >18 years old, Acute pain (<1 month), Subacute pain (1-3 months), Chronic pain (>3 months)
Does not include - Management of pain related to sickle cell disease, Management of cancer-related pain, Palliative Care, End-of-life care
12 recommendations are grouped into four areas of consideration
- Determining whether or not to initiate opioids for pain
- Selecting opioids and determining opioid dosages
- Deciding duration of initial opioid prescription and conducting follow-up
- Assessing risk and addressing potential harms of opioid use
Recommendation 1: Determining whether or not to initiate opioids for pain
Nonopioid therapies are at least as effective as opioids for many common types of acute pain.
* Maximize use of nonpharmacologic and nonopioid pharmacologic therapies
Nonopioid therapies include:
*Nonopioid medications such as acetaminophen, non-steroidal anti- inflammatory drugs (NSAIDs), and selected antidepressants and anticonvulsants
Recommendation 2:
Nonopioid therapies are preferred for subacute and chronic pain.
* Maximize use of nonpharmacologic and nonopioid pharmacologic therapies
Nonopioid therapies include:
*Nonopioid medications such as acetaminophen, non-steroidal anti- inflammatory drugs (NSAIDs), and selected antidepressants and anticonvulsants
Recommendation 3:
When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting opioids.
Recommendation 4:
When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage.
Recommendation 5:
For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage.
If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If benefits do not outweigh risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids.
Recommendation 6:
When opioids are needed for acute pain, clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.
Recommendation 7:
Clinicians should evaluate benefits and risks with patients within 1–4 weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Clinicians should regularly reevaluate benefits and risks of continued opioid therapy with patients.
Recommendation 8:
Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone.
Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk. This may include offering naloxone, asking patients about drug and alcohol use to assess for substance use disorders, and/or using PDMP data and toxicology screening to assess for concurrent controlled substance use.
Recommendation 9:
When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose.
Recommendation 10:
When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances.
Recommendation 11:
Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants.
Recommendation 12:
Clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder.
Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of
increased risks for resuming drug use, overdose, and overdose death.
FDA-approved medications indicated for the treatment of opioid use disorder include buprenorphine, methadone, and naltrexone.
When to Reduce/Taper Opioids
Requests dosage reduction
Does not have clinically meaningful improvement in pain and function (e.g., at least 30% improvement on the 3-item PEG scale)
Is on dosages ≥ 50 MME*/day without benefit or opioids are combined with benzodiazepines
Shows signs of substance use disorder (e.g. work or family problems related to opioid use, difficulty controlling use)
Experiences overdose or other serious adverse event
Shows early warning signs for overdose risk such as confusion, sedation, or slurred speech
How to Reduce/Taper Opioids
Avoid abrupt tapering or sudden discontinuation of opioids.
Decrease dose by 10% per month if patients have taken opioids for more than a year
Decrease dose by 10% per week for patients that have taken opioids for a shorter time (weeks to months)
Once lowest available dose is reached, the interval between doses can be extended. If discontinuing opioids, they may be stopped when taken less than once a day.
Opioid Laws - 2014 Chronic Pain Law
Applies to any patient: Taking >60 opioid pills /month >3mo; Taking an opioid >15 MME for >3mo; Using a transdermal opioid patch >3mo; Taking tramadol (if greater than 300mg/day) for >3mo; Taking any dose of an extended release controlled med
Exemptions: Terminal condition, Palliative care, Hospice, Nursing Home
All practitioners are required to: Perform your own evaluation; Assess mental health; Assess risk for substance misuse; Check INSPECT (with each prescription or q90d if on pain contract); Sign and discuss Treatment Agreement/ Functional Goals; Reassess and document risk/discussion if greater than 60 MED
Opioid Laws - 2-17 opioid 7 day prescribing limit
Physician issuing initial opioid prescription for a patient may not prescribe more than a 7-day supply - Limit applies to that physician’s first opioid prescription to that patient; No specific exception for practitioners in the same practice
Exceptions to 7-Day Limit: Cancer; Medication assisted treatment (MAT) for a substance-abuse disorder; Palliative care; Professional judgment (must document that a non-opiate not appropriate and physician is using his or her professional judgment to prescribe >7-day limit)
Opioid Laws- 2019 INSPECT requirement
Requires checking INSPECT each time before prescribing an opioid or benzodiazepine to any patient
No exceptions for hospice, palliative care, or long term care patients
Patients on pain management contract – check INSPECT every 90 day
Pain Contract
A written agreement between the patient and prescriber
Does not legally prevent another provider from prescribing opioids or a pharmacy from filling opioids prescribed by a different provider - However, the patient would no longer receive opioid prescriptions from the original provider
As Needed Pain Medication
Only administered when patient is in pain
Minimize exposure to limit toxicity
Scheduled Pain Medication
Given at a set interval
May be better option for continual pain
Can still use breakthrough analgesia
Michigan Opioid Prescribing Engagement Network (OPEN)
Excessive prescribing of opioids after surgery places patients at risk of becoming new persistent users
Procedure-specific prescribing recommendations were developed by Michigan OPEN to curb over- prescribing of post-operative opioids
Michigan Opioid Prescribing Engagement Network (OPEN) - recommended scheduled dosing of acetaminophen and ibuprofen
Acetaminophen 650mg q6h while awake
Ibuprofen 600mg q6h while awake
Alternate to take medication q3h
Michigan Opioid Prescribing Engagement Network (OPEN) - patient education
You can expect to have some pain after surgery. This is normal and part of the healing process.
Pain is typically worse the day after surgery, and quickly begins to get better.
The goal is to manage your pain so you can do the things you need to care for yourself and heal: Eat, Breathe deeply, Walk, Sleep
Treatment of Acute Pain - hospitalized patients
Hospitalized patients may have multiple orders for pain medications
Can only have one order for each severity of pain
Patient Controlled Analgesia (PCA)
Allows patient to decide when they will get a dose of pain medicine
IV line is placed into patient’s veins. A computerized pump attached to the IV allows patient to release pain medicine by pressing a handheld button
Prescriber sets parameters of dose and frequency which a patient can receive analgesia through the PCA
Used for severe acute non-malignant pain: Post-operative, Pancreatitis, Sickle cell crisis
Recommended Treatments for Low Back Pain
Self-care and education in all patients - Advise patients to remain active and limit bedrest
Nonpharmacological treatments: Exercise, Cognitive behavioral therapy, Interdisciplinary rehabilitation
Medications: First-line - Acetaminophen, Non-steroidal anti inflammatory drugs (NSAIDs); Second-line - Serotonin and norepinephrine reuptake inhibitors (SNRIs), Tricyclic antidepressants (TCAs)
Recommended Treatments for Osteoarthritis
Nonpharmacological treatments: Exercise, weight loss, patient education
Medications: First-line - Acetaminophen, Oral or topical NSAIDs; Second-line - Intra-articular hyaluronic acid, Capsaicin
Recommended Treatments for Fibromyalgia
Nonpharmacological treatments: Low-impact aerobic exercise (e.g., brisk walking,
swimming, water aerobics, or bicycling), Cognitive behavioral therapy, Biofeedback, Interdisciplinary rehabilitation
Medications: FDA-approved: Pregabalin, duloxetine; Other options: TCAs, gabapentin, venlafaxine
Recommended Treatments for Neuropathic Pain
First line: SNRIs, Gabapentin/pregabalin
Second line: Topical lidocaine, TCAs
Hospice
Utility: provide comfort to patient in pain; decrease respiratory drive to aid in natural end of life processes
Route of administration: Buccal/sublingual, Parenteral (usually a continuous infusion), Transdermal
Monitoring: Patient comfort (pain assessment to see how well pain controlled); Less concerned with side effects unless making patient uncomfortable
Hospice: treating pain relief and air hunger
Morphine IV or solution (20mg/mL) under tongue * Could use fentanyl or hydromorphone
Hospice: treating anxiety/agitation
Lorazepam IV or SL as needed
Hospice: treating nausea/vomiting
Ondansetron ODT
Hospice: treating secretions
Atropine ophthalmic drops under tongue
Glycopyrrolate IV as needed
Scopolamine patch
