PHRM845-FINAL EXAM Flashcards
Non-malignant pain part 4
Clinical practice guidelines for prescribing opioids for pain (12 recommendations)
Includes:
-Outpatients (>18 y/o)
-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 (uncurable disease–>HF or end-stage COPD)
-End-of-life care (hospice–>goals are different at at this point)
~Last 6 months of life; not trying to keep pt alive, just keeping them comfy (ex: if they get an infection and it does not cause pain, they will NOT get antibiotic)
4 groupings for considering opioid use
- Determine whether or not to initiate opioids for pain
- Selecting opioids and determining opioid dosages
- Decide duration of initial opioid prescription and conducting follow-up
- Assessing risk and addressing potential harms of opioid use
Step 1: Determining whether or not to start opioids
-Non opioid tx are at least as effective as opioids for many common types of acute pain (maximize use of non-opioid and non-pharm options)
-Non opioid tx are preferred for subacute and chronic pain (maximize use of nonpharm and non-opioid)
-Non-opioid tx includes acetaminophen, NSAIDs, and selected anti-depressants and anticonvulsants (gabapentinoids and carbamazepine)
Step 2: Selecting opioids and determining opioid dosages
-When starting opioid tx for acute, subacute, or chronic pain, clinicians should prescribe immediate-release options instead of extended-release and long-acting because they are easier to titrate.
-When opioids are initiated for opioid-naive patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage (get more SE if use more than what is needed)
-For pts already receiving opioid tx, clinicians should carefully weigh risks, benefits, and exercise care when changing opioid dosages
Step 3: deciding duration of initial opioid prescription and conducting follow-up
-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.
-Clinicians should evaluate benefits and risks with patients within 1-4 weeks of starting opioid tx for subacute or chronic pain or of dosage escalation. Clinicians should regularly re-evaluate benefits and risks of continued opioid tx with pts.
Step 4: Assessing risk and addressing potential harms of opioid use
-Clinicians should work with pts to incorporate into the management plan strategies to mitigate risk, including offering naloxone, asking pt about drug and alcohol use, and/or using PDMP data and toxicology screening (urine test) to assess concurrent controlled substance use.
-When prescribing initial opioid tx 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 programs (PDMP=INSPECT) to determine whether the pt is receiving opioid dosages or combinations that put the pt at high risk of OD.
-Clinicians should use particular caution when prescribing opioids and benzos concurrently and consider risk vs benefit.
-Clinicians should offer or arrange tx with evidence-based medicine to tx pts with opioid use disorder
-Detox on its own, without meds for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, OD, and OD death.
-FDA-approved meds initiated for tx of opioid use disorder include buprenorphine, naloxone, and methadone.
When to reduce/taper opioids
-Pt requests dosage reduction
-Does not have clinically meaningful improvement in pain and function
-Pt is on dosages > 50 MME/day w/o benefit or opioids are combined with benzos
-Shows signs of SUD (work/fam problems related to use)
-Experiences OD or other serious ADR
-Shows early warning signs for OD risk such as confusion, sedation, or slurred speech
How to reduce/taper opioids
-Avoid abrupt tapering or sudden discontinuation of med
-Decrease dose by 10% per month if pts have taken opioids for more than a year
-Decrease dose by 10% each 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 d/c opioids, they may be stopped when taken less than once/day
Opioid laws
-Applies to
-Exemptions
-Practitioner requirements
Applies to
-Pt taking > 60 opioid pills/month x 3 months
-Taking an opioid > 15 MME for > 3 months
-Using transdermal patch > 3 months
-Taking tramadol (if > 300 mg/d) for > 3 months
-Taking any dose of ER controlled med
Exemptions: terminal condition, palliative care, hospice. nursing home
Requirements:
-Perform your own evaluation
-Assess mental health
-Assess risk for substance misuse
-Check INSPECT
-Sign and discuss tx agreement/functional goals
-Reassess and document risk/discussion if > 60 MED
Prescribing limit on opioids
Exemptions for limit
7 day prescribing limit
-MD issuing script may not prescribe more than 7-day supply
~Limit applies to physician’s first opioid script to that pt
~No specific exception for practitioners in the same practice
Exceptions
-Cancer
-Medication assisted tx (MAT) for SUD
-Palliative care
-Professional judgement (MUST document that a non-opiate is not appropriate and MD is using his/her professional judgment to prescribe > 7d supply)
2019 INSPECT requirement
-Requires checking INSPECT each time before prescribing an opioid or benzo to ANY PATIENT
-No exceptions for hospice, palliative care, or long-term care
-Pts on pain management contract–Check INSPECT q90d
What is a pain contract?
-Written agreement between pt and prescriber
-Does not legally prevent another provider from prescribing opioids or a pharmacy from filling opioids prescribed by a different provider
~However, the pt would no longer receive opioid scripts from original provider (Don’t want to burn bridges with other prescribers)
**OWNESS is all on the PATIENT if they have a pain contract
Tx of acute pain
Step 1: non-opioid +/- adjuvant analgesic
Step 2: Opioid for mod/mild pain + non-opioid +/- adjuvant analgesic
Step 3: Opioid for moderate-severe pain + non-opioid +/- adjuvant analgesic
As needed vs scheduled pain med
As needed (PRN) analgesia
-Get less drug overall
-Only administered when pt is in pain
-Minimize exposure to limit toxicity
Scheduled/around the clock (ATC) analgesia
-Given at a set interval
-May be better option for continual pain
-Can still use breakthrough analgesia
-If pain is 24h/day, this is the best to prevent breakthrough pain
Michigan opioid prescribing engagement network (OPEN)
-Excessive prescribing of opioids after surgery places pts at risk of becoming new persistent users
-Procedure-specific prescribing recommendations were developed by Michigan OPEN to curb over-prescribing of post-op opioids
-Gives general recs based on procedure
OPEN recommended schedule dosing of acetaminophen and ibuprofen
-Acetaminophen: 650 mg q6h while awake
-Ibuprofen: 600 mg q6h while awake
-Alternate to take medication q3h
**Remember all of the ibuprofen C/I
OPEN pt education
-Pt should expect to have some pain (this is a normal part of the healing process)
-Pain is typically worse the day after surgery, and quickly begins to get better
-Goal is to manage your pain so you can do the things you need to care for yourself: eat, breathe deeply, walk, sleep
Tx of acute pain regimen
-Hospitalized pts may have multiple orders for pain meds
-Can only have one order for each severity of pain
**Severe pain should be an IV med
Patient-controlled analgesia (PCA)
-Allows a pt to decide when they will get a dose of pain med
-IV line is placed into pt’s veins. Computerized pump is attached to the IV and allows pt to release pain med by pressing a button
-Prescriber sets parameters of dose and frequency which a pt can receive analgesia through the PCA
-Used for severe acute non-malignant pain:
~Post-op
~Pancreatitis (can’t take anything PO)
~Sickle cell crisis (painful)
Recommended tx 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)
**Opioids are never first line
Recommended tx 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 tx for fibromyalgias
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
Tx for neuropathic pain
First line
-SNRIs (venlafaxine, duloxetine)
-Gabapentin/pregabalin
Second line
-Topical lidocaine
-TCAs
Hospice
-6 months or less of life left
-When pt opts for this, they usually have a much shorter time
-If on meds not in line with pain relief, they can be d/c (ex: statin, BP meds, antibiotics)
-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
What to do in hospice for
-Pain relief and air hunger
-Anxiety/agitation
-N/V
-Secretions
Pain relief and air hunger
-Morphine IV or solution (20mg/mL) under tongue
~Could use fentanyl or hydromorphone
Anxiety/agitation
-Lorazepam IV or SL as needed
N/V
-Ondansetron ODT
Secretions (want to dry these up or else pt feels like they are drowning)
-Atropine ophthalmic drops under tongue
-Glycopyrrolate IV as needed
-Scopolamine patch
