Disclosures. Ms. Walsh has nothing to disclose Ms. Broglio is on the speaker s bureau for Genentech and Meda Pharmaceuticals

Transcription

1 Anne F. Walsh, MSN, ANP BC, ACHPN, CWOCN Kathleen Broglio, MN, ANP BC, ACHPN, CPE Disclosures Ms. Walsh has nothing to disclose Ms. Broglio is on the speaker s bureau for Genentech and Meda Pharmaceuticals Objectives Differentiate between addiction, physical tolerance, and dependence Discuss five key components of a comprehensive pain assessment Describe four elements of a pain treatment plan for a patient with co morbid substance use disorder Indicate the reasons for breakthrough medications, opioid rotation, and titration

2 Overview Pain is prevalent in advanced disease and may not be adequately managed People with histories of substance abuse face greater risks of being undertreated Pain should be treated in this population while providing safeguards to prevent misuse Substance Use Disorder Dependence on and abuse of alcohol and/or drugs including nonmedical use of prescription drugs taken voluntarily for their effect on the central nervous system or to prevent withdrawal 1 Prevalence estimated to be more than 22 million in U.S. 2 Prevalence in those with advanced disease unknown 3 1 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV TR). Arlington, VA: American Psychiatric Publishing, Inc; 2005: McCance Katz EF. Psychiatric disorders and substance abuse. (Statistical data). Psychiatric Times. 2007;24, Nabati L, Abrahm J. The palliative care patient. In: Smith HS, Passik SD, eds. Pain and Chemical Dependency. New York, NY: Oxford University Press; 2008: Addiction Primary, chronic neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestation Characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving Adapted from American Academy of Pain Medicine, American Pain Society and American Society of Addiction Medicine (2001). Paice JA, Fine PG. Pain at the end of life. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. New York, NY: Oxford; 2006:

3 Physical Dependence State of adaptation that is manifested by a drug class Syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood levels of drug and/or administration of an antagonist Adapted from American Academy of Pain Medicine, American Pain Society and American Society of Addiction Medicine (2001). Paice JA, Fine PG. Pain at the end of life. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. New York, NY: Oxford; 2006: Tolerance State of adaptation in which the exposure to a drug induces changes that result in a diminution of one or more of the drug s effects over time Ex: decreases the opioids side effects such as nausea, pruritus, and respiratory depression May decrease the analgesic s ability to reduce pain at the current dose Adapted from American Academy of Pain Medicine, American Pain Society and American Society of Addiction Medicine (2001). Paice JA, Fine PG. Pain at the end of life. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. New York, NY: Oxford; 2006: Case Study JW 68 y.o. man with widely metastatic pancreatic cancer s/p Whipple procedure; currently receiving chemotherapy seen by Palliative Care NP at home Uncontrolled abdominal pain with radicular symptoms to the back History of substance abuse with recent urine toxicology positive for cocaine and heroin; occasional alcohol use; smokes one pack cigarettes daily Lives with daughter who appeared intoxicated during home visit

4 Case Study (cont) Pain severity 10/10, stabbing/shooting with no exacerbating factors MD unwilling to prescribe opioids Takes acetaminophen 500 mg q4h without relief; gets some relief from oxycodone 5mg/APAP 325mg which he obtains from visits to the emergency room Previously tried adjuvants (gabapentin, duloxetine) without relief, does not want to try again Refuses referral to interventional radiology Pain Assessment Location Duration Onset Characteristics Severity Aggravating factors Relieving factors Associated symptoms Adverse side effects

5 Location Location of Pain Ask about all locations of pain Ask patient to point to area of pain Determine if dermatomal/myotomal Determine if there is radicular spread Duration and Onset Duration and Onset When did it start? How long has there been a problem? Is it chronic versus acute? Patterns of pain if episodic? How long is each episode? Does it occur at specific times of day? Is it related to any activity? Characteristic Characteristic of Pain Ask patient to describe how pain feels. If patient is unable to describe give examples Throbbing, stabbing, shooting, burning, pins and needles, etc Key point of asking about characteristic is to attempt to establish if pain is neuropathic, nociceptive or both

6 Severity Severity Ask about pain at worst, best, in the last week, and now Explain use of pain scale used when eliciting information Use scale appropriate to age and cognitive level Aggravating/Relieving Factors Aggravating factors What makes it worse? How long do pain flares last? Relieving Factors What makes it better (medications, rest, activity, heat, ice, complimentary therapies) Past successful treatments Associated Symptoms Associated symptoms Appetite changes, weight loss or gain Changes in ability to perform ADLs Changes in relationships Mood changes Sexual disturbances Sleep disturbances

7 Adverse Effects Adverse side effects of pain or medications Anorexia Constipation Lack of sexual desire Nausea/vomiting Pruritus Sedation Sweating Assessing Risks Ask about current/history of use of illicit drugs, tobacco or alcohol. Be specific when asking about drug use (ex: have you used marijuana, cocaine, heroin, prescription drugs not used for pain management). Ask when last used Assess for co morbid psychiatric conditions Assess safety of home environment Be observant of signs of aberrant behavior Indicators of Aberrant Behavior Prescription forgery Abuse of illicit drugs Multiple prescription losses Selling prescription drugs Multiple dose escalations without provider acknowledgement Stealing or borrowing other s drugs Obtaining prescription drugs from non medical sources Kirsh KL, Compton P, Passik SD. Caring for the drug addicted patient at the end of life. In: Ferrell BR, Coyle, N. eds. Textbook of Palliative Nursing. New York, NY: Oxford; 2006:

8 Follow up Assessments Analgesia (better, worse, the same) Function (may not be applicable in advanced disease) Adverse effects (nausea, vomiting, constipation, etc) Aberrant behavior Passik SD, Weinreb HJ. Managing chronic nonmalignant pain: overcoming obstacles to the use of opioids. Adv Ther. 2000;17: Case Study (cont) JW agreed to discontinue use of illicit substances if pain was treated Treatment agreement was completed Agreed to use of one prescriber, one pharmacy, and weekly visits Agreed to random urine toxicology screens Started on fentanyl transdermal 12 mcg/hr patch and a limited supply of morphine sulfate 15 mg PO q2h PRN breakthrough pain Home care referral to help with medication management and family support

9 Treatment Plan Medication management Use of extended release or long acting opioids Limited use or avoidance of short acting opioids Use of low street value opioids to prevent diversion Use of nonopioids and nondrug adjuvants Limited supply of medications Treatment Plans (cont) Frequent follow up visits with assessment for appropriate use of analgesics Use of lock boxes in home Multidisciplinary approach Collaboration between providers Treatment Plan (cont) One prescriber/one pharmacy Complete documentation of all prescriptions given Use of treatment agreements Urine toxicology screens when appropriate

10 Treatment Plan Patients in recovery or on maintenance programs Communication with maintenance program especially if treatment will include opioids Use of extended release opioids with limited doses of breakthrough medication Possible addition of extra doses of methadone to provide pain management Patient/family education Passik, SD, Kirsh KL. Pain in patients with alcohol and drug dependence. In: Bruera E, Higginson IJ, Ripamonti C, von Gunten C. eds. Textbook of Palliative Medicine. London: Oxford; 2006; Case Study (cont) The fentanyl patch was titrated to 25 mcg/hr and then to 50 mcg/hr as breakthrough doses exceeded five times daily Fentanyl patch discontinued and extended release morphine started after three weeks due to severe contact dermatitis Morphine immediate release for breakthrough pain four times daily

11 Breakthrough Pain Transitory increase in pain when baseline pain controlled on an analgesic regimen 1 Incidence 40 80% for those with cancer 2 Causes multifactorial and include End of dose failure Incident pain (i.e. from activity) Spontaneous/idiopathic pain 2 1 Portenoy RK, Hagen NA. Breakthrough Pain: Definition, prevalence and characteristics. Pain. 1990;41: Fine P, Portenoy RK. Initiating and optimizing opioid therapy. In: Fine P, Portenoy RK Opioid Analgesia, 2nd ed. New York, NY: McGraw Hill: 2007: Treating Breakthrough Pain Use 10 15% of total daily dose of opioids as breakthrough dose. Give oral breakthrough medications every 2 hours as needed, IV medications every 1 hour Increase dose of extended release opioid if amount of breakthrough doses exceeds three times daily Fine P, Portenoy RK. Initiating and optimizing opioid therapy. In: Fine P, Portenoy RK Opioid Analgesia, 2nd ed. New York, NY: McGraw Hill: 2007: Breakthrough Medications Consider using same agent as extended release agent except in the case of methadone Use single agent products versus those combined with acetaminophen May consider use of rapid onset breakthrough medications (transmucosal fentanyl), but consider risk factor in terms of abuse/diversion

12 Opioid Titration Titration often necessary in setting of worsening disease states Rate of titration Based on total quantity of breakthrough medication consumed in last 24 hours 30% to 50% of current daily dose of extended release medications Fine P, Portenoy RK. Initiating and optimizing opioid therapy. In: Fine P, Portenoy RK Opioid Analgesia, 2nd ed. New York, NY: McGraw Hill: 2007: Opioid Titration Increment may be larger if pain is severe or smaller in those with advanced debility or major organ failure Titrate methadone only every 5 7 days Titrate breakthrough medications to equal 10 15% of total daily opioid dose Opioid Rotation Trials of different opioid drugs to attain most favorable balance between analgesia and adverse effects Clinical improvement seen in more than 50% of patients after rotation Mercandante S, Bruera E. Opioid Switching: A systematic and critical review. Cancer treat Rev. 2006;32:

13 When to rotate opioids Inadequate analgesia despite opioid titration Inability to escalate opioid due to adverse side effects Rapid dose escalation without pain relief Different route of administration needed (i.e. transdermal) How to Rotate Opioids Calculate current dose of extended release opioids in terms of morphine equivalent Calculate morphine equivalent dose of new opioid and reduce the dose of the new opioid by 25 50% When rotating to fentanyl transdermal do not reduce the dose When rotating to methadone the dose may be reduced by up to 90% (expert consultation recommended) Consider decreasing dose further based on patient s condition Fine P, Portenoy RK. Initiating and optimizing opioid therapy. In: Fine P, Portenoy RK Opioid Analgesia, 2nd ed. New York, NY: McGraw Hill: 2007:53. Case Study (cont) JW required multiple escalations of his opioid medications until pain was better controlled There were no ED visits for pain management and there were no requests for early refills As disease progressed he was transitioned to hospice care and died peacefully at home

14 Summary Pain can be effectively controlled in those with histories of substance abuse Careful assessment and follow up is necessary Treatment plans should be comprehensive to safeguard against misuse Medications should be titrated to effect and rotated if analgesia not achieved or adverse side effects develop