Learning objectives 1. Identify the contribution of psychosocial and spiritual factors to pain 2. Incorporate strategies for identifying and mitigating opioid misuse 3. Incorporate non-pharmaceutical modalities into the treatment of chronic pain
Universal Precautions and Opioid Risk Questions: Assessment How often do you screen your patients for risk of misuse when prescribing opioids? Does your current health system have policies and procedures in place for safe prescribing?
Prescription Drug Monitoring Programs All states except Missouri have passed legislation establishing PDMPs Have been shown to reduce opioid prescription rates Have not been shown to reduce prescription opioid abuse or overdoses https://www.ilpmp.org/
Aligning pain rating to functioning probably safer way to assess
PEG (Pain, Enjoyment, General Activity) Scale
Risk of opioid misuse
Opioid misuse risk Known risk factors -Age < 45 -Personal history substance abuse -Family history substance abuse -Legal history (i.e. DUI, incarceration) -Mental health problems -Sexual abuse
Opioid Risk Tool
Risk screening tools: how can these Level of concern communicated to the patient Level of monitoring should be implemented Need for pain specialist or addiction consultant? Some patient may be too risky for opioids, use nonopioid modalities as much as possible results be used?
Screen for unhealthy Etoh or drug use Alcohol: do you sometimes drink wine or beer or other alcoholic beverages? How many times in the past year have you had 5 (4 or more for a woman) in a day? How many times in the past year have you used illegal drugs or prescription medications for non medical reasons?
Screen for mental health problems Screen for mental health problems e.g. PHQ2, PHQ9 Screen for self harm Screening tool for addiction risk (e.g. COMM) Screen for PTSD
Universal precautions for opioid prescribing Consistent application takes pressure off provider Reduces stigmatization of patients Standardizes office policies Concurs with national guidelines -American Pain Society, American Academy of Pain Medicine
Common universal precautions Ensure there is a single prescriber, regular visits Use multidimensional and nonpharmacological approaches to pain management Monitor for adherence, misuse, diversion -random pill counts, patient agreements, random urine drug testing Enroll patient in a recovery program if evidence of addiction Provide supportive counseling Manage psychiatric co-morbidities
Patient Prescriber Agreement Means of setting boundaries Should not be used with the intent of getting rid of problematic patients Should be readable, reasonable and flexible
When using opioids the Four A s Document Analgesia Document Aberrant behaviors Document Adverse Events Document Activities of Daily Living Document the name and dose of all pain medications on admission note and at all clinic visits. Document the route of administration. Look for patient agreement pain contract in EMR
Monitoring strategies during patient visits Assess progress towards goals (function) Patient engagement in self-care (exercise, stretching) Use of non-pharmaceutical modalities (CAM, PT) Psychiatric, emotional, social issues How patient has been taking medications Objective information: pill counts, urine test
When to refer to pain management/consultant? Increased risk patient: in recovery/ family history but no current psychiatric or addictive disorder Referral to a multidisciplinary pain management clinic for on-going pain management if uncontrolled pain or active chemical dependency, psychiatric problem Communicate these concerns with the pain clinician when making the referral Gourlay 2004
Case # 54 YO man with recurrent oral squamous cell carcinoma neuropathic neck pain Pain is electrical in the lateral neck area, severe for most of the day and interfering with sleep and mood Doses of his Transdermal Fentanyl patch have been increased multiple times at his most recent appointments. He is currently taking TD Fentanyl 300MCG q 72 hours. He has run out of his breakthrough medication early in the last 2 months His imaging studies do not show evidence of progression of disease He is also taking Gabapentin 1200MG PO TID
Multidimensional approach to treatment Opioids Adjuvants Neuralaugmentation Ablative Surgery Suffering Pain Perception Nociception Psychotropics Anti-depressants/ Cognitive therapies Relaxation Spiritual NSAIDS Radiation Chemotherapy Local blocks Surgery Physical modalities Loeser JD, Cousins MJ. Med J Aust. 1990;153:208-12, 216.
Case # (cont) His PHQ 9 is positive for anxiety Further conversation between the physician and patient reveal that he is ruminating about a hospitalization when he had surgery for his cancer. He has frequent flashbacks to this time He is fearful that he won t survive to his daughter s graduation from high school in 2 years time He previously went to church weekly but is angry at God because of his illness, loss of independence, inability to work and the disfigurement from the surgery
Possible treatment options You recommend that he meet with the Cancer Center psychologist. You tell him that psychological modalities such as mindfulness can provide up to 30% relief for cancer pain You ask him to meet with the chaplain who is assigned to the Cancer Center. The chaplain has used Dignity therapy with other patients in your care and he has helped them with legacy building
Case # 51 yo woman with diffuse visceral, neuropathic pain brain and liver metastases on 4 th line chemotherapy for breast cancer Diffuse spinal metastases with several compression fractures, has had XRT, not interested in meeting with neurosurgery Medications: -Oxycodone IR 40 mg q4 hours prn (using every dose) -Diphenhydramine 50MG q 8 hrs prn itch (requesting dose increase) -Alprazolam 0.5MG BID prn (using every dose) Runs out of medications early Frequently sleepy when she comes in for chemotherapy
Case # (continued) Depressed, not seeing a mental health provider Condominium recently repossessed You request involvement of her husband at her next visit so that he can help with monitoring of her prescription opioids She is skeptical of this. Her husband doesn t understand her. -Is she addicted? What do you do?
What additional therapeutic modalities should we offer this patient?
Non-Pharmacologic Modalities
Non medication therapies The palliative social worker has two half days in the cancer center. You ask her how she can help this patient: - She will help the patient with identifying disability entitlements and affordable insurance products; - She will initiate a trial of cognitive behavioral therapy - She will offer to provide family counseling for the patient and her husband An acupuncturist offers acupuncture in the Cancer Center on a sliding scale payment basis You refer her to the hospital orthotist to measure her for a Thoracolumbosacral Orthotic brace
Integration of cognitive behavioral therapies into management of pain targeted to specific symptoms such as pain and fatigue can significantly reduce pain severity Level of Evidence I (Given B 2002, Anderson KO 2007) Patients need to be given realistic expectations of the potential benefits Other modalities such as Art Therapy and Music Therapy have been shown to be helpful for procedural pain in pediatric cancer patients J of Pediatric Oncol Nursing 2010 May-Jun;27(3):146-55 RCTs have also shown benefits for hypnosis on procedural and peri )operative pain J of the National Cancer Institute 99:17 2007
Conclusions Be mindful of the risk of narcotic dependence and chemical coping in patients taking opioids in the palliative setting Screen for mental illness and substance abuse Involve the interdisciplinary team Use non medication modalities.