Lecture 78 - Non-Malignant Pain Part 4

Question 1

2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain

Answer 1

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

Question 2

12 recommendations are grouped into four areas of consideration

Answer 2

1. Determining whether or not to initiate opioids for pain
2. Selecting opioids and determining opioid dosages
3. Deciding duration of initial opioid prescription and conducting follow-up
4. Assessing risk and addressing potential harms of opioid use

Question 3

Recommendation 1: Determining whether or not to initiate opioids for pain

Answer 3

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

Question 4

Recommendation 2:

Answer 4

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

Question 5

Recommendation 3:

Answer 5

When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting opioids.

Question 6

Recommendation 4:

Answer 6

When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage.

Question 7

Recommendation 5:

Answer 7

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.

Question 8

Recommendation 6:

Answer 8

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.

Question 9

Recommendation 7:

Answer 9

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.

Question 10

Recommendation 8:

Answer 10

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.

Question 11

Recommendation 9:

Answer 11

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.

Question 12

Recommendation 10:

Answer 12

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.

Question 13

Recommendation 11:

Answer 13

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.

Question 14

Recommendation 12:

Answer 14

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.

Question 15

When to Reduce/Taper Opioids

Answer 15

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

Question 16

How to Reduce/Taper Opioids

Answer 16

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.

Question 17

Opioid Laws - 2014 Chronic Pain Law

Answer 17

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

Question 18

Opioid Laws - 2-17 opioid 7 day prescribing limit

Answer 18

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)

Question 19

Opioid Laws- 2019 INSPECT requirement

Answer 19

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

Question 20

Pain Contract

Answer 20

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

Question 21

As Needed Pain Medication

Answer 21

Only administered when patient is in pain
Minimize exposure to limit toxicity

Question 22

Scheduled Pain Medication

Answer 22

Given at a set interval
May be better option for continual pain
Can still use breakthrough analgesia

Question 23

Michigan Opioid Prescribing Engagement Network (OPEN)

Answer 23

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

Question 24

Michigan Opioid Prescribing Engagement Network (OPEN) - recommended scheduled dosing of acetaminophen and ibuprofen

Answer 24

Acetaminophen 650mg q6h while awake
Ibuprofen 600mg q6h while awake
Alternate to take medication q3h

Question 25

Michigan Opioid Prescribing Engagement Network (OPEN) - patient education

Answer 25

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

Question 26

Treatment of Acute Pain - hospitalized patients

Answer 26

Hospitalized patients may have multiple orders for pain medications
Can only have one order for each severity of pain

Question 27

Patient Controlled Analgesia (PCA)

Answer 27

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

Question 28

Recommended Treatments for Low Back Pain

Answer 28

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)

Question 29

Recommended Treatments for Osteoarthritis

Answer 29

Nonpharmacological treatments: Exercise, weight loss, patient education
Medications: First-line - Acetaminophen, Oral or topical NSAIDs; Second-line - Intra-articular hyaluronic acid, Capsaicin

Question 30

Recommended Treatments for Fibromyalgia

Answer 30

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

Question 31

Recommended Treatments for Neuropathic Pain

Answer 31

First line: SNRIs, Gabapentin/pregabalin
Second line: Topical lidocaine, TCAs

Question 32

Hospice

Answer 32

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

Question 33

Hospice: treating pain relief and air hunger

Answer 33

Morphine IV or solution (20mg/mL) under tongue * Could use fentanyl or hydromorphone

Question 34

Hospice: treating anxiety/agitation

Answer 34

Lorazepam IV or SL as needed

Question 35

Hospice: treating nausea/vomiting

Answer 35

Ondansetron ODT

Question 36

Hospice: treating secretions

Answer 36

Atropine ophthalmic drops under tongue
Glycopyrrolate IV as needed
Scopolamine patch