Pain tx Flashcards
(27 cards)
Pain treatment 12 recommendations grouped into 4 categories
- Determining whether or not to intiate opioids for pain
- Select opioids and determine dose
- Decide duration of initial opioid rx and followup
- assess risk and harms
- Determining whether or not to initiate opioids for pain (rec 1-2)
- Nonopioid therapies are at lease as effective as opioids
- Nonopioid therapies preferred
12 opioid recommendations
- Nonopioids at least AS effective as opioids
- Nonsteroid tx preferred
- Select IR opioids
- Lowest effective dosage
- weigh risk v benefits when changing dose
- no greater quanity than needed for duration of pain
- pro v con in pt within 1-4 weeks, continual pro v cons
- strategies to mitigate risk
- assess OD risk (past hx and dosage forms)
- consider toxicology testing to assess for prescribed and nonprescribed controlled substances
- caution when prescribing opioid pain medication and benzos
- arrange tx w evidence-based meds, detoc on its own not recommended
Changing opioid dosage
-optimize non-opioids
-taper to lower dosages
Strategies to mitigate risk
-offer naloxone
-assess drug/alc use
-consider toxicology screening
When to reduce/taper opioids
-pt requests dose reduction
-no clinically meaningful improvement in pain and function
-is on doses >50 MME/day wo benefit or also on benzos
-shows sx of substance use disorder
-experiences OD or serious ADR
-show early warning signs of OD (confusion, sedation, slurred speech)
How to reduce/taper opioids
-avoid abrupt dc
-dec dose 10% per month if pt have taken opioids for more than a year
-dec dose 10% per week for pt that have taken opioids for shorter time (weeks to months)
-inc interval between doses once lowest dose reached
-can d/c when taken less than once a day
Opioid Laws
-2014 Chronic Pain Law
-2017 Opioid 7 day rx limit
-2019 INSPECT requirement
2014 Chronic Pain law
-applies to any pt for the past 3+ months who:
-taking 60 pill/month
-taking >15MME
-transdermal patch
-taking tramadol
-any dose of ER controlled med
-(not terminal, palliative, hospice, or nursing home tho)
-practitioners required to:
-perform own evaluation
-assess mental health
-assess risk for substance use
-check INSPECT (w each rx orq90d if on pain contract)
-sign and discuss treatment agreement/goals
-reassess and document risk if >60 MED
2017 Opioid 7 day rx limit
-only rx for 7 or less days for first rx
-no specific exception for practicioners in same practice
-NOT for cancer, med assisted tx, substance abuse disorder, palliatatic ecare, professional judgement
2019 INSPECT requirement
-check INSPECT each time before rx an opioid ot benzo
-no exceptions to the usuals: hospice etc
-pt on pain management contract: check INSPECT q90d
Pain contract
-between pt and prescriber
-doesnt prevent another provider from rx opioids but pt would no longer receive opioids from og provider
Acute pain treatment
- non-opioid =/- adj analgesic
- opioid + nonopioid +/- adj
Michigan OPEN
-procedure-specific prescribing recommendations to curb over prescribing of post op opioids
-acetaminophen and ibuprofen schedule
-pt education
Acetaminophen, ibuprofen scheduling Post-op
-acetaminophen 650mg q6h while awake
-ibuprofen 600mg q6h while awake
-alternate to take meds q3h for 3 days until no longer needed
Post-op pt education
-pain is normal
-worse the day after but gets better
-manage pain
Multiple pain med orders in hospital
-can only have one order for each severity of pain
-mild, mod, severe?
Patient controlled analgesia (PCA)
-allows pt to decide when they will get dose of pain med
-IV line place into pt veins
-pump allows pt to release pain meds by pressing button
-dose and freq limits set by provider
-post-op, pancreatitis, sickle cell
Recommended treatments for low back pain
-exercise, CBT, rehab
1. acetaminophen / NSAID
2. SNRIs / TCAs
Recommended tx for osteoarthritis
-exercise, wt loss
1. acetaminophen / NSAID (topical or oral)
2. Intra-articular hyaluronic acid / capsaicin
Recommended tx for fibromyalgia
-low impact exercise, CBT, biofeedback, rehab
-pregabalin, duloxetine
-TCA, gabapentin, venlafaxine
Recommended tx for neuropathic pain
- SNRIs / gabapentin, pregabalin
- topical lidocaine / TCAs
Hospice
-provide comfort to pt in pain
-dec respiratory drive to aid in natural end of life processes
-buccal/sublingual
-parenteral (usually continuous infusion)
-transdermal
-monitor pt comfort over side effects
Hospice pain relief and air hunger tx
-morphine IV or solution (20mg/mL) under tongue
-can use fent or hydromorphone
