More info for Pain Management

By Anais Carbonell, M.D.

NON-OPIOIDS:

� Acetaminophen 650-1000 mg TID scheduled

� Check Vitamin D and replete as needed as low Vitamin D is associated with pain

TOPICALS

� Lidocaine TID, mix with menthol salicylate

� Menthol-Salicylate - TID

� Capsaicin TID to QID

� Diclofenac *Formulary if they failed menthol-salicylate, PADR no longer required*. 1% gel up to 2g 4x/day (do not exceed 32 g/day total)

� Lidocaine Patch NF, must fail the cream apply patch for 12 hours then remove

� Doxepin Cream NF, must fail essentially all other topicals including capsaicin but can be used for neuropathic pain

NSAIDS: Cannot be used in CAD/CABG, renal disease, GIB

� Celecoxib 100 mg BID or 200 mg daily

� Ibuprofen 400 mg every 4-6 hours prn, max 3200 mg daily

� Sulindac 150 mg BID max is 400 mg QD (200 mg BID)

� Naprosyn 500 mg q12 hours Max is 1000 mg QD

� Diclofenac 75 mg BID or 50 mg TID

� Salsalate 750-1000 mg TID max dose 3 grams per day

� Meloxicam 15 mg once daily

ALPHA 2 ADRENERGIC AGONISTS help with symptoms of opioid withdrawal

� Clonidine

TCAs must get EKG first, should not use in patients with CAD and can cause sleepiness so should be taken at night (Causes QT prolongation and has anticholinergic effects which usually improve with time), anticholinergic. Not dialyzable so this is not a good choice for patients with SI. Never use in patients above 65. Great for neuropathic pain but slow to act 3-6 months to act). NEVER use with methadone because this can cause heart block. Beers Criteria meds

� Amytryptiline good for fibromyalgia with coexisting depression. Start at 10 mg QHS and can increase weekly to max dose of 50 mg QHS

� Nortryptiline Better for older patients than amytryptiline because shorter duration start with10-25 mg QHS and can increase to 100 mg/day �

� Doxepin low dose helps with mood, insomnia and pain 25 to 50 mg QHS with max dose of 100-300 mg daily

SSRIS/SNRIS

� Duloxetine Start at 30 mg daily for one week then increase dose to 60 mg daily (can go to 90 mg daily). Must taper off when discontinuing. Note that it can cause insomnia so tell patients to take no later than 3 PM.

� Venlafaxine good for neuropathic pain start at 37.5 mg QHS and can increase in 37.5 mg increments to 375 mg/day. (ER 1/day, IR divide in 2-3x/day) but should not be used in heart disease that is uncontrolled because it is associated with an increase in BP and tachycardia. Lower the dose by HALF in CKD.

� Mirtazapine 15 mg QHS, can titrate ever 1-2 weeks up to 45 mg QHS. Causes weight gain and sleepiness so best in patients with insomnia, depression and are underweight due to the depresison

ANTI-EPILEPTICS

� Gabapentin Max dose 3600 mg/day in 3 divided doses (1200 mg TID) BUT must start slow and titrate up and can take 2 months to take effect. If you want to switch to lyrica start at 100 of lyrica and reduce the gabapentin by 800 until you get to max dose of lyrica 300 BID but usually only need 400 mg usually.

� Pregabalin (Lyrica) Start at low dose 25 to 50 mg at bedtime for patients at increased risk of side effects. Can increase to 75 mg BID within the first week. Can then double to 150 mg BID after another week and uptitrate to the max dose of 450 mg (225 mg BID)

� Topiramate similar to gabapentin better for tension HA and migraines and good for peripheral neuropathy BUT cannot use with glaucoma, renal stones, renal insufficiency (worsens CKD), lose depth perception (should not use in a long distance driver). Helps patients lose weight and stabilizes mood. �Start at 25 mg QHS and can uptitrate to 50 mg BID

� Carbamazepine Only used for trigeminal neuralgia because can cause leukopenia so you must monitor CBCs at 2 weeks, 1 month, 3 months to ensure stability of CBC. �Also do not use in Asian people without testing for the HLAB27 because if +they get TEN with it. Start at 100 mg BID and increase in 200 mg increments up to 1200 mg/day.

MUSCLE RELAXANTS

� Methocarbamol up to 1 gram QID

� Baclofen Start at 5 mg TID and can go up to 40-80 mg daily total.

� Cyclobenzaprine start at 5 mg TID, can increase to 10 mg TID but should only be short term for 2-3 weeks

� Tizanidine Start at 2 mg TID, up to 36 mg/day

MISC:

� Magnesium Oxide 420 mg BID

� Medrol Dose pack for acute pain exacerbation

OPIOIDS

-When starting, always start with IR formulations NOT ER

-Goal should be less than 30 MME/day up to 50 MME/day, no more than 90 MME/day in any situation.

� 1 mg oxycodone:1.5 mg morphine (33 mg oxycodone = 50 MME; 60 mg oxycodone = 90 MME)

� 1 mg hydrocodone: 1 mg morphine (50 mg hydrocodone = 50 MME; 90 mg hydrocodone = 90 MME)

� Dilaudid 1 mg: 4 mg morphine

� Codeine 1: 0.15 mg morphine (codeine is dose limiting because of severe constipation)

� Fentanyl is expontial according to dose so much use calculator!

� Methadone is expontial according to dose so much use calculator!

***Risk Factors for Opioid Misues***

-NARX score should be less than 300, 300 to 400 is moderate risk, above 500 is an unacceptable risk

-Illegal Drug use or prescription drug misuse

-History of substance abuse disorder or overdose

-MH conditions depression/anxiety

-Sleep disordered breathing (uncontrolled OSA)

-Concurrent Benzo use these really should not be given together.

Immediate Release	Dose	Half life
Tramadol	25-50 mg q6 hours	6-9 hrs b/c metabolite
*Morphine - preferred	7.5-15 mg q4 hours	2-3 hours (IR lasts 3-6 hours)
Oxycodone	2.5-5 mg every 4-6 hours	2-3 hours
Hydromorphone	1-2mg every 3-4 hours	2-3 hours

Long Acting	Dose	Half Life
Morphine Sulfate ER (MS Contin)	15-30 mg BID	8-12 hours
Oxycodone ER (OxyContin)	10,15,20,30 mg BID	12 hours

PROSTHETICS

TENS UNIT

SELF CARE UNIT Like TENS with heat/cold/vibration

HEATING PAD

ICE PACKS

BRACES BACK/NECK/KNEE

NON-PHARMACOLOGICAL

PHYSICAL THERAPY

POOL THERAPY (KT)

PAIN PSYCHOLOGY/PAIN SCHOOL

INTERVENTIONAL PAIN

BFA

CHIROPRACTOR

TRADITIONAL ACUPUNCTURE

OCCUPATIONAL THERAPY Iontophoresis can be done for carpal tunnel pain

RMS Recreational Therapy for projects to help coping with chronic pain

CHAMPS for headache

CLINIC GUIDE

Every Patient: Address the 4 A's

1. Analgesia: Original history (Old Carts), Interim History for follow ups, efficacy of current regimen

2. ADE: Confirm regimen and any improvement/worsening in pain

3. ADLs: How are ADLs affected?

4. Aberrant Behaviors: Nicotine/ETOH, habits, Uncontrolled depression, SI/HI

ASSESSMENT/PLAN

� Chronic Pain Syndrome is always the #1 diagnosis, then you write what it is secondary to. Always write if optimally or suboptimally controlled

� PLAN:

1. Consults/Imaging: MRI, Xrays, PT, pool therapy, pain psych, interventional pain, chiropractor, acupuncture (BFA or traditional)

2. Pain Medications: Opioids and Non-Opioids

3. Non-Pharmacologic: Heat, Cold, Tens, Neck in line traction unit (do not use if patient has had surgery), DDS500 Lumbar traction belt (also do not use if they have had surgery)

4. Lifestyle Modifications: Weight loss, aerobic exercise, relaxation, meditation, Tai-Chi, Yoga, adaptive techniques

5. UDS/Labs: Always review if appropriate

Encounter

� Chronic Pain Syndrome is always the #1 diagnosis

� STORM Note for risk factor review is needed 1x/year

� PDMP (State prescription drug monitoring is needed every time you renew an opioid)

OPIOD PATIENTS

� Consent in I-Med consent must be on file for ever patient

o Must sign a new one if this is the first time they are starting opioids OR if there has been a significant amount of time since the person has been on opioids.

� F/u with patient every 11 weeks as they must have a face to face encounter every 3 months.

o Note that Marie will do the opioid safety education on any patient that is new to opioids

� STORM note � must be done once per year

o In CPRS go to tools � Reach � STORM patient review of opioid risk and once you look up the patient there is a link under there name to generate the chart note which will open a PDF that you can then copy

o Note is called Opioid Risk Provider Review Database

� PDMP must be done every time you refill the opioid Rx. Note this is true for testosterone, opioids and benzos ie any controlled substances.

� Opioid order: The Rx must say Non-Acute Chronic Pain. Acute prescriptions must say Acute Pain Exemption 7 days and the max you can prescribe is 3-7 days. Opiods are NEVER recommended for acute on chronic pain.

E-Consults:

-PCPs should never start opioids for chronic pain without an E-consult first.

-When completing an E-consult review the following:

� MH issues

� If the patient is already on opioids is there a pain agreement in place?

� UDS appropriate?

� Review medications and illnesses for risks/side effects

� Review STORM tool

� When completing the encounter Enter time it took to answer the consul plus the diagnsosis which the first one is always chronic pain syndrome