Termination of Pain Management Care

Pain Management and Opioid Use

• Monitor patients for signs of abstinence syndrome during the withdrawal period, such as nausea, diarrhea, muscle pain, and myoclonus.
• Clonidine can be used to manage withdrawal symptoms, with a dose of 0.1 to 0.2 mg every 6 hours or a 0.1 mg patch over 24 hours weekly.

Reasons for Termination of Opioid Treatment

• Pain issue is resolving in stable patients and no further opioid management is indicated.
• Patient is experiencing intolerable and unmanageable adverse events.
• Patient has been referred to another provider for treatment due to complexity of issues or plateauing of progress.
• Patient has been admitted to a long-term healthcare institution and the provider does not have clinical privileges.
• Patient is incarcerated.
• Patient has proven to be noncompliant with the Pain Management Agreement (PPA).

Considerations for Termination Documentation

• Have a practice policy in place to guide the termination process.
• Document compliance issues and mitigation strategies.
• Keep copies of all written communication with the patient.
• Document the decision-making process in the clinical record.
• Do not withhold future release of records.

Pain Management in Special Populations

• Undertreatment of pain is common in very young, older adults, and minority populations.
• Infants and young children have a robust inflammatory response to pain, but enzyme systems that metabolize drugs are immature.
• Pregabalin has anxiolytic effects and is helpful for mood stabilization in patients with neuropathic pain.

Medications for Pain Management

• Tramadol is a nonopioid analgesic that binds to the m receptor and has weak opioid and SNRI activity.
• NSAIDs are useful for mild to moderate pain and inflammation, but carry risks of cardiovascular disease, GI bleeding, and renal dysfunction.
• Acetaminophen is a good choice for older adults, but liver function should be monitored.
• Opioids can be used for moderate to severe pain, but have a high risk of addiction and side effects.

Opioid Rotation

• Calculate the current opioid daily dose and select a new opioid using an equianalgesic comparison chart.
• Reduce the dose by 25% to 50% based on clinical judgment.
• Monitor the impact of the change and adjust as necessary.

Breakthrough Pain

• Mitigate breakthrough pain with the addition of a long-acting opioid in the same drug family.
• Long-acting opioids provide a stable blood level and can improve dose compliance.

Adverse Effects of Opioid Therapy

• Common adverse effects include nausea, itching, mild skin rash, headache, sweating, and constipation.
• Constipation is the most common opioid side effect.
• Opioid-induced respiratory depression is a chief hazard, especially in older adults and those with existing respiratory compromise.
• Serotonin syndrome is a risk when combining opioids with serotonergic antidepressants.

Pediatric Pain Management

• Pain assessment in infants and young children can be challenging due to their inability to verbally express discomfort.
• Validated pain scales for preterm and term infants, such as the Premature Infant Pain Profile and the CRIES Postoperative Pain Scale, can be used.
• Children as young as 18 months may be able to indicate their discomfort, and children aged 3 to 4 years and older can use self-report pain scales.

Pain Management in Older Adults

• Older adults experience physiological changes that can increase the pain threshold, alter metabolism and excretion of drugs, and affect absorption.

• Pain is common in older adults, especially in those older than 85, and is often due to arthritis.

• Older adults may be reluctant to report pain, and assessment can be challenging, especially in the presence of cognitive decline.

• Respiratory depression and constipation are major pain medication side effects in older adults.### Pain Management in Older Adults

• Pain, especially persistent pain, is common in older adults, particularly in those over 85, often due to arthritis.

• Older adults may be reluctant to report pain due to fear of additional tests, costs, and perceived weaknesses.

• Assessment of pain can be challenging, especially with cognitive decline.

• Practitioners should clarify the words used by older adults to describe their discomfort.

Pain Medication Side Effects and Considerations

• Respiratory depression and constipation are major pain medication side effects for older adults.
• Education on medication administration, concomitant use of other medications, and assessing risk for falls, cognitive changes, and altered physiological status is crucial.
• Be aware of caregiver drug diversion susceptibility in older patients.
• Initiate a bowel care regimen and reduce starting dose by one-third to one-half the usual adult dosage, especially in debilitated, frail, and opioid-naïve patients.

Physiological Changes and Comorbid Conditions

• Older adults experience physiological changes in anatomy and underlying neurophysiological mechanisms of pain, along with comorbid conditions, which can increase the pain threshold, alter metabolism and excretion of drugs, and affect absorption.

Alternative Therapies and Complementary Approaches

• Herbal preparations are not regulated, but they may play a role in treating chronic pain conditions.
• Internet consumers can find multiple Web sites listing "natural painkillers" such as turmeric, feverfew, eucommia, kava, capsaicin, and devil's claw.
• Practitioners should educate themselves about possible interactions among herbs and pharmaceuticals.

Prescribing Pain Medications

• Prescribing pain medications is based on individual patient needs, treatment goals, pain source, and expected length of treatment.
• Pain medications can be separated into three groups: adjuvant analgesics, nonopioids and NSAIDs, and opioid analgesics.
• Consider the complete history and physical assessments, including risk for abuse and misuse, medication cost, and prescriber's familiarity and comfort with the medication.

Adjuvant Analgesics and Multiuse Medication Treatment

• Adjuvant medications can have a synergistic effect to reduce pain when used in combination with analgesics.
• SNRIs and TCAs can be used to manage depression or anxiety, along with pain modulation.
• Duloxetine and venlafaxine can be effective for diabetic peripheral neuropathy.
• TCAs are effective for several types of neuropathic pain but may take up to 6 weeks for full analgesic effect.

Pain Assessment and Management in Patients with Dementia

• Dementia and cognitive impairments are more common in older adults, but can occur at any age.
• Reduced mental capacity does not mean physiological responses to pain are also reduced.
• Pain assessment becomes a challenge when patients are unable to clearly communicate their symptoms and needs.
• Formal tools can aid the provider in assessing pain behaviors, such as the Mini Mental Status Examination, the Checklist of Nonverbal Pain Indications, and the PAINAD scale.

Pain Management in Pregnant Women

• Opioid exposure during pregnancy may cause increased risks to the fetus.
• Discuss the risks and benefits of opioid therapy with women of childbearing potential.
• Consider using acetaminophen, naproxen, oxycodone, or topical anesthetics during pregnancy.
• Counsel women on the risks of neonatal opioid withdrawal syndrome and the importance of minimal or no opioid use during pregnancy.

Chronic Pain Management Strategies

• The Institute for Clinical Systems Improvement recommends strategies for managing chronic pain, including relaxation techniques, meditation, imagery, diaphragmatic breathing, and muscle relaxation exercises.
• Interventions that may require a therapist include biofeedback, hypnosis, guided imagery, and counseling.