M3-PPT-ALTOs-Nurse-Pharmacist-Training.pptx

This course is designed for Intermediate EMT students in the management of pain

1. Alternatives to Opioids (ALTOs) Revised 8/19/19

2. Review the Rocky Mountain Chapter of the Society of Hospital Medicine (SHM) alternative to opioid (ALTO) pain pathways by indication Learn how to use ALTO medications per the SHM pathways Recognize the safety profile and potential adverse drug events of ALTO medications Comprehend the changes that impact clinician practice including policies and scope of practice Learning Objectives

3. Non-opioid medications first Opioids as rescue therapy Multimodal and holistic pain management For specific conditions Pain Pathways: Pleuritic pain Extremity pain Abdominal pain Musculoskeletal pain Renal colic ALTO Fundamental Principles

4. Goal: To utilize non-opiate approaches as first-line therapy and educate our patients on: Alternatives to opioids as a first line treatment for pain Offer non-pharmacologic treatments Discuss realistic pain management goals Discuss addiction potential and side effects of opioids Opiates can be given as rescue medication if needed ALTO Approach to Pain Management

5. Pleuritic pain PNA, inflammatory pleuritic, rib fracture Extremity pain Cellulitis, DVT, neuropathy Abdominal pain Non-pregnant patients without GI bleed, perforation or obstruction Musculoskeletal pain Joint/arthritis, muscular, myofascial pain Renal colic Nephrolithiasis pain SHM ALTO Pain Pathways by Indication

6. How ALTOs Work

7. Channels/Enzymes/Receptors Targeted Analgesia (CERTA) Shift from a symptom-based approach to a mechanistic approach Targeted, patient-focused analgesic approach utilizing combinations of non-opioid analgesics Results in: Greater analgesia Reduced doses of each medication Fewer side effects Shorter length of stay ALTOs and the CERTA Approach

8. Channels: Sodium (Lidocaine) | Renal Colic pain pathway Calcium (Gabapentin) | Extremity and musculoskeletal pain pathways Enzymes: COX 1,2,3 (NSAIDS) | All pain pathways Receptors: MOP/DOP/KOP (Opioids) NMDA (Ketamine) | Musculoskeletal pain pathway GABA(Gabapentin) | Extremity and musculoskeletal pain pathway 5HT1-4(Haloperidol/Ondansetron/Metoclopramide) | Abdominal pain pathway D1-2(Haloperidol/Prochlorperazine) | Abdominal pain pathway SHM ALTO Pathway - CERTA Examples

9. How does the CERTA pain management approach work in conjunction with ALTOs? Discussion Point

10. Therapeutic ALTOs

11. Action : Non-competitive voltage dependent sodium channel blockade. Decreases nerve depolarization and propagation of the pain signal ALTO Indication : Neuropathic pain, sharp, burning, aching pain and discomfort to sensitive skin areas Route : Topical and IV Dose for Topical application : Prescription strength - 5% patches TD 1-3 patches Pleuritic, extremity, musculoskeletal pain pathways Dose for IV route :  Extremity pain: 1mg/kg/ hr x 24 hr infusion if severe neuropathy or ischemia Renal colic: 1mg/kg/ hr infusion x 24 hours IV lidocaine may be given in non-ICU areas Lidocaine

12. Notes : Lidocaine rescue kit should be available when administering IV lidocaine At low IV doses, lidocaine is generally benign IV lidocaine patients are always on a cardiac monitor Short half-life (1.5 – 2 hours) If side effects do occur, they are generally transient and rapidly reversible Lidocaine

13. Action : Antagonizes NMDA receptors. The activation of NMDA receptors has been associated with hyperalgesia, neuropathic pain and to inhibit opioid receptors ALTO Indication : Works to reduce the opportunity for opioid tolerance Route : PO Dose : 25-50 mg PO Q 4 hr PRN Musculoskeletal pain pathway Notes : Avoid in patients with PTSD Monitor vital signs 1 hr after initial dose then Q 4 hrs Watch for changes in heart rate, B/P and CNS Ketamine

14. Action : Inhibition of prostaglandin synthesis by completive blocking of enzyme cyclooxygenase (COX) – (natural substance that causes inflammation) ALTO Indication : NSAID – anti-inflammatory, antipyretic and analgesic; used for short-term treatment of moderate to severe pain Route : IV Dose : 15 mg IV Q 6 hr x 5 days max as alternative to oral NSAID Pleuritic, extremity, abdominal and renal colic pathways Notes : Risk for bleeding Higher risk for cardiovascular episodes Evaluate gastric ulcer risk prior to starting NSAIDs especially if on concomitant therapeutic anticoagulation Ketorolac (Toradol)

15. Action : Antipsychotic drug that blocks the effects of dopamine and increases its turnover rate; decreases abnormal excitement in the brain ALTO Indication : Nausea and abdominal pain Route : IV/PO Dose : 1-2 mg IV/PO Q 4 hr PRN if uncontrolled nausea Abdominal pain pathway Notes : Potential for prolonged QT wave Double check medication interactions: anticoagulants, vitamins, antihistamines, anti-anxiety meds Often used to treat psychotic disorders Haloperidol (Haldol)

16. Action : Increases urine concentration and decreases urine production by increasing water permeability in the renal tubular cells ALTO Indication : Likely, the antidiuretic mechanism of desmopressin is responsible for making it effective for the treatment of renal colic  Route : PO Dose : 0.4 mg PO daily when NSAIDs are contraindicated Renal colic pathway Notes : Potential side effects: diarrhea, abnormal thinking, headache, stomach cramps Alert to patients with history of blood clotting, high B/P, fluid or nutrient imbalance, kidney disorders Used for diabetes insipidus, bedwetting, hemophilia A, high blood urea levels Serious side effects more likely in the elderly Desmopressin (DDAVP)

17. Action : Anticholinergic drugs inhibit the transmission of parasympathetic nerve impulses, thereby reducing spasms of smooth muscles ALTO Indications : Anti spasmodic and anticholinergic Route : IM/PO – never IV Dose : 10-20 mg IM/PO TID Abdominal pain pathway Notes : Take care when giving to patients with coronary heart disease and hypertension Take care with the elderly patient Never give IV Dicyclomine ( Bentyl )

18. Action : Antiepileptic drug designed to inhibit the alpha 2-delta subunit of voltage-gated calcium channels ALTO Indication : Neuropathy Route : PO Dose : 100-300 mg PO 1-3x daily Musculoskeletal and extremity pain pathways Notes : Well tolerated with few side effects Most common adverse event is somnolence Gabapentin (Neurontin®)

19. Action : Decrease prostaglandin synthesis ALTO Indication : Compared to opioids: similar pain relief for mild-moderate pain; decrease opioid requirements in moderate-severe pain Route : PO/PR Dose : 1000 mg PO TID Abdominal, musculoskeletal, pleuritic, renal colic and extremity pain pathways Notes : Delayed onset (PO 45-minutes) NSAIDs found to be equally as efficacious as opioids at reducing pain associated with renal colic, but have less side effects NSAIDs found to be equally as efficacious as opioids at reducing pain associated with renal colic, but have less side effects APAP + NSAID

20. Opioids are the last resort . . . not the first option.

21. The Role for the Nurse Leader

22. Nurse education : Learn about the new multi-modal, opioid-sparing ALTO Pathways Work with physicians to limit the use of opioids Be proactive with patient and family concerns Begin conversations regarding best practices to manage pain Manage pain expectations Provide educational resources Talk about realistic pain goals Scripting regarding “control” of pain versus “relief” of pain Promote “increasing comfort” Engage patients in developing unique pain plans, which may include both acute and chronic pain management Education

23. Patient education : Educate patient and families on how to use the pain assessment tools Provide non-pharmacologic alternatives to medication: Music therapy Pet therapy Ice Heat Environmental changes Provide resources on the dangers of opioids Provide resources on ALTOs Education

24. Survey of nurses participating in the ED ALTO pilot indicated the following were the top three challenges: Patients do not understand the program (37 percent) Program was poorly understood by some clinicians and nurses (25 percent) Takes too much time and doesn’t fit into everyday workflow (8 percent) Stay Alert to Potential Challenges

25. What do you see as potential challenges for implementation of the CO’s CURE SHM Guidelines? Discussion Point

26. How do we explain this to patients? We will try to control pain, not eliminate pain We are trying to make patients more comfortable, not pain-free Example: “This medication is called ketorolac and will help control your pain by reducing inflammation.” Working with Our Patients: Scripting

27. Pain : Assess patient prior to administration of any pain intervention: Standardized pain assessment tools Use scripting that medication will help “ control your pain and improve your comfort ” Reassessment within a reasonable time frame: Reasonable time frame is what hospital policy says it is If pain is not controlled, provide other options Two Types of Patient Assessments

28. Risk of Addiction : Risk for abuse: Personal or family history of substance abuse Age between 16 and 45 years Mental health history History of sexual abuse Comorbidities: Pulmonary disease Cardiac disease Renal or hepatic failure Elderly Mental health Chronic pain Two Types of Patient Assessments

29. The Role for the Pharmacy Leader

30. Nurse, physician and pharmacist education : CPOE Create pain treatment order set Create order strings for unique entries – clearly label “for pain” Smart Pumps Addition of new medications – clearly label “for pain” Lidocaine Bolus = 1 mg/kg in 100 mL NS over 60 min Education

31. High-Risk Medication Administration Lidocaine 1 mg/kg bolus over 60 min = non-ICU areas Cardiac lidocaine = ICU Lead Policy Changes

32. Opioids are a last resort, not the first option Opioids may still be necessary for some patients Engage patients and families in creating an integrated, holistic approach to pain management Assess patients for both pain and risk of addiction This will help establish a baseline for developing the best multi-modal treatment plan High-risk policies will likely need to change Make sure clinician policies change to match scope-of-practice changes Conclusions

33. Questions and Feedback

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35. Motov , Sergey , MD , Lyness , David, MD,. CERTA Opioid Approach to Pain Management. Originally put on website in July 2016. Retrieved Aug. 3, 2019 from: ​ https://www.propofology.com/infographs/certa-opioid-alternatives-as-analgesics Federal Healthcare System Experience: VA Implementation, Maintenance, and Evaluation C. Bernie Good MD, MPH Veterans Affairs Pharmacy Benefits Management May, 2017. Retrieved July 28, 2019 from: https://www.fda.gov/media/105295/download Opioid Crisis: Scrap Pain as 5th Vital Sign? Groups call on JC and CMS to re-evaluate policies that could lead to opioid overprescribing; Kristina Fiore, Associate Editor, MedPage Today, April 13, 2016. Retrieved July 28, 2019 from: https://www.medpagetoday.com/publichealthpolicy/publichealth/57336 Masoumi , Kambiz , Darian, Ali Asgari , Forouzan , Arash , Barzegari , Hassan, Rahim, Fakher, Feli , Maryam, Sheidaii , Mehdi Fallah Bagher, & Porozan , Samaneh . (Volume 2014). The Efficacy of Intranasal Desmopressin as an Adjuvant in the Acute Renal Colic Pain Management. Pain Research and Treatment , Article ID 320327 Retrieved Aug. 1, 2019. http://dx.doi.org/10.1155/2014/320327 Cunha, John. P, DO, FACOEP. RxList . Retrieved Aug. 2, 2019 from: https://www.rxlist.com/consumer_lidocaine_lidopen/drugs-condition.htm; https://www.rxlist.com/ddavp-drug/patient-images-side-effects.htm#whatis Pack, Alison M. In Osteoporosis Anticonvulsant-Related Bone Disease (Fourth Edition) Science Direct, 2013. Retrieved Aug. 3, 2019 from: https://www.sciencedirect.com/topics/neuroscience/gabapentin Johannessen, Svein I. Johannessen, Drug Monitoring and Clinical Chemistry in Handbook of Analytical Separations, 2004-2013 Science Direct. Retrieved Aug. 3, 2019 from: https://www.sciencedirect.com/topics/neuroscience/gabapentin References continued

36. Cohen, V, et al. Am J Health Syst Pharm, 2015. 72:2080-86 Mattson, A. PharmD, BCPS. (Aug. 16, 2016). Curbing Opioid Use Alternatives to Opioids for Acute Pain in the Emergency Department. A Emergency Medicine Clinical Pharmacist. Pharmacy Grand Rounds Mayo Clinic. https://ce.mayo.edu/sites/ce.mayo.edu/files/Curbing%20Opiod%20useMattson%208%2016%2016.pdf Turturro MA, et al. Annals Emerg Med. 1995;26:117-20. Catapano MS. J Emerg Med.1996;14(1):67-75 Motov S, et al. Anesthesiology Clin. 2016;34:271-285 Rose, M. A. & Kam, P. C. A.. (2002). Gabapentin: pharmacology and its use in pain management. Anaesthesia , 57pages 451-462. https://onlinelibrary.wiley.com/doi/epdf/10.1046/j.0003-2409.2001.02399.x Editorial Staff: American Addiction Center. (June 24, 2019). Addiction Among Those With Comorbid Medical Conditions. https://sunrisehouse.com/addiction-demographics/comorbid-medical-conditions/ References continued