Michelle Peck | Geriatric Nurse Practitioner | Health Care Consultant | Professional Speaker | Nursing Faculty| Legal Nurse Consultant | Mindful Geriatrics In collaboration with Dr. Linh Nguyen, Supportive Medicine at UTHealth Medical School, we have created this slide deck for Advanced Practice Nurses. Our mission is to simplify the pharmacologic basics of good pain prescribing. We have not provided very much detail about schedule II controlled substances due to the current limitations on Texas Nurse Practitioner prescribing in primary care. This lecture is designed to meet our Advanced Practice Nursing audience where they are at and provide tools, knowledge and practical tips. Areas where we detect mastery with our polling questions are briefly touched upon and more time and examples are given are to areas of audience identified needs. Prescribing pain medication for Advanced Practice Nurses is dynamic, complex and ever changing We have also included a special focus (our passion) for pain prescribing in the geriatric population. Beer’s Criteria medications, to be used with caution or avoid completely in geriatrics are mentioned throughout this presentation. This presentation starts with the audience writing down their biggest fear about pain prescribing. We then categorize these fears, so that throughout our lecture we can give special focus and alleviate fears with practical tips, guidelines and real life examples. Our objectives are to discuss: 1. Benefits and side effects of common analgesics 2. The impact of patient-related factors on drug selection & dose based on knowledge of patient related changes 3. Medications to avoid, use with caution, explain why 4. Management of pain based on client care goals We hope you Learn it-Live it-Love it!

2. Let’s Discuss…
Benefits & side effects of common analgesics
Impact of patient-related factors on drug selection &
dose based on knowledge of patient related changes
Medications to avoid, use with caution, explain why
Management of pain based on client care goals

3. Reality
http://www.consumerreports.org/cro/video-hub/3705124027001/
The Dangers of Painkillers:
A Special Report.
Published: July 2014

9. Critical
Techniques

10. My primary area of work is…
Ambulatory Care Facility
Community Health Agency
Doctor’s Office/Clinic
Home Health
Hospital
Nursing Facility/Rehab
Nursing School/Education
Surgical Center
Other

11. My primary specialty area is…
Adult /Geriatric
Pediatric/Neonatal
Family
Women’s Health
Psychiatric
Acute Critical Care
Education
Hospice
Other

13. Follow the Guidelines
American Academy of Pain Medicine (AAPM)
“Pain is one of the most common reasons people consult a physician. Yet it
frequently is inappropriately treated.”
AAPM believes pain should be diagnosed and treated in a comprehensive,
systematic, collaborative, patient-centered fashion
http://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf

14. Physiologic
Psychologic
Behavioral
Social
Cultural
Religious
PAIN is a
Multifaceted
Experience

15. Agency for Healthcare Research & Quality (AHRQ)
Practice guidelines for chronic pain management.
An updated report by the American Society of
Anesthesiologists Task Force on Chronic Pain
Management and the American Society of Regional
Anesthesia and Pain Medicine.
Optimize pain control, recognizing that a pain-free state may not be attainable
Enhance functional abilities and physical and psychological well-being
Enhance the quality of life of patients
Minimize adverse outcomes
Target population
http://www.guideline.gov/content.aspx?id=23845

16. Agency for Healthcare Research & Quality (AHRQ)
Practice guidelines for chronic pain management.
Pharmacologic interventions
Anticonvulsants
Alpha-2-delta calcium channel antagonists
Sodium channel blockers
Membrane-stabilizing drugs
Antidepressants
Tricyclic antidepressants
Selective serotonin–norepi reuptake
inhibitors
Selective serotonin reuptake inhibitors
Benzodiazepines
N-methyl-D-aspartate (NMDA) receptor antagonists
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Opioid therapy
Sustained or controlled-release opioids
Tramadol
Skeletal muscle relaxants
Topical agents
Capsaicin
Lidocaine
Ketamine

17. Which statement about pharmacologic
management IS TRUE according to AHRQ
Practice Guidelines?
A. For selected patients, nonsteroidal anti-inflammatory drugs, and topical
agents may be used.
B. Anticonvulsants should be used as part of a multimodal strategy for patients
with visceral pain.
C. Selective serotonin reuptake inhibitors should be avoided for patients with
diabetic neuropathy.
D.A strategy for monitoring and managing side effects, adverse effects, and
compliance should be considered for selected patients undergoing any long-
term pharmacologic therapy.

18. The American Geriatrics Society (AGS)
Clinical Practice Guideline:
Pharmacological Management of
Persistent Pain in Older Persons
Consider Acetaminophen initial & ongoing pharmacotherapy mild to moderate
musculoskeletal NSAIDs & COX-2 selective inhibitors considered rarely, with caution, in
highly selected individuals
Consider for opioid therapy:
 Moderate to severe pain
 Pain-related functional impairment
 Diminished quality of life due to pain
http://www.americangeriatrics.org/health_care_professionals/clinical_practice
/clinical_guidelines_recommendations/persistent_pain_executive_summary

20. Client Selection, Risk Stratification
Prior to initiating COT:
Conduct an H&P and
assessment of risk of substance
abuse, misuse, or addiction
Perform and document a
benefit-to-harm evaluation

21. Informed Consent &
Management Plans
Obtain informed consent: goals, expectations,
potential risks, and alternatives
Written opioid management plans/agreements:
obtaining opioids from one prescriber
filling opioids prescriptions at one pharmacy
urine drug screens, pill counts, limited prescriptions

22. Initiation & Titration of COT
Therapeutic trial to determine if opioid is appropriate
Individualize opioid selection, initial dosing, and titration

23. Monitoring
Documentation of pain intensity & level of function
assessments & progress towards achieving
Monitor for aberrant drug-related behaviors
Periodic urine drug screens:
Low risk: 1-2; Moderate risk:3-4
High risk:>=4, every month, office visit, or every drug refill

24. High-Risk Clients
Restructure therapy if needed
Consider consultation:
Mental health
Addiction specialist
Discontinuation of COT

26. Follow WHO pain ladder
World Health Organization Stepwise
Analgesic Ladder, Focus on
Proper selection, dosing, titration, and administration of
analgesics
Five concepts: by mouth, by the clock, by the ladder, for the
individual, with attention to detail

27. Mild pain 1 - 3 on a 10 point scale
Analgesics include:
Aspirin
Acetaminophen (Tylenol)
Nonsteroidal anti-inflammatory
drugs (Elderly need to be cautious)
Coanalgesics
Step 1

28. Moderate pain 4 - 6 on 10 point scale
Analgesics include:
Codeine
Hydrocodone
Oxycodone
Nonopioid analgesic
Coanalgesics
Step
2

29. Severe Pain 7 - 10 on a 10 point scale
Analgesics include:
Morphine
Oxycodone
Hydromorphone
Fentanyl
Nonopioid analgesics
Coanalgesics
Step
3

30. Which of the following is TRUE
regarding the WHO pain
ladder?
1.Five concepts include by mouth, by the clock, by the ladder,
for the individual, with attention to detail
2.Mild pain 1 - 5 on a 10 point scale analgesics include Aspirin
3.Severe pain 7 - 10 on a 10 point scale analgesics include
Oxycodone

32. Notable Fame: Comedian, Actor
Cause of Death: Overdose, Combination of
Morphine and Cocaine
Drug Category: Mixed
When: 1997
Age: 33
Name this Celebrity -Chris Farley

34. Pain Management
Goals:
Prevention of acute pain
Control of chronic pain
Optimizing function
Improving quality of life
Interdisciplinary team

35. Effective Management
Requires the health care providers to be aware
of personal biases surrounding pain and its
management

36. CHOOSE
WISELY
AND
CONSIDER
COST

38. Rate your knowledge level of
Beer’s Criteria…
1.Expert
2.Moderate
3.Minimal
4.None
5.I prefer wine over Beer’s

39. BEER’S CRITERIA
Expert Panel from around the world
Developed list of Medications to Avoid if you are over 65
Recently Updated in 2012
Severity ratings of medications on High to Low Scale
Problems grouped based on Disease
Concerns listed independent of Disease

40. Beer’s List - Pain Rx Decisions
Drug Rationale Recommend
Quality of
Evidence
Strength
Recommend
NSAIDs oral
Aspirin >
325 mg/d
GI bleeding;
Protection
with PPIs or
misoprostol
Avoid
chronic use
Moderate Strong
Skeletal
Muscle
Relaxants
Ineffective at
tolerated
doses,
antichol, falls
Avoid Moderate Strong
Tertiary
TCAs, alone
or in
combination:
Amitriptyline
Highly
antichol,
sedating,
and cause
orthostatic
hypotension
Avoid High Strong

41. Notable Fame: Singer, Actress
Cause of Death: Drowning, Complications of
Cocaine, Heart Disease
Flexeril, Marijuana, Xanax and
Benadryl found in her body
Drug Category: Mixed
When: 2012
Age: 48
Name this Celebrity -Whitney Houston

42. Topical Agents
Local Anesthetics
Lidocaine and Bupivacaine
Block Na+ influx of voltage-gated ion channels in afferent neuron terminals
Inhibiting depolarization and generation of action potentials
Resulting in the transmission of fewer nociceptive impulses to the spinal cord
Topical lidocaine is used for neuropathic pain
Blocks hyperactive sodium ions in damaged peripheral nerves
Inhibit transmission of ectopic impulses to the dorsal horn

43. Notable Fame: Singer
Cause of Death: Cardiac arrest, Lidocaine,
Propofol, Midazolam,
Diazepam, Lorazepam
Drug Category: Prescription drug overdose
When: 2009
Age: 50
Name this Celebrity -Michael Jackson

44. Topical Agents
Analgesic Creams, Rubs, and Sprays
Counterirritants - Ingredients such as menthol, methylsalicylate, and camphor create a
burning or cooling sensation -distracts your mind from the pain (Icy Hot and Biofreeze)
Salicylates - Same ingredients that give aspirin its pain-relieving quality , when absorbed
into the skin, they may help with pain (Aspercreme and Bengay) appear to be more
effective for muscle aches
Capsaicin - Main ingredient of hot chili peppers, one of the most effective ingredients for
topical pain relief (Capzasin and Zostrix) more often used for pain associated with
damaged nerves

45. Topical Agents
Capsaicin
Defunctionalizes nerve fiber terminals through multiple mechanisms
Initial reduction in neuronal excitability and responsiveness
Inactivation voltage-gated Na channels
Direct desensitization of plasma membrane TRPV1 receptors
Followed by extracellular Ca2+ entry TRPV1, release from intracellular stores overwhelm
TRPV1 receptor
May initially cause pain -substance P released from nociceptive terminals, gets better over time
May need to apply for a few days to a couple of weeks before pain relief noticed

46. Topical Prescription
Pain Products
FDA has approved several topical products (Voltaren, Pennsaid, others)
Contain the prescription NSAID diclofenac, OA in joints close to the skin's
surface
Patches containing a numbing medication, such as lidocaine (Lidoderm)
Approved in the U.S. to treat a painful complication of shingles
May be used for other pain types, insurance may not pay off-label costs

47. NSAIDs
Inhibit conversion of arachidonic acid to prostaglandins catalyzed by COX isozymes
Nonselective NSAIDs inhibit COX-1 & 2 and include ibuprofen, aspirin, and naproxen
Nonselective action inhibits the formation of gastroprotective mediating prostaglandins
and pain-promoting prostaglandins increasing the risk of serious GI complications
Selective COX-2 inhibitors, fewer GI side effects, increased risk of cardio-renal morbidities
Disease Drug Rationale Recommendation Quality of
Evidence
Strength
Chronic kidney
disease Stages
IV and V
NSAIDs May increase risk of
kidney injury
Avoid Moderate Strong
Hx of gastric,
duodenal
ulcers
Aspirin (>325)
Non–COX-2
selective NSAIDs
May exacerbate existing
ulcers or cause new
or additional ulcers
Avoid unless other
alternatives are not
effective & can take
gastroprotective agent
Moderate Strong
Heart Failure NSAIDs and
COX-2 inhibitors
Potential for fluid retention
and exacerbating HF
Avoid Moderate Strong

48. Acetaminophen
Included in combination with many prescription opioids
Analgesia is achieved through central inhibition of prostaglandin
Not anti-inflammatory
Side-effect profile is relatively benign with intermittent
Long-term or high-dose use can be hepatotoxic
Daily dose should never exceed 4000mg
Recommended over NSAIDs in patients with GI, renal, or cardiovascular comorbidity
http://www.consumerreports.org/cro/video-hub/3907633633001/

49. Anticonvulsant Drugs
Gabapentinoids
Gabapentin, Pregabalin effective wide neuropathic pain
Selective binding/blockade voltage-gated Ca channels brain, dorsal spine
Inhibits the release of glutamate, norepinephrine, substance P
Decreases spinal cord levels of neurotransmitters, neuropeptides
Binding affinity of pregabalin is 6 times greater than gabapentin
Gabapentin possesses a shorter half-life and nonlinear absorption
Pregabalin is easier to titrate and better tolerated

50. Anticonvulsant Drugs
Lacosamide
Modulation collapsin-response mediator protein 2
Inhibits the NMDA receptor subunit NR2B
Topiramate
Suppression of action potentials Na & Ca channel blockade
GABA receptor & AMPA receptor antagonism and kainate inhibition
Also a glutamate antagonist

51. Antidepressants
Tricyclic Antidepressants
Widely used in neuropathic pain, blocking pre-synaptic reuptake norepinephrine/serotonin
Reducing neuronal influx of Ca of Na ions and activity with adenosine and NMDA
Secondary amines nortriptyline and desipramine are favored over the tertiary amines
amitriptyline and imipramine due to more benign side effect
Disease Drug Rationale Recommendation Quality of
Evidence
Strength
Chronic
Constipation
Tertiary TCAs Can worsen constipation Avoid unless no
other alternatives
Moderate Weak
Syncope Tertiary TCAs Increases risk of orthostatic
hypotension or bradycardia
Avoid Moderate Strong
Delirium All TCAs Avoid in older adults with or at high
risk of delirium, taper off
Avoid Moderate Strong
Hx falls or
fractures
TCAs
SSRIs
Ability to produce ataxia, impaired
psychomotor function, syncope, falls
Avoid unless safer
Not available
High Strong

52. Antidepressants
Serotonin-Norepinephrine Reuptake Inhibitors
Duloxetine, Venlafaxine, and Milnacipran
Duloxetine is used in painful diabetic neuropathy efficacy at 60 to 120 mg/day
Venlafaxine behaves like a SSRI at doses of ≤150 mg/day and like an SNRI at doses
>150 mg/day, dose ≥150 mg/day is often necessary to achieve pain control
Milnacipran has the greatest affinity for norepinephrine
Duloxetine has the greatest potency in blocking serotonin
Venlafaxine selectively binds to the serotonin but not the norepinephrine transporter
SNRIs are better tolerated than TCAs because they lack affinity for cholinergic,
histaminic, and adrenergic receptors

53. Antidepressants
Mirtazapine
Atypical tetracyclic antidepressant
Inhibition of 5HT-2, 5HT3, H1-a2-hetero, and alpha-2-adrenergic receptors
Beneficial effect in the adjuvant treatment of migraine headache, anxiety, agitation, depression,
insomnia, and low appetite
H1-receptor antagonism is most prominent at low doses (≤30 mg)
Drug Rationale Recommend Quality of
Evidence
Strength
Mirtazapine
Serotonin–norepinephrine
reuptake inhibitor
Selective serotonin
reuptake inhibitor
Tricyclic antidepressants
May exacerbate or cause syndrome of
inappropriate antidiuretic hormone
secretion or hyponatremia; need to
monitor sodium level closely when
starting or changing dosages in older
adults due to increased risk
Use with
caution
Moderate Strong

54. Glutamate Antagonists
Dextromethorphan
Oral cough suppressant, NMDA receptor antagonist, a sigma-1 receptor agonist, an N-
type calcium channel antagonist, and a serotonin reuptake transporter antagonist
Rapid hepatic metabolism interferes with maintaining plasma concentrations sufficient
for analgesia
Co-administration of quinidine has been found to maintain therapeutic levels
FDA approved dextromethorphan for use in the treatment of pseudobulbar palsy
Also used in painful diabetic polyneuropathy

55. Avoiding drugs with strong anticholinergic
properties is imperative in the elderly with
cognitive impairment. Which drug combination
would you NOT prescribe?
1.Skeletal muscle relaxants & Acetylcholinesterase
inhibitors
2.Acetylcholinesterase inhibitors & some
antidepressants
3.Skeletal muscle relaxants & some antidepressants

56. Glutamate Antagonists
Ketamine
Phencyclidine anesthetic given parenterally, neuraxially, nasally, transdermally or orally in
subanesthetic doses to alleviate a variety of pain conditions, including severe acute pain,
chronic or neuropathic pain, and opioid tolerance by NMDA receptor antagonism.
Also has activity on nicotinic, muscarinic, and opioid receptors and exerts both anti-
nociceptive and anti-hyperalgesic effects
Potentially distressing adverse reactions (psychotomimetic side effects) and unwanted
changes in mood, perception, and intellectual performance limit its use in pain control

57. Notable Fame: American golfer (LPGA)
Cause of Death: Asphyxia, Butalbital,
Temazepam, Alprazolam,
Codeine, Hydrocodone,
Tramadol
Drug Category: Prescription drug overdose
When: 2010
Age: 25
Name this Celebrity -Erica Blasberg

58. Opioids
Tramadol
Centrally acting, weak mu opioid receptor agonist
Inhibits norepinephrine and serotonin reuptake
Promotes serotonin release
Peripheral activity absent - no effects on blood pressure, ulcer, heart failure
Disease Drug Rationale Recommendation Quality of
Evidence
Strength
Chronic
seizures
or epilepsy
Tramadol Lowers seizure threshold; may be
acceptable in patients with well-controlled
seizures in whom alternative agents have
not been effective
Avoid Moderate Strong

59. Notable Fame: Actor, Musician, Singer
Cause of Death: Heart arrhythmia, possibly
aggravated by multiple
prescriptions - Methadone,
Codeine, Barbiturates, Cocaine
Drug Category: Mixed
When: 1977
Age: 42
Name this Celebrity - Elvis Presley

60. Morphine & Other Mu Opioid
Receptor Agonists
Analgesia through opioid receptor binding on cell membranes, producing simultaneous activity at multiple
presynaptic, postsynaptic, and nervous system sites
Each opioid produces a unique spectrum of effects - analgesia, somnolence, respiratory depression, dysphoria,
euphoria, decreased GI motility, altered circulatory dynamics, histamine release, physical dependence
Morphine, Codeine, Hydrocodone, and Oxymorphone, have greatest affinity for the mu opioid receptor
Presynaptic opioid receptor activation inhibits release of nociceptive neurotransmitters, substance P, glutamate
Postsynaptic activation inhibits pain by opening K or Cl channels, hyperpolarize and inhibit neuronal firing
Inhibits pain signal transmission from peripheral afferents to ascending spinal cord neurons, activates
descending pathway inhibition, and will alter limbic activity, decreasing pain awareness

62. Notable Fame: Actor
Cause of Death: Combined Toxicity
Oxycodone, Hydrocodone,
Alprazolam, Diazepam,
Temazepam, Doxylamine
Drug Category: Prescription drug overdose
When: 2008
Age: 28
Name this Celebrity - Heath Ledger

63. Alpha-2 Adrenoceptor Agonists
Clonidine and Tizanidine
Antinociceptive activity
Modulating dorsal horn neuron function, norepinephrine and 5-HT release
Potentiating mu-opioid receptors, decreasing neuron excitability - calcium channel
modulation
Clonidine, transdermal, local use enhances release of endogenous encephalin-like substances
Tizanidine is used as a muscle relaxant and antispasticity agent

64. Other Agents
Baclofen
Muscle relaxant that induces analgesia
Agonist action on inhibitory GABA-B
receptors
Efficacious for trigeminal neuralgia
Anti-spasticity properties of baclofen may
induce analgesia
Botulinum Toxin
Neurotoxic protein synthesized by the
bacterium Clostridium botulinum
Produces analgesia, blocking neurotransmitter
release and TRPV1 receptor signaling in C-fibers
Inhibits substance P and CGRP release
Reduces neurogenic inflammation
Increases heat pain threshold

65. Other Agents
Sulfasalazine
Tetrahydrobiopterin
Essential co-factor in producing nitric oxide
and monoamines
FDA-approved anti-inflammatory agent that
inhibits sepiapterin reductase
May represent an effective therapy for
neuropathic pain
Ondansetron
5-HT3 receptor antagonist
Anti-nociceptive effects
Blocking descending
serotonergic facilitatory drive
to the dorsal horn laminae

67. Signs & Symptoms of Toxicity
Classic signs of opioid intoxication
Depressed mental status
Decreased tidal volume
Decreased bowel sounds
Decreased respiratory rate:
best predictor RR < 12
Miotic pupils:
normal exam does NOT exclude opioid intoxication

68. Signs & Symptoms of Toxicity
Opioid-Induced Neurotoxicity
A syndrome of neuropsychiatric consequences of opioid administration
Occurs when active opioid metabolites build up (could be due to
dehydration and/or decreasing kidney function)
Commonly occurs in response to rapid escalation of opioid medicines
Features include cognitive impairment, severe sedation, hallucinosis,
delirium, myoclonus, seizure, hyperalgesia, and allodynia

69. Suspect Opioid-Induced
Neurotoxicity:
1. Painful experience from a source that is not
normally painful.
2. Complaints of :all over” body pain, or a pain
that becomes generalized.
3. Worsening pain, but no worsening of disease.
4. Involuntary muscle twitching.
5. Confusion, hallucinations, disorientation,
decreased LOC.
6. Seizures.
Treatment:
If caused by dehydration giving IVF will reverse.
If caused by decrease in kidney function
reducing the opioid dose usually will reverse.
If caused by rapid escalation of opioid medicine,
reducing the dose or rotating to a different
opioid will usually reverse.

70. Risk
Assessment
Patient reported history
Psychology interview
Risk screening tools:
Screener and Opioid Assessment for Patients
with Pain(SOAPP)
Opioid Risk Tool(ORT)
Pain Medication Questionnaire (PMQ)
CAGE Questionnaire
Clinical impression
Risk
Monitoring
Prescription monitoring programs
Pain medication diaries
Pill counts
Urine drug testing (UDT)
Risk monitoring tools:
Current Opioid Misuse Measure (COMM)
The Addiction Behavior Checklist (ABC)
Behavior patterns “Red Flags”

71. Red Flags
Medication loss
Frequent telephone calls
Frequent ER visits
Drug hoarding
Doctor shopping
Aggressive demand for more drugs
Drug seeking
Clinging to specific drugs
Use for non-prescribed indications (ex. Anxiety, insomnia)

72. Which of the following clinical
interventions can increase risk
of diversion?
1. Attention to patterns of prescription requests
2. Annual review in the prescription monitoring program database
3. Urine and/or blood drug screening & pill counts
4. Frequent follow up and client contact

73. Amphetamines
Barbiturates
Benzodiazepines
Cocaine
Methadone
Opiates
Phencyclidine
Propoxyphene
Tetrahydrocannbinol
UDS 9 UDS 12
Amphetamines
Barbiturates
Benzodiazepines
Cocaine
Methadone
Methaqualone
Opiates - confirms if Codeine,
Hydrocodone, Hydromorphone,
Morphine, or Oxycodone
Phencyclidine
Propoxyphene
Tetrahydrocannabinol
For Tramadol, Fentanyl, or Buprenorphine:
A separate order is needed

74. How Many Times Have You Looked Up a Client
on the Prescription Access in Texas (PAT)
System?
1.Never
2.1-5 times
3.5-10 times
4.More than 10 times

77. Consultation & Referral
Be willing to refer:
When pain problems remain intractable, unremitting
To obtain other approaches to assessment or management
To determine if interventional procedures would help relieve pain
Psychosocial indications for consultation:
History of substance abuse
Interpersonal dynamics that seem to complicate the treatment
Give special attention to clients risk for Rx misuse, abuse, diversion
May be required for psychiatric disorders