Pain Management Discussion Nursing Essays

The first patient is a 79 year old male who has been prescribed hydrocodone/APAP 10/325 for lower back pain.  The directions on his prescription is to take one to two tablets every four to six hours as needed for pain, and the patient reports that he is taking two tablets every four hours, or twelve pills per day for severe pain.  Based on this information, the patient is taking a total daily dose of 120 mg of hydrocodone.  When converting hydrocodone to extended release morphine, or MS Contin using the standard MME dosage conversion (cdc.gov), the patient should receive 120 mg of equianalgesic however to decrease the risk of sedation I have chosen to lower the dose by 25%  for a total daily dose of MS Contin 90 mg daily divided in 3 doses.  Decreasing the dose by this amount is done to prevent overdose and to allow for incomplete cross tolerance that can occur when switching from one opioid to another (cdc.gov, 2018).  Another motivating factor to discontinue the use of Vicodin is that this patient is also consuming 3,900 mg of acetaminophen daily and while that is just below the daily allowance of 4,000 mg, caution should be exercised in this patient due to his age and potential for decreased renal function.  This patient has been taking this medication on a scheduled basis rather than as needed so it is clear that his pain is not well managed using Vicodin.  Mehalick et al (2016) demonstrated that the use of opioid pain medication versus the use of combination non-opioid/opioid medications for treatment of low back pain did not demonstrate a significant difference in reports of pain levels, either increase or decrease.  Therefore, it is clinically beneficial to eliminate acetaminophen in this case as he may increase the frequency of administration on his own.

CM is a 20 year old female who reports symptoms associated with acute migraine headaches that are severe in nature.  Initial treatment of mild to moderate migraines should begin with NSAIDs, however since CM reports her symptoms as severe she meets criteria for a migraine specific medication such as Sumatriptan 25 mg by mouth, with instructions to repeat the dose if no effect in two hours (MacGregor, 2017).  This medication can also be given intranasally if nausea presents and CM cannot tolerate anything by mouth, but it is also more rapidly absorbed and provides faster relief of symptoms.  Non-pharmacological treatment of migraines should include a comprehensive review of CM’s diet and suggested dietary changes to avoid caffeine, artificial sweeteners and MSG (MacGregor, 2017).  A full assessment of triggers and timing can indicate whether the attacks are as a result of hormonal changes in the menstrual cycle and whether or not an aura exists.  Since CM’s attacks do not follow a specific pattern, nor does she have fifteen or more attacks per month, I would not recommend prophylactic treatment for her, rather I would follow her closely to determine if increased doses of acute medications are warranted.

Centers for Disease Control and Prevention. (2018). CDC guidelines for prescribing opioids for chronic pain. https://www.cdc.gov/drugoverdose/prescribing/guideline.html

MacGregor, E.A. (2017). In the clinic. Migraine. Annals of Internal Medicine, 159(9), 1-16. Doi: 10.7326/AITC201704040

Mehalick, M., McPherson, S., Schmaling, K., Blume, A., & Magnan, R. (2016). Pharmacological management of chronic low back pain: A clinical assessment. Journal of Pain Management, 9(1), 39-48. http://web.b.ebscohost.com.wilkes.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=9&sid=d04dba72-9552-49ef-b9b5-ca650bc0e737%40pdc-v-sessmgr03

Pain Management

Hydrocodone is an opiate often used in a combination with other substances as a pain reliever (Chisholm-Burns et al., 2016). The drug works by altering the brain’s perception of pain. The problem with the drug is consumption against how they were prescribed is the risk of an overdose. This surplus consumption of hydrocodone occurs due to the addictive factors of the medication. An overdose is observable from symptoms like slowed heartbeats, sleepiness, seizures, shallow breathing, narrow pupils, or death in worst scenarios.

The conversion process encompassed analyzing the amount of morphine relative to the opioid quantity. The physician recommended Vicodin 10/325 Q4- 6h prn. Since the quantity was 120 for 30 days, the patient was to take four tablets daily. Upon the conversion with a percentage reduction of 25%, the victim ought to receive a morphine dose of 30mg every four to six hours (Practical Pain Management, 2020). The new dosage is attributable to the patient increasing their dosage to 12 tablets a day.

Migraines

Migraines are neurological mishaps that cause headaches among individuals (Puledda & Shields, 2018). Its situation becomes worse when pharmacological remedies are insufficient in pain management. Healthcare professional often recommends non-drug methods like nutraceuticals, behavioral modifications, noninvasive neuromodulation, and invasive modulation. The first mechanism centralizes on employing food supplements to enhance one’s health and control of migraines. The second technique comprises of actions meant to deter the dire consequences of the condition by relaxing the one’s cognitive muscles. The last two methods are advisable for individuals with chronic migraines (Rokyta & Fricova, 2014). Both processes involve nerve stimulation. I believe CM is a suitable patient for prophylactic therapy due to the severity of her migraines. According to Modi and Lowder (2006), she is best suited to utilize Topiramate, a first-line agent in migraine control. Such medication would mitigate the losses she faces due to her condition by advancing her life quality and thus making her more productive Pain Management Discussion Nursing Essays.

References

Chisholm-Burns, M. A., Wells, B. G., & Schwinghammer, T. L. (2016). Pharmacotherapy principles and practice. McGraw-Hill.

Modi, S., & Lowder, D. M. (2006). Medications for migraine prophylaxis. American family physician, 73(1), 72-78.

Practical Pain Management. (2020). Opioid Calculator. https://opioidcalculator.practicalpainmanagement.com/conversion_results

Puledda, F., & Shields, K. (2018). Non-pharmacological approaches for migraine. Neurotherapeutics, 15(2), 336-345.

Rokyta, R., & Fricova, J. (2014). Noninvasive neuromodulation methods in the treatment of chronic pain. Pain and Treatment. London: IntechOpen Limited, 175-190.

Module V:  Pain Management

When starting opioid therapy for a patient after non-opioid therapies have been used, the patient should be started on a short acting drug at the lowest dose possible.  In our case study, the patient was taking the short acting opioid at the maximum dosage around the clock, instead of using it when the pain was in the moderately severe to severe range, as prescribed.  When taking a pain medication in a way not indicated, the patient can develop a tolerance to the opioid and require a stronger dose to achieve pain control.

As degenerative disc disease is a chronic pathology, this patient will continue to experience pain and requires multifocal pharmacological management.  The hydrocodone ordered for the patient was ordered with a maximum dosage of between 40 mg (if the patient took 10 mg hydrocodone every 6 hours) and 120 mg (taking 20 mg every 6 hours).  As the patient is already taking the maximum dosage, an extended release equivalent dose would be more effective.  The conversion of our patient’s hydrocodone dose to oxycodone, a pure agonist opioid, would be a maximum dosage (which is the current amount the patient is taking) of 80 mg per day (Brennan et al., 2020) dosed as 40 mg every 12 hours. The medication could be written for oxycodone 20 mg 1-2 pills every 12 hours as needed for severe pain with education provided to the patient to start with the lowest dose.

A prescriber needs to be noticeably clear when prescribing these medications and ensure the patient understands how it is being written and signs an opioid contract for how they would take it (Dowell et al., 2016).  Another appropriate intervention would be to refer the patient to a pain clinic as they have additional therapies available, in addition to trained addiction therapists and doctors. However, all providers must be aware of the drawbacks of opioid therapy and their potential for abuse.  In the elderly population, usage of oxycodone shows a significantly greater incidence of respiratory depression (Kinnunen et al., 2019).  As such, our patient must also be prescribed naloxone, an opioid antagonist, and he and other family members must be educated on how and when to use it (Chimbar, 2018).

At some point in their lives most people experience headaches.  However, it is important to be able to distinguish a typical headache from a more severe headache such as a migraine, cluster headache, or tension related headache.  Migraine headaches have an unclear etiology but activation of the trigeminovascular pathways resulting in an imbalance in serotonergic and noradrenergic neurons is a widely accepted pathology (Goadsby et al., 2017).  Migraine headache symptoms include a unilateral pulsatile or throbbing pain indicated in the moderate to severe category, along with photosensitivity, nausea, and vomiting (Goadsby et al., 2017).  Migraines tend to effect females three times as often as men.  Research suggests that approximately 38% of those with episodic migraines would be benefitted by prophylactic treatment, however only 3-13% utilize it (Ha & Gonzalez, 2019, p. 17) Pain Management Discussion Nursing Essays.

CM is endorsing severe, prolonged headaches lasting 2-3 days each, at a frequency of twice monthly.  Additional symptomatology indicates mild anxiety and difficulty sleeping.  In order to evaluate triggers to migraines, CM will be encouraged to keep a headache diary for 30 days in which she documents headache quality, intensity, length of time, other symptoms such as nausea and vomiting, whether or not she experienced aura, food she consumed, medications she took, her menstrual cycle, and the daily weather.  If CMs neurological examination is normal and she does not have any red flags such as seizures or swelling of her optic nerve, then an imaging study is not indicated (Charles, 2017).  A  complete medication history will also be obtained, as some medications, such as oral contraceptives, proton-pump inhibitors, and selective serotonin-reuptake inhibitors can exacerbate migraines (Ha & Gonzalez, 2019).

Most providers agree that preventative therapy should be initiated when migraines occur at least once per week or for 4 or more days per month (Charles, 2017).  CM will be provided with a serotonin receptor agonist, commonly referred to as a triptan, such as sumatriptan or zolmitriptan, to take at the onset of a migraine (Ha & Gonzalez, 2019).  After CM completes her headache diary, it can be analyzed to determine the best prophylactic therapy.  First-line prophylactics for migraines include beta blockers such as propranolol, anticonvulsants such as valproic acid, antiepileptic such as topiramate, and tricyclic antidepressants such as amitriptyline (Ha & Gonzalez, 2019).  Venlafaxine has also been used as a prophylactic with good results.  Venlafaxine’s mechanism of action is to decrease 5-HT levels which affect development of vestibular symptoms (Liu et al., 2017).  As CM uses an inhaler for asthma, beta blockers such as propranolol would not be a good first line option for her, but instead topiramate or venlafaxine would be considerations.  Since CM also endorses mild anxiety, venlafaxine would be a good first line therapy for her.  Studies show that venlafaxine decreases the number of migraine attacks per month significantly, in addition to decreasing their length and severity (Ha & Gonzalez, 2019).  CM will have the maximum benefit in combination therapy, utilizing cognitive behavior therapy and relaxation therapy along with her medication.

References

Brennan, M., Fudin, J., & Perkins, R. (2020). Practical pain management. Opioid calculator. Retrieved September 30, 2020, from http://opioidcalculator.practicalpainmanagement.com

Charles, A. (2017). Migraine. New England Journal of Medicine, 377(6), 553–561. https://doi.org/10.1056/nejmcp1605502

Chimbar, L. (2018). Naloxone effectiveness: A systematic review. Journal of Addictions Nursing, 29(3), 161–171. https://doi.org/10.1097/JAN.0000000000000230

Dowell, D., Haegerich, T. M., & Chou, R. (2016). Cdc guideline for prescribing opioids for chronic pain—united states, 2016. JAMA, 315(15), 1624. https://doi.org/10.1001/jama.2016.1464

Goadsby, P. J., Holland, P. R., Martins-Oliveira, M., Hoffmann, J., Schankin, C., & Akerman, S. (2017). Pathophysiology of migraine: A disorder of sensory processing. Physiological Reviews, 97(2), 553–622. https://doi.org/10.1152/physrev.00034.2015

Ha, H., & Gonzalez, A. (2019). Migraine headache prophylaxis. American Family Physician, 99(1), 17–24.

Kinnunen, M., Piirainen, P., Kokki, H., Lammi, P., & Kokki, M. (2019). Updated clinical pharmacokinetics and pharmacodynamics of oxycodone. Clinical Pharmacokinetics, 58(6), 705–725. https://doi.org/10.1007/s40262-018-00731-3

Liu, F., Ma, T., Che, X., Wang, Q., & Yu, S. (2017). The efficacy of venlafaxine, flunarizine, and valproic acid in the prophylaxis of vestibular migraine. Frontiers in Neurology, 8. https://doi.org/10.3389/fneur.2017.00524

Module V discussion Advanced Pharmacology

Prescription opioids are powerful pain-reducing medications that have both benefits as well as potentially serious risks. The addiction rates of opioids continue to rise, despite the FDA’s efforts to regulate and control their use. As healthcare professionals we must be educated on properly managing these highly addictive drugs. Opioids must be appropriately indicated for the patient that it is being prescribed and only at doses and durations that match the clinical reason the drug is being prescribed.

Due to the highly addictive nature of opioids our case study patient a 79-year-old male should take his Vicodin only as prescribed. This patient has been taking 12 tables of Vicodin per day, the maximum dose of Vicodin 10mg/300mg is 8 tables(Caldwell et al., 2019). This medication can become habit forming and also contains acetaminophen that can be toxic to onus’s liver. Do to the fact that our patient is not getting relief from the Vicodin as prescribed, the next course of action would be a long acting pain medication such as morphine ER. Utilizing the opioid calculator to determine the converting dose from hydrocodone to morphine ER, I would change this patient to morphine ER 45mg every twelve hours reducing calculation by 25% to give room for incomplete tolerance.

Chronic migraines have been shown to be a greater burden on life than other headache conditions. Migraines can interfere with your life, causing missed work and taking time away from one’s family. The key is attempting to prevent migraines from even starting, because taking acute mediations too often can lead to medication overuse headache conditions(Perlman & Weisman, n.d.) Pain Management Discussion Nursing Essays.

CM is a 20-year-old female who is seeking treatments for migraines, Since CM has difficulty sleeping and mild anxiety, I would suggest she tried to improve sleeping habits. Establish regular sleep hours, unwind at the end of the day by having a warm bath or listening to soothing music, and avoiding caffeine at the end of the day. I would offer CM some tips to manage stress time management, relax, try doing something special for herself at least 15 minutes per day. Other ways she could prevent migraines is eating healthy, getting regular exercise, keeping a migraine diary to look for triggers to avoid. Often times inhalers have the side effect of causing headaches, so controlling asthma and the need for inhalers may help CM, or reducing the dose of possible. CM would be a good candidate for prophylactic treatment of migraines my first line drug of choice would be amitriptyline, this medication could help to prevent migraines as well as help with CM’s mild anxiety.

References

Caldwell, W. K., Freedman, B., Settles, L., Thomas, M. M., Camacho, E. T., & Wirkus, S. (2019). The vicodin abuse problem: A mathematical approach. Journal of Theoretical Biology, 483, 110003. https://doi.org/10.1016/j.jtbi.2019.110003

Perlman, A., & Weisman, R. (n.d.). Own your health: Pain: Back pain, arthritis, migranes, joint pain, and more. Health Communications, Incorporated.

Pain management, which affects approximately 25.3 million adults nationwide,¹ can be a difficult and frustrating experience Haverfield et al. (2018). Patients and providers have different views on making decision about pain. Clinicians report difficulty in prescribing opioids and trusting their clients pain reports, clients also feel that the clinicians are not listening to their problems Haverfield et al. (2018). Patient-centered care defines the clinician’s attentiveness to the clients care preferences and need. Patients should be involved in their care; communication is the best tools that will help to satisfy and meet patient’s care.

Opioids are the most potent drugs producing analgesia and is used in the treatments both acute and chronic pain. The largest part of prescriptions regarding opioids are oxycodone, hydrocodone, morphine, codeine, methadone and transdermal morphine and fentanyl Cardia et al. (2018).

Currently, patient is taking Hydrocodone 10/325 at a rate of 120 MME per day total. The conflict is the maximum MME prescribed is 60 MME per day total, but the patient is taking the prescribed medicine at double the dosage prescribed by the doctor. Changing the prescription to Morphine ER 15-20 mg orally based on the conversion scheduled, it will be recommended the patient takes one tablet every 12 hours and a breakthrough pain relieved with Ibuprofen 600mg if not contracted.

PATIENT CALCULATION:

[10 mg] *[12 tablets] = 120 mg Vicodin/day à [120 mg Vicodin] *[1] = 120 MME per day total

PRESCRIBED CALCULATION:

[10 mg] *[6 tablets] = 60 mg Vicodin/day à [60 mg Vicodin] *[1] = 60 MME per day total

NEW PRESCRIPITON:

[20 mg] *[2 tablets] = 40 mg Morphine/day à [40 mg Morphine] *[1] = 40 MME per day total

Migraine is a chronic neurologic disease that varies in its frequency, severity, and impact on patients’ quality of life. Migraine treatment for CM should be based on the diagnosis, symptoms, and coexistent or comorbid conditions and her expectations, needs and goals to improve quality life Silberstein (2015).

American Academy of Neurology’s evidence-based guidelines for clinicians). These guidelines include:

•  Recurring migraine attacks that significantly interfere with a patient’s quality of life and daily routine despite trigger management, appropriate use of acute medications, and lifestyle modification strategies
• Frequent headaches (four or more attacks per month or eight or more headache days per month) because of the risk of chronic migraine
• Failure of, contraindication to, overuse of, or troublesome side effects from acute medications
• Patient preference, that is, the desire to have as few acute attacks as possible
• Presence of certain migraine conditions: hemiplegic migraine; basilar migraine (now called migraine with brainstem aura); frequent, prolonged, or uncomfortable aura symptoms; or migrainous infarction Silberstein (2015).      Preventive treatments can be preemptive, short term or maintenance. Preemptive treatment is used when headache

triggers migraine such, exercise or sexual activities. Patient is asked to take prescribed

medication for migraine before the activity.

Patient can benefit from topiramate 15 mg at bedtime and the dose titrated to 50 mg twice daily for over a course of 6 weeks Silberstein (2015). Usually there is a reduction of headache days per month and the reduction of duration of attacks for less than 60 minutes after taking sumatriptan 100 mg Silberstein (2015). Other medications that can be used is Ibuprofen 600 mg for other attacks.

Reference

Cardia, L., Calapai, G., Quattrone, D., Mondello, C., Arcoraci, V., Calapai, F., Mannucci, C., &   Mondello,             E. (2018). Preclinical and Clinical Pharmacology of Hydrocodone for        Chronic Pain: A Mini             Review. Frontiers in pharmacology, 9, 1122.            https://doi.org/10.3389/fphar.2018.01122

Haverfield, M. C., Giannitrapani, K., Timko, C., & Lorenz, K. (2018). Patient-Centered Pain      Management Communication from the Patient Perspective. Journal of general internal   medicine, 33(8), 1374–1380. https://doi.org/10.1007/s11606-018-4490-y

Opioid Calculator. (n.d.). Retrieved from

https://opioidcalculator.practicalpainmanagement.com/disclaimer.php

Silberstein S. D. (2015). Preventive Migraine Treatment. Continuum (Minneapolis, Minn.), 21(4 Headache), 973–989. https://doi.org/10.1212/CON.0000000000000199 Pain Management Discussion Nursing Essays

The first case scenario is a 79 yr old male with severe back pain due to degenerative disc disease diagnosed several months ago. He is currently taking hydrocodone/APAP 10/325mg for pain. His provider prescribed 120 pills for him to take q 4 to 6 hours for 30 days. He takes as many as 12 tabs a day instead of the specified amount of up to 4 pills a day. He states the reason he is taking two tabs every four hours is due to the pain is so bad he can’t tolerate it. The problem with the way this patient is taking his medication is the fact that he is taking double the amount of hydrocodone recommended for a 24 hr. period. He is taking up to 120mg of hydrocodone when the recommended max dose is 60mg in a 24 hr. period. Instead of taking his medication as needed, he is taking it scheduled, which Vicodin is not a recommended scheduled medication. The problem with pain medication for older patients is they are more prone to adverse outcomes such as disruption of sleep, falls, and depression (Zis et al., 2017). First, a full pain assessment and x-rays before routine pain regiment is prescribed (Zis et al., 2017). However, morphine extended-release would be acceptable. I would attempt topical lidocaine patches and Voltaren gel, and orthopedics consult for a possible injection before going straight to pain medication. I would recommend morphine extended-release as my last resort due to his age and diagnosis.

The second case scenario is a twenty-year-old female with two to three-day migraines twice per month. She is having difficulty sleeping and is mildly anxious. Migraines are among the most common somatic complaints among children and young adults (Andersson et al., 2017). Due to the prevalence of migraines in young adults, many patients try to self-treat when they become frustrated with other prescribed methods (Andersson et al., 2017). Young adults with migraines or cluster headaches are at high risk for suicide due to pain and frustration and illegal drug use that they may be trying to self treat due to other failed methods (Andersson et al., 2017). With this patient, I would do a full pain assessment and neurological assessment before prescribing migraine medication (Andersson et al., 2017).

Additionally, the goal is to provide treatment for headache day and prevent future headaches. Many migraine medications have drug interactions with other medicines, so a full history of drugs and diseases is essential before writing scripts. Providing she has no other conditions, I would recommend Topamax 25 mg/day to start as a preventative medication and Sumatriptan nasal spray 5mg for a PRN on the go medication (Andersson et al., 2017). The challenge with managing this population is that they usually do not want to take the time to define the triggers of the migraine (Andersson et al., 2017). I would do all I can to educate the patient on journaling and medication management.

Andersson, M., Persson, M., & Kjellgren, A. (2017). Psychoactive substances as a previous resort-a qualitative study of self-treatment of migraine and cluster headaches. Harm Reduction Journal, 14(1), 60–10. https://doi.org/10.1186/s12954-017-0186-6

Chisholm-Burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Bookstaver, P. B., & Lee, K. C. (2019). Pharmacotherapy principles & practice. McGraw-Hill Education.

Zis, P., Daskalaki, A., Bountouni, I., Sykioti, P., Varrassi, G., & Paladini, A. (2017). Depression and chronic pain in the elderly: links and management challenges. Clinical Interventions in Aging, 12, 709–720. https://doi.org/10.2147/cia.s113576

Module 5 Pharm

The treatment of chronic pain is a fine line that all clinicians must walk carefully, especially in this age of opioid abuse and all the repercussions of addiction. In our gentleman with the back pain it seems like the intent of the original prescriber was for him to take one tablet every 6 hours as needed for pain-which would have lasted him a month. The directions stated he could take 1-2 every 4-6 hours, which he followed taking the maximum dose prescribed. I would assess his pain and if no contraindications to initiating an extended release morphine I would do so. According to Balch, while morphine was a good short acting medication for acute pain, the advent of sustained release allows for a more stable serum concentration and better pain control. (Extended-release Morphine Sulfate in Treatment of Severe Acute and Chronic Pain, 2010) Utilizing the opioid conversion tool, 60 mg of hydrocodone can be converted to 48 mg Morphine (utilizing a 20% reduction due to his age).(Opioid Conversions and Opioid Dosing Calculator – Conversion Results, 2020) In using an extended release morphine such as MS Contin I would split that dose into 15 mg q 8 hours around the clock and advise him to utilize 650 mg Tylenol in between doses for a max of 3 doses per day.  I would have him keep a pain diary and followup in two weeks to see how he was doing and to see if his pain had improved to a tolerable level. Education regarding side effects would also be completed Pain Management Discussion Nursing Essays.

CM seems to have her quality of life disturbed by her twice monthly episodes of debilitating migraine. I would first advise she keeps a headache diary to isolate and avoid triggers and I would determine what environmental factors either lessen her pain or exacerbate her discomfort.(Chisholm-burns et al., 2019, pp. 539–540) If trigger avoidance and environmental changes do not improve her symptoms, I would begin her on a trial of the newly approved FDA drug Ubrelvy. (Fda Approves New Treatment for Adults with Migraine, 2019) Ubrelvy is the first CGRP antagonist approved to treat migraine with or without aura and lists very few side effects or medication interactions. (Ubrelvy, 2020) This new drug is very expensive , so I would make sure that it is covered by her insurance plan to assist with compliance.

References

Chisholm-burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, K. C., & Bookstaver, P. B. (2019). Pharmacotherapy principles and practice, fifth edition (5th ed.). Mcgraw-hill Education / Medical.

Extended-release morphine sulfate in treatment of severe acute and chronic pain. (2010). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3004644/

Fda approves new treatment for adults with migraine. (2019). U.S. Food and Drug Administration. https://www.fda.gov/news-events/press-announcements/fda-approves-new-treatment-adults-migraine

Opioid conversions and opioid dosing calculator – conversion results. (2020). PPM. https://opioidcalculator.practicalpainmanagement.com/conversion_results

Ubrelvy. (2020). RxList. https://www.rxlist.com/ubrelvy-drug.htm

Chronic Low Back Pain

This gentleman is unfortunately experiencing chronic pain.  In chronic pain, it may not be a possibility to completely alleviate all pain, but to reduce the pain to a tolerable level.  The physician has prescribed 1-2 tablets every 4-6 hours with the anticipation the prescription would last one month.  However, the patient is taking the highest dose prescribed in the shortest time frame possible.  It is important to educate the patient that complete pain control may not be possible and to assist him in identifying what is tolerable to him.  It would also be helpful, using a numerical pain scale to define with and for the patient when one tablet or two tablets are appropriate and to associate an accompanying time frame.  The patient may need counseling or therapy to deal with the psychological and emotional effects of chronic pain.

Adjunct medication may also be appropriate, including the addition of ibuprophen to raise the pain threshold.  It may also be appropriate to add Cymbalta.  Cymbalta would not only aid the depression the patient will most likely suffer with chronic unresolved pain, but to reduce the pain effects.  Hauser et al. (2018) points out that many do not benefit from the additional Cymbalta so this should be closely monitored and discontinued if no benefit is noted.

Lastly, it has been suggested the provider’s assessment of this patient indicates a necessary change to a long acting opiate.  The patient is currently taking 250mg of Vicodin every 24 hours.  I would start MS Contin 15mg Q12 hours.  I would continue the Vicodin prescription for breakthrough pain, but change the prescription to one tablet Q6 hours.  I would re-evaluate the patient’s pain control in 3-4 weeks and adjust the dosages accordingly.

The patient should be educated on long acting pain medication benefit of sustained blood levels and more even pain control.  I would also educate the patient on the benefits of nonpharmacologic therapies such as heat, ice, massage, and exercise.  Edmond et al. (2018) emphasizes the patients buy in so suggesting highly encouraging nonpharmalogic therapies would be better receive.  I would also encourage physical therapy for pain management modalities.

Migraine

For CM, I would want additional assessment information.  I would request that CM complete a headache diary, paying close attention to factors such as foods, fluids, and menstrual cycle surrounding migraine headaches.  I would educate CM regarding the environmental contributory factors and ask she make diet modification to see if this made a positive impact on her headaches.

I would also suggest therapy to help CM reduce her anxiety and to identify sleep hygiene to assist in attaining better sleep in hopes of reducing the incidence and severity of her migraines.

Initially, while working on the headache diary and working on environmental factors, I would attempt an over the medications such as Excedrin Migraine with the combination of aspirin and caffeine.  If there is no improvement in headache symptoms or frequency, I would move on to a prescription treatment such as a triptans.

At present, I would not start a prophylactic therapy as I feel we should fully evaluate all treatment options prior to initiating a routine prophylactic medication. In addition, Reuter, et al. (2018) discusses many are unable to tolerate oral prophylactic medications anyway Pain Management Discussion Nursing Essays.

References

Edmond, S. N., Becker, W. C., Driscoll, M. A., Decker, S. E., Higgins, D. M., Mattocks, K. M., . . . Haskell, S. G. (2018). Use of non-pharmacological pain treatment modalities among veterans with chronic pain: Results from a cross-sectional survey. Journal of General Internal Medicine, 33(S1), 54-60. doi:10.1007/s11606-018-4322-0

Häuser, W., Welsch, P., Üçeyler, N., Klose, P., Walitt, B., & Häuser, W. (2018). Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia. Cochrane Library, 2020(7), CD010292. doi:10.1002/14651858.CD010292.pub2

ORDER A PLAGIARISM-FREE PAPER NOW

Reuter, U., Goadsby, P. J., Lanteri-Minet, M., Wen, S., Hours-Zesiger, P., Ferrari, M. D., & Klatt, J. (2018). Efficacy and tolerability of erenumab in patients with episodic migraine in whom two-to-four previous preventive treatments were unsuccessful: A randomised, double-blind, placebo-controlled, phase 3b study. The Lancet (British Edition), 392(10161), 2280-2287. doi:10.1016/s0140-6736(18)32534-0

 Current guidelines recommend opioid therapy for older adults with moderate to severe persistent pain with diminished quality of life due to the pain (Guerriero, 2017). However, the patient’s inability to tolerate pain has him using opioids beyond what is prescribed in order to obtain relief. As such, individuals with chronic pain who have greater sensory and cognitive reactivity to pain are at elevated risk for prescription opioid misuse (McHugh et al., 2016). According to McHugh et al., “distress intolerance is modifiable with behavioral interventions, and treatments designed to reduce distress intolerance and have demonstrated preliminary efficacy for those with substance use disorders, including opioid-dependent patients” (2016, p.808). Accordingly, my recommendations would include cognitive behavior therapy (CBT) with a psychologist to teach positive effective coping strategies. Additionally, I would review the importance of following dosing instructions, the difference between prn and scheduled, and agree upon a realistic treatment plan. Next, I would evaluate creatinine clearance and hepatic function for any age-related physiological changes. Since there is a significant deterioration of his spine, I would also order physical therapy. Increasing mobility and strengthening exercises at least two times a week have been shown to decrease lower back pain in seniors (Wong et al., 2017). The use of, extended-release morphine offers the convenience of twice-daily dosing which often leads to improved patient compliance. Another advantage of the sustained-release morphine is that patient’s serum concentrations of the medication tend to remain more stable (Balch and Trescot, 2010). The equivalent uncorrected dose of morphine to hydrocodone that he was taking is 80mg daily. However, had he followed instructions correctly, it was meant to be 40 mg per day. Due to his advanced age, and the depressive effects of MS Contin,  I would start slow and low with 30mg every 12 hours, 60 tablets. Additionally, a significant side effect of opioid use is constipation. For this complication, I would prescribe senna one tor two tablets at bedtime to obtain the desired effect (Guerriero, 2017).

CM’s migraine management would include determining if she experiences an aura. The treatment plans differ according to her subtype. According to Diener et al., “the recent International Classification of Headaches (ICHD-3) criteria define chronic migraine as headache on 15 or more days per month over more than 3 months” (Olesen, (no date given) as cited in Diener et al., 2015, p.345). Since CM does not meet these criteria, she is considered to have episodic migraines. As such my treatment would include a headache diary. A diary can track the frequency, triggers, and patterns of her headaches, as well as her medication use (Steiner et al., 2019). A thorough history and physical may uncover oral contraceptives, menses, or blood pressure as possible causes. Additionally, I would recommend a thorough dental checkup as conditions such as clenching and TMJ are possible causes of headaches. My recommendations are biofeedback and cognitive behavioral therapy which can help manage her anxiety too. Both have been shown to be effective in migraine management (Steiner et al., 2019). Medications would first include acetaminophen 1000mg, every 4-6 hours with a maximum of 4000mg, at the onset of headache symptoms. Also, due to her anxiety, she is not a candidate for caffeine treatment. If after three weeks there is not an improvement, I would prescribe a low dose SNRI such as venlafaxine 25mg daily taken in the morning (Sprenger et al., 2018). Furthermore, I would recommend a headache specialist since she is not a good candidate for triptans or beta-blockers as there is a possibility of a reaction that can worsen her asthma.

                                                          References

Balch, R. J., & Trescot, A. (2010). Extended-release morphine sulfate in the treatment of severe acute and chronic pain. Journal of pain research, 3, 191–200. https://doi.org/10.2147/JPR.S6529

Diener, H. C., Solbach, K., Holle, D., & Gaul, C. (2015). Integrated care for chronic migraine patients: epidemiology, burden, diagnosis and treatment options. Clinical medicine (London, England), 15(4), 344–350. https://doi.org/10.7861/clinmedicine.15-4-344

Guerriero F. (2017). Guidance on opioids prescribing for the management of persistent non-cancer pain in older adults. World journal of clinical cases, 5(3), 73–81. https://doi.org/10.12998/wjcc.v5.i3.73

McHugh, R. K., Weiss, R. D., Cornelius, M., Martel, M. O., Jamison, R. N., & Edwards, R. R. (2016). Distress Intolerance and Prescription Opioid Misuse Among Patients With Chronic Pain. The journal of pain: official journal of the American Pain Society, 17(7), 806–814. https://doi.org/10.1016/j.jpain.2016.03.004

Sprenger, T., Viana, M., & Tassorelli, C. (2018). Current Prophylactic Medications for Migraine and Their Potential Mechanisms of Action. Neurotherapeutics: the journal of the American Society for Experimental NeuroTherapeutics, 15(2), 313–323. https://doi.org/10.1007/s13311-018-0621-8

Steiner, T. J., Jensen, R., Katsarava, Z., Linde, M., MacGregor, E. A., Osipova, V., Paemeleire, K., Olesen, J., Peters, M., & Martelletti, P. (2019). Aids to management of headache disorders in primary care (2nd edition): on behalf of the European Headache Federation and Lifting The Burden: the Global Campaign against Headache. The journal of headache and pain, 20(1), 57. https://doi.org/10.1186/s10194-018-0899-2

Wong, A. Y., Karppinen, J., & Samartzis, D. (2017) Pain Management Discussion Nursing Essays. Low back pain in older adults: risk factors, management options and future directions. Scoliosis and spinal disorders, 12, 14. https://doi.org/10.1186/s13013-017-0121-3

https://docs.google.com/document/d/1QSFk22MMaPTDxbGyWkWJayd18eqs3XibzV37jMgc6n8/edit?usp=sharing