Developing Peer and Patient Education Materials

Developing Peer and Patient Education Materials “Teaching is a skill and a gift, a talent and a technique.�

Heimlich and Norland, 1994

Mary Lynn McPherson, Pharm.D., BCPS Professor and Vice Chair for Education University of Maryland School of Pharmacy mmcphers@rx.umaryland.edu 1

Disclosure • Nothing to Disclose

Learning Objectives • At the conclusion of this session, the PainWeek attendee will be able to: – Describe all eight elements of a Design Plan with 100% accuracy.

– Describe all nine events of instruction that comprise a Lesson Plan with 100% accuracy.

– Given a topic and supporting materials, prepare a Design Plan and Lesson Plan that includes all elements.

Design Plan A detailed explanation of the educational project

• • • •

Rationale Target population Description Objectives

• • • •

Evaluation Strategy Participant Prerequisites Facilitator Prerequisites Deliverables

Opioid-Induced Hyperalgesia

Rationale • Opioids are commonly used to treat pain • Practitioners know most common adverse effects of opioids • Many practitioners are unfamiliar with opioidinduced hyperalgesia (OIH) • Survey of hospice medical directors showed only moderate confidence in staff physicians; low confidence in non-hospice physicians at identifying and managing OIH

Target Population Course Description • Target population – Staff hospice physicians – Referring physicians

• Course description – 2 hour session on recognition and management of OIH – Facilitated by hospice Medical Director

Course Objectives • Upon conclusion of this learning activity, the participant will be able to:

– Given an actual or simulated opioid-tolerant pain patient, differentiate between opioid-induced hyperalgesia and five other clinical scenarios that may warrant an opioid dose increase, based on two aspects of pain presentation and response to therapy.

– Given an actual or simulated opioid-tolerant pain patient with suspected opioid-induced hyperalgesia, calculate an equianalgesic dosage regimen of methadone, including total daily dose, dosing frequency and timing of dosage conversion.

– Given an actual or simulated opioid-tolerant pain patient with suspected opioid-induced hyperalgesia, write an order for ketamine, including starting dose, dosing frequency, and titration schedule.

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Evaluation Strategies Objective

Evaluation Strategy

1a. The physician will be able to differentiate between worsening pain pathology, opioid tolerance, opioid withdrawal, opioid addictive disease, pseudoaddiction and opioid-induced analgesic based on pain presentation, specifically quality of pain complaint, and region or radiation of pain complaint.

1b. The physician will be able to differentiate between worsening pain pathology, opioid tolerance, opioid withdrawal, opioid addictive disease, pseudoaddiction and opioid-induced analgesic based on temporal aspect of pain presentation (e.g., gradual vs. abrupt, or variable).

Peer and facilitator observation, and Level 2 evaluation

1c. The physician will be able to differentiate between worsening pain pathology, opioid tolerance, opioid withdrawal, opioid addictive disease, pseudoaddiction and opioid-induced analgesic based on response to opioid increase (e.g., pain improves or worsens).

Peer and facilitator observation, and Level 2 evaluation

2a. The physician will be able to calculate the patient’s total daily dose of opioid including scheduled doses and average use of “as needed� doses.

2b. The physician will be able to determine the appropriate morphine : methadone ratio (e.g., 10:1 or 20:1) given patients age, total daily oral morphine dose equivalent and potential drug interactions.

2c. The physician will be able to calculate the oral methadone dosage regimen including milligram dose, dosage formulation (e.g., tablet or oral solution strength), dosing interval, and time to start relative to last dose of previous opioid.

3a. The physician will be able to order a starting dose of ketamine for both oral and parenteral administration.

Peer and facilitator observation

3b. The physician will be able to increase ketamine including the frequency of increase, and magnitude of dosage increase.

3c. The physician will be able to list three ketamine-induced dose-limiting adverse effects.

Peer and facilitator observation,

Peer and facilitator observation, and Level 2 evaluation

Peer and facilitator observation

Peer and facilitator observation, and Level 2 evaluation Peer and facilitator observation, and Level 2 evaluation

Level 2 evaluation

Prerequisites • Participants – Hospice staff physicians – Non-hospice physicians who refer to hospice

• Facilitator – Hospice Medical Director – Completed “Train-the-Trainer” education

Deliverables Design plan Lesson plan Draft of all materials PowerPoint presentation with notes for facilitators • Participant handouts • • • •

– Think-Pair-Share Worksheets – PowerPoint slide handout – Methadone and ketamine protocols

• Levels 1 and 2 evaluations

Lesson Plan 9 Events of Instruction • Preparation for learning – Gaining attention – Direction – Recall

• Delivery and Practice of New Material – – – –

Content Application feedback – level 1 Application feedback – level 2 Application feedback – level 3

• Wrap-Up

– Evaluation – Closure

Opioid-Induced Hyperalgesia: Seriously, I’m making things WORSE? Name of speaker Affiliation

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Gaining Attention (10 minutes)

Meet Mr. P. • 48 year old Caucasian male with an admitting hospice diagnosis of sepsis • Patient quadriplegic.

• History of MI, CVA, PEG placement and removal, seizures, extensor tone spasms (that bent cervical titanium rod in cervical spine), chronic neuropathic pain, sacral wound • Recently elected comfort care only (no further admissions) 15

Mrs. P. says…

• She is very worried about new plan of care because the patient has “excruciating pain when he becomes septic…he screams until he becomes hoarse from the pain.”

• She has experienced this for the past 5 years.

• Patient a complete assist for all ADLs. • Patient 72”, weight 170 lbs, BMI 23 • PPS 20% 16

Analgesics for Mr. P. on Admission • Implanted pump delivering baclofen (“stateallowed maximum dose”) • Transdermal fentanyl 150 mcg/hour • Transitioned from oral morphine 750 mg per day to hydromorphone 8 mg/hour continuous IV infusion (RN then called pharmacist) • Patient hypervigilant, spasming, screaming in pain, says it hurts EVERYWHERE • What to do?

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Direction (5 minutes)

Upon conclusion of this learning activity, the participant will be able to: • Given an actual or simulated opioid-tolerant pain patient, differentiate between opioid-induced hyperalgesia and five other clinical scenarios that may warrant an opioid dose increase, based on two aspects of pain presentation and response to therapy. • Given an actual or simulated opioid-tolerant pain patient with suspected opioid-induced hyperalgesia, calculate an equianalgesic dosage regimen of methadone, including total daily dose, dosing frequency and timing of dosage conversion. • Given an actual or simulated opioid-tolerant pain patient with suspected opioid-induced hyperalgesia, write an order for ketamine, including starting dose, dosing frequency, and titration schedule.

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Recall (10 minutes)

Opioid Therapy • Cornerstone of therapy for the treatment of moderate to severe pain (cancer, non-cancer) • Increased availability and comfort level in using opioids in recent years – Greater attention to pain management – Better education – Used earlier in disease process – Used in higher doses

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Adverse Effects of Opioids • • • •

Nausea, vomiting Constipation Pruritus Sleepy

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What’s going on?

• A common clinical observation:

Progression

Clin J Pain 2008;24:479-496

Opioid Tolerance

Opioid-Induced Pain

Disease

Opioid Tolerance

Disease Progression

– Opioid-requiring patients need a dosage increase to maintain adequate analgesia. Why? OpioidInduced Pain (OIH)

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Content (15 minutes)

CNS Adverse Effects of Opioids • Adverse effects of opioids on CNS (neurotoxicity - damage to nerve cells) – Reduced level of consciousness (sedation, drowsiness, sleep disturbance) – Adverse effects on thinking process and ability to reaction (cognitive impairment, psychomotor impairment, delirium, hallucinations, dreams, nightmares) – Direct toxic effect on neurons (myoclonus, seizures, hyperalgesia and tolerance) 25

OIH and Opioid Tolerance

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OIH vs. Tolerance

Clin J Pain 2008;24:479-496; A – OIH; B - Tolerance

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Vicious Cycle of Opioid-Induced Neurotoxicity

http://palliative.info/pages/TeachingMaterial.htm

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Application 1 (10 minutes)

Exercise 1 • ES is a 72 year old man admitted to hospice with end-stage colon cancer, widely metastatic.

• On admission to hospice he was receiving long-acting oral morphine 60 mg by mouth every 12 hours. His pain was primarily in his abdomen, and he rated it as a 6 on average, a worst of 8 and a best of 4.

• Over the month after admission, his pain increased (8 on average, worst of 10, best of 6-7) and his morphine was increased to 120 mg by mouth every 12 hours, with oral morphine solution 30 mg every 2 hours as needed (using about 6 doses per day).

• He now states the pain has extended well beyond his abdomen, in fact “it hurts pretty much everywhere.” He complains that his pajamas and even the bed sheets are painful to his skin.

• Complete Exercise 1.

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When opioids don’t get the job done Condition

Nature of pain

Presentation of onset of pain

Response to Opioid Admin

Worsening pain pathology

Localized to site of pre-existing pain or new site of pathology

Variable, depending on source of pain

Pain improves

Opioid tolerance

Localized to site of pre-existing pain

Gradual onset

Pain improves

Opioid withdrawal

Increased sensitivity to pain; diffuse, may extend beyond distribution of pre-existing pain

Abrupt with SA opioids or antagonist administration; gradual with LA opioids

Pain improves

Opioid addictive disease

Increased sensitivity to pain; diffuse, may extend beyond distribution of pre-existing pain

Gradual onset

Pain may improve, but function may worsen

Pseudoaddiction

Localized to site of pre-existing pain; pain is undertreated, causing patient to seek opioids (may be mistaken for addiction)

Variable, depending on source of pain

Pain improves

Opioidinduced hyperalgesia

Pain abnormal in presentation (often with allodynia); increased sensitivity to pain; diffuse, may extend beyond distribution of pre-existing pain or be widespread (panalgesia); may be associated with delirium, agitation, seizures, myoclonus

Abrupt onset with rapid opioid escalation or high-dose opioid administration

Pain worsens

J PeriAnesthesia Nursing 2012;27(1):46-50; Br J Clin Pharm 2010;2:153-156

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Content (continued) (25 minutes)

Br J Clin Pharm 2010;2:153-156.

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Morphine and Hydromorphone

Active Metabolite Accumulation in Renal Failure

http://palliative.info/pages/TeachingMaterial.htm

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Analgesics for Mr. P. on Admission • Implanted pump delivering baclofen (“stateallowed maximum dose”) • Transdermal fentanyl 150 mcg/hour • Transitioned from oral morphine 750 mg per day to hydromorphone 8 mg/hour continuous IV infusion (RN called pharmacist) • Patient hypervigilant, spasming, screaming in pain, says it hurts EVERYWHERE • What to do?

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Management of OIH • Hydration if clinically appropriate • Reduce the opioid dose – Consider use of an opioid-sparing coanalgesic • Acetaminophen, NSAID

• Opioid rotation – Allows comparable analgesia at a lower equianalgesic dose – Fentanyl – Methadone • NMDA receptor antagonist

• Ketamine (NMDA receptor antagonist) 36

Methadone

(refer to Methadone Protocol) • Potential candidates / inappropriate candidates • Assessing co-morbidities / cardiovascular risk • Calculate total daily dose / convert to oral morphine • 10:1 or 20:1; adjust for interacting drugs • Selecting the methadone dose • Implementing therapy • Monitoring response; adjusting therapy • Educating patients, families, caregivers 37

Application 2 (10 minutes)

Exercise 2 – Mr. P. • Implanted pump delivering baclofen (“state maximum dose”) • Transdermal fentanyl 150 mcg/hour • Hydromorphone 8 mg/hour continuous IV infusion (call to pharmacist) • How would you convert Mr. P. to oral methadone? See Exercise 2.

• Patient is receiving no other medications.

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Exercise 2 – Mr. P. • Transdermal fentanyl 150 mcg/hour – 300 mg oral morphine per day

• Hydromorphone 8 mg/hour continuous IV infusion – 8 mg/hour x 24 hours = 192 mg IV HM per day – 192 mg x 20 = 3840 mg oral morphine per day

• TDD oral morphine = 4140 mg • Use a 40:1 (oral morphine : methadone conversion) → 103.5 mg oral methadone per day – No interacting drugs – Methadone 30 mg po q8h – Oral morphine solution 60-100 mg hourly as needed • Or could keep IV hydromorphone for prn dosing

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Content (continued) (10 minutes)

Ketamine (refer to Ketamine Protocol) • • • •

Mechanism of action – NMDA antagonist Indications for use / contraindications Adverse effects Dosage and administration – IV, SQ, continuous infusion – Oral, topical

• Monitoring and response to therapy 42

Application 3 (10 minutes)

Exercise 3 – Ms. R. • Ms. R. is a 43 year old woman with end-stage cervical cancer. She is admitted to hospice from the hospital, on IV morphine 80 mg/hour with a 20 mg bolus every 15 minutes (uses about once an hour).

• She is experiencing myoclonus, and the hospice medical director prescribed lorazepam 2 mg po q6h scheduled.

• Two days after admission the patient went on vacation for a week to the ocean.

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Exercise 3 – Ms. R. • When the patient returned from vacation, she was admitted directly back to the hospital. It was discovered that she spent most of her ocean side vacation in the local hospital complaining of increased pain and myoclonus.

• On returning home, she is now on IV morphine 130 mg/hour plus a 30 mg bolus, which she uses once or twice an hour, plus a continuous infusion of midazolam at 10 mg/hour. She continues to experiences significant myoclonus.

• Patient has a history of a prolonged QTc and refuses methadone therapy.

• Determine a plan that incorporate ketamine to treat Ms. R.

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Exercise 3 – Ms. R. • Begin ketamine 10 mg po q6h, mixed in orange juice • Empirically reduce morphine infusion by 30% to 90 mg/hour; keep bolus in place • Empirically reduce midazolam infusion by 50% to 5 mg/hour • Increase ketamine by 10 mg per dose every 23 days (while titrating morphine and midazolam down) 46

Wrap-Up/Evaluation (10 minutes)

Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain (APS/AAPM) • “Management of treatment-refractory patients on high doses of COT is challenging.”

– Substance abuse, diversion – Increased adverse effects

• “Hyperalgesia, neuroendocrinologic dysfunction and possibly immunosuppression may be more likely at higher opioid doses…[> 200 mg oral morphine TDD]” – Opioid treatment may be require restructuring J Pain 2009;10:113-130; COT – chronic opioid therapy; TDD – total daily dose

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Clinical Features OIH History • Increasing sensitivity to pain stimuli (hyperalgesia) • Worsening pain despite increasing doses of opioids • Pain that becomes more diffuse, extending beyond the distribution of pre-existing pain • Can occur at any dose of opioid, but more commonly with high parenteral doses of morphine or hydromorphone and/or in the setting of renal impairment/failure.

Fast Facts and Concepts #142: Opioid-Induced Hyperalgesia

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Clinical Features OIH Physical Examination • Pain elicited from ordinarily non-painful stimuli such as stroking skin with cotton (allodynia) • Presence of other opioid hyperexcitability effects – Myoclonus, delirium, seizures

Fast Facts and Concepts #142: Opioid-Induced Hyperalgesia

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Clinical Features OIH Proposed Mechanisms • Toxic effect of opioid metabolites (e.g., morphine3-glucuronide or hydromorphone-3-glucuronide) • Central sensitization as a result of opioid-related activation of N-methyl-D-aspartate (NMDA) receptors in the central nervous system • Increase in spinal dynorphin activity • Enhanced descending facilitation from the rostral ventromedial medulla • Activation of intracellular protein kinase C Fast Facts and Concepts #142: Opioid-Induced Hyperalgesia

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Clinical Features OIH Therapies • Reduce or discontinue the current opioid • Change opioid to one with less risk of neurotoxic effects: fentanyl or methadone • Add an infusion of a non-opioid NMDA receptor antagonist such as ketamine • Add a non-opioid adjuvant such as acetaminophen or NSAID • Initiate epidural, intrathecal, regional or local anesthesia and taper/discontinue systemic opioids • Increase hydration if clinically appropriate Fast Facts and Concepts #142: Opioid-Induced Hyperalgesia

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Closure (5 minutes)

What are the three most important things you learned today?

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Evaluation (Level 1)

Evaluation (Level 2)

Opioid-Induced Hyperalgesia: Seriously, I’m making things WORSE? Seasons Hospice & Palliative Care

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Developing Peer and Patient Education Materials “Teaching is a skill and a gift, a talent and a technique.�

Heimlich and Norland, 1994

Mary Lynn McPherson, Pharm.D., BCPS Professor and Vice Chair for Education University of Maryland School of Pharmacy mmcphers@rx.umaryland.edu 58