WV SEMP Guidelines www.sempguidelines.org
West Virginia Safe & Effective Management of Pain
(SEMP) Guidelines
WV Expert Pain Management Panel
West Virginia (WV) has the highest drug overdose death rate of 35 per 100,000 (Age Adjusted), with a large margin over the next closest state of New Mexico having a rate of 27, while the national average is 14. A geographically and professionally diverse expert panel of West Virginia professionals was formed with intention of creating guidelines for the safe and effective overall management of pain, which build upon the CDC Chronic Pain Opioid Guidelines of 2016. The guidance, included herein, aims to first provide a risk reduction strategy for the appropriate use of all pain treatments, and secondly, to develop pain management clinical treatment algorithms.
Clinical Treatment Algorithms
Safe and effective clinical pain management algorithms based on best practices, clinical experience, and evidence-based literature addressing the three main classification of pain: nociceptive, neuropathic, and mixed.
Risk Reduction Strategy
A major concern of healthcare professionals and patients alike is the question of what is the “gold standard” approach to managing pain, particularly chronic pain. Previously, pain management strategies have been largely based upon subjective evaluation methods versus more objective assessments. The risk reduction strategy contained herein, aims to minimize patient risk and reduce healthcare professional anxiety in the overall management of chronic pain, which is paramount for ensuring the safest and most effective management of pain.
Nociceptive Pain
Pain arising from noxious stimuli affecting thermal, mechanical, or chemical receptors (nociceptors) in normal tissues
Neuropathic Pain
Abnormal processing of sensory input by the Central and/or Peripheral Nervous Systems (CNS/PNS)
Mixed Pain
Combination of both Nociceptive and Neuropathic Pains
Patient&Provider(s)Agreement
OpioidRiskScreening
DrugInteraction&Pharmacogenetics
Review
ImprovedFunction&ReducedPain
Goal
EndofTherapyGoal
Initial&AnnualPsychologicalEvaluation
MedicationStorage&Disposal
Naloxone
PrescriptionDrugMonitoring
Program(PDMP)
UrineDrugScreening/Testing
PillCounts
DEARedFlags
Risk Reduction Strategy www.sempguidelines.org
West Virginia Safe & Effective Management of Pain
(SEMP) Guidelines
Nociceptive Pain Neuropathic Pain Mixed Pain
1st L
ine
2nd L
ine
3rd L
ine
4th L
ine
Non-Pharmacological (Active & Passive)
APAP then +/-NSAID*
Topical Agent (NSAID, Lidocaine, Capsaicin)
Non-Pharmacological (Active & Passive)
Acute Trial of NSAID*/APAP
Add on Topical Agent (NSAID, Lidocaine, Capsaicin)
Gabapentinoids**
Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)
Tricyclic Antidepressant (TCA)
Non-Pharmacological (Active & Passive)
Acute Trial of NSAID*/APAP
Topical Agent (NSAID, Lidocaine, Capsaicin)
Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)
Combination 1st & 2nd Line Agents
Spinal Cord/Dorsal Root Ganglion Stimulation
Consider Referral to Specialist Consider Referral to Specialist Consider Referral to Specialist
Referral to Specialist Needed Referral to Specialist Needed Referral to Specialist Needed
Combination 1st & 2nd Line Agents Combination 1st & 2nd Line Agents
Consider Clinical Trial Consider Clinical Trial Consider Clinical Trial
Clinical Treatment Algorithms www.sempguidelines.org
West Virginia Safe & Effective Management of Pain
(SEMP) Guidelines
Tricyclic Antidepressant (TCA)
Controlled Substance Class IV
Anti-Epileptic Drugs (AEDs)
Controlled Substance Class IV
Gabapentinoids**
Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)
Tricyclic Antidepressant (TCA)
Controlled Substance Class IV
Acute Add-On Muscle Relaxer** Acute Add-On Muscle Relaxer*** Acute Add-On Muscle Relaxer***
Controlled Substance Class III Controlled Substance Class III Controlled Substance Class III
Interventional Therapy Interventional Therapy
Interventional Therapy
Controlled Substance Class II (IR) Controlled Substance Class II (IR) Controlled Substance Class II (IR)
Spinal Cord/Dorsal Root Ganglion Stimulation
Spinal Cord/Dorsal Root Ganglion Stimulation
Controlled Substance Class II (ER) Controlled Substance Class II (ER)
Controlled Substance Class II (ER)
Implantable/Intrathecal (IT) Morphine/Baclofen/Ziconotide
Implantable/Intrathecal (IT) Morphine/Baclofen/Ziconotide
Implantable/Intrathecal (IT) Morphine/Baclofen/Ziconotide
Botox Injection****
ActiveCardio Exercise
Resistance ExerciseAquatic Exercise
Walking AidsYoga, Tai Chi, & QigongMeditation or Hypnosis
RelaxationCognitive Behavioral TherapyAcceptance & Commitment Therapy
BiofeedbackGraded Motor Imagery
Occupational/Physical Therapy
PassiveNutrition
Heat or ColdTENS/EMS DevicesHyperbaric OxygenSpinal Manipulation
(Chiropractor)Massage
UltrasoundParaffin WaxInfrared Light
Spinal TractionAcupuncture
Non-Pharmacological Treatments www.sempguidelines.org
West Virginia
Safe & Effective Management of Pain (SEMP) Guidelines
[Type here]
Medication MME Factor MME Relative Doses
Tramadol 0.1 300mg
Meperidine 0.1 300mg
Codeine 0.15 200mg
Dihydrocodeine 0.25 120mg
Pentazocine 0.37 ~100mg
Tapentadol 0.4 75mg
MORPHINE 1 30mg
Hydrocodone 1 30mg
Opium 1 30mg
Oxycodone 1.5 20mg
Oxymorphone 3 10mg
Heroin (SC Diacetylmorphine) 3 10mg
Hydromorphone 4 7.5mg
Methadone 1-20 mg/day 4 7.5mg
21-40 mg/day 8 3.75mg
41-60 mg/day 10 3mg
>/=61 mg/day 12 2.5mg
Levorphanol 11 ~3mg (2mg Available)
Fentanyl Transdermal (TD) Patch 7.2 (Divide By Days) 12.5mcg/hr Patch
Buprenorphine TD Patch 12.6 (Divide By Days) 15mcg/hr Patch
Buprenorphine SL & Buccal 0.03 (for mcg) 1000mcg (900mcg Available)
Morphine Milligram Equivalents MMEs
www.sempguidelines.org West Virginia
Safe & Effective Management of Pain (SEMP) Guidelines
Using the MME Factor Multiply the mg or mcg respectively of the chosen opioid by the
MME Factor to calculate the MME of the chosen opioid.
Using the MME Relative Doses Comparative doses of opioids to 30mg of oral morphine
www.cms.gov/Medicare/Prescription‐Drug‐Coverage/PrescriptionDrugCovContra/Downloads/Opioid‐Morphine‐EQ‐Conversion‐Factors‐March‐2015.pdfCDC.(2016).CDCGuidelineforPrescribingOpioidsforChronicPain‐UnitedStates,2016.MorbidityandMortalityWeeklyReport.*Buprenorphine&HeroinReferencesincludedwithinthefullSEMPguidelinesdocument
Prescription Drug Monitoring Programs (PDMPs) www.sempguidelines.org
West Virginia Safe & Effective Management of Pain
(SEMP) Guidelines
West Virginia PDMP or Controlled Substance Monitoring Program
• ToRegister,DelegateAccess,orLog‐In:https://www.csapp.wv.gov/Account/Login.aspx
• AlllicensedprescribersmustcheckthePDMPattheinitiationofopioidtherapyandataminimumofeveryyearthereafter.
• AphysicianworkinginapainmanagementclinicmustcheckthePDMPattheinitiationofthecontrolledsubstancetherapyandataminimumofevery90daysthereafter.
• AlllicenseeswhodispenseScheduleII,III,andIVcontrolledsubstancestoresidentsofWVmustprovidethedispensinginformationtotheWVBoardofPharmacy(BOP)atleastevery24hours.
Prescription Drug Monitoring Programs (PDMPs) www.sempguidelines.org
West Virginia Safe & Effective Management of Pain
Guidelines
West Virginia PDMP or Controlled Substance Monitoring Program
• ToRegister,DelegateAccess,orLog‐In:https://www.csapp.wv.gov/Account/Login.aspx
• AlllicensedprescribersmustcheckthePDMPattheinitiationofopioidtherapyandataminimumofeveryyearthereafter.
• AphysicianworkinginapainmanagementclinicmustcheckthePDMPattheinitiationofthecontrolledsubstancetherapyandataminimumofevery90daysthereafter.
• AlllicenseeswhodispenseScheduleII,III,andIVcontrolledsubstancestoresidentsofWVmustprovidethedispensinginformationtotheWVBoardofPharmacy(BOP)atleastevery24hours.
Opioid CYP450 Enzyme
Common Interacting Medications(s) Result Comments
codeine
2D6 celecoxib, duloxetine, bupropion, fluoxetine, & paroxetine Inhibit conversion to active metabolite Decreased Analgesia
n/a SSRIs/SNRIs Increased central serotonin levels
Monitor for Serotonin Syndrome
fentanyl 3A4 clarithromycin, diltiazem,
verapamil, & erythromycin Increased fentanyl concentration Adjust fentanyl dose
meperidine
n/a acyclovir Increased meperidine concentration n/a 3A4 phenytoin, carbamazepine, &
phenobarbital Decreased meperidine concentration n/a n/a
SSRIs/SNRIs Increased central serotonin levels Monitor for Serotonin
Syndrome n/a cimetidine Increased meperidine concentration Choose alternative H2RA
morphine n/a
rifampin & ranitidine Decreased morphine concentration &
conversion to active metabolite May result in decreased
analgesia
2D6 celecoxib, duloxetine, bupropion,
fluoxetine, & paroxetine Increased methadone concentration Reduce dose of methadone
methadone
3A4 phenytoin, carbamazepine, & phenobarbital Decreased methadone concentration
May precipitate opioid withdrawal
3A4 clarithromycin, diltiazem, verapamil, & erythromycin Increased methadone concentration Reduce dose of methadone
tramadol
2C9 carbamazepine Increases tramadol metabolism Avoid combination 2D6 celecoxib, duloxetine, bupropion,
fluoxetine, & paroxetine Inhibit conversion to active
metabolite Decreased Analgesia n/a SSRIs/SNRIs Increased central serotonin levels Monitor for Serotonin Syndrome
hydrocodone
2D6 celecoxib, duloxetine, bupropion, fluoxetine, & paroxetine Inhibit conversion to active metabolite Decreased Analgesia
3A4 clarithromycin, diltiazem, verapamil, & erythromycin Increased hydrocodone levels Adjust hydrocodone dose
oxycodone
2D6 celecoxib, duloxetine, bupropion, fluoxetine, & paroxetine
Increased oxycodone levels, but decreased oxymorphone (metabolite) levels n/a
3A4 phenytoin, carbamazepine, & phenobarbital Decreased oxycodone concentration Decreased Analgesia
3A4 clarithromycin, diltiazem, verapamil, & erythromycin Increased oxycodone levels Adjust oxycodone dose
Opioid Drug-Drug Interactions www.sempguidelines.org
West Virginia Safe & Effective Management of Pain
(SEMP) Guidelines
1. ClinicalPharmacology[Internetdatabase].GoldStandard,Inc.,2007.Availableat:http://www.clinicalpharmacology.com.AccessedJune2016.2. CommonOpioid‐DrugInteractions:WhatCliniciansNeedtoKnow.PracticalPainManagement,2012.
UrineDrugScreening(UDS) UrineDrugTesting(UDT)Immunoassayscreen(i.e.Cup) GC‐MSorLC‐MS/MS
In‐office,point‐of‐care,orlab‐based Laboratory,highlyspecificandsensitive
Resultswithinminutes Resultsinhoursordays
Detectsafewlegal&illicitmedicationsbystructuralclass
Measuresconcentrationsofallmedications,illicitsubstances,&metabolites
Guidanceforpreliminarytreatmentdecisions Definitiveidentification&analysis
Cross‐reactivitycommon:morefalsepositives False‐positiveresultsarerare
Highercutofflevels:morefalsenegatives False‐negativeresultsarerare
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TargetDrugTest Cross‐ReactantCannabinoids NSAIDs,dronabinol,promethazine,&pantoprazole
Opioids Poppyseeds,chlorpromazine,rifampin,dextromethorphan,quinolones,diphenhydramine,&quinine
Amphetamines Methylphenidate,trazodone,bupropion,amantadine,propranolol,labetalol,ranitidine,&menthol
PCPIbuprofen,tramadol,chlorpromazine,venlafaxine,thioridazine,meperidine,dextromethorphan,
diphenhydramine,&doxylamine
Benzodiazepines Oxaprozin,sertraline,&someherbals
Alcohol Asthmainhalers
Methadone Quetiapine
Opioid OpioidsExpectedinTestingResults(BasedonMetabolites)
Morphine Morphine&hydromorphone*
Hydromorphone Hydromorphone
Hydrocodone Hydrocodone&hydromorphone
Codeine Codeine,hydrocodone*,morphine,&hydromorphone
Oxycodone Oxycodone&oxymorphone
Oxymorphone Oxymorphone
Fentanyl Fentanyl
Tramadol Tramadol
Methadone Methadone
Heroin Heroin,morphine,&hydromorphone*Minor
Urine Drug Screenings & Tests
www.sempguidelines.org West Virginia
Safe & Effective Management of Pain (SEMP) Guidelines
Opioid Tapering Tool www.sempguidelines.org
West Virginia Safe & Effective Management of Pain
(SEMP) Guidelines
General Considerations
Determine if the goal is to reduce or discontinue the opioid medication. Gradual tapering can take 2 to 6 months (Some may benefit from longer time frame of 18 to 24 months) and is best
for avoiding withdrawal symptoms.
More rapid tapering is possible and sometimes desired, with an emphasis on monitoring for withdrawal symptoms.
Formulations that offer smaller dose increments are useful for more gradual tapers, especially once in the lower end of the dosage range.
Consult with pain management specialists as needed.
Tapering Timeline
If discontinuing opioid, the final 20-60 MME may require more time.
Opioid Withdrawal Symptoms & Treatments
Pain
NSAID and/or Acetaminophen
Diarrhea
Loperamide
Nausea/Vomiting
Dimenhydrinate
Anxiety
Hydroxyzine
Insomnia
Sleep Hygiene
Tachycardia
Clonidine
Initial dose reductions in the range of 10% every 1 to 2+
weeks.
Once 1/3 of original dose is reached, smaller reductions
(5% every 2 to 4 weeks) may be useful.
Naloxone www.sempguidelines.org
West Virginia Safe & Effective Management of Pain
(SEMP) Guidelines
Candidates to Carry Naloxone
• Anypatientreceiving>50mgMorphineMilligramEquivalent(MME)ofopioidtreatment• Respiratorycondition
• COPD,Asthma,SleepApnea,orSmokingofmarijuana,hooka,tobacco,etc.• Patientsbeingtreatedforopioidusedisorder(DSM‐V)• PersonalorFamilyhistoryofsubstanceabuse(alcoholordrugs)• Patientsreleasedhavingexperiencedanopioidoverdose• Benzodiazepine,Hypnotics,MuscleRelaxers,orothersedativeuse• Patientsbeingswitchedbetweenopioidsproductformulations• Thosewithdifficultaccesstoemergencyservices(rural)• Heavyalcoholuse• Voluntaryrequestfrompatientorcaregiver
Opioid Overdose Signs/Symptoms
Key Points of Naloxone Administration
• Call911,EmergencyMedicalServicesEMS• ClearingofairwayandRescueBreathing• Afternaloxoneadministration,therescuepositioncanhelp
• LayingonSide,onelegextended,otherlegbent,&handunderhead• StayingwithpersonatleastuntilEMSarrives.
• SlowGargledBreathing(orNoBreathing)• BlueLipsand/orNails• Cold&ClammySkin• Unresponsive• Pin‐PointPupils• Hypotension
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