1: PCA Medication Record Update: Follow-Up Evaluation

MPS 2016 Poster Abstracts

1: PCA Medication Record Update: Follow-up Evaluation

Authors: Monika K. Lach, PharmD, David M. Dickerson, MD, Pauline Lee, PharmD, Monica Malec, MD, Randall W. Knoebel, PharmD, BCOP

Institution: University of Chicago Medicine

Introduction:

Patient controlled analgesia (PCA) is a delivery system in which patients can self-administer predetermined doses of analgesic medications to relieve pain. When initiating a PCA, numerous variables need to be considered including patient characteristics and drug administration settings. In March 2016, PCA medication orders required assessment of opioid tolerance or naivety which triggered dosing recommendations through cascading logic.

Methods:

Via a single center, retrospective chart review the influence of standardized PCA orders on opioid dosing was evaluated for April 2015 and April 2016. Data collection included: PCA mode, loading dosing, demand dosing, and PCA dose frequency. Naloxone administration in this population was also assessed.

Results:

A total of 840 PCA orders were analyzed. 485 were in the pre-implementation group and 355 were post-implementation. Adult patients made up 90% of PCA orders. PCA orders with continuous infusion modes increased by 7.2% post-implementation (22.7% vs. 29.9%). Median loading doses were lower post-implementation in adult patients (7 mg vs. 3.5 mg). There was no difference in demand dose prescribed. Post-implementation, all pediatric lockout frequencies were greater than or equal to 10 minutes. In adult patients, frequencies of less than 10 minutes were reduced by 23% post-implementation (43% vs. 20%, p <0.001). Frequencies of less than 8 minutes were reduced by 7% in adult’s post-implementation (13% vs. 6%, p <0.002). There was also a 50% reduction in naloxone administrations for patients receiving a PCA (18 vs. 9, respectively).

Conclusions/Discussion:

These results suggest that PCA medication order standardization resulted in lower loading doses and reduction in lockout frequencies of less than 10 minutes, leading to a potential improvement in patient safety as indicated by a lower utilization of naloxone.

2: Factors of Spousal Support Related to Elevations in Chronic Pain

Authors:

Tracy Aneziris, M.A. Illinois School of Professional Psychology at Argosy University, Schaumburg

Samantha Harfenist, M.A. Illinois School of Professional Psychology at Argosy University, Chicago

Institution: Northshore Integrative Health Care, Illinois School of Professional Psychology at Argosy University, Schaumburg

Objective: Couples coping with chronic pain experience stressful changes in their relationship. While significant others support is known to be correlated with better outcomes for partners with chronic pain, specific factors positively and negatively related to recovery and comfort need further exploration. Methods: The Multidimensional Pain Inventory is a self-report measure examining the impact of pain on one’s life, ability to perform activities, and responses by significant others. On the significant other’s section, many items are related to partners or spouses avoiding, being frustrated with, or assisting their partner in order to create a total significant other support score. The poster will present data from 177 patients who completed the MPI as part of a pre-surgical evaluation and examine the relationship between significant other’s responses to patients’ pain and patient depression, anxiety, and pain measures. Results: The results indicated that there was multiple statistically significant relationships between variables. The primary relationship found was patients who rated their significant others as highly frustrated, also rated their significant others as being highly avoidant (r = .580, p< 0.01). Several other similar relationships were found and will be presented in the poster. Conclusions: This information may provide more clear direction for clinicians to understand what areas of strengths and weaknesses need to be focused on when working with couples coping with chronic pain. It is especially important to focus on reducing spousal frustration related to chronic pain, as it is significantly related to patient depression, level of assistance provided, and avoidance of patient from his/her spouse.

References:

Bruns, D., Kerns R. (2013). Managing Chronic Pain: How Psychologist can Help with Pain Management. Retrieved September 30, 2016, from

Catalano, E. M. (1989). The Chronic Pain Control Workbook. The Clinical Journal of Pain, 5(4), 363-364.

Chronic Pain Information Page: National Institute of Neurological Disorders and Stroke (NINDS). (n.d.). Retrieved September 30, 2016, from

Newton-John, T. R., & de C Williams, A. C. (2006). Chronic pain couples: Perceived marital interactions and pain behaviours. Pain, 123(1), 53-63.

Surah, A., Baranidharan, G., & Morley, S. (2013). Chronic pain and depression. Continuing Education in Anaesthesia, Critical Care & Pain, mkt046

3: Evaluation of Inpatient Pain Management for Vasoocclusive Crisis in Patients with Sickle Cell Disease

Authors: Angela Kerins PharmD, Hailey Soni PharmD, Samantha Bastow PharmD, David Gajdosik PharmD, Sumeet Deogan PharmD, Monica Malec MD, David Dickerson MD, Randall Knoebel PharmD

Institution: University of Chicago Medicine (UCM)

Introduction: Pain is the hallmark clinical manifestation of sickle cell disease vasoocclusive crisis (SCD VOC), with acute pain episodes being the most common reason for both pediatric and adult patients to seek medical attention. Furthermore, recent guidelines promote multimodal analgesia (MMA) to reduce opioid prescribing. The purpose of this study was to evaluate the current pain management strategies for the treatment of SCD VOC pain crisis at UCM.

Methods: This single center, retrospective study evaluated adult and pediatric patients admitted to UCM with a SCD VOC over a two-year period, from September 1, 2014- August 31, 2016. Data collection included the number of doses of opioids, gabapentinoids, NSAIDs, acetaminophen, topical lidocaine, intrathecal/epidural bupivacaine, and antidepressants (SSRIs, SNRIs and TCAs) administered. The primary objective of the study was to determine the percentage of patients treated with opioids alone compared to multimodal analgesia.

Results: A total of 283 patients with 1,009 hospital encounters were identified for the study. Opioid only management was identified in 17% of encounters. Non-opioid analgesics were administered including: gabapentinoids 14%, acetaminophen 54%, NSAIDs 55%, antidepressants 12%, local anesthetic 0.5%, lidocaine 15%, and ketamine 0.5%. There were 5% of patients who received opioids in combination with an NSAID, acetaminophen and a gabapentinoid medication.

Conclusion/Discussion: 83% of SCD VOC patients received an opioid plus non-opioid agent, while 17% received opioid monotherapy. However, there are still many patients that rely on opioids alone and there is room for improvement in expanding and standardizing the utilization of non-opioid medication options. The next step of this project will be to outline a SCD VOC pain crisis treatment pathway and re-analyze the above endpoints to compare the data before and after the pathway was implemented.

References:

1. Marret E, et al. Anesthesiology 2005;102:1249-1260

2.Ella N. Anesthesiology 2005;103:1295-1304

3.Okpala, E, et al. J R Soc Med 2002;95:456-458

4.Ballas, SK. Hematol Oncol Clin N Am 2005;19:785-802

4: Optimizing institutional care of inpatient drug delivery devices

Authors: Angela Kerins, PharmD, BCPS, Randall Knoebel PharmD, BCOP, David M. Dickerson, MD

Institution: University of Chicago Medicine (UCM)

Introduction: Intrathecal drug delivery (IDD) is an important component of the armamentarium to treat patients with refractory intractable pain or spasticity. Continuous intrathecal delivery of opioid medications allows for higher central nervous system concentrations, improved pain scores, and less frequent side effects when compared with systemic opioid administration. Guidelines and literature exist to assist with appropriate patient and drug selection for IDD, however, the process for implementation of IDD is highly variable posing potential risks for patients and institutions.

Methods: An interdisciplinary team including members of the pain medicine faculty, primary medical service, pharmacy and nursing was formed. The team sought to develop a standard process for IDD trialing, implantation, refill and identification of patients admitted to the hospital with IDD.

Results: Key vulnerabilities identified within the IDD trialing and first fill after implantation included: non-standard written orders, manual calculations within pharmacy, a non-standard medication record within the electronic health record and a manual 1st and 2nd pharmacist check. Additionally, the team identified that there was no standard method to identify patients admitted to the hospital with an IDD device. Key best practices were recommended and implemented: a standard acute pain service progress note, replacement of manual calculations with an excel calculator, medication record development, provider order entry, and a chartable nursing record (flow sheet for implantable devices). Table 1 describes several vulnerabilities and best practices developed to address the specific issues.

Conclusion/Discussion: The complexity and acuity of IDD create institutional risk. Timely identification of patients receiving IDD can prevent injury related to the pump or medications within. Standardized practices for medication preparation and IDD patient care can be identified and implemented through interdisciplinary quality improvement processes.

Table 1. Vulnerabilities and proposed standardization for intrathecal drug delivery device management

Vulnerabilities / Standardized Practice
Medication fill /

1. Non-standard written order
2. Manual calculation
3. Non-standard medication record
4. Manual pharmacist 1st and 2nd check

/

1. Standardized written order
2. Excel calculator developed
3. Medication record developed
4. Automated 1st and 2nd pharmacist check

Identification of IDD on admission /

1. No standard way to identify patients

/

1. Developed screening question as part of admission process
2. Created placeholder medication record as means of communicating IDD in place

References:

1. Deer TR, et al. Pain Physician. 2011 May-Jun;14(3):E283-315; Lawson EF, Wallace MS. Curr Opin Anaesthesiol. 2012 Oct;25(5):572-6.

3. Knight KT, et al. Croat Med J.2007 Feb;48(1):22-34. 4. Kosturakis BA, Gebhardt. Pain Physician. 2012 Nov-Dec;15(6):475-7.

5: Sedentary Behavior is Associated with Physical Impairment and Fatigue in Adolescents with Juvenile Fibromyalgia

Authors: Megan Pfeiffer, BS; Gregory D. Myer, PhD; Tracy V. Ting, MD, MSc; Sara E. Williams, PhD; Staci Thomas, MS; Katie Kitchen, BA; and Susmita Kashikar-Zuck, PhD

Institution: Cincinnati Children’s Hospital Medical Center

Introduction: Juvenile fibromyalgia (JFM) is a debilitating pain condition associated with high levels of physical impairment2, 3. Reduced participation in physical activity has been associated with a host of negative outcomes in various chronic pain conditions4 but has not been examined in teens with JFM specifically. The objective of the current study was to use accelerometry to evaluate relationships between physical activity and self-reported pain, fatigue, functioning, and depressive symptoms in adolescents with JFM.

Methods: Forty adolescents (Mage = 15.26, SD = 1.56) with JFM completed the Functional Disability Inventory, PROMIS Fatigue, Children’s Depression Inventory, average pain rating in the past week (0-10cm VAS). They also wore a waist-mounted accelerometer for seven days. Amount of time spent in sedentary activity and moderate-vigorous activity (MVPA) was examined1. Those who were in the high versus low levels of sedentary and MVPA (based on median splits) were compared on pain, fatigue, function and depressive symptoms.

Results: Overall, participants spend the majority of their day at a sedentary level (median = 13.17 hours per day) and engaged in about 1.5 hours of MVPA (median = 91.17 minutes). Those in the high sedentary group were significantly more impaired than those in the low sedentary category in terms of function (p = .035) and fatigue (p = .046). These differences were not seen when using median splits of MVPA.

Conclusions/Discussion: Adolescents with JFM who are more sedentary report greater impairment in daily function and high levels of fatigue. Intervention efforts directed at improving activity levels in adolescents with JFM are needed. Although MVPA appeared to meet guidelines of at least 30 minutes per day, it should be noted that most of this time was in moderate activity and not necessarily sustained activity. This study adds to the literature on the importance of physical activity participation in adolescents with chronic musculoskeletal pain.

1.ActiGraph. ActiLife 6.11.9, 2009-2015

2.Kashikar-Zuck S, Flowers SR, Verkamp E, Ting TV, Lynch-Jordan AM, Graham TB, Passo M, Schikler KN, Hashkes PJ, Spalding S. Actigraphy-based physical activity monitoring in adolescents with juvenile primary fibromyalgia syndrome. The Journal of Pain. 11:885-893, 2010

3.Kashikar-Zuck S, Lynch AM, Slater S, Graham TB, Swain NF, Noll RB. Family factors, emotional functioning, and functional impairment in juvenile fibromyalgia syndrome. Arthritis and Rheumatism. 59:1392-1398, 2008

4.Wilson AC, Palermo TM. Physical activity and function in adolescents with chronic pain: a controlled study using actigraphy. The Journal of Pain. 13:121-130, 2012

6: Pain Perception and Quality of Life Following a Structured, Interdisciplinary Smoking Cessation Intervention for Chronic Pain Patients

Authors: Linda Strozdas, PsyD, Candice Ryan, PsyD, Sarah Parnow, MA, Maria Torres, MD, Frank Yurasek, PhD, LAc, Azzam Alkhudari, MD, Taruna Penmetcha, MD, Abed Rahman, MD, Gunar Subieta, MD, & Peter Ji, PhD

Institution: Stroger Hospital of Cook County

Introduction: Research shows that a complex interaction exists between psychological factors, pain, and smoking behavior. Smoking cessation interventions like nicotine replacement therapy (the patch, gum, medications) as well as peer group support are known to help smokers achieve smoking cessation. This study sought to explore whether a protocol combining three structured interventions: 1) a psychoeducational/peer support group 2) acupuncture and 3) prescribed medication management using nicotine replacement therapy (NRT) for smoking cessation, alter pain perception and the psychological factors of depression, self-efficacy and pain catastrophizing.

Methods: Nicotine-dependent chronic pain patients (N = 31) receiving outpatient treatment at Stroger Hospital Pain Clinic participated and completed a tri-part interdisciplinary intervention designed for chronic pain patients who smoke. Using a pre-test, post-test design, participants completed measures assessing pain perception, depression, self-efficacy, and pain catastrophizing. Interventions included four weekly one-hour smoking cessation psychoeducational/support group sessions followed by auricular acupuncture. These sessions were augmented by Nicotine Replacement Therapy (NRT) prescribed by pain clinic physicians at session #2. A paired samples t-test was performed.

Results: Rumination, a component of pain catastrophizing, was significantly decreased at post-test (t = 2.15, p < .05). Pain self-efficacy significantly improved (t = 2.46, p < .05). There were no significant differences in pain perception or depression.

Conclusions/Discussion: A structured Interdisciplinary intervention for smoking cessation in chronic pain patients resulted in improvements in specific psychological variables of self-efficacy and pain catastrophizing. Chronic pain patients experienced improvements in their ability to cope with their pain and perform tasks despite their pain. They also experienced a reduction in rumination about their pain.

Borsbo, B., Gerdle, B., & Peolsson, M. (2010). Impact of interaction between self-efficacy, symptoms and catastrophizing on disability, quality of life and health in with chronic pain patients. Disability and Rehabilitation, 32, 1387–1396.

Hooten, M., Townsend, C. O., Hays, T., Ebnet, K. L., Gauvin, T. R., Gehin, J. M. … Warner, D. O. (2014). A cognitive-behavioral smoking abstinence intervention for adults with chronic pain: A randomized controlled pilot trial. Addictive Behaviors, 39, 593–599.

White, A. R., Rampes, H., Liu, J. P., Stead, L. F., Campbell, J. (2011). Acupuncture and related interventions for smoking cessation. Cochrane Database of Systemic Reviews, 1, 1–18.

Wittchen, H. U., Hoch, E., Klotsche, J. & Muehlig, S. (2011). Smoking cessation in primary care – a randomized controlled trial of bupropione, nicotine replacements, CBT and a minimal intervention. International Journal of Methods in Psychiatric Research, 20, 28–39.

7: The Use of Sacred Turtle Abdominal Acupuncture For The Treatment of 46 Pain Patients

Authors: Frank Yurasek, PhD, MS, LAc; Tsegi Mololtsog, MD, MSAc (Mongolia)

Institution: Stroger Hospital of Cook County, Pain Management Center

Introduction: Abdominal Acupuncture, incorporating the body map of the Sacred Turtle diagram, is an Acupuncture Micro-System widely used throughout China and Europe. In 1992 Professor Zhiyan Bo, while treating a difficult case of Sciatica that had not responded to western medicine or traditional forms of acupuncture treatments, decided to treat his patient using the low back and hip points on the abdomen, based on the ancient theory of Biao and Li (External/Internal) dating back to 2,200 BC, with powerful results, Professor Bo’s research over the next 20 years showed that due to the abdominal area producing 80% of the body’s serotonin, pain, appetite, sleep, and mood were positively affected.

Our purpose of studying the use of Bo’s Style Abdominal Acupuncture was to measure its effect on Back Pain Patients in the reduction of pain and pain medication. An advantage of this remote form of needle stimulation, away from the site of pain, allowing for movement of the painful area of the body while the needles are retained, allowing for real-time pain assessment.

Methods: Stroger Hospital Acupuncture Patients with chronic pain received abdominal acupuncture every two weeks, were asked to identify their level of pain before and after treatment, using the Visual Analog Pain Scale (VAS). Patients were also asked how many days any reduction in pain lasted after their last treatment. Sacred Turtle Points used included Ren 12, 10, 6, Stomach 26, and hip knee and leg referral points based on the palpation of “ashii” (spontaneously sensitive) points.

Results:

Of the 37 patients receiving Abdominal Acupuncture for back pain:

5 patients had VAS reduction from 10/10 to 2/10

3 patients had VAS reduction from 7/10 to 0/10

12 patients had VAS reduction from 8/10 to 3/10

9 patients had VAS reduction from 7/10 to 2/10

5 patients had VAS reduction from 6/10 to 3/10

2 patients had VAS reduction from 7/10 to 6/10

1 patient had no change in VAS

26 patients reported that pain reduction lasted 3 to 7 days.

10 patients reported that pain reduction lasted 2 to 3 days.

Conclusions/Discussion:

Of 37 pain patients receiving abdominal acupuncture for back pain at 2 week intervals 36 had VAS pain reductions ranging from a high of 8 to a low 1 point, with no response from one patient. The effect lasted from 2 to 7 days. An advantage to this type of remote acupuncture stimulation, away from the area of pain, is that the patient can move that part of the body experiencing pain, allowing for needle adjustment or addition real-time, allowing more efficacious results. Preliminary findings suggest that a larger number of patients be treated with this method, on a more frequent basis, and a long enough period of time, in order to also track the influence of this therapy on their frequency and dosage levels of pain medication.