#47 dr.wojciehoski ebtofbainpack.ppt · patient takes more pain medication than prescribed....

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Randal F. Wojciehoski, D.P.M., D.O.

President, Medical Topics Unlimited, L.L.C.

Medical Director

Ministry Medical Group

Occupational Medicine, Cardiac Rehabilitation

Employee Health

Stevens Point, WI

�Emergency Physician, Ministry St.Michael’s Hospital

�Medical Director, Encore Unlimited, LLC

�Medical Director, MMG-Occupational Medicine

�Medical Director, MMG-Cardiac Rehab, Employee Health

�Medical Director, Harley-Davidson/Walgreens

�Board Certified Emergency & Internal Medicine

�Podiatrist

�Medical-Legal Consultant

�Syndicated Columnist and Author

�Clinical Professor at Marquette, UW, Fitch Medical School

�Commercial Pilot

�Husband and Dad4/15/2013 2www.drwojo.com

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“Have airplane, will travel!”

�Second most common work excuse

�60-90% of Americans will experience

�50% have recurrent episodes

�5 million disabled by back pain

�Number one disability for <45 yrs

�$50 billion spent annually on medical treatment

�Associated with “Other Baggage”

�1% of Americans on LTD and STD at any given time

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�Seven cervical vertebrae

�Twelve thoracic vertebrae

�Five lumbar vertebrae

�Sacrum and Coccyx

�Pathophysiology�Muscles

�Tendons

�Ligaments

�Nerves

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�Duration is a few days to weeks

�Due to overuse or trauma

�Shooting or stabbing pain, limited, ROM

�Pain may radiate

�May progress to chronic if untreated

�74% have resolution within 1 month

�93% have resolution within 3 months

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�A precise diagnosis can be made�85% can not be diagnosed precisely

�X-Rays reveal etiology�Consider imaging after 6 weeks

�Bed rest facilitates recovery�More than 2-3 days prolongs recovery

�Specialists improve recovery� 56% primary care, 54% seek alternative medicine

�Back exercises facilitate recovery-Truth

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�Aging�Decreased strength, elasticity, tone

�Trauma� Sprain or Strain�Disc compression due to lack of hydration

�Nerve root compression

�Bone lesions�Cancer

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�Males = Females

�Age 30-50

�Sedentary Lifestyle

�Pediatrics� 13,260 injuries due to back packs!

�Children should use both straps

�Lighter loads, use legs

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�Patients > 70 years old

�Mild Trauma > 50 years old

�Prolong steroid use

�Weight Loss

�Fever

�Immunosuppression

�IV Drug use

�CA

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�American College of Occupational and Environmental Medicine Policy Statement

� “Prolonged absence from one’s normal roles including absence from the workplace, is detrimental to a person’s mental, physical, and social well being.”

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�Nerve root irritation causing distal pain

�Herniated disk

�Spinal Stenosis

�Degenerative Disk Disease

�88% recovered spontaneously in 6 months

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�Painful disorder produced by sciatic nerve irritation

�Longest nerve in the body

�Persistent pain down the sciatic nerve

�Dull, aching pain

�Starts in back going to foot

�May last 6-12 weeks

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�No advantage for bed rest

�183 Patients randomized

�2 weeks of bed rest vs. watchful wait� 70% improved vs. 65% improved

�12 weeks 87% same

�Activity does not cause permanency

�Early return individualizedNEJM, 1999

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�Arthritis changes causing breakdown of the vertebrae

�Chronic pain and stiffness

�Neurological symptoms result

�Weakness

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�Degenerative change whereby a disc slips out of place

�May have no symptoms, incidental finding

�Genetics

�Overuse

�Pain

�Muscle spasm

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�Narrowing of the spinal column

�Causes compression of the spinal cord and nerves

�Aging

�Heredity

�Ischemia

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�X-Ray

�Discography

�CT Scan

�MRI

�EMG

�Bone Scan

�Ultrasound

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�Bed rest

�Exercise

�Medications�NSAIDS�COX-II Inhibitors�Narcotics�Anti-convulsants�Anti-depressants

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�Studies support use of NSAIDs

�51 trials showed that NSAIDs improved symptoms modestly over placebo

�NSAIDs may be as effective as Tylenol� (Cochrane Review 2011)

�COX-II inhibitors good for chronic pain

�Adverse effects for NSAIDs and COX-II

�No one NSAID better than another

�Up to 25% side effect rate

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�Corticosteroids: Limited studies� Small studies have revealed no benefits

� Side effects are problematic

�Anticonvulsants, Antidepressants�Tricyclic Antidepressants show efficacy

�No evidence based support for Anticonvulsants or Lidoderm Patches

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�Exercise is counter productive with acute back pain. Helps with rehab. No long term studies.

�Physical Therapy�No benefit to hot or cold therapy�Early referral has not improved outcome�Wait for 3 weeks prior to referral

�TENS revealed no benefit. Limited studies

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�Manipulation: 2004 study revealed it was better than sham therapy

�680 pts. studied for 18 months

�Chiro, Chiro w/PT, Medical, Medical w/PT

�No improvement with Chiro Modalities

�5 week study of Chiro, Accupunture, Massage, Medical Care revealed same results.

�Treatment courses of no more than 4-9 weeks

�Manipulation does NOT reduce re-occurance

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�Muscle Relaxants: Flexeril, Soma, Baclofen

�2005 review showed more effective than placebo at one week for acute back pain

�Combination drug study with questionable results

�Opioids used with clinical judgement

�Abuse potential and constipation problems� Should be utilized short term

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� 5% of citizens 12 or older in Wisconsin (224,000 people) used pain killers for a non-medical use in the past year

� 7% of teens aged 12 to 17 years old in Wisconsin (31,000 people) used pain killers for a nonmedical use in the past year

Office of National Drug Control Policy

Opiates: pain-killers

� Vicodin, Oxycontin, Tylenol Codeine

CNS Depressants

(Sedatives/Tranquilizers):

treat anxiety and sleep disorders

� Xanax, Ativan, Valium, Soma

Stimulants: ADHD, weight loss

� Adderall, Ritalin, Concerta, Dexedrine, Fastin

Reported Non-Medical Prescription Drugs of Abuse

(2005)

S edatives

S timulants

Tranquilizers

Painkillers

4,700,000

1,800,000

1,100,000

272,000

(Substance Abuse and Mental Health Services Administration [SAMHSA], 2005)

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Refers to a patient's persistent, manipulative, and/or

demanding behavior to obtain medication.

It may include obtaining or attempting to obtain a

prescription drug, procure or attempt to procure the

administration of a prescription drug by fraud, deceit,

willful misrepresentation, forgery, alteration of a

prescription, willful concealment of a material fact, or use

of a false name or address.

Seeking excessive prescribed drugs is a crime when it

involves fraud, forgery, deception or subterfuge.

�Oxycontin

�Valium

�Vicodin

�Percocet

�Xanax

�Soma

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� JACHO Guidelines 2000:

� Mandated pain assessment and treatment

� Nurse and physician education required

� When opioids prescribed properly for pain, addiction

rare in patients without underlying risk factors

� Vulnerabilities same as for other addictions: genetic,

peer and social influences, trauma and abuse history

�Opiate (naturally occurring in poppy)

� Low potency

�Pain relief via 10% conversion to morphine

�Most commonly prescribed opioid in the world

�Probably the most widely used analgesic

�(Excluding aspirin)

� Hydrocodone with Tylenol:� Norco

� Lortab

� Vicodin

� Lorcet

� Hydrocodone with ibuprofen: Vicoprofen

� Hydromorphone: Dilaudid

� Oxycodone with Tylenol: Percocet

� Oxycodone with aspirin: Percodan

� OxyContin

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� Used to treat pain associated with arthritis, lower

back injuries, and cancer

� Most commonly in tablet form: 10mg, 20mg,

40mg, 60mg, and 80mg tablets

� Dosed every 12 hours, half-life 4.5 hours

� Abuse: may be chewed, crushed, snorted or

injected� Eliminates time-release coating

� Enhances euphoria, “rush”

� Increases risk for serious medical consequences

�Methadone

�Demerol (meperidine)

�Fentanyl

�Suboxone/Subutex (buprenorphine)

�Tramadol�Complex mechanism of action�Nonscheduled, less abuse potential

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� Verification of patient identity (ID)

� Suspicion patient is falsely presenting

� Red Flag Rules

� Out of town patients

� Multiple allergies

� Minimal injury with maximal pain

� Normal vitals with maximal pain complaints

� Convoluted story

� Health care providers to health plans

� Treatment

� Payment

� Health Care Operations

� Health plans to health care providers

� Payment and health care operations

� Provider decision to use the information

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� Patient takes more pain medication than prescribed.

� Requests prescriptions from multiple doctors.

� Use of alcohol or other medications to increase the effects of the pain medication.

� Patient takes pain medication to deal with other problems, such as anxiety or stress.

� Doctor, friends or loved ones express concern about use of

pain medication.

�Most back pain resolves in time

�NSAIDs and Narcotics are standard tx

�Physical Therapy plays a role

�Surgery is rarely necessary

�Recovery requires several resources

�Treatment should be guided by evidenced-based medicine

�Narcotic treatment must be monitored

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Questions?