opioid analgesic use, overuse, and abuse among patients at university health centers acha meeting...

Opioid Analgesic Use, Overuse, and Abuse among Patients at

University Health Centers

ACHA Meeting

May 31, 2012

David C. Dugdale, MD

Director, Hall Health Primary Care Center

Division of General Internal Medicine

University of Washington

[email protected]

Disclosures/Financial Relationships

I have NO actual or potential conflict of interest in relation to this educational activity or presentation

I consult about pt education materials for the following companies:

ADAM CorpMilliman Care Guidelines

Acknowledgements

• Mary Watts, MD– Associate Director for Medical Affairs, Hall

Health– Division of General Internal Medicine, UW

• Alex Cahana, MD– Director, UW Pain Center– Division of Pain Management, UW

Overview—Learning Objectives

• Describe the scope of opioid use– Definitions (5 minutes)– Issues & concerns (20 minutes)

• Compare and contrast opioid use for chronic and acute pain syndromes (10 minutes)

• Describe our clinical approach and QI program aimed at chronic pain management (20 minutes)

• Describe our clinical approach and QI program aimed at acute pain management (20 minutes)

Self-assessment Questions – IAll True-False

• Drug tolerance is defined as a drug-induced loss of effect over time

• In the US, the annual death rate from unintentional drug overdose has been about the same from 2003 to 2007

• Pills “left over” from a valid prescription are a common source of opioids diverted for non-medical use

Self-assessment Questions – IIAll True-False

• In the US, the most commonly prescribed opioid is methadone

• Hydrocodone is about a tenth as strong as morphine

• Chronic pain management emphasizes function over complete pain control

Scope of Opioid Use: Definitions

• Pain• “Narcotics”• Opiates• Opioids• Drug

– Dependence– Tolerance– Abuse– Addiction– Diversion


• Pain– A subjective, unpleasant sensory and emotional

experience– Acute pain—acute tissue injury– Chronic pain

• Cancer pain• Chronic non-malignant pain

– Pain is usually due to apparent external stimulus, but not always

– Pain intensity is modulated by many physiologic and psychosocial factors


• “Narcotics”– This term is widely used to mean

something other than opiates or opioids• Original meaning: any substance with sleep-

inducing properties• Its imprecision as a term makes it undesirable


• Opiates vs. opioids– Opiate means something naturally derived

from opium– Codeine and morphine are the clinically

most important opiates


• Opiates vs. opioids– Opioids includes opiates plus synthetic or

semi-synthetic derived substances• Fentanyl (Duragesic)• Hydrocodone (Vicodin and others)• Hydromorphone (Dilaudid)• Methadone• Oxycodone (Percocet and others)


• Drug Dependence– Characterized by the occurrence of

withdrawal symptoms with the abrupt cessation of a drug

• Drug Tolerance– Drug-induced loss of effect (over time)– Often associated with dose escalation


• Drug Abuse– Use of a drug in a manner that deviates

from medical, legal, or social standards– Commonly used alternative terms:

• “non-medical use”• “illicit use”

– An important concern of all college health programs


• Drug Addiction is a disease (UpToDate)– With a strong genetic component

• Affects ~10% of people

– Defined by aberrant drug-taking behavior:• Craving• Loss of control• Compulsive use• Continued use despite harm


• Drug Diversion (UpToDate)– Distribution of a drug into the illicit marketplace– A strong likelihood that diversion of prescribed

drugs is occurring MUST stop prescribing– Suspected abuse or addiction prescribing

may legally continue if appropriate medical actions are being taken to:

• stop the behavior• regain control over the prescribing, and • manage the medical and psychiatric condition of the

patient

Scope of Opioid Use--Issues

• Acute pain setting– Acute pain management is usually straightforward,

but using opioids brings a number of possible issues and complications

– Although there are well established typical doses, significant variations in response occur

– Sedation can be profound, and – Inadvertent overdoses are possible in the acute

pain management setting


• Longer term opioid use can be associated with:– physical dependence– tolerance and dose escalation– addiction with pervasive psychological, social,

and physical harm– harms that can be accidental!


• Opioids can be drugs of abuse—euphoria—and if overused can lead to excess sedation, coma, and death– Fatal overdoses can be accidental or

intentional

• Opioids are controlled substances—therefore there are legal and regulatory issues related to their use


• Chronic pain mgmt is far more complex than acute pain management– Application of the principles of acute pain

management or cancer pain management has created a clinical morass

– This started in the late 1980s

• The field of “Chronic Non-Cancer Pain” has developed to address this– The role of opioids in this domain has generated

intense controversy


• Relevance to college health settings– There are rising concerns about use,

overuse, and abuse of opioid analgesics in all people in the US

– There are special concerns about adolescents and young adults

– “Nonmedical” use of opioids by young adults is one of the most common forms of drug abuse

Drug Overdose and Opioid use in the US:

Statistical Overview

US Deaths in 2008

• Drug overdose: 36,450

• Motor vehicle accidents: 39,973

MMWR 2011;43:1487-1492

Washington State Deaths

• Accidental death from “poisoning” recently surpassed death from motor vehicle accidents as the #1 cause of death of young adults in Washington State

• Of deaths by drug overdose, 55% were due to prescription drugs– Opioids were implicated in 74% of these

US Drug Overdoses—an “Epidemic”

Okie S. NEJM 2010;363(21):1981-1985

US Drug Overdoses by Agent

Okie S. NEJM 2010;363(21):1981-1985

Drug Overdose Death Rates (US, 2008 per 100,000 people)

Intent All drugs Prescription drugs

Opioids Illicit drugs

Overall 11.9 6.5 4.8 2.8

Unintentional 9.2 4.8 3.9 2.6

Undetermined 1.1 0.6 0.5 0.2

Suicide 1.6 1.1 0.5 0.1

MMWR 2011;43:1487-1492

Drug Overdose Death Rates(US, 2008 per 100,000 people)

Gender All drugs Prescription drugs


Overall 11.9 6.5 4.8 2.8

Men 14.8 7.7 5.9 4.3

Women 9.0 5.3 3.7 1.4

MMWR 2011;43:1487-1492

Drug Overdose Death Rates (US, 2008 per 100,000 people)

Age (yrs) All drugs Prescript drugs


Overall 11.9 6.5 4.8 2.8

15-24 8.2 4.5 3.7 2.2

25-34 16.5 8.8 7.1 4.4

35-44 20.9 11.0 8.3 5.3

45-54 25.3 13.8 10.4 6.0

MMWR 2011;43:1487-1492

US Opioid Use—also an “Epidemic”

• 100 million prescriptions for hydrocodone per year– Top drug by # of prescriptions dispensed*

• US has 4% of the world’s population– Uses 99% of world’s supply of hydrocodone– Uses 80% of world’s supply of opioids

• 3% of the US population without cancer (~8 million people) are regular users of opioids**

*http://www.rxlist.com (accessed 1/5/2012)**Sullivan, et al. Pain 2005;119:95-103.

US Opioid Sales

• Sales of opioids– 2010: 7.1 kg per 10,000 people (710 mg

per person per year)• That’s 142 Vicodins per person per year!!

– 2010 sales were 4 fold greater than 1999 sales

MMWR 2011;43:1487-1492

US Opioid Overdose and Sales Rates

Kuehn BM. JAMA 2012(1):19-21

US Opioid Prescribing Patterns

• 3% of physicians accounted for 62% of opioids prescribed

MMWR 2011;43:1487-1492

Association between Drug Overdose Deaths & Sales of Opioids

• Range of annual sales (kg per 10,000 people): – 3.7 kg (IL) – 12.6 kg (FL)

• Among the 27 states with OD rates above national mean– 21 had rates of opioid sales above the national

mean• Among the 24 states with OD rates at or

below national mean– 5 had rates of opioid sales above the national

mean

MMWR 2011;43:1487-1492

Nonmedical Use of Opioids

• Range of prevalence of nonmedical use of opioids:– 3.6% (NEB) – 8.1% (OK)

MMWR 2011;43:1487-1492

Association between Drug Overdose Deaths & Nonmedical Use of Opioids

• Among the 27 states with OD rates above national mean– 21 had rates of nonmedical use above the national

mean

• Among the 24 states with OD rates at or below national mean– 6 had rates of nonmedical use above the national

mean

MMWR 2011;43:1487-1492

2012 National Drug Control Strategy

• Has 7 core areas of focus– Prevention, early intervention, treatment,

disruption of distribution

• Identifies 13 important steps forward– Step #4 is “responding to the prescription drug

abuse epidemic”– The Administration’s Prescription Drug Abuse

Prevention Plan, focusing on education, monitoring, proper disposal, and enforcement

http://www.whitehouse.gov/ondcp/2012-national-drug-control-strategy, accessed May, 2012

Drug Abuse and Overdoses in the US: Summary

• A serious problem, especially among younger adults as a portion of cause of death

• A growing problem• It seems virtually certain that the rising

prevalence of prescribed opioids has contributed to this

Opioid Prescriptions and “Non-medical Use” or Abuse:

Some Data…

Opioid Prescription Trends in Adolescents: 2001 & 2005

• 20-40% of adolescent patients with common pain syndromes received opioid prescriptions

Richardson, et al. Gen Hosp Psych 2011;33:423-428

Drug Abuse Rates

• For adults age 18-25, rate of drug abuse in previous month (excluding alcohol)– All drugs 21.5%– Marijuana 18.5%– Nonmedical use of psychotherapeutic agents

5.9%– Hallucinogens 2.0%– Cocaine 1.5%

National Survey on Drug Use and Health (2010)

Drug Abuse Rates

• Nonmedical use of psychotherapeutic agents– Pain relievers 49%– Tranquilizers 36%– Stimulants 15%


Drug Diversion

• Sources of diverted opioids include– Relative or friend

• 55% “for free”• 11% “bought”• 5% “took without asking”

– Use or sharing of leftover prescribed opioids

– Illicit drug purchases (5%)


Frequency (%) of “Non-prescribed” Use of Prescription Drugs in past 12 Months: College Students

NCHA-II, spring, 2011

Drug Class Male Female All

Antidepressant 2.9 3.3 3.2

ED drugs 1.4 0.8 1.0

Pain killers 8.6 6.8 7.5

Sedatives 4.4 4.1 4.3

Stimulants 8.7 7.2 7.8

1 or more of the above

15.5 14.0 14.6

Risk Factors among College Students for Non-medical Prescription Drug Use

• 2008 survey of 599 undergrads at SE university

• Assessed substance use in previous year• Males, “Greeks”, and freshmen more likely to

use non-medical prescription drugs• Multivariate analysis found that the MOST

influential factors were:– Excessive alcohol use– Other illicit drug use

Lanier, et al. JACH 2011;59(8):721-727

Characteristics of Prescription Drug Use among Adolescents

• Classroom based survey (2008) at mid-Atlantic urban university

• Asked about drug use “since entering high school”

• Paper survey, distributed through one of several introductory classes

Rozenbroek, et al. JACH 2011;59(5):358-363


• No significant gender difference

• Age 20 or more associated had slightly higher rates of use (medical and non-medical)

• Whites more likely to use than Asians or African-Americans




Type of use Opioids CNS depressants

Stimulants

Medical 27.9% 4.4% 5.3%

Non-medical 4.4% 2.9% 7.8%

Both 4.8% 1.7% 1.9%

Non-user 62.9% 91.0% 85.0%

Most Common Reasons for Non-medical Use of Prescription Drugs


Reason Opioids CNS depressants

Stimulants

Makes me feel good

49.1% 37.9% 15.1%

Just to try it 32.0% 24.3% 20.0%

Help me study 3.8% 21.6% 53.8%

Help manage sleep

0% 10.8% 9.2%

Reasons for Prescription Drug Misuse among College Students: “Rx for a Party”

• Survey of 91 current students at a public SW university

• 55% reported at least one episode of “sociorecreational” prescription drug use in the previous year

• Manage highs & drug substitution (for alcohol)• Participate in social use (as distinguished from

independent “drug seeking”)• 42% had no concerns about dangers of what they

were doing

Quintero G. JACH 2010;58(1):64-70

Clinical Approach to Pain

• Acute pain

• Chronic pain

Acute Pain

• One of the most common reasons that people consult a medical provider

• Only a small fraction of people with acute pain go on to develop chronic pain

Chronic Pain--Definitions

• International Association for the Study of Pain– Pain without apparent biologic value that has

persisted beyond the normal tissue healing time (usually assumed to be 3 months)

• American College of Rheumatology– Widespread or regional pain for at least 3 months

Chronic Pain--Definitions

• American Society of Anesthesiologists– Pain not due to neoplastic involvement

extending beyond the expected temporal boundary of tissue injury and normal healing and adversely affecting the function or well-being of the individual

• DSM-4 – Persistent pain for 6 months

Chronic Non-cancer Pain--Overview

• A prevalent condition: data from NHANES:– Back pain 10%– Leg/foot pain 7%– Arm/hand pain 4%– Headache 3%– Complex regional pain 11%– Widespread pain 4%

• Much less prevalent in the college-age population— reliable data difficult to find

Chronic Non-cancer Pain--Overview

• A complex syndrome with historically highly variable clinical approaches

• Most aggressive approaches attempted to directly apply principles of cancer pain treatment– Pain as the “5th vital sign”

• Most now agree that was/is inappropriate

Chronic Pain Management: General Principles

• Establish treatment goals, with measures as objective as possible

• Treat all established diagnoses– Low threshold for mental health referral

• Distinguish between pain treatment and opioid treatment– E.g., pain Rx has many options other than

opioids

Chronic Pain Management, cont’d

• Emphasize function over pain control

• Exercise and other physical modalities prioritized

• Medication management– Non opioid– Opioid


• Medication management—non-opioids– Acetaminophen– NSAIDs– Tricyclic agents


• Medication management—non-opioids and neuropathic pain

• Some syndromes have specific agents that are FDA approved– Postherpetic neuralgia: gabapentin, pregabalin,

capsaicin– Pregabalin—diabetic neuropathy, post herpetic

neuralgia, fibromyalgia• Others have clinical trial data

– Tricyclics and diabetic neuropathy– Carbamazepine or oxcarbazepine and trigeminal

neuralgia


• Non-opioid neuropathic pain agents– Tricyclic agents– Other antidepressants: duloxetine,

venlafaxine– Anticonvulsants: gabapentin, pregabalin,

carbamazepine, oxcarbazepine– Topical lidocaine– Topical capsaicin

Chronic Opioid Management

• Opioid management has its own set of specific needs– Realistic expectations: 30% drop in pain

score is typical—7/10 to 5/10 for example– Monitor for effectiveness– Monitor for complications– Monitor for deviations from expected

treatment process

Chronic Opioid Management, cont’d

• Opioid management has its own set of specific needs– Informed consent– Treatment agreements or “contracts”

• These reduce risk of opioid misuse by 7-23%

– Urine drug testing

Starrels JL, et al. Ann Intern Med 2010;152(11):172


• Overdose risk is highly correlated with prescribed dose– Dunn, et al examined morphine equivalent

doses in an HMO– 1-20 mg per day: 0.2% annual OD rate– 50-99 mg per day: 0.7% annual OD rate– 100+ mg per day: 1.8% annual OD rate

Dunn KM, et al. Ann Intern Med 2010;152(2):85


• Fatal overdose risk is highly correlated with prescribed dose– Bohnert, et al examined morphine equivalent

doses in the VA– Identified 100+ mg per day as having markedly

increased risk compared to 1-20 mg per day– Chronic pain: RR 7.2– Cancer pain: RR 12.0– Acute pain: RR 6.6

Bohnert, et al. JAMA 2011;305(13):1315-1321


• Urine drug testing– Examines for adherence to regimen– Examines for drugs of abuse that might

preclude opioid therapy– Interpretation can be difficult– Overall added value is controversial—but it

is widely recommended

Urine Drug TestingDrug Duration of

DetectabilityFalse Positive Causes

Amphetamines 2-3 days Pseudoephedrine, phenylephrine, bupropion, desipramine, methylphenidate, Adderall & more

Cocaine 2-3 days Topical anesthetics containing cocaine

Marijuana 1-7 days (light)

~1 month (heavy)

Ibuprofen, naproxen, hemp seed oil

Opiates 1-3 days Rifampin, fluoroquinolones, quinine

Phencyclidine 7-14 days Dextromethorphan

Urine Drug Testing--Pearls

• At UW Medicine lab:– “Standard” drug screen is starting point– Oxycodone is not detected by this (it is a

semisynthetic opioid—but hydrocodone and hydromorphone are)

– Methadone and fentanyl (synthetic opioids) are not detected by this

– Amphetamine by gas chromatography is highly specific

Chronic Pain QI Project at Hall Health

• Motivated by evolving care and legal standards in Washington State and delivery system issues in Seattle

• Develop a standardized approach to assessment and follow-up

• Distinguish between pain management and use of chronic opioid therapy to manage pain

• Still a “work in progress” in our health system

Chronic Pain Assessment

• Standard H&P– Mandatory review of prior records

• Standard questionnaire and metrics for clinical status– Pain intensity scale– Anxiety and depression status– Functional status

Chronic Pain Assessment, cont’d

• Mandatory screening for substance abuse, family history of substance abuse, and psychiatric disorders (depression and anxiety most common)– These are most predictive of aberrant drug related

behavior

• Use standard charting tools in the Electronic Health Record (EpicCare “Smart tools”)

Chronic Pain Assessment, cont’d

• Careful assessment of functional status: social, recreational, occupational

• Establish a diagnosis!– Especially neuropathic pain

• Urine toxicology screening if indicated based on current treatment plan

Chronic Pain Management

• Establish treatment goals, with measures as objective as possible

• Treat all established diagnoses– Low threshold for mental health referral

• Distinguish between pain treatment and opioid treatment– E.g., pain Rx has many options other than

opioids


• Emphasize function over pain control

• Exercise and other physical modalities prioritized

• Medication management– Non opioid– Opioid

Opioids Implicated in Drug Overdoses

• “Chronic pain meds”: usually morphine, methadone, or fentanyl

• “Acute pain meds”: most often codeine, hydrocodone, and oxycodone

“Morphine Equivalence” of Opioids

• “Morphine equivalence” calculator available at http://www.agencymeddirectors.wa.gov/Files/DosingCalc.xls

• Each of the below equals 20 mg morphine– 135 mg codeine– 20 mg hydrocodone– 13 mg oxycodone

“Morphine equivalence” calculator

“Morphine equivalence” calculator

• The dose calculator is NOT designed to determine doses for medication transition– Only an approximation– Does not account for incomplete cross-

tolerance and pharmocokinetics– Especially difficult for methadone and

fentanyl


• Criteria for referral to pain specialist– Mainly based on severity of disability– BEFORE “pain behaviors” have coalesced

or maladaptive coping strategies have emerged

– In Washington State—if opioid dose is >120 mg/day “morphine equivalents”

• This is now a law—January, 2012!


• Criteria for referral to substance use treatment– Careful history taking important here– Objective tools:

• Pharmacy dispensing records (from WA state prescription management program)

• Urine toxicology testing

Washington State Regulatory Changes

• Recently passed legislation (HB 2876)– Regulates the use of chronic opioid

therapy – Creates information about best practices

as a way of reducing drug diversion and the potential for overdose

– http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf


• Recently passed legislation– Requires practitioner training program– About 2 hours, on-line option available– Creates prescription management program

to allow prescribers on-line access to pharmacy dispensing records


• Recently passed legislation– Requires pain specialty consultation in

specified circumstances—tied to dose and other factors

• Greater than 120 mg daily morphine equivalent dose

• http://www.doh.wa.gov/hsqa/professions/painmanagement/files/mdpapainmgmt.pdf

Chronic Pain Management: Summary

• Complicated biopsychosocial problem– Not very common at student health centers– But there is a need to understand the “state of the

art”

• Proliferation of opioids has multiple implications

• Regulatory agencies paying more attention• Search for best practices ongoing

– At Hall Health, our practice guideline reduced provider stress & created better practice

Acute Pain Management QI Project at Hall Health

• Addressing chronic pain issues was important to our center and provider group

• Opportunities for improvement in the area of acute pain management were not “on the radar” of providers

Acute Pain Management QI Project at Hall Health

• However, opioid scripts for acute pain outnumbered chronic pain 30:1 (or more)

• Data about accidental OD potential of opioids usually used for acute pain became known

• A parent complained that her son received 28 Vicodins for a self-limited illness

Project Goals

• We sought to optimize the indications for and size of opioid prescriptions

• We expected this to reduce the amount of opioids available through on campus sources

Methods

• We had already conducted a pilot study to assess opioid prescriptions for chronic vs. acute pain

• Based on this review, we identified a small cohort of patients under management for chronic pain– This was typically less than 10 patients at

any time

Methods

• Using our EHR, we identified all patients who received an opioid prescription from October 1, 2010 to December 31, 2010—the “baseline” period

• We excluded patients who were under management for chronic pain

Methods

• We collected patient demographic and prescriber data, as well as data about specific medication(s), amount of pills prescribed, and directions for use

• We focused on codeine, hydrocodone, and oxycodone

Intervention

• 2010:– Educational modules about chronic non-

cancer pain – CME program on same subject– Practice guideline for assessment and

management of chronic non-cancer pain developed and implemented by mid-2010

Intervention

• In late 2010 we designed several interventions for implementation in early January, 2011

• Educational module for acute pain including practice guideline for prescription size

• Prescribing tools revised, with #10 being the default prescription size (previously #28)

• Educational module repeated in April, 2011

Intervention

• We collected follow-up data for 2 time periods:– January 1, 2011 to March 31, 2011– April 1, 2011 to June 30, 2011

Results

Oct-Dec, 2010

Jan-Mar, 2011

Apr-Jun, 2011

# visits 7785 8965 8624

# opioid scripts

260 372 299

% of visits with opioid script

3.34 % 4.15 % 3.47 %

Results

% of total scripts

Oct-Dec, 2010

Jan-Mar, 2011

Apr-Jun, 2011

Codeine 24 16 17

Hydro-codone

65 74 63

Oxycodone 8 9 19

Results

Oct-Dec, 2010

Jan-Mar, 2011

Apr-Jun, 2011

# opioid scripts, all

253 364 295

Mean # pills per script (95% CI)

19.8 (1.0) 15.6 (1.0) 16.2 (1.1)

p<0.001 (Jan vs. Oct)

p=0.94 (Apr vs. Jan)

Results

% of scripts for 10 pills or less

Oct-Dec, 2010 Jan-Mar, 2011 Apr-Jun, 2011

Codeine 44 45 38

Hydrocodone 20 56* 57

Oxycodone 5 28* 46**

All 25 52* 52

* p<0.001

** p<0.05

Limitations

• Data were limited to prescriptions from the student health center– Patients of the center may access other

sources of care

• Limited ability to assess clinical appropriateness of prescriptions

Conclusions

• Using a combination of educational programs and prescribing tools we were able to decrease pills per script of hydrocodone, oxycodone, and all opioids– This did not occur with codeine– This led to 1000-1500 fewer opioid pills being

prescribed per quarter

• There was no evidence of increased return visits for poorly controlled pain

Discussion & Questions

References--1

• Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Eng J Med 2003;349:1943-1953.

• Becker WC, et al. Nonmedical use of opioid analgesics obtained directly from physicians: prevalence and correlates. Arch Int Med 2011;171(11):1034-1036.

• Bohnert ASB, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011;305(13):1315-1321.

• Christo PJ, et al. Urine drug testing in chronic pain. Pain Physician. 2011;14(2):123-143.

• CDC. Overdoses of prescription opioid pain relievers—US, 1999-2008. MMWR 2011;43:1487-1492.

References--2

• Dunn KM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85-92.

• Lanier, et al. What matters most? Assessing the influence of demographic characteristics, college-specific risk factors, and poly-drug use on nonmedical prescription drug use. JACH 2011;59(8):721-727.

• McCabe SE, et al. Medical use, illicit use, and diversion of abusable prescription drugs. JACH 2006;54(5):269-278.

• National Survey on Drug Use and Health, 2010 (available at samhsa.gov)

References--3

• Paulozzi LJ, et al. A national epidemic of unintentional prescription opioid overdose deaths: how physicians can help control it. J Clin Psych 2011;72(5):589-592.

• Quintero G. Rx for a party: A qualitative analysis of recreational pharmaceutical use in a collegiate setting. JACH 2010;58(1):64-70.

• Richardson LP. Trends in the prescription of opioids for adolescents with non-cancer pain. Gen Hosp Psych 2011;33:423-428.

• Rozenbroek, et al. Medical and nonmedical users of prescription drugs among college students. JACH 2011;59(5):358-363.

New patient chronic pain template

• Fred L Zz Frederickson is an 67 year old male who presents for initial evaluation for management of chronic pain. Pt is already on chronic pain medications.

• Brief history of chronic pain syndrome ***• How long have you been on medications for pain? ***• Who has been prescribing your medications? ***• 1. Where do you feel your pain? {PAIN LOCATION:104450}• 2. Which word best describes your pain? {PAIN QUALITY:104449}• 3. On a scale of 0 to 10, which best describes your pain at its WORST

in the last month: {PAIN SCALE:104448::"0 (No Pain)"}• 4. On a scale of 0 to 10, which best describes your pain at its LEAST in

the last month: {PAIN SCALE:104448::"0 (No Pain)"}• 5. On a scale of 0 to 10, which best describes your pain at ON

AVERAGE in the last month: {PAIN SCALE:104448::"0 (No Pain)"}• 6. On a scale of 0 to 10, which best describes your pain RIGHT NOW:

{PAIN SCALE:104448::"0 (No Pain)"}


• 7. Previous use of opioids to control pain? {YES ADDL DEFAULT NO:104995::"Yes, ***"}

• 8. Prior history or current alcohol or illicit substance use? {YES ADDL DEFAULT NO:104995::"Yes, ***"}

• 9. Have you ever been diagnosed or treated for depression? {YES ADDL DEFAULT NO:104995::"Yes, ***"}

• 10. Do you think you are suffering from depression now? {YES ADDL DEFAULT NO:104995::"Yes, ***"}

• 11. What side effects are you having:• a. Nausea: {PAIN SIDE EFFECT SCALE:104452}• b. Constipation: {PAIN SIDE EFFECT SCALE:104452}• c. Trouble Thinking: {PAIN SIDE EFFECT SCALE:104452}• 12. On a scale of 0 to 10, which best describes how, DURING THE PAST

WEEK, the pain has INTERFERED with your:• a. General Activity: {PAIN INTERFERENCE SCALE:104453} • b. Mood: {PAIN INTERFERENCE SCALE:104453} • c. Normal Work: {PAIN INTERFERENCE SCALE:104453} • d. Sleep: {PAIN INTERFERENCE SCALE:104453} • e. Enjoyment of life: {PAIN INTERFERENCE SCALE:104453} • f. Ability to concentrate: {PAIN INTERFERENCE SCALE:104453} • g. Relations with Others: {PAIN INTERFERENCE SCALE:104453}


• 13. Goals of therapy:• What does your pain keep you from doing that you most want to do? ***• If it is not possible to get you back to 100% what percent improvement

would make a significant difference in your quality of life? ***• Objective:• {GENERAL APPEARANCE:50::"healthy","alert","no distress"}• {AFFECT:103406}• {Go to "forms" to fill out PHQ 9 if appropriate}• ASSESSMENT:• Candidate for ongoing management of chronic pain {YES NO

(HH):104741::"YES"}• Patient agrees to provide a copy of medical records {YES NO

(HH):104741::"YES"}• Pain Contract reviewed and signed by patient; copy provided to patient:

{YES NO (HH):104741::"YES"}• Consent for chronic opioid treatment signed and copy given to the patient

{Use "special consent for medical care" U2224}: {YES NO (HH):104741::"YES"}

• {Urine tox screen recommended at the first visit. Document when last dose of medication was taken. See "clinical pearls" about ordering urine tox screen}

Return patient chronic pain template• SUBJECTIVE:• Patient reports taking medications as prescribed {YES NO (HH):104741::"YES"}• The next 3 questions have to do with pain intensity; 1 is no pain and 10 is unbearable pain)• 1. Average pain level this week: {NUMBERS 0-10:102198}• 2. Worst pain level this week: {NUMBERS 0-10:102198}• 3. Today's pain level: {NUMBERS 0-10:102198}• 4. On a scale of 0 to 10, which best describes how, DURING THE PAST WEEK, the pain has

INTERFERED with your:• a. General Activity: {PAIN INTERFERENCE SCALE:104453} • b. Mood: {PAIN INTERFERENCE SCALE:104453} • c. Normal Work: {PAIN INTERFERENCE SCALE:104453} • d. Enjoyment of life: {PAIN INTERFERENCE SCALE:104453} • 5. Are you experiencing any other symptoms or have you had any illnesses since your last visit?

***

• {Update social history. Type .soch to bring in brief social history}• {type .phq9 to bring in phQ9 depression survey}

• Objective:• Appears well, in no apparent distress. Vital signs: There were no vitals taken for this visit..• {AFFECT:103406}

• ASSESSMENT:• Candidate for ongoing treatment of chronic pain medications: {YES NO (HH):104741::"YES"}• {Consider ordering random urine tox screen}

Pain management agreement• The purpose of this Agreement is to prevent misunderstandings about certain medicines you will

be taking for pain management. This is to help both you and your doctor comply with the laws regarding controlled medications.

• I understand that if I break this Agreement, my doctor will stop prescribing these pain-control medicines.

• I will not share, sell, or trade my medication with anyone. This is against the law.

• I agree that I will submit to random urine drug testing.

• I understand the reason for this random urine drug testing.

• I agree that I will use my medicine only as it is prescribed.

• I understand that I will not receive early refills on my narcotic pain medications

• I will not attempt to obtain any controlled medicines, including but not limited to opioid pain medicines, controlled stimulants, or antianxiety medications from any other doctor.

• I will not use any illegal substances, including but not limited to marijuana, cocaine, amphetamine, and heroin.

• I will safeguard my pain medicine from loss or theft.

• I understand lost or stolen medicines will not be replaced.

• I agree that refills of my prescriptions for pain medicine will be made only at the time of an office visit or during regular office hours.

opioid analgesic use, overuse, and abuse among patients at university health centers acha meeting...

Documents

minutes slide

definitions drug abuse

contrast opioid use

opioid analgesic use

nonmedical use slide

uw slide

complete pain control

acute pain management