prescribing pain medications a scientific approach?
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Prescribing Pain Medications A Scientific Approach?. Christopher Dietrich MD. Scope of the Problem. 42% of Emergency Room Visits – Pain Problems Estimated 44 million pain related visits made to US emergency departments annually 30%-40% of adults experience back pain . - PowerPoint PPT PresentationTRANSCRIPT
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Prescribing Pain MedicationsA Scientific Approach?
Christopher Dietrich MD
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Scope of the Problem
• 42% of Emergency Room Visits – Pain Problems• Estimated 44 million pain related visits made to US
emergency departments annually
• 30%-40% of adults experience back pain
Pletcher MJ, Kertesz SG, Kohn MA, Gonzales R. Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA. 2008;299:70-78.
Verhaak PFM, Kerssens JJ, Decker J, et al. Prevalence of chronic benign pain disorder among adults: A review of the literature. Pain 1998; 77:231-239.
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Self-medication
Persistent Pain Treatment Ladder
Scheduled OpioidsScheduled Opioids
Surgical & OtherSurgical & OtherInterventionsInterventions
Mild
Mild
Mod
erat
eM
oder
ate
Seve
reSe
vere
HCP intervention
HCP intervention
HCP intervention
AcetaminophenAcetaminophenNonNon--Prescription NSAIDsPrescription NSAIDs
COXCOX--2 Inhibitors2 InhibitorsPrescription NSAIDsPrescription NSAIDs
TramadolTramadol
HCP = Healthcare Professional
Traditional Treatments
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Normal Pain Pathway
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Approach to Patient with Pain• Detailed Patient History
– Location, quality, timing, severity, exacerbating, palliative factors
– Mechanism of injury– Acute vs chronic
• “6 months”• Physical Examination
– Motor– Detailed Neurological exam– Provocative tests
• Imaging Studies• EMG
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Identify Type of Pain
• Acute vs Chronic– “6 months”
• Nociceptive • Somatic• Visceral• Neuropathic
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Nociceptive Pain
• Direct stimulation of pain receptors/nociceptors
• Typically involves direct tissue injury
• Sharp, aching, throbbing• Worse with movement
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Somatic Pain
• Nociceptive Pain• Bone, Soft tissue, muscle, skin• Aching, throbbing• Easy to locate/describe
• A-delta fiber stimulation
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Most Responsive Treatments
• Acetaminophen• Cold Packs• Local Anesthetic
– Topical– Infiltrated
• Corticosteroids• NSAIDS• Opioids
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Visceral Pain• Nociceptive pain that
involves cardiac, lung, gastrointestinal, or genitourinary tissues
• Difficult to localize pain• Difficult to describe
– “Dull”– “Deep”
• C-delta fibers
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Most Responsive Treatments
• Corticosteroids• NSAIDs• Opioids
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Opioids Action
• • presynaptic inhibition of production of neurotransmitters• postsynaptic suppression of evoked activity in nociceptive path• increased transmission of the descending inhibition of spinal nociceptive conduction
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Neuropathic Pain
• Compression, transection, ischemia, or metabolic injury to a nerve
• Burning, tingling, shooting, stabbing, electrical
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Most Responsive Treatments
• Anticonvulsants– Gabapentin, Pregabalin
• Corticosteroids• Nerve Block• NSAIDs• Opioids• Tricyclic Antidepressants
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Tramadol
Surgical & OtherInterventions
Scheduled Narcotics
Use before scheduled narcotics in adults who require around-the-clock treatment for an extended period of time
Mild
Mod
erat
e
Seve
re
AcetaminophenNon-Prescription NSAIDs
ULTRAM ER
Prescription NSAIDsCOX-2 Inhibitors
Modified Pain Treatment Ladder
Topical Agents
Physical therapy, Modalities
Neuropathic Pain Agents
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Central Sensitization
• Nervous system changes
• Nociceptive neurons in the dorsal horn of spinal cord
• “Wind-up”, pain threshold changes
• Maintains pain after initial insult has resolved
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Central Sensitization
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Approach to Patient with Pain
• Identify type of pain– Nociceptive, Neuropathic– Acute vs Chronic– Peripheral vs Central Sensitization
• Identify pain generator• Review aggravating/ameliorating factors • Develop initial treatment plan• Review/modify treatment if necessary
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How to Identify/Prevent Problems
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Prescription Drug Abuse Statistics
• 6.2 Million Americans who are current non-medical users of Psycho-therapeutic Drugs
• Greater than the number of those abusing cocaine, hallucinogens, and heroin combined
• Non-medical use of prescription drugs ranks 2nd only to marijuana
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Prescription Drug Abuse Statistics
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Prescription Drug Abuse Statistics
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Prescription Drug Abuse Statistics
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Prescription Drug Abuse Statistics
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Abuse Statistics
• Pain Med 2008 May-Jun;9(4):444-59.• What percentage of chronic nonmalignant pain patients exposed to chronic
opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review.
• Fishbain DA, Cole B, Lewis J, Rosomoff HL, Rosomoff RS.
– 3.27% rate of addiction/abuse (all study patients)– 0.19% - rate of addiction – when eliminate all prev
abuse pts– 11.5% Adverse Drug Related Behaviors – 0.59% ADRB when eliminate all prev abuse pts
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Risks/problems associated with prescribing controlled substances
• Concern about patients– Fear of addiction– Fear of Drug Abuse– Concerns about
diversion– Concern about safety
of medications– Identifying “doctor
shoppers”– Tolerance– Dose Escalation
• Regulatory concern– Concern about DEA
scrutiny– Rules vs myths
• Prescribing Logistics– Monthly prescription
refills– Drug Testing– Opiate Agreements
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How to Decrease Risk when Prescribing Controlled Substances
• Documentation – 4As• Written Opiate treatment Agreements – “not contracts”• Drug screens
– ICD-9 = V58.69 Chronic Med Use• Adequately treat pain & identify patients at risk for
abuse/diversion– SOAPP-R (Screener and Opioid Assessment for Patients
with Pain – Revised)– Determine how often to monitor, who to monitor
• Patient Database/registry – Prescription Drug Monitoring Program(PDMP)
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Documentation
• 4 A’s – Criteria looked at by DEA/Reviewers– Analgesia – documented pain score– Activity/Function – ADLs, functional outcomes– Adverse events – side effects, complications– Aberrant Behavior – drug seeking, abnormal drug screens,
should have explanations, plan, course of action
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Narcotic Agreement• Agreement to Treat with Narcotics
– Not a contract– Contract implies service or product for $$– Include terminology that allows:
• Prescriber to communicate with pharmacy, primary care MD, ER• Prescriber to obtain drug screens when clinically indicated• Patient only uses one pharmacy• Agrees to take medications exactly as prescribed
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Drug Screens• Drug screens
– Codes/What to order:• RCRH Lab – UDS panel – confirm positive opiates• ClinLab – 764819• Sanford Lab – drugs of abuse panel with expanded
opiate panel – 38081N- 9907– ICD-9 = V58.69 Chronic Med Use
• Drug Screen/Test Specifics– Look at Creatinine level (way to determine if valid
test)– Make sure test includes synthetic opiates
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• When to use/screen– Initial assumption of care– Scheduled basis
• Determined by clinician• Determined by SOAP-R• Random system
– SOAPP-R (Screener and Opioid Assessment for Patients with Pain – Revised)
Drug Screens
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SOAPP-R
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SOAPP-R Scoring
• High Risk = 22 or greater• Moderate Risk = 10 – 21• Low Risk = < 9
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Prescription Drug Monitoring Program(PDMP)
• Program designed to deter prescription drug abuse• Keeps track of all dispenser/prescriber records• Reports can be requested to aide prescribers,
dispensers, and law enforcement• “Allow clinicians to adequately treat legitimate pain
patients and identify and curb inappropriate non-medical use of controlled substances, stop doctor shoppers, and decrease prescription drug diversion”
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