#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?