prescribing pain medications a scientific approach? christopher dietrich md
Post on 19-Jan-2016
214 Views
Preview:
TRANSCRIPT
Prescribing Pain MedicationsA 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
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.
32
Self-medication
Persistent Pain Treatment Ladder
Scheduled OpioidsScheduled Opioids
Surgical & OtherSurgical & OtherInterventionsInterventions
Mild
Mild
Moder
ate
Moder
ate
Sev
ere
Sev
ere
HCP intervention
HCP intervention
HCP intervention
AcetaminophenAcetaminophenNonNon--Prescription NSAIDsPrescription NSAIDs
COXCOX--2 Inhibitors2 InhibitorsPrescription NSAIDsPrescription NSAIDs
TramadolTramadol
HCP = Healthcare Professional
Traditional Treatments
Normal Pain Pathway
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
Identify Type of Pain
• Acute vs Chronic– “6 months”
• Nociceptive • Somatic• Visceral• Neuropathic
Nociceptive Pain
• Direct stimulation of pain receptors/nociceptors
• Typically involves direct tissue injury
• Sharp, aching, throbbing• Worse with movement
Somatic Pain
• Nociceptive Pain• Bone, Soft tissue, muscle, skin• Aching, throbbing• Easy to locate/describe
• A-delta fiber stimulation
Most Responsive Treatments
• Acetaminophen• Cold Packs• Local Anesthetic
– Topical– Infiltrated
• Corticosteroids• NSAIDS• Opioids
Visceral Pain
• Nociceptive pain that involves cardiac, lung, gastrointestinal, or genitourinary tissues
• Difficult to localize pain• Difficult to describe
– “Dull”– “Deep”
• C-delta fibers
Most Responsive Treatments
• Corticosteroids• NSAIDs• Opioids
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
Neuropathic Pain
• Compression, transection, ischemia, or metabolic injury to a nerve
• Burning, tingling, shooting, stabbing, electrical
Most Responsive Treatments
• Anticonvulsants– Gabapentin, Pregabalin
• Corticosteroids• Nerve Block• NSAIDs• Opioids• Tricyclic Antidepressants
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
era
te S
evere
AcetaminophenNon-Prescription NSAIDs
ULTRAM ER
Prescription NSAIDsCOX-2 Inhibitors
Modified Pain Treatment Ladder
Topical Agents
Physical therapy, Modalities
Neuropathic Pain Agents
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
Central Sensitization
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
How to Identify/Prevent Problems
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
Prescription Drug Abuse Statistics
Prescription Drug Abuse Statistics
Prescription Drug Abuse Statistics
Prescription Drug Abuse Statistics
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
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
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)
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
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
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
• 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
SOAPP-R
SOAPP-R Scoring
• High Risk = 22 or greater• Moderate Risk = 10 – 21• Low Risk = < 9
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”
top related