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+/- Opioid Management
Kristen Zeller, M.D.Interventional Pain
Management Specialist
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• Pain – “Unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”
*1994 International Association for the Study of Pain
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Basic Neuroanatomy of Pain
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Biochemical mediators of the Dorsal Horn
• Excitatory Neuromediators
-Excitatory amino acids-glutamate and aspartate
-Neuropeptides-substance P (SP) and calcitonin
gene-related peptide (CGRP)
-Growth Factor-brain-derived neurotrophic factor
(BDNF)
• Inhibitory Neuromediators
-Endogenous opiods, such as enkephalin and
B-endorphin
-Gamma-aminobutyric acid (GABA)
-Glycine
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Yin/Yang
1. Excitation occurs in an injury
2. A patient needs counter balance or pain can be out of control
3. Patients have natural inhibition
4. Opioids particularly in an acute injury function as inhibition in the pain pathway
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Target Sites for Pain Therapies
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Individual Pain Experience
Nociception Perception of Pain
Suffering Pain Behavior
Fear
Secondary Gain
Cancer
Depression
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Nociception
Perception of Pain
SufferingPain Behavior
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Nociception
Perception of Pain
Suffering Pain Behavior
Fear
Secondary Gain
Depression
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High Pathology
ACUTE PAIN
CHRONIC PAIN
Low Pathology
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OPIOID MANAGEMENT
PAIN
OPIOIDS
DIAGNOSIS
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OPIOID MANAGEMENT
DIAGNOSIS ?
SOMATIC (Acute post-op,
Fractured bone, Cancer
metastasis to the bone, etc)
NEUROPATHIC (RSD, Neuroma, Peripheral Neuropathy, Radiculopathy, etc.
VISCERAL (Distention of hollow viscous, SBO, etc.
Very Helpful ? Utility ?Utility
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OPIOID MANAGEMENT
• AGE ? - Is tolerance going to be an issue
• Pathology ? - Chronic benign pain with low pathology
• Chemical Dependency ? – Denial - Urine Screen
• Functional ability ? – Coach Potatoes
• Long Term Goals ? – Briefly use opioids to facilitate rehabilitation and then taper off
• Personality Disorders/Psychiatric issues/Psychosocial issues ?
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OPIOID MANAGEMENT
• Difficult medications to manage - Utility
• Physical Dependence
• Hyperalgesia state with withdrawal
• Potential for a paradoxical effect with chronic use
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Education• 1. If rapid tolerance develops unlikely to be
a long-term solution to the patients pain state.
• 2. If the patient has an injury that needs time to heal if they take opioids they may not get the proper feedback on biophysical pain mechanisms.
• 3. Opioids are typically not a solution to a pain state, so to use opioids ONLY without other treatments will likely lead to tolerance and increasing doses……..poor pain control
• 4. Long-term use seems to loose its efficacy and the side effects of opioid remain. (cognitive delay, constipation)
• 5. I do not want to see you suffer and I will treat your pain, but I want you to understand the risks and limitations of these medications.
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Rehabilitation
Middle Road of Activity
Over Activity
Under Activity
PAIN
PAIN
TIME
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Urine Drug Screen
• Needs to be random
• Test temperature of urine
• Most Urine Drug screens were developed for illicit use of drugs
• More challenges and more variables when testing for compliance of narcotic use
• (hydration, dosing, metabolism, body mass, urine pH, duration of use, drug’s pharmacokinetics)
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Urine drug screen
• Opiates• Codiene• Hydrocodone• Hydromorphone• Morphine
• Semi-synthetic opiates• Oxycodone• Oxymorphone
• Synthetic-methadone, Fentanyl, Tramadol• Benzodiazapines-Alprzolam, Nordiazepam• Illicit Drug-Methamphetamine, Cocaine metabolites, THCA/marijuana,
Heroin metabolite
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Urine Drug Screen
• Immunoassay
• Susceptible to false positives
• Gas Chromatography-Mass Spectrometry (GC/MS)
• When a positive result is on Immunoassay then need to go to GC/MS. GC/MS is an confirmation assay that is highly reliable and specific test with rare interferences.