medications for pain: what you need to know for treatment in workers’ compensation suzanne novak,...
TRANSCRIPT
Medications for Pain:What You Need to Know for Treatment in
Workers’ Compensation
Suzanne Novak, MD, PhD
5/17/07
Outline
Opioids in general Adderall Actiq NSAIDS Benzodiazepines Barbiturates Soma Anti-depressants Prialt
Opioids: How did they get so popular?
These drugs were noted to treat both acute pain and cancer pain effectively
This was extended to treatment of chronic pain
Addiction was thought to arise only rarely during legitimate treatment of pain
Tolerance could be overcome by dose escalation
Opioids: What we learned
50% of patients abandon treatment in trials because they don’t work or they have side effects
Patients become refractory to treatment These drugs have significant neuroendocrine
effects Behavioral problems, and often, frank
addiction interfere with treatment
Opioids: Failed Treatment
Is there evidence of failed treatment?- Opioid hyperalgesia- Frank tolerance
What did we do in the past?
- Increase the dose until tolerance is overcome
Opioids: How to avoid failed treatmentStart to address the use of opioids early in treatment
Rule Out Risk Factors for Possible Misuse Cage Questionnaire Screener and Opioid Assessment for
Patients with PainHistory of substance abuse
Legal problems Heavy Smoking
Cravings Mood Swings
Opioids: How to avoid failed treatmentStart to address the use of opioids early in treatment
Consider a Psychological Evaluation
Diagnoses that have a poor outcome with opioid therapy:
Conversion disorder Somatization disorder Pain disorders associated with depression
and/or anxiety
Additional Steps Before a Trial
Set treatment goals Document baseline pain and functional
assessments Function assessments (social, physical,
psychological, daily and work activities) Could the claimant be weaned? Treatment agreement
Once started: What to look for
Prescriptions from a single practitioner and single pharmacy
Ongoing review:
Current pain Least/most pain
Average pain How long before relief
How long it lasts
Once started: What to look for
The 4 A’s for Ongoing Monitoring Pain Relief Side Effects Physical and Psychosocial Function Occurrence of Aberrant/non-adherent
Behavior
Opioids: Side Effects
Constipation Nausea Dizziness Somnolence or Drowsiness Vomiting Dry Skin Itching/Pruritis
Opioids: When to continue and when to discontinue
Continue: Don’t stop if it’s working Improved pain and function Return to work
Discontinue No overall improvement in function Continuing pain with intolerable adverse
effects
Opioids: When to continue and when to discontinue
Illegal activities: diversion; forgery; arrest related to drugs
Suicide attempts Threatening behavior in the office
Repeated slips from the drug agreement:
Suggest a consult with a physician trained in addiction
Treatment of Opioid-Related Sedation:Most Common Initially and With Dose Increases
Eliminate unnecessary medications Rest Exercise Timing Opioid rotation Reducing the dose
Psychostimulants for Management of Sedation: Adderall
Not recommended
Data supporting the use of this treatment is lacking in clinical trials.
Actiq
Ongoing review: Current pain, Least/most pain, Average pain, How long before relief, How long it lasts
Not recommended for musculoskeletal pain
Recommended for breakthrough cancer pain
NSAIDs
There is no current evidence for long-term effectiveness for pain or function
There is a risk of gastrointestinal and cardiovascular side effects
GI/no CV: Non-selective +PPI or Cox-2 CV: Naproxyn if required
Benzodiazapenes
Not recommended for long-term use
(No more than 4 weeks)
Tolerance develops rapidly
Barbituates
Not recommended
The potential for drug dependence is high
No evidence of clinically important analgesic effect
Soma
Metabolized to meprobamate: anxiolytic Main effect may be due to sedation Withdrawal symptoms may occur with abrupt
withdrawal Soma-Coma: Street-drug name when used
with opioids
Anti-depressants
First-line treatment for neuropathic pain Possible for non-neuropathic pain Analgesia occurs within a few days
Tricyclic anti-depressants
SNRIs: Effexor (venlafaxine) and Cymbalta (duloxetine)
Wellbutrin (bupropion)
Prialt
Not recommended until all other intrathecal medication options have been exhausted
Advantage: Considered non-addictiveDisadvantage: Possible side effects including
severe psychiatric symptoms and neurological impairment
Use with caution in patients with history of depression and psychosis
Questions