A Standardized Approach for theChronic Pain PatientTraci Dieckmann, DO, PGY 3

University of Kansas School of Medicine – WichitaFamily Medicine Residency Program at Wesley

April 10th , 2015

Objectives• Four serial chronic pain visits

– Stepwise standardized approach

• Monitoring and follow up• Pros and cons• Tips for adapting to your practice

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Visit Overview

Visit 1• Informationgathering

• Screen forpatientappropriateness

Visit 2• Physical exam• “PainInventory”

Visit 3• Recap• Treatmentplan

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Case

• L.M., 61 year old white female• Medical History:

– Chronic pain• Fibromyalgia• Diffuse neuropathy

– Asthma– Depression– Osteoarthritis

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A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO

Family Medicine Spring Symposium April 10, 2015

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Chronic Pain Visit 1 of 3

• Information Gathering and Goal Setting– Review plan of care and expectations– Thorough review of patient’s history– History of abuse, legal problems and substanceuse

– Review of previous testing, imaging, work up, etc.– Collection of outside records

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Chronic Pain Visit 1 of 3 cont’d• Screening

– PHQ 9 (Depression Screen)– Opioid Risk Tool– CAGE/CAGE AID (Adapted to Include Drugs)– Mania Self Reporting Tool

• Patient Appropriateness– DIRE (Diagnosis, Intractability, Risk, Efficacy Score)– SOAPP (Screener and Opioid Assessment forPatients with Pain)

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Case• Long history of fibromyalgia• Diffuse neuropathy/weakness

– Work up negative for: MS, autoimmune, B12deficiency, and thyroid disease

• MRI brain, C and L spine, EMG/NCT and LP – nondiagnostic

• Previous Prescriptions:PregabalinGabapentinTramadolOxycodone

CitalopramLidocaine patchMorphine

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Case

• Screening– PHQ 9: 17/37 (mod severe depression)

• On Citalopram– Opioid Risk Tool: 5/14 (Moderate)– CAGE/CAGE AID: Negative– Mania Self Reporting: Negative– DIRE score 18/21 (may be a candidate for longterm opioid analgesia)

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A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO

Family Medicine Spring Symposium April 10, 2015

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Chronic Pain Visit 1 of 3, cont’d

• Patient Education– Comparative Pain Scale– Set expectations

• Frequency monthly to bi annually• Rx only for 28 day supply until established• Random UDS

• Brief Pain Inventory– Used to follow patient throughout care plan

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Chronic Pain Visit 2 of 3

• Physical exam• Review of information gathered since CPV #1• Kansas Tracking and Reporting of ControlledSubstances(KTRACS)

• Urine Drug Screen (UDS)• Brief Pain Inventory

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Case

• Exam noted foot drop– Patient referred for bracing

• UDS obtained– Positive for oxycodone and tramadol

• Agreeable with current treatment regimen

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Behavioral Group Visit• Led by psychologist• Group visit• Mind body education• Emphasis placed on relationship betweenpain and well being

• Lifestyle considerations

http://www.peanuts.com/characters/lucy/

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A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO

Family Medicine Spring Symposium April 10, 2015

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Chronic Pain Visit 3 of 3

• KTRACS and UDS as indicated• Brief Pain Inventory• Physical Functional Ability Questionnaire(FAQ5)– Score followed throughout care plan

• Evaluate need for/efficacy of current painregimen

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Case

• Reviewed KTRACs – no aberrant behavior• Current pain meds:

– Tramadol and Oxycodone• Prescribed prn but taking regularly

– Pregabalin

• Transitioned to long term Fentanyl patch– Low dose oxycodone for breakthrough

• Switched to Fluoxetine for depression

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Follow up

• Use screening tools to guide follow up• Prescriptions kept in lock box• Random UDS

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Pros and Cons

• Patient fairness andequality

• Ensure safety forphysicians and patients

• Monitor compliance• Avoid abuse

• Time consuming• Uncomfortable for

established patients• Limited resources

(psychology)• Plan for patients that

are not appropriate

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A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO

Family Medicine Spring Symposium April 10, 2015

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Practice Tips

• Divide appointment time– Half with RN, half with doctor

• Contact community resources• More time for new patients• Establish cut off for appropriate patients

– DIRE– Morphine Equivalent Doses– SOAPP

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References• Blackman K., Odom A., Identifying and Initiating Treatment for

Bipolar Disorder in the Family Medicine Office. STFMPreconference Workshop. 2010.

• Hooten WM, et al. Assessment and Management of ChronicPain. Institute for Clinical Systems Improvement. UpdatedNovember 2013.

• Kroenke, K, et al. The PHQ 9: validity of a brief depressionseverity measure. J Gen Intern Med. 2001 Sept. 16(9): 606 13.

• Moeller, K. et al. Urine Drug Screening: Practical Guide forClinicians.Mayo Clinic Proceedings; Jan 2008; 83 (1): 66 76

• PainEDU.org• Scanlan, T. Drug Testing: Overview. Clinical Topic.• Scanlan, T. Drug Testing: Interpreting Results. Clinical Topic.• Webster, LR and Webster, RM, Pain Med: 2005; 6:432 442

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A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO

Family Medicine Spring Symposium April 10, 2015

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