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Non-‐Acute Pain Medical Treatment Guidelines: 2014

MODULE 1 – Introduction

Slide 1-‐1:

Hello, my name is Doctor Elain Sobol Berger. I am the Medical Director and Senior Policy Advisor at the

New York State Workers’ Compensation Board. Our topic today will be the Non-‐Acute Pain Medical

Treatment Guidelines 2014.

Slide 1-‐2:

This activity has been planned and implemented in accordance with the accreditation requirements and

policies of the Medical Society of the State of New York, through the joint providership of MSSNY and

the New York State Workers’ Compensation Board. MSSNY is accredited by the Accreditation Council for

Continuing Medical Education to provide continuing medical education for physicians. The Medical

Society of the State of New York designates this live activity for a maximum of 3.0 AMA PRA category-‐1

credits.™ Physicians should claim only the credit commensurate with the extent of their participation in

the activity.

Slide 1-‐3:

Policies and standards of the Medical Society of the State of New York and the Accreditation Council for

Continuing Medical Education require the speakers and planners for continuing medical education

activities to disclose any relevant financial relationships they may have with commercial interests whose

products, devices or services may be discussed in the content of a CME activity. The planners and faculty

participants do not have any financial arrangements or affiliations with any commercial entities whose

products, research, or services may be discussed in these materials.

Slide 1-‐4:

Our course objectives today are: (1) to understand the Non-‐Acute Pain Medical Treatment Guideline key

concepts, definitions, and criteria for diagnosing non-‐acute pain in injured workers; (2) to learn and

apply the Non-‐Acute Pain Medical Treatment Guideline standards to appropriately care for injured

workers with non-‐acute pain; (3) to learn and apply the continuum of non-‐pharmacological and non-‐

opioid treatment options that should be used prior to considering opioids; (4) to apply a systematic

approach to initiating, transitioning, and managing patients on long-‐term opioids; and, finally and most

importantly, to collaborate with the injured worker to develop a self-‐management program to address

non-‐acute pain.

Slide 1-‐5:

Studies support that growing concerns regarding the use and misuse of opioids are shared by workers’

compensation. More frequent and longer-‐term use of opioids may lead to addiction, increased disability

or work loss, and even death. Doctor Gary Franklin in the State of Washington was the first to raise a red

flag about the use of opioids and the increased death rate. In response to the need for effective

strategies to manage non-‐acute pain in injured workers, and the nationwide epidemic of opioid misuse

and abuse, the New York State Workers’ Compensation Board and its Medical Advisory Committee

developed a comprehensive, evidence-‐based, Non-‐acute Pain Medical Treatment Guideline to address

the complex needs of injured workers with chronic or non-‐acute pain.

Slide 1-‐6:

The term “non-‐acute” was deliberately chosen instead of “chronic” to focus on pain that persists beyond

anticipated recovery, and to avoid the negative implications that are normally associated with the term

“chronic pain.”

Slide 1-‐7:

This guideline provides an overview of a comprehensive approach to identify non-‐acute pain early,

assess and treat delayed recovery, and select non-‐pharmacological and pharmacological treatment

approaches guided by measurable functional outcomes. Opioids should be a later-‐stage choice in the

treatment plan.

Slide 1-‐8:

The Non-‐Acute Pain Medical Treatment Guideline identifies strategies for the appropriate use of opioids when they are indicated. Nuckols et al.*, in a recent article published in the Annals of Internal Medicine, reviewed available guidelines on the use of opioids for chronic pain that were published between January 2007 and July 2013. The authors of the study concluded that the guidelines reviewed made similar recommendations about strategies to decrease opioid misuse and overdose. Although there was a clinical consensus on these recommendations, the authors recommended further research to directly examine the effectiveness of these strategies. * Nuckols TK, et al. Opioid Prescribing: A Systematic Review and Critical Appraisal of Guidelines for Chronic Pain. Ann Inter Med. 2014; 160: 38-‐47)

‐9:

The guidelines agree on strategies such as upper-‐dosing thresholds for opioids, cautious dose titration,

cautions with certain drug/drug and drug/disease interactions, risk assessment tools, treatment

agreements, and urine drug testing.

Slide 1-‐10:

The New York Non-‐Acute Pain Medical Treatment Guideline addresses the strategies and

recommendations contained in that study and more. It contains a comprehensive continuum of

treatment options and approaches that address the evaluation and management of chronic pain, and

provides recommendations to avoid the use of opioids, ensure appropriate use of opioids when

indicated, and mitigate the risk of misuse, abuse, overdose, and death.

Slide 1-‐11:

Before proceeding with the actual Medical Treatment Guideline recommendations, I’d like to give you

an overview of the contents. The guidelines contain eight basic sections. In addition to the eight basic

sections, there is an appendix with required and recommended forms and questionnaires, as well as

reference tables and an extensive bibliography at the end.

Slide 1-‐12:

The Medical Treatment Guideline begins with a General Guideline Principles section, which is the same

in every existing Medical Treatment Guideline, followed by definitions, the introduction to the key

concepts of non-‐acute pain, followed by evaluation and diagnostic procedures (basically the type of

history and physical examination including the psychological history and exam), then non-‐

pharmacological approaches, pharmacological approaches including Non-‐Opioids and Opioids, Spinal

Cord Stimulators and Intrathecal Drug Delivery, or Pain Pumps, and finally, functional maintenance care.

Slide 1-‐13:

I just want to briefly address the General Principles. As I mentioned, they are contained in every one of

the Treatment Guidelines. The Non-‐Acute Pain Medical Treatment Guideline incorporates the 22

important General Principles that form a foundation for evaluation and management of patients with

non-‐acute pain, as well as patients who have work-‐related injuries. The General Principles are necessary

to appropriately apply and interpret the guideline recommendations and identify treatment goals

leading towards the ultimate goal of restoring functional ability.

Slide 1-‐14:

There are several General Principles that I’d like to briefly review before moving on to the rest of the

training. The key principle is that medical care should be focused on restoring functional ability required

to meet a patient’s daily and work activities, and return to work. If a given treatment or modality is not

producing a positive result, and by a positive result we mean objective functional improvement, the

physician should modify or discontinue the treatment regime or reconsider the diagnosis. In addition,

the physician needs to reevaluate the efficacy of treatment two to three weeks after the initial visit, and

three to four weeks thereafter. Finally, no treatment plan is complete without addressing patient

education as a means of facilitating self-‐management of symptoms and prevention of future injury. It’s

not unusual for us to see cases where repeat injuries occur and there is no attempt made by the

physician or provider to adjust or educate the patient on interventions that could prevent re-‐injury.

Slide 1-‐15:

The last General Principle we’ll talk about is the Principle that relates to pre-‐authorization. As with the

existing Medical Treatment Guidelines, according to the General Principle A.13, pre-‐authorization is not

required, with very limited exceptions, as we will discuss below. For diagnostic imaging, testing, non-‐

surgical and surgical therapeutic procedures – these procedures can proceed, if the criteria of the

Guidelines are met, and are based on a correct application of the Guidelines.

Slide 1-‐16:

Pre-‐authorization is required for the following specific procedures. I won’t read through all of them, but

I do want to point out that intrathecal drug delivery, or pain pumps, is newly added to the pre-‐

authorization list. It is new to the Non-‐Acute Pain Medical Treatment Guidelines, and was not in any of

the prior Guidelines. The list of pre-‐authorized procedures continues on the next slide.

Slide 1-‐17: List of Pre-‐Authorized Procedures. There is no sound on this slide.

‐18:

Next we’ll go into the definitions and the criteria for non-‐acute pain. Pain is traditionally defined by the

International Association for the Study of Pain as “an unpleasant sensory and emotional experience

usually associated with actual or potential tissue damage or described in terms of such damage.”

Slide 1-‐19:

In our Guideline, we differentiate between acute versus non-‐acute pain as follows: acute pain is usually

linked to a specific precipitating event; maybe a trauma or surgery. It is often physiologically helpful and

can protect against potentially dangerous tissue damage. Pain follows a continuum from acute to non-‐

acute, and as pain continues, bio/psycho/social factors play an increasing role.

Slide 1-‐20:

In our Guideline, non-‐acute pain is defined as a bio/psycho/social process which is recognized when

the patient reports enduring pain that persists beyond the anticipated time of recovery, and results in

concurrent functional limitations.

Slide 1-‐21:

The key differentiation that the Medical Advisory Committee members wanted to ensure was that there

not be specific timeframes that limited the Non-‐Acute Pain Guideline; that the guiding factor would be

that when a patient was not progressing as anticipated, and delayed recovery appeared to be an issue

that should be addressed, rather than waiting for a three or six-‐month timeframe. Enduring pain is pain

that is extended beyond the expected duration of healing and recovery, based on history, exam, special

studies (if indicated, not required), and treatment. It has not responded to previous appropriate

treatment recommendations, whether according to the Medical Treatment Guidelines, or, if related to a

non-‐medical treatment guideline covered body part or injury, according to standard medical practice for

the particular injury or condition. Enduring pain persists after reconsideration of initial diagnosis and

consideration of alternative diagnoses.

Slide 1-‐22:

Concurrent functional limitations mean pain that is accompanied by objectively documented functional

impairment, in spite of healing of the underlying pathology, and by this, we mean there’s a significant

documented change from pre-‐injury functional baseline. Function is a key concept that exists

throughout the guidelines – throughout all of the Medical Treatment Guidelines – and particularly for

the Non-‐Acute Pain Medical Treatment Guideline.

Slide 1-‐23:

There are two paradigm shifts that are significant and should be understood. The first is a shift from the

biomedical to the bio/psycho/social model. And what does this mean? In the biomedical model, disease,

or the patho-‐physiology, fully explains a patient’s symptoms. So basically, if the medical problem is

cured, then the pain will be eliminated. On the other hand, the bio/psycho/social model recognizes that

pain and disability are a complex interplay of many factors, including biological, psychological, and social

factors that must be addressed rather than simply the presumed underlying pathophysiology.

Slide 1-‐24:

The second important paradigm shift is a corollary to the first. And that is, a shift from a medical to a

self-‐management model. In the medical model, the responsibility rests primarily with the provider to

cure the pain. The self-‐management model recognizes that pain must be managed, not necessarily and,

often, not cured. Unlike the medical model, the self-‐management approach places primary

responsibility with the patient. The patient and the provider (the physician) must collaborate in patient

education and self-‐management of pain. These are very important paradigm shifts.

Slide 1-‐25:

There are a few key concepts that I will briefly address in this session that will be further discussed in the

non-‐pharmacological approaches to the management of non-‐acute pain. Four basic approaches: delayed

recovery, early identification of delayed recovery, psychological assessment and intervention, and non-‐

acute pain management programs, to include the interdisciplinary or functional restoration programs.

Slide 1-‐26:

Let’s begin with a brief look at delayed recovery. Delayed recovery occurs when a patient fails to make

expected progress after an injury. The transition from acute to non-‐acute is a very critical time for an

injured worker. Time away from work results in adverse medical, family, economic, and psychological

consequences, which exacerbate the pain complaints. For patients who fail to make expected progress 6

to 12 weeks after an injury, the diagnosis and treatment plan should be reconsidered, and psychosocial

factors identified and addressed. This is a recurrent theme throughout the Non-‐Acute Pain Guideline:

the need to re-‐assess to make sure that the diagnosis is accurate and that psychosocial factors that may

play a role in recovery have been identified, and ultimately treated.

Slide 1-‐27:

Patients at risk for delayed recovery should be identified as early as possible. Some factors that will help

identify patients at risk include: those patients who are unresponsive to conservative therapies,

demonstrated to normally be effective for a specific diagnosis. Those with significant psychosocial

factors that are negatively impacting recovery. Those who have prolonged absence from work, or have

lost employment, are particularly at high risk to experience delayed recovery. And finally, patients

whose employers do not accommodate patient needs.

Slide 1-‐28:

The last definition or brief explanation will be on functional restoration, and keeping in mind that most

often, pain is self-‐limited, and many injured workers require little, if any treatment. Others can be

managed with straightforward interventions that do not require complex interventions. However,

patients who have complex or refractory problems may benefit from a well-‐integrated functional

restoration program. And, bottom line: independent self-‐management is the long-‐term goal of all forms

of functional restoration.


MODULE 2 – Evaluation and Diagnostic Procedures

Slide 2-‐1:

Hello, my name is Doctor Linda Cocchiarella. I’m the Assistant Medical Director of the New York

State Workers’ Compensation Board. And today we will be discussing the evaluation and

diagnosis of individuals with non-‐acute pain.

Slide 2-‐2:

The evaluation and diagnosis of individuals with non-‐acute pain requires a detailed history and

physical examination.

Slide 2-‐3:

The history and the physical examination are essential to establish the foundation for the medical

diagnosis, and they serve as the basis to determine diagnostic and therapeutic procedures.

Slide 2-‐4:

The history of individuals with non-‐acute pain needs to document the following areas: a detailed

pain history, as well as their present illness, their medical history in relation to their non-‐acute pain, a

physical exam, which may need to be targeted to the areas of concern, and particular attention to red

flags, which may result in changes in management or diagnosis.

Slide 2-‐5:

A thorough pain history is essential to characterize the patient’s pain and their response to pain.

And with other areas in medicine, these constitute key elements in order to determine an

appropriate treatment plan.

Slide 2-‐6:

Key elements in the pain history are the site of pain, for example, where is the pain localized,

and how is it distributed? Is it central, or is it peripheral? A pain diagram is often very useful to

document the distribution of pain, and may give clues to the diagnosis and management. What is the

onset of pain? For example, was there an accident, a stressful incident, or was it spontaneous? And the

duration of the pain.

Slide 2-‐7:

Other critical factors to identify in the pain history and present illness include the characteristics

of pain. For example, is the pain burning, shooting, stabbing, or aching? Again, this can help

identify the cause and dictate therapy. What are the anatomical correlates of the pain? Are they

consistent with the actual pain complaints? And it’s important to document the degree of pain. For

example, this can be seen by using pain assessment tools, such as the visual analog scale, or pain

diagrams. The reader may find the appendix very helpful in assessing some pain tools.

Slide 2-‐8:

Listed here is an example of a pain assessment tool known as the Visual Analog Scale. This tool, as well

as others in the appendix, are very helpful to document current pain, as well as to guide future pain

management.

Slide 2-‐9:

The pain history also needs to include details on associated symptoms with pain. For example,

is there weakness, bowel or bladder dysfunction, allodynia, hyperesthesia? Associated symptoms can

give clues to other diagnoses. Are there sleep disturbances, which may impair progress? Is there the

avoidance of activities because of fear? Appendix A lists a fear avoidance questionnaire, which can help

the practitioner identify how important fear avoidance is in limiting function.

Slide 2-‐10:

The pain history also needs to identify how pain impacts activities, including activities of daily

living, as well as work activities. It’s important for the practitioner to actually list the activities

which can aggravate pain, ameliorate it, or may have no effect on the level of pain. And it’s also

important to discuss the range of pain throughout the day. In identifying activities of daily living,

which are impacted by pain.

‐11:

The pain history should also include a detailed discussion of prior treatment, preferably in chronologic

order. For example, what diagnostic tests have been performed, and are they consistent with the

current presentation? Review the medical records and identify what treatments the individual believes

has helped him or her in the past. And also, what has been the impact of surgery on their pain and

current function?

Slide 2-‐12:

Include in your history a detail of their medication use, including over-‐the-‐counter, herbal, and

dietary supplements. These are especially important to note, because many over-‐the-‐counter

preparations include acetaminophen and may have interactions with prescribed medications. Determine

what their history has been regarding drug use, compliance, and abuse. Also identify whether they have

experienced side effects, or have documented drug allergies, as these can guide further treatment. And

it’s also important to identify what has been their adherence to prescribed medications in the past, and

do they comply with appropriate dosing schedules?

Slide 2-‐13:

Assess the patient’s psychological functioning. For example, determine if they are depressed, anxious, or

if there is any evidence of significant workplace or home stressors. Also, it’s important to establish if

there is a past history of psychological problems. Explore any confounding psychosocial issues, which

can impact treatment and progress.

Slide 2-‐14:

Since patients have different expectations regarding treatment, this is an area which is important to

explore. Does the patient expect to increase their abilities at their current job, or be able to return to

work at their pre-‐injury job? It’s been noted that a major predictor in the patient’s ability to return to

work, and also in their functional ability, are their expectations regarding return to work.

Slide 2-‐15:

The level of education as well as language barriers may influence a patient’s ability to understand the

clinician’s instructions, information, and participation in treatment decisions, especially when

interpreters are used. Be cautious and ensure that the patient’s level of understanding regarding their

condition and treatment is appropriate. The past medical history should also identify details regarding

their work history and occupation. Are they currently employed? Identify their current job activities, and

the mechanical or physical requirements of their job. How long have they been employed, are they

satisfied with their job, and especially, what’s been the impact of their injury on their ability to perform

specific job duties, as well as activities of daily living? Have they had prior work accidents and injuries

which may impact their ability to return to work?

Slide 2-‐16:

In their past medical history, identify their marital status and their family environment. Do they

have adequate social support? Explore their cultural or belief system, which may also impact

their medical care. And review their other medical conditions to identify the interplay between

those conditions and their pain complaints.

Slide 2-‐17:

Their psychosocial history is important to explore any history of either substance abuse,

physical, emotional, or sexual abuse, as a history of abuse is strongly correlated with delayed

recovery. Identify medications which the patient took which may not have been prescribed by

the treating provider, and also identify their alcohol and tobacco use, quantify the number of drinks per

week, packs per year, and include any

use of nicotine substitutes.

Slide 2-‐18:

Their physical exam should include accepted and appropriate exam techniques and tests applicable to

the areas being examined. Record their vital signs. And also, use accepted pain assessment tools, such as

the Visual Analog Scale or Numerical Rating Scale, which are listed in Appendix B. These tools are

especially helpful to document the change in their pain status over time, and can help to guide or

identify the success of treatment.

Slide 2-‐19:

Their physical examination should include a general inspection and incorporate aspects regarding

observations of their gait (for example, is it antalgic?), their posture and their stance. A general physical

exam is conducted as indicated, with a more focused exam performed based on clinical circumstances.

‐20:

The neurologic exam is important to include the appropriate detail to substantiate their diagnosis and

guide future treatment, and often requires detail regarding cranial nerves, muscle tone and strength,

atrophy, a detailed sensory, as well as detailed motor exam, and appropriate provocative neurologic

maneuvers. When doing provocative maneuvers, such as the Lasegue Test, it is important to also include

the degrees at which a test, for instance the straight leg raising test, is positive.

Slide 2-‐21:

The physical examination includes a sensory evaluation, which often includes routine quantitative

sensory testing, such as the Semmes-‐Weinstein Monofilament Test, which may be useful to identify any

sensory abnormalities. Note that electrodiagnostic tests are separate procedures, and not part of the

clinical evaluation. The practitioner should follow the specific sections of the relevant Medical

Treatment Guidelines before ordering these tests.

Slide 2-‐22:

The physical examination musculoskeletal section typically includes details regarding range of

motion, segmental mobility, provocative maneuvers, and observations on the individual’s

functional activities. The myofascial exam is important, when relevant, to include responses for

palpating soft tissues, such as whether there is evidence of spasm or trigger points.

Slide 2-‐23:

The physical exam may also include an assessment of Waddell Signs in the following categories:

tenderness, pain with stimulation, regional findings, traction, or inconsistency in straight-‐leg raising, or

overreaction to physical examination maneuvers.

Slide 2-‐24:

The Waddell Signs are not used to predict or diagnose malingering. They are significant to identify

inconsistencies between the formal exam and observed abilities of range of motion, motor strength,

gait, and cognitive emotional state.

‐25:

When conducting the physical examination, pay particular attention to red flags. These red flags can

raise suspicion of potentially serious conditions. For example, include evaluation of red flags such as

fractures, dislocation, infection, tumor, or progressive neurologic deficits. If red flags are present,

further evaluation or consultation and possibly urgent or emergent care may be indicated.

Slide 2-‐26:

Psychosocial clinical evaluation is indicated in select cases. When the physician recognizes that the

problem is persisting beyond the anticipated time for tissue healing, the physician’s diagnosis and

treatment plan should be reconsidered and psychosocial risk factors should be identified and addressed.

The interpretation of a psychosocial clinical evaluation will provide the clinicians with a better

understanding of the patient in terms of his or her social environment, and enable a more effective

rehabilitation.

Slide 2-‐27:

The psychosocial clinical evaluation should be performed by a psychiatrist or a psychologist. It includes

details on the patient’s history, especially noteworthy when given in the patient’s own words; their

nature of injury; the psychosocial circumstances; the treatment results; the history of response to

prescription medication; and their compliance with treatment.

Slide 2-‐28:

The psychosocial clinical evaluation is important. Include information on the patient’s coping strategies.

For example, do they perceive a loss of control? How have they perceived the medical system and their

employer?

Slide 2-‐29:

Other elements of the psychosocial clinical evaluation are listed here. Again, emphasizing aspects such

as their history of alcohol or substance abuse, their current ability to perform activities of daily living,

and any prior injuries, including disability, impairment or compensation.

‐30:

The psychosocial clinical evaluation includes details regarding their childhood, and whether there was

any history of abuse or neglect; their education history; their family history, including disability in the

family; their marital history and other significant adulthood activities; and their current and past

interpersonal relationships, support, and living situation.

Slide 2-‐31:

The psychosocial evaluation commonly includes details regarding their legal history, employment,

military duty, financial history, and identifies any signs of pre-‐injury psychological dysfunction, which

may impact treatment and progress.

Slide 2-‐32:

The psychosocial clinical evaluation includes a detailed mental status exam, an assessment of whether

the patient poses any danger to self or others; identifies current psychiatric diagnosis or pre-‐existing

psychiatric conditions; and makes treatment recommendations with specific goals identifying the

frequency of treatment, the timeframe, and the expected outcomes.

Slide 2-‐33:

Tests of psychological evaluation may be useful in assessing mental conditions, pain disorders,

as well as cognitive functioning. Psychometric testing is a valuable component of the psychosocial

clinical evaluation and assists the physician in making a more effective treatment plan, vocational plan,

and in evaluating the effectiveness of their treatment.

Slide 2-‐34:

In conclusion, history taking and physical examination establish the foundation for medical

diagnosis, and serve as the basis for and dictate subsequent stages of diagnostic and

therapeutic procedures. The medical record should document the pain history and present

illness, including pain assessment tools, past medical history, physical examination,

psychosocial evaluation, and intervention when indicated, and identification of red flags.


MODULE 3 – Non-‐Pharmacological Approaches

Slide 3-‐1:

My name is Doctor Jaime Szeinuk, I am the Co-‐Medical Director of the Workers’ Compensation Board,

and I’m going to cover the topic of non-‐pharmacological approaches within the Non-‐Acute Pain Medical

Treatment Guidelines. Non-‐pharmacological approaches are an integral part of the continuum of care

for non-‐acute pain. This section of non-‐pharmacological approaches to the treatment of non-‐acute pain

starts with a detailed consideration of delayed recovery.

Slide 3-‐2:

Delayed recovery has been defined in the General Principles section, and we’re going to cover in a little

more detail what this section talks about, covering the topic of delayed recovery. This section of the

Non-‐Acute Pain Guidelines further elaborates on delayed recovery, describing factors which impact

functional recovery and recommending a course of action, as stated and detailed in this slide. For

further references on factors that impact delayed recovery, viewers are directed to look at the actual

text of the guidelines.

Slide 3-‐3:

The Non-‐Acute Pain Guidelines strongly state that referrals to mental health professionals should

be regarded as an integral part of the assessment of delayed recovery. These referrals can identify

variables which, if appropriately addressed, may positively impact the patient’s recovery process. And

the guidelines strongly state that these referrals to mental health providers, for example psychologist or

psychiatrist referrals, for the evaluation and management of delayed recovery, do not require the

establishment of a psychiatric or psychological claim. They are considered an integral part of the

treatment of non-‐acute pain, and they should not be seen as a separate medical diagnosis.

Slide 3-‐4:

The Non-‐Acute Pain Guidelines address the issue of psychological evaluations and interventions as an

integral component of the non-‐pharmacological treatment modalities. This slide describes the

indications of psychological evaluation, stating that for patients who fail to make expected progress

after an injury, a formal psychological or psychosocial evaluation should be considered. And again, this

ties into the whole concept of the bio/psycho/social model that we have been describing as the core

consideration in the treatment of non-‐acute pain under these Medical Treatment Guidelines.

Slide 3-‐5:

This slide defines the recommended frequency for psychological evaluations.

Slide 3-‐6:

This slide describes psychosocial interventions. Psychosocial treatment should be implemented

as soon as the need is identified. The guidelines contain several modalities recommended for

psychological intervention, such as psychotherapeutic treatment, cognitive-‐behavioral therapy,

and biofeedback. And we’ll elaborate a little on those in the coming slides.

Slide 3-‐7:

This slide illustrates the frequency and duration recommended for psychological and psychiatric

interventions. The guidelines allow a maximum duration of three to six months for psychological

interventions. However, for selected patients, for whom further counseling is indicated, this is allowed

under the guidelines, as long as the treating provider documents the nature of the psychological factors,

projects a realistic functional prognosis, and keeps referring to functional gains as part of the

documentation included in the psychological interventions.

Slide 3-‐8:

Cognitive-‐behavioral therapy is one of the recommended modalities for psychological

intervention. The guides clarify that cognitive-‐behavioral therapy can be done in groups, or

individually, or as part of an interdisciplinary pain program. This slide also lists the frequency

recommended for cognitive-‐behavioral therapy.

Slide 3-‐9:

Biofeedback is another recommended psychological intervention for the treatment of non-‐acute

pain. The ultimate goal of biofeedback in this context is to transfer the learned skills to the workplace

and the daily life of the patient. And again, this ties into the concept of self-‐management, a central

theme for the Non-‐Acute Pain Treatment Guidelines.

‐10:

Biofeedback is not recommended for the treatment of acute pain or acute injury. This slide

illustrates the recommended frequency of biofeedback in the treatment course of non-‐acute pain

management. The guidelines recommend a maximum duration of 10 to 12 sessions for biofeedback,

with an optimum duration of five to six sessions. However, treatment beyond 12 sessions is allowed as

long as there is documentation with respect to the need, expectations, and ability to facilitate positive

functional gains. And again, just to remark, the documentation of positive functional gains is central and

is key to all the Medical Treatment Guidelines and the Non-‐Acute Pain Guideline is not an exception.

Slide 3-‐11:

This slide describes the interdisciplinary functional restoration programs. The key factors of

these programs are that they focus on restoration and function, and are made or composed of a

team of professionals who keep constant integration and communication on the progress of the

patient. And these two elements really define what these interdisciplinary or functional

restoration programs are. The core team of the program is usually composed by a physician, a

nurse, a psychologist, a physical and/or an occupational therapist, and may include additional

professionals as indicated. But, the oversight of the team is always provided by a physician.

Slide 3-‐12:

This slide illustrates the core components of the interdisciplinary functional restoration program.

As stated, these programs emphasize functional improvement over the elimination of pain by

using different modalities and formulating an after-‐discharge plan of care for self-‐management

of the non-‐acute pain condition. And again, just to reiterate, this ties into the entire model that

we are proposing for management of non-‐acute pain, where functional gains are the number

one objective of the treatment, and a self-‐management program is really what covers the entire

purpose of the treatment of this condition.

Slide 3-‐13:

This slide describes multidisciplinary programs, and these programs are different from the

interdisciplinary programs. They include limited communication among the members of the team, and

often focus on interventional pain management rather than non-‐interventional pain management, as in

the other program.

‐14:

This slide describes the goal of pain management programs. I’m going to read a couple of them

that I think are very important to consider when planning or instituting pain management

programs. It is important that these programs plan to maximize function while minimizing pain.

They have to provide measurable improvement in physical and functional capabilities, and just

to reiterate, incorporating these goals is key to the documentation in the Medical Treatment

Guidelines. They are centered on return to work as much as possible. They should assist the patient in

assuming independent self-‐management responsibilities, again, going back to the core theme of the

Medical Treatment Guidelines for Non-‐Acute Pain. They are focused on maintaining the functional gains

upon discharge, and they should aim to decrease medication utilization as much as possible.

Slide 3-‐15:

Finally, this section covers other non-‐pharmacological treatment options, such as injection therapies,

physical medicine modalities, and other modalities. For these modalities, treating professionals are

referred to recommendations in the existing Medical Treatment Guidelines, as relevant to the injured

site, or the standard of care for those injuries that are not covered under the Medical Treatment

Guidelines.

Slide 3-‐16:

This module has covered the following key concepts for the non-‐pharmacological approaches to the

management of non-‐acute pain: delayed recovery, early identification of delayed recovery,

psychological assessment and intervention, and non-‐acute pain management programs, including

interdisciplinary or functional restoration programs.


MODULE 4 – Non-‐Opioid Medications and Medical Management

Slide 4-‐1:

My name is Doctor Jaime Szeinuk. I am the Co-‐Medical Director of the Workers’ Compensation Board,

and we’re going to talk about non-‐opioid medications and medical management under the Non-‐Acute

Pain Medical Treatment Guidelines.

Slide 4-‐2:

The Guidelines recognize that there is no simple formula for pharmacological treatment of patients with

non-‐acute, non-‐malignant pain. This section starts with General Principles, some of which are world-‐

recognized principles in the everyday practice of medicine, and set the standard, and the goals of non-‐

opioid medication management for non-‐acute pain. As stated before, a thorough medical medication

history, including the use of alternative and over-‐the-‐counter medications, should be performed at the

time of the initial visit and updated periodically. Many over-‐the-‐counter medications contain

acetaminophen, which has to be taken into account when calculating the daily dose of this medication

that can be potentially damaging to the liver. The appropriate use of pharmacological agents depends

on the patient’s age, past history, drug allergies, and the nature of medical problems, and this is a

general principle in medicine that is adopted by the guidelines.

Slide 4-‐3:

This slide describes the goals of medication management in the context of non-‐acute pain management.

It relates to the overall theme of the Medical Treatment Guidelines, as stated in the slide. The goal of

the treatment is to improve function, which is, again, the cornerstone of the Medical Treatment

Guidelines. And it focuses on the development of self-‐management skills, which is the end goal of the

bio/psycho/social model of the treatment of non-‐acute pain. The control of non-‐acute pain is expected

to involve the use of medication. However, patients should understand that medications alone will not

provide complete pain relief, and that in addition to medications, and even more important than

medication, participation in self-‐management plans including active therapies, home therapies, and self-‐

directed management therapies, is very important and essential for a successful management of non-‐

acute pain.

‐4:

The next slides describe pharmacological principles that are important in considering the use of

medications for non-‐acute pain. And again, many of these are part of general medical practice. Side

effects and interaction should be considered and taken into account when prescribing medications. All

medications should be given an appropriate trial, in order to test for therapeutic effect. And it is

recommended that patients with non-‐acute pain be maintained on drugs that have the least serious side

effects.

Slide 4-‐5:

Many of the drugs that are discussed in the medication section were licensed for indications other than

analgesia. However, there is evidence to support that these medications are effective in the treatment

of pain, and as such, they have been included as recommended in these Medical Treatment Guidelines.

Finally, there is no evidence-‐based support for the increased efficacy of brand name versus generic

name medication.

Slide 4-‐6:

We wanted to finalize the review of the pharmacological principles with a very important principle that

was adopted in the Medical Treatment Guideline, and is stated in this slide. Topical, oral, and/or

systemic compounded medications are not recommended under any indication in the Medical

Treatment Guidelines for Non-‐Acute Pain.

Slide 4-‐7:

The review of the medications that is included in the Non-‐Acute Pain Medical Treatment Guidelines is

just an overview and highlights some aspects that we thought are important in the management of non-‐

acute pain, and in the general consideration of prescription medication. This review is not intended to

substitute for standard medical texts or medical searches in prescribing medications, and physicians are

directed to consult a pharmacy or text for standards of medical practice for prescribing medications.

Slide 4-‐8:

This slide highlights one of the updates that was included in the Non-‐Acute Pain Medical Treatment

Guidelines on the use of acetaminophen. The guidelines state that in general, the total daily dose of

acetaminophen should not exceed three grams per day, from all sources. This is in agreement with FDA

recommendations.

Slide 4-‐9:

The guidelines consider and recommend the use of anticonvulsants for the management of pain.

Anticonvulsants, however, are not considered first-‐line medications in the treatment of non-‐acute pain.

They are not recommended for axial spine pain, unless there is evidence of related neuropathic

component.

Slide 4-‐10:

The guidelines list several anticonvulsants as recommended for the treatment of non-‐acute

pain, and highlights two of the most frequently used medications, Gabapentin and Pregabalin.

Gabapentin may be considered for the treatment of severe neurogenic claudication from spinal

stenosis, or chronic radicular pain. Pregabalin may be considered in the treatment of patients

with neuropathic pain as a second-‐line agent, after a trial of tricyclics.

Slide 4-‐11:

The use of antidepressants is recommended in the guidelines for the treatment of non-‐acute

pain. The guidelines recognize that pain responses to antidepressants may occur at lower doses and

with shorter response times than that recommended for the treatment of depression. It’s important

that all patients being considered for antidepressant therapy should be evaluated and continually

assessed for suicidal ideation and mood swings with the use of these medications.

Slide 4-‐12:

This slide lists some of the antidepressants considered in the Medical Treatment Guidelines for

Non-‐Acute Pain. The tricyclics are recommended for radicular pain. The selective serotonin reuptake

inhibitors are not recommended for neuropathic pain. They can be used for treatment of depression,

but they are not recommended as medications for treatment of pain. On the other hand, the selective

serotonin norepinephrine reuptake inhibitors and the serotonin norepinephrine reuptake inhibitors are

not recommended as first or second line treatment, but are reserved for patients who fail other

regimens due to side effects.

‐13:

The use of hypnotics and sedatives is generally not recommended for the treatment of non-‐acute

pain. The Guidelines recognize that these medications should be used with extreme caution when the

patient is on chronic opioids, and that most insomnia in non-‐acute pain can be managed primarily

through behavioral interventions, leaving medications only for secondary measures.

Slide 4-‐14:

The Guidelines have an extensive review on the use of non-‐steroidal anti-‐inflammatory drugs and this

slide highlights some of the updates to this section. The chronic use of non-‐steroidals is generally not

recommended for non-‐acute pain. However, the guidelines recognize that some patients may need

chronic use of a non-‐steroidal, and recommend that these be used cautiously in selected cases with

regular monitoring. As is customary medical knowledge, the guidelines recognize that these medications

may increase the risk for serious cardiovascular thrombotic events, myocardial infarction, and stroke,

which can be fatal. Finally, Cox-‐2 inhibitors should not be the first-‐line medication for low-‐risk patients

who will be using non-‐steroidals short-‐term. But the guidelines recognize that they are indicated in

selected patients for whom traditional non-‐steroidals are not tolerated.

Slide 4-‐15:

The Non-‐Acute Pain Guidelines recognize that skeletal muscle relaxants are most useful for acute

musculoskeletal injury, or exacerbation of injury, and are not recommended for chronic use in non-‐

acute pain.

Slide 4-‐16:

The Non-‐Acute Pain Guidelines include an updated and thorough revision on the use of topical drug

delivery, including capsaicin, lidocaine, topical non-‐steroidals and topical salicylate and non-‐salicylate

preparations. There are all acceptable forms to be used in the treatment of selected patients. The

guidelines recommend that these medications be prescribed with strict instructions for application and

a maximum number of applications per day. Physicians should consider that topical medications can

result in toxic blood levels.

‐17:

Finally, in this section we have included some opioid-‐related medications that, in the guideline, are part

of the opioid section. We have included them for purposes of presentation in the review of this section.

We’re going to review the use of tramadol, methadone, buprenorphine and tapentadol, medications

that are included in the Guideline.

Slide 4-‐18:

Tramadol should not be considered as a first-‐line medication. This medication has physically

addictive properties, and withdrawal may follow abrupt discontinuation. Tramadol is not

recommended in those with prior opioid addiction.

Slide 4-‐19:

The Guidelines extensively review the topic of methadone in the treatment of non-‐acute pain.

Methadone is a medication that has long and unpredictable half-‐life, which can result in

associated increased risk for accumulating toxic levels. The guidelines strongly state that, with

repetitive dosing, methadone is approximately ten times more potent than indicated in standard

opioid conversion tables, and call the prescriber’s attention to this important principle when

prescribing this medication. Prescribers must be aware of the safety precautions and have

adequate training and experience when prescribing methadone for non-‐acute pain.

Slide 4-‐20:

Again, prescribers must be knowledgeable that doses and dosing schedules used for analgesic purposes

are different from those used for addiction management. The use of methadone as an analgesic

requires the same assessment skills as those required for opioid drug management, and even greater

scrutiny in patient monitoring and side effects. Methadone should not be prescribed for opioid-‐naïve

patients.

Slide 4-‐21:

The Non-‐Acute Pain Guidelines include accommodations for the use of buprenorphine as one of

their armamentarium in the management of non-‐acute pain. Just a reminder, in order to prescribe

buprenorphine, a physician needs to take an 8-‐hour online course that is offered, and get a special DEA

number. This slide has links to those sites where you can get information on the 8-‐hour course to

prescribe this medication. The guidelines state that only the transdermal patch presentation is approved

for the treatment of pain and is recommended as a treatment. Oral buprenorphine is not recommended

as a treatment for non-‐acute pain.

Slide 4-‐22:

Finally, the Guidelines include a revision of tapentadol, stating that tapentadol should not be considered

as a first-‐line medication, and very importantly, there is no equianalgesic dose conversion guidance for

tapentadol, or tapentadol extended release to oral morphine. In conclusion, we have presented a review

of the medications that are recommended for the treatment for non-‐acute pain. Thank you.


MODULE 5 – Pharmacological Approaches: Opioids

Slide 5-‐1:

Hello, my name is Doctor Elain Sobol Berger. I am the Medical Director and Senior Policy Advisor at the

New York State Workers’ Compensation Board. I will be presenting the next section of the Non-‐Acute

Pain Medical Treatment Guidelines: pharmacological approaches, in particular, opioids.

Slide 5-‐2:

The Non-‐Acute Pain Medical Treatment Guideline addresses two basic patient groups for whom long-‐

term treatment with opioids is being considered: the opioid-‐naïve patient, and patients who are

currently on opioid medications. The Guidelines provide a common pathway for both patient groups:

the safe and effective use of opioids when indicated.

Slide 5-‐3:

There are times that we find a statement that catches our attention because it says very simply what

lots of words don’t always say. And Dr. Gouden had the following sentence: “Opioids are like any other

medication. We are going to start it, we are going to give it a trial, we’ll escalate the dose – we call it a

titration phase – but if you don’t improve significantly from both an analgesic and functional standpoint,

this is not a medicine you’re going to stay on.” In these few words, Dr. Gouden has basically summarized

the recommendations that are contained within this Non-‐Acute Pain Medical Treatment Guideline, so

let’s move on to look at this in more detail.

Slide 5-‐4:

Let’s begin with this opioid-‐naïve patient. When considering the use of long-‐term opioids, the physician

must ensure that other pain management approaches or regimes, including physical, behavioral and

non-‐opioid measures, have failed, and that a successful opioid trial during which the patient

demonstrates sustained improvement in function and pain has been completed.

‐5:

The goals of a successful therapeutic trial include: improved function, including return to work and/or an

increase in activities of daily living; at minimum, a 30% reduction in pain, as measured by validated pain

scales; no significant adverse side effects; and no aberrant drug-‐related behaviors.

Slide 5-‐6:

What happens when goals are not met? In this situation, if goals are not met in a trial of a maximum of

30-‐60 days, the trial should be discontinued, opioids tapered or discontinued, and an alternative

approach taken. The caveat here is that if it becomes obvious early in the trial period that the patient is

not responding to opioids, the trial period does not have to be a minimum of 30 days or a maximum of

60. The trial can be discontinued earlier and does not require a full trial period.

Slide 5-‐7:

Prior to considering a therapeutic opioid trial, a physician should complete a physical and psychological

assessment. Screen for potential comorbidities and risk factors, including risk for substance abuse,

misuse and addiction, so that anticipated risk can be monitored accordingly. The opioid risk tool, the

ORT, is a validated clinical instrument that is required to be used to evaluate and assess risk.

Slide 5-‐8:

Prior to the trial, the patient should be stratified low, medium, or high-‐risk based on the ORT. High-‐risk

patients are those who have active substance abuse of any type, and/or a history of abuse of opioid

medications. The strongest predictive factor for misuse is a personal or family history of substance

abuse.

Slide 5-‐9:

The ORT basically has two purposes. One, to assess and stratify risk, but as we will discuss later on, it will

also provide a basis for the frequency of urine drug testing.

Slide 5-‐10:

The trial criteria for opioid-‐naïve patients are not different than what will be presented further on when

we discuss other types of situations. It’s a recurring theme. And the theme is that when we are

considering opioids, pain management alternatives, including active therapies, cognitive-‐behavioral

therapies, pain management techniques, have failed. It is important to have a baseline for function and

pain because this is what will be used to determine whether or not a patient is responding to the opioids

in the course of a therapeutic trial.

Slide 5-‐11:

Psychological issues that may drive or complicate a clinical presentation have been treated. Critical: the

opioid benefits outweigh the harm. And, finally, the physician or the clinician has to commit to continue

to monitor the effects of treatment, including a plan to discontinue opioid therapy, if necessary.

Slide 5-‐12:

Long-‐term opioids, whether we’re talking about initiating opioids in an opioid-‐naïve patient or whether

we are talking about continuing opioids, should only be initiated or continued based on an explicit

decision and agreement between the patient and the physician using the following required forms. The

first form is the Patient Informed Consent Form, which basically explains the risks and benefits of

opioids, and must be signed by the patient and physician. And the physician has to acknowledge he or

she has attempted to answer all questions. This is no different than any consent form that’s provided

before giving treatments, whether in surgery or certain types of interventions. It’s an explanation of the

risks involved. The second form is the Patient Understanding for Opioid Treatment. In some situations,

it’s called the Patient Agreement or the Patient Contract. In this situation, the Medical Advisory

Committee wanted to make this a non-‐legal sounding type of a document and therefore called it a

Patient Understanding for Opioid Treatment. It outlines provider’s and patient’s responsibility in opioid

therapy. For example, it requires that prescriptions be obtained from a single practitioner. It requires

that the patient not go to the emergency room on a frequent basis to obtain opioid medications. It lays

out the shared duties and responsibilities between the patient and the physician. And again, it must be

signed by both the patient and physician.

Slide 5-‐13:

I’ve given you an excerpt of the Patient Informed Consent Form. And basically it says that the patient

understands that he or she will be getting a medication called opioids.

‐14:

It lays out what the potential side effects are. The confusion, the nausea, the vomiting, and goes down

to the potential for addiction and even death.

Slide 5-‐15:

This slide shows us a sample of the Patient Understanding For Opioid Treatment Form.

Slide 5-‐16:

And on the next two slides – there are some sample questions and comments that the patient and the

provider agree to, including examples such as “I will take my medication exactly the way the doctor tells

me to.” The patient also agrees to have lab work done, and not specifically urine drug testing, but lab

work which includes urine drug testing. In addition, the patient understands the situation – the

circumstances – under which doctor may stop giving pain medication.

Slide 5-‐17:

In this slide, the doctor outlines a situation where medication may be discontinued. This includes if a

patient is not following the agreement, if the medication is not helping a patient, and goes on to list

other reasons: bad side effects, or if it becomes obvious that the patient is not using the medication and

is providing them to someone else.

Slide 5-‐18:

Physicians who prescribe opioid therapy must comply with I-‐STOP regulations and other relevant

legislation. In addition, the physician must complete the education recommended by the FDA, namely

the risk evaluation and mitigation strategies generally known as REMS in order to assure that the

medications are prescribed appropriately. This is not just for opioid-‐naïve patients; this same principle

applies to any patient on long-‐term opioids being transitioned or continued on long-‐term opioid

therapy.

Slide 5-‐19:

A treatment plan and goals must be established including an initial and subsequent regular monitoring

schedule. These next couple things may sound obvious but we need to reiterate: start with a low dose,

increase gradually, and monitor for effectiveness until optimal dose is attained. There is no evidence

that any particular opioid is superior to any other, so it’s a matter of making a determination and

following the general recommendations for whatever drug is used. Follow-‐up every 7 to 10 days is

advised initially to titrate and assess clinical efficacy.

Slide 5-‐20:

It’s important to continue all appropriate adjuvant therapies that help relieve pain, and help the patient

cope with pain condition. Critical: during dose titration, the patient needs to be advised and monitored

to avoid safety-‐sensitive occupational and non-‐occupational activities until a dose is stable, and it is

certain that the opioids do not cause sedation. And probably the most important point, and one that we

will reiterate throughout this presentation: if a patient demonstrates benefit from the opioid, supported

by improved function and pain, continuation of opioids may be appropriate. Concerns have been raised

that the Non-‐Acute Pain Guidelines do not recommend the use of opioids. That is not true. And it is

again documenting the benefit (of opioids) – not just the pain, but the function.

Slide 5-‐21:

Ongoing therapy, however, requires ongoing assessment and monitoring to include urine drug testing

and random pill counts. Tapering and discontinuation or potentially a referral to a pain management or

an addiction medicine specialist should be considered if there is no improvement in function and pain,

or the opioid therapy produces significant adverse effects, or the patient exhibits aberrant behavior,

drug-‐seeking behaviors or diversion.

Slide 5-‐22:

Transitioning and managing patients on existing opioid therapy. Again, two important points very much

related to each other, but necessary in order to safely manage a patient who comes to you, or comes to

the physician already on opioids. Patients who are on long-‐term opioids should not have their

medications discontinued simply because they have not met the trial criteria or the criteria for safe,

long-‐term opioid management. The goal is to transition to the standards of care as recommended in the

Guidelines, and to avoid abrupt discontinuation of opioids in patients who have been receiving long-‐

term therapy prior to the initiation of the Non-‐Acute Pain Medical Treatment Guideline.

‐23:

Careful evaluation and re-‐evaluation of a patient’s condition to include: documentation of

a patient’s pain condition, including pain relief and functional status; physical and psychological

assessment, including a full evaluation for alcohol or drug addiction; an appropriate referral for

treatment of psychosocial conditions that may complicate the clinical presentation; and completion of

the Risk Assessment and Stratification Form.

Slide 5-‐24:

The evaluation and re-‐evaluation is ongoing and includes a continuation of appropriate adjuvant non-‐

opioid therapies, monitoring for side effects for co-‐morbid conditions that could potentially cause

adverse effects, aberrant or drug-‐seeking behavior or noncompliance with the Patient Understanding

Form. It is important to update the Patient Informed Consent and Understanding Forms when there’s a

change in opioid dose, type, or patient condition.

Unannounced urine drug testing and/or random pill counts based on risk assessment or

aberrant behavior – and, again, this links to the ORT tool as well as clinical observation,

in speaking with a patient.

Slide 5-‐25:

For any patient on long-‐term opioids, once a decision is made to institute and/or continue chronic

opioid therapy, the physician is responsible for routine monitoring for the safety and effectiveness of

the treatment. And again, review, complete, and update the Patient Informed Consent for Opioid

Treatment and Patient Understanding for Opioid Treatment Form.

Slide 5-‐26:

The principles for safe opioid management include using the lowest possible dose, limiting the type of

opioids to two: the long-‐acting for maintenance of pain relief and a short-‐acting for rescue use. If more

than two opioids are being considered, a second opinion should be obtained either from an addiction

medicine or pain medicine specialist.

‐27:

There is a need to review, update and continue all appropriate adjuvant non-‐opioid therapies, and

again, the monitoring and screening to include the assessment of pain relief, functional status,

appropriate medication use and side effects, risk assessment and stratification, random urine drug

testing, as necessary according to risk, and unannounced pill counts according to risk category. I can’t

tell you how often we’ve reviewed files and it becomes very obvious that the assessments have not

been done, and the only documentation provided is simply, “Patient’s pain continues, increase

medication.” Pain becomes the marker and it is not even clear what type of pain or to what part of the

body the pain is referred, and function is not even on the horizon.

Slide 5-‐28:

A very important key concept: if no reasons for dose reduction or discontinuation are identified, and the

patient demonstrates benefit from opioid therapy, continuation of opioids can be appropriate with

ongoing assessment and monitoring.

Slide 5-‐29:

Low-‐risk patients can be monitored less frequently, every 3-‐6 months. High-‐risk, more frequently,

depending upon the severity of the risk and the problems that have been identified.

Slide 5-‐30:

Patients who are very high-‐risk may require weekly monitoring, or perhaps consideration of co-‐

management or referral to an addiction medicine specialist.

Slide 5-‐31:

Patients who receive ongoing therapy need monitoring and evaluation to ensure or to determine

whether a patient can participate in safety-‐sensitive activities. In the Appendix, there is a Pain

Assessment and Documentation Tool – PADT, as it’s commonly known – and it provides an effective

approach for systemically documenting each encounter, and it allows for easy monitoring from visit to

visit, and is strongly encouraged.

‐32:

Once again, I just want to emphasize these principles or approaches for all phases of care for patients

who are receiving opioids, whether the initial, transition, or the continuation of opioids, the need for the

physician to assess and reassess, in particular function and pain status.

Slide 5-‐33:

Again, if there are no indications for dose reduction, and the patient demonstrates benefit from the

opioid therapy, validated by measures of improved function and pain, continuation of opioids may be

appropriate.

Slide 5-‐34:

To reiterate, absence of objective functional improvement should result in efforts to wean

and/or discontinue opioid use.

Slide 5-‐35:

Now we’re going to delve a little bit into some of the monitoring tools. And we will start with the urine

drug testing. The purpose of urine drug testing is to identify aberrant behavior, identify undisclosed drug

use and/or abuse, and verify compliance with treatment. It is a mandatory component of the ongoing

opioid management. It is essential to obtain baseline urine drug testing when a patient is being

considered for opioid therapy, and on all transferring patients, meaning patients who are now being

transitioned to the standards of care within the treatment guideline.

Slide 5-‐36:

Urine drug tests, like all lab work, in and of themselves do not suggest a definitive course of action. They

should be interpreted in the context of the individual’s clinical condition, and used with other clinical

information to decide whether a change in therapy is required. Some of the additional information to

look at, or to consider: results of pill counts, review of the prescription drug monitoring program

information, information from family or other providers. Put this together with the results of the urine

drug testing when making a decision whether to continue, adjust, or discontinue treatment.

‐37:

The patient needs to understand why the urine drug testing is being done, and the physician should

inform the patient of the reason for the testing, the expectation of future testing, and the consequences

of unexpected results. In addition, this is reinforced in the Patient Understanding Form. The frequency

of the random urine drug testing is based upon a patient’s risk category. Table 4 on the next slide

summarizes the relationship between the score, the ORT risk category score, and the frequency of urine

drug testing. Important: if a patient demonstrates aberrant behavior, for example lost prescriptions,

multiple requests for early refills, opioids from multiple physicians, or unauthorized dose escalation,

then the patient should be tested at that visit.

Slide 5-‐38:

This slide is the ORT category and frequency of urine drug testing.

Slide 5-‐39:

The patient has a right to refuse a urine drug test, but will receive no prescription for opioid medication

as a consequence of the refusal. Urine drug tests are not to be released to the carrier, employer, or the

Board. Rather, the treating physician must certify the patient’s adherence to or non-‐compliance with the

Patient Understanding for Opioid Treatment Form in the medical record. Employers cannot use urine

drug testing results to fire or discipline a worker in any discriminatory manner.

Slide 5-‐40:

There are two basic types of urine drug testing: immunoassay drug testing and high performance

chromatography.

Slide 5-‐41:

Immunoassay drug testing is usually an initial test or screen. It’s the most common method of testing

and can be performed in a lab or office. Basically what they call at the point of care, or POC. It can detect

the presence or absence of drug or drug class, but not the drug dose used.

Slide 5-‐42:

An advantage of the immunoassay drug testing is that it can concurrently test for multiple drug classes

and provides rapid results. However, the immunoassays can react with other drugs and vary in

sensitivity and specificity. Unexplained results should always be verified, and there should be clear office

protocols and procedures.

Slide 5-‐43:

Chromatography is a confirmatory drug test for verification or identification of a specific drug. It is

normally laboratory-‐based.

Slide 5-‐44:

Let’s take a look at red flags in relationship to urine drug testing. Red flags can be negative test results

for a prescribed opioid, a positive test for different medications than those prescribed, or for other

abuse substances, or positive test results for alcohol.

Slide 5-‐45:

In Table 5, we have a summary of red flag results.

Slide 5-‐46:

Let’s look at negative results and their implication. If confirmatory testing and clinical judgment

substantiate a red flag, and the result is negative for a prescribed opioid, the patient should be called

back for a pill count and repeat urine drug testing. If the repeat test is still negative, the patient should

return to the office in two days and be evaluated for the presence of withdrawal. If there is no evidence

of withdrawal, consider stopping opioids, as diversion is suspected.

Slide 5-‐47:

If confirmatory testing and clinical judgment show a red flag that is positive for a non-‐prescribed

schedule drug, or other drugs, the physician must assess the clinical significance of the result, reiterate

to the patient the Patient Understanding for Opioid Treatment, wean or terminate the opioid

prescription, and perform more frequent monitoring. Referral to specialty care should be considered.

Slide 5-‐48:

A patient is classified as high-‐risk and treated consequently as such when a positive result occurs. And

again, random pill counts occur on a periodic basis. And subsequent second positive urine drug testing

without a valid explanation, or a deviation from anticipated medication frequency count, should result

in medication tapering to immediately commence, or potentially inpatient medically assisted withdrawal

program in conjunction with longer-‐term support.

Slide 5-‐49:

There are certain behaviors that result in a patient being placed in a high risk category. And these would

include selling prescription drugs, forging prescriptions, stealing or borrowing drugs, frequently losing

prescriptions, aggressive demand for opioid medication, unsanctioned use, unsanctioned dose

escalation, receiving opioids from multiple providers, or recurrent emergency room visits for pain

medication. These behaviors are similar to the ones that are identified in the Patient Understanding

Form, and the patient should be aware and knowledgeable in the fact that they are not compliant with

the agreement.

Slide 5-‐50:

We’re now going to talk a little bit about optimizing opioid doses. Once more, use the lowest possible

effective dose and titrate slowly. Repeat dose escalations can be a marker for abuse or diversion, or can

paradoxically induce abnormal pain sensitivity, most commonly hyperalgesia and allodynia. Patients

should be evaluated shortly after switching to a new opioid.

Slide 5-‐51:

Opioid rotation is a possible choice for patients who have inadequate symptom relief despite dose

escalations. And once more, that important theme: if opioid treatment is benefitting the patient, as

demonstrated by objective measures of function and pain, then continuing treatment may be

appropriate.

Slide 5-‐52:

Let’s talk a little bit about the equiananalgesic doses. All conversions from one opioid to another are

generally estimates, based on equianalgesic dosing. Because of large patient variability in responses to

opioids, it’s recommended that after calculating an appropriate conversion dose, the dose should be

reduced by 50% to ensure patient safety. Opioid withdrawal symptoms may be unpleasant, but they are

not life-‐threatening. So if the dose has been underestimated, the situation can be remedied by

increasing medication. Overdosing is life-‐threatening. Families should be warned about signs of opioid

overdose.

‐53:

Morphine Equivalent Doses. This is a concept that’s important for patients who are taking more than

one opioid. Morphine equivalent doses, or MED, for the different opioids must be added together to

determine the cumulative dose. In general, the total daily dose of opioids should not exceed 100

milligrams of morphine equivalent doses. The risk for overdose or adverse effects substantially increase

at doses greater than 100 milligrams MED.

Slide 5-‐54:

Except for pain management or addiction medicine specialists, a provider should not prescribe more

than 100 milligrams MED without the patient either demonstrating improvement in pain and function

without aberrant behavior, or first obtaining a consultation from a pain management specialist or

physician specializing in addiction medicine. If the narcotic dosing has reached 100 milligrams MED per

day, and the patient has not received pain relief or has developed hyperalgesia, dose reduction or

discontinuation is warranted.

Slide 5-‐55:

Table 6 contains the oral opioid analgesic equivalents to oral morphine 30 milligrams.

Slide 5-‐56:

The following is an example of how to calculate a morphine equivalent dose. In the example that we’re

going to use, a patient is taking six hydrocodone, 5 milligram and two 20 milligram oxycodone, and we

want to calculate the cumulative dose using morphine 30 milligrams as the reference. Looking at the

summary table on the slide, six hydrocodone at 5 milligrams comes up to 30 milligrams of hydrocodone.

The two oxycodone, 20 milligrams, comes up to 40 milligrams, and then if you do the conversion,

the hydrocodone you multiply by 1 for the morphine equivalence, and that gives you 30 milligrams MED.

The second drug, oxycodone, we multiply by 1.5, for the morphine equivalent, and that gives you 60

milligrams. And if we add 30 and 60, the cumulative morphine equivalent dose would be 90 milligrams.

So, this is the approach that we use to calculate the total morphine equivalent dose when a patient is

taking more than one narcotic, keeping in mind that 100 milligrams MED is a red flag for reevaluation

and reconsideration.

‐57:

Missing from the oral opiate analgesic equivalence table is transdermal fentanyl. Table 7 on the next

slide was developed to provide the relationship between oral morphine and fentanyl. The fentanyl patch

should be initiated using the recommended dose and titrate patients no more frequently than 3 days

after the initial dose, and every 6 days thereafter, until analgesic efficacy is reached. The majority of

patients are adequately maintained with fentanyl patch administered every 72 hours.

Slide 5-‐58:

And as I noted before, Table 7 provides the 24-‐hour equivalent dose and the corresponding fentanyl

patch dose. Of note, this table should only be used when converting from another opioid to the fentanyl

patch.

Slide 5-‐59:

There are important reasons to discontinue opioids. And if you remember that initial quote at the

beginning of our presentation, “If you don’t improve significantly from both an analgesic and functional

standpoint, this is not a medicine you’re going to stay on.” So some of the reasons to discontinue

opioids include: no improvement in function and pain; opioid therapy produces significant adverse

effects; patient exhibits aberrant or drug seeking behaviors or diversions, which we described

previously; recurring emergency room visits for additional pain medication.

Slide 5-‐60:

Medically, weaning from opioids can be done safely without significant health risks by slowly tapering

the opioid dose, and taking into account the following: a decrease by 10% of the original dose per week

is usually well tolerated with minimal physiological adverse effects. Some patients can be tapered more

rapidly without problems, some require longer time frames.

Slide 5-‐61:

The recommendations for tapering and discontinuing opioids in the Non-‐Acute Medical Treatment

Guidelines are not meant to cover all situations, and physicians are referred to appropriate sources for

the management of tapering or discontinuing opioids, or referral to a physician specializing in addiction

medicine or to a pain specialist. For more complicated cases that require more medically assisted

detoxification, referral to an inpatient or outpatient program may be indicated.

‐62:

There are times that assistance may be needed and specialty consultation should be sought.

Consultations with addiction or pain management specialists may be indicated for certain high-‐risk

patients; moderate-‐risk patients for referral or co-‐management; tapering or discontinuing opioids;

complex problems; aberrant drug behaviors; opioid doses greater than or equal to 100 milligram MED

per day. If more than two opioids are being considered for long-‐term use; use of fentanyl, methadone or

buprenorphine addiction management. This slide summarizes many of the specialty

consultations that we indicated earlier.

Slide 5-‐63:

Additional specialty consultations may consist of psychiatry, for deterioration in the psychological state

during opioid withdrawal; for symptoms of mood, anxiety and psychotic disorders; or for undiagnosed

psychiatric psychological disorders. Other consultations to address severe pain with no improvement

despite opioid treatment may include a wide array of potential consults such as neurology, PM&R,

orthopedics, and inpatient treatment may be required for complex cases.

Slide 5-‐64:

Let me conclude this section of the opioid training with a story that came from the New York Times: “A

Soldier’s War on Pain.” A 27-‐year-‐old sergeant in Afghanistan had his armored truck blown apart by a

roadside bomb, and the article talks about how for three years, Sergeant Savage struggled to navigate a

drugged fog. He was on more than 300 milligrams of morphine, and as his dose increased he became

more lethargic and detached. His wife said he would zone out for hours. Finally, one day his older

daughter confronted him, telling him she could no longer bear the person he had become. That night,

Sergeant Savage decided to wean himself off opioids. To his surprise, he soon felt better, not worse.

Eventually he participated in a multidisciplinary program. His statement, as he worked through his pain

medication withdrawal, his participation in therapeutic activities including volunteer work, developing a

hobby, working with horses, and he basically said you have to find alternative ways to get out, stay

active, and manage pain. Doctors today remain focused on treating pain, just one symptom of chronic

pain syndrome, or non-‐acute, as we call it. As a result, they often chase pain. Our goal is to change the

pattern, to come up with recommendations that allow for a patient to improve functionally, as well as

have improvement in pain, and, in the event that pain cannot be removed, to learn to manage pain.

And, as so aptly summarized by the sergeant, to stay active and to manage pain. Thank you.


MODULE 6 – Spinal Cord Stimulator and Intrathecal Drug Delivery

Slide 6-‐1:

Hello, my name is Doctor Linda Cocchiarella. I am the Assistant Medical Director at the Workers’

Compensation Board. Today we will be addressing two areas: spinal cord stimulators and intrathecal

drug delivery, both of which require pre-‐authorization.

Slide 6-‐2:

Implantable spinal cord stimulators are also known as dorsal column stimulators. These devices use

implanted electrical leads and a battery-‐powered implanted pulse generator. These devices require pre-‐

authorization with a C-‐4, and it’s essential that all criteria are met for this select group of patients that

require implantable spinal cord stimulators. The criteria include appropriate patient selection,

psychological evaluation, and a screening trial.

Slide 6-‐3:

Implantable spinal cord stimulators are used only in select patients with chronic back or neck

radicular pain. Specifically, patients who have failed neck or back surgery syndrome, who also

meet the following indications: these patients need to have persistent, severe, and functionally

disabling radicular neck or back pain. These devices are not used for axial neck pain, or for axial low back

pain. These patients also must have been provided the option for conservative, non-‐surgical treatment,

and they must have undergone surgical treatment that failed to relieve their symptoms and improve

their function. And when further surgery has been considered, but is not being pursued at this time.

Slide 6-‐4:

Before considering a spinal cord stimulator, the patient may consider enrolling in an authorized

functional restoration program, although if they decline this option, this does not preclude their ability

to obtain a spinal cord stimulator. Spinal cord stimulators may also be an option in individuals with

complex regional pain syndrome, phantom limb, and spinal cord injury dysesthesias.

‐5:

Proper patient selection is essential for this procedure and includes a detailed history, physical exam,

complete diagnostic workup, and a thorough psychological evaluation. A detailed psychological

evaluation is essential before a patient undergoes a spinal cord stimulator, to ensure that there are no

significant psychological or behavioral factors that would predict a poor response.

Slide 6-‐6:

The goal of the psychological evaluation is to assist the clinician to determine whether this patient is

suitable for spinal cord stimulator implantation. The psychological evaluation includes a clinical

interview, a complete review of their medical records, a standardized detailed personality inventory,

and a pain inventory. It’s also important to understand the patient’s expectations, ensure they are

realistic, and that they understand the treatment goals.

Slide 6-‐7:

Before a patient can obtain a spinal cord stimulator, the psychological evaluation needs to demonstrate

that the patient has no primary psychiatric risk factors or red flags, which means that they do not have

severe psychiatric disorders such as severe psychosis, active suicidal ideation, severe depression, or

addiction, or concurrent substance abuse. Note that tolerance and dependence are not addictive

behaviors, and they do not preclude a spinal cord stimulator implantation. The patient also has to

demonstrate a history of motivation and adherence to prescribed treatments.

Slide 6-‐8:

The spinal cord stimulator requires pre-‐authorization of a screening trial. Once the screening trial has

been authorized, the patient will use a temporary external neural stimulation system for between three

to seven days, while they complete a diary of their daily activities and of their pain. Note that all the

evaluation criteria – the indications, the patient selection, and the psychological evaluation – must be

met prior to the spinal cord stimulator screening trial.

Slide 6-‐9:

What are the criteria for a successful spinal cord stimulator screening trial? For a trial to be successful,

the stimulation must cover the patient’s pain areas. The patient needs to be comfortable with the

degree of sensation and stimulation present. It must be documented that the patient experiences at

least a 50% decrease in pain, which must be confirmed by validated measures such as a VAS or an NRS.

The patient must demonstrate objective functional gains, or a decreased use of pain medication. To

meet these criteria, the clinician must ensure that they know the individual’s functional abilities before

and after discontinuation of the trial.

Slide 6-‐10:

In order to qualify for a permanent spinal cord stimulator implantation, the patient must have a

successful screening trial, and then the clinician must request pre-‐authorization from the carrier

to implant a permanent spinal cord stimulator.

Slide 6-‐11:

In limited situations, for example if there were extreme co-‐morbidities, a spinal cord stimulator may be

considered in a patient without previous low back or neck surgery. In this case the physician may

contact the Medical Director’s Office for an expedited determination in these unusual circumstances.

Slide 6-‐12:

Intrathecal drug delivery, or pain pumps, are not a pre-‐authorized procedure. In order to be authorized

to insert a pain pump, the patient must be evaluated and have the recommendation of at least one

physician certified in chronic pain management, and consultation with the primary treating physician.

The physician who performs the intrathecal drug delivery system must be experienced in the

performance of this procedure. And again, all criteria for indications, patient selection, psychological

evaluation, and a screening trial must be met.

Slide 6-‐13:

What are the indications for a pain pump? The patient must have a diagnosis of a specific physical

condition known to be chronically painful, based on objective findings. Second, all reasonable surgical

and non-‐surgical treatments have been exhausted, including a failure of conservative therapy, active

and passive treatment, medication, or therapeutic injections. Next, there may be no practical issues, for

example, extremes of body size, that might interfere with device placement, maintenance, or

assessment. And a pre-‐trial psychological evaluation must be completed.

‐14:

The pre-‐trial psychiatric or psychological evaluation needs to demonstrate the following: that there are

no primary psychiatric risk factors or red flags, that the patient is motivated and has adhered to

prescribed treatments, and that there is no evidence of current addictive behavior.

Slide 6-‐15:

Before a patient is selected for a pain pump screening trial, they are to be offered treatment at a

functional restoration program. All the evaluation criteria must be successfully met, as well as the

successful trial of continuous infusion by a percutaneous spinal infusion pump for a minimum of 24

hours.

Slide 6-‐16:

When is a pain pump screening trial considered to be successful? The patient needs to experience at

least a 50% decrease in pain, which may be confirmed by VAS or objective pain assessment tools, and

they need to demonstrate objective functional gains, or decreased use of pain medication. Again, this

documentation of objective functional gains needs to be determined

Slide 6-‐17:

If the screening trial is successful, the treating physician must request pre-‐authorization from the

carrier to implant a permanent pain pump.

Slide 6-‐18:

In conclusion, spinal cord stimulators and intrathecal drug delivery require pre-‐authorization, and

strict patient selection, psychological evaluation, and successful screening trial criteria must be met.


MODULE 7 – Functional Maintenance Care

Slide 7-‐1:

My name is Doctor Jaime Szeinuk, and I am the Co-‐Medical Director of the New York State Workers’

Compensation Board. We’re going talk about functional maintenance care, which is the last section of

the Non-‐Acute Pain Medical Treatment Guidelines. This topic of functional maintenance care is not a

new concept to the Medical Treatment Guidelines, but the Non-‐Acute Pain Medical Treatment

Guidelines have expanded this topic and put it in a general context of treating non-‐acute pain.

Slide 7-‐2:

The Medical Treatment Guidelines recognize that maximum medical improvement shall not preclude

the provision of medically necessary care for injured workers. The guidelines recognize as well that while

patients at MMI typically do not require ongoing maintenance medical care, there may be episodes of

clinical flare-‐ups and fluctuations that require episodic care. There is a Medical Director’s Office Bulletin

published in 2012 that describes the requirements for the treatment of exacerbations in the course of a

patient’s injuries. The functional maintenance care program has three components: ongoing

independent self-‐management plan, self-‐directed pain management plan, and ongoing maintenance

care. And we’re going to describe these components in detail in the next slides.

Slide 7-‐3:

As patients progress or plateau in their responses to treatment, the physician and the patient should

work to develop clinically appropriate independent self-‐management programs that encourage physical

activity and/or work activities despite residual pain, with the goal of preserving functional status. These

independent programs may include active techniques such as strengthening and stretching, range of

motion, exercise, and other physical exercises that are typically home-‐based and self-‐directed by the

patient.

Slide 7-‐4:

The physician and the patient should work together to develop a self-‐directed pain management plan.

This plan is to be initiated by the patient without the need to consult the medical provider in the event

that symptoms worsen and function decreases. The plan may include self-‐directed short-‐term

interventions, such as exercises, stretching, or strengthening at home, and/or medication use that can

be self-‐initiated by the patient, for example: over-‐the-‐counter acetaminophen or non-‐steroidals for a

short course.

Slide 7-‐5:

The physician should periodically review this self-‐management or self-‐directed plan together with the

patient and consider any new clinical information, especially in relation to possible alternative causes of

deterioration of function, and modify or revise as clinically indicated.

Slide 7-‐6:

As the condition becomes more stable, the guidelines recommend that longer trials of therapeutic

withdrawal should be attempted to ascertain whether these therapeutic gains that have been achieved

so far can be maintained in the absence of active clinical interventions. The Guidelines recognize that

when a patient’s condition no longer shows functional improvement from therapy, a decision must be

made on whether the patient will need to continue treatment or can maintain functional status with a

self-‐management program without additional medical interventions.

Slide 7-‐7:

When therapy modalities are not necessary to maintain functional status, this therapy modality should

be discontinued, and the patient should return to an independent, home-‐based, self-‐directed program.

Slide 7-‐8:

In case that symptoms of function worsen, the Guidelines recommend that an evaluation should be

performed in order to rule out co-‐morbid conditions that can explain the worsening of symptoms or

function. There should be an assessment of the adequacy of the current independent home-‐based self-‐

management program and/or the need to modify this program, and the physician should make a

determination of the value, if any, of reinstituting clinical interventions as part of an ongoing

maintenance program in addition to the self-‐management program that is tailored to the specific needs

of the patient.

‐9:

An ongoing maintenance care program is a maintenance program of one of the following modalities:

physical therapy or occupational therapy, or spinal manipulation provided by a physician, an MD or DO,

a chiropractor or a physical therapist. A maintenance program may be indicated in certain situations

after the determination of MMI when tied to maintenance functional status. Again, the important

consideration here is that it has to be tied to a maintenance of functional status, without which the

function of the patient will deteriorate. In order to qualify for ongoing maintenance care program, the

patient must have reached MMI and have a permanent disability, have been diagnosed with non-‐acute

pain, and demonstrated a decline in functional status without the identified treatment modality, despite

an ongoing participation in a self-‐management plan. And these three requirements must be fulfilled in

order to engage in an ongoing maintenance care program.

Slide 7-‐10:

An ongoing maintenance care program should have specific objective goals that should be identified and

measured as treatment progresses. It should include progressively longer trials of therapeutic

withdrawal, to determine whether the therapeutic goals can be maintained in the absence of clinical

interventions. These longer trials of withdrawal should start within a year, and tried at least annually

after the institution of the ongoing maintenance care program. Finally, the ongoing maintenance care

program should include an ongoing patient self-‐management plan performed by the patient and

regularly reviewed by the patient and the physician, and a self-‐directed pain management plan initiated

as indicated.

Slide 7-‐11:

The ongoing maintenance care program is recommended for a maximum of up to ten visits a year after

the determination of MMI, and according to the objectively documented maintenance of functional

status. No variance – and this is very important – there is no need for a variance and there is no variance

that can be granted on the maximum frequency of ongoing maintenance care.

Slide 7-‐12:

In conclusion, the functional maintenance care program has three components: an ongoing independent

self-‐management plan; a self-‐directed pain management plan; and ongoing maintenance care, when

necessary. Again, all of these programs are based on self-‐management to encourage the preservation of

functional status.

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