Treatment of Injured Workers on Chronic Pain Medications Mark Miles Passey MD Utah Spine and Joint Specialists 801 314-2308
<ul><li>Review State of the Art for long term opioid use for managing chronic pain </li></ul><ul><li>Review Standard of Ca...
State of the Art and the State of our Understanding
 
 
<ul><li>Until there's more scientific evidence, doctors &quot;should not continue to prescribe high-dose opioids&quot; for...
Reinecke H. et al., S3 guideline LONTS: Long-Term Administration of Opioids for on-Tumor Pain,  Schmerz , 2009;23(5):440-7...
Current Opinions in Anesthesiology, 2010;23:598-601 <ul><li>“ Many argument [in favor of opioids] are solely based on trad...
 
<ul><li>“ The consensus now is that some patients with chronic pain should be considered as candidates for long-term opioi...
<ul><li>G.S. is a 42 y.o. male who has been my patient since October 2003.  Works full-time as a research biologist at the...
Standard of Care for long term opioid use for managing pain in injured workers <ul><li>Medical care is provided for all ne...
 
<ul><li>In the absence of adequate evidence to determine the true benefits and best practices in use of these medications,...
Opioid Treatment for Chronic Pain <ul><li>10) An opioid treatment trial should be discontinued if the goals are not met an...
<ul><li>In 2011 it can be within the community standard of care to use opioids for chronic pain.  </li></ul><ul><li>In 201...
Conservative Opioid Prescribing
The Patient Already on Opioids <ul><li>Opioid tolerance is a medical condition. </li></ul><ul><li>If a worker sustains an ...
Case Study <ul><li>Mr. S., a 23-year-old man, falls while at work and dislocates his right shoulder.  The clinical course ...
The new chronic pain condition
Preexisting pain in the acute industrial injury  <ul><li>ISSLS  Prize winner: Early predictors of chronic work disability:...
<ul><ul><li>Conclusion:  Among workers with new lost work-time back injury claims, risk factors for chronic disability inc...
<ul><li>SPINE Volume 33, Number 25, pp 2789–2800; 2008:  Surgical  Versus  Nonoperative Treatment for Lumbar Disc Herniati...
 
Principles of Conservative Opioid Prescribing <ul><li>Think beyond drugs.  </li></ul><ul><li>Practice more strategic   pre...
Principles of Conservative Prescribing <ul><li>My idea--- Avoid prescribing practices that mimic the way addicts take opio...
Universe of Addiction Universe of Chronic Pain Management Counterproductive use of opioids Frequent dose raising IV Heroin...
 
 
 
 
 
 
Principles of Conservative Opioid Prescribing <ul><li>Avoid short acting opioids </li></ul><ul><li>Never prescribe, author...
<ul><li>Hydromorphone also known as Dilaudid or &quot;Dillies&quot; are &quot;Top of the food chain&quot; when it comes to...
<ul><li>Consider overnight oximetry to screen for sleep apnea in chronic opioid use. </li></ul><ul><li>Opioids predictably...
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2011 passey treatment chronic pain

  1. 1. Treatment of Injured Workers on Chronic Pain Medications Mark Miles Passey MD Utah Spine and Joint Specialists 801 314-2308
  2. 2. <ul><li>Review State of the Art for long term opioid use for managing chronic pain </li></ul><ul><li>Review Standard of Care for long term opioid use for managing pain in injured workers </li></ul><ul><li>Conservative Opioid Prescribing </li></ul>
  3. 3. State of the Art and the State of our Understanding
  4. 6. <ul><li>Until there's more scientific evidence, doctors &quot;should not continue to prescribe high-dose opioids&quot; for chronic non-cancer pain. Narcotic drugs for short-term relief of pain are fine, but Katz says there's insufficient evidence to support their use over the long haul. </li></ul>
  5. 7. Reinecke H. et al., S3 guideline LONTS: Long-Term Administration of Opioids for on-Tumor Pain, Schmerz , 2009;23(5):440-7 <ul><li>There is evidence that opioid therapy relieves pain in the 3 weeks to 3 months timeframe. </li></ul><ul><li>There is evidence that opioids can improve the level of physical functioning for neuropathic pain, joint pain, and back pain. </li></ul><ul><li>Randomized controlled trials examining the long-term effects of opioids do not exist. </li></ul>
  6. 8. Current Opinions in Anesthesiology, 2010;23:598-601 <ul><li>“ Many argument [in favor of opioids] are solely based on traditions, expert opinions, practical experience and uncontrolled anecdotal observations.” </li></ul>
  7. 10. <ul><li>“ The consensus now is that some patients with chronic pain should be considered as candidates for long-term opioid therapy, and some will gain great benefit from this approach.” - Russell Portenoy MD, 2004 </li></ul>
  8. 11. <ul><li>G.S. is a 42 y.o. male who has been my patient since October 2003. Works full-time as a research biologist at the U of U. </li></ul><ul><li>Anterior L5-S1 fusion April 2003. Residual 5/10 low back and left lower extremity pain. </li></ul><ul><li>Methadone 10 qid, soma 1 nightly, amitriptylene 25mg hs, ibuprofen and CPAP machine. </li></ul>
  9. 12. Standard of Care for long term opioid use for managing pain in injured workers <ul><li>Medical care is provided for all necessary and reasonable medical services which are needed to help the employee heal from their work injury. </li></ul><ul><li>Community standard </li></ul>
  10. 14. <ul><li>In the absence of adequate evidence to determine the true benefits and best practices in use of these medications, these Guidelines were developed to assist physicians who choose to use opioids to treat patients with pain to manage that treatment as safely as possible. </li></ul>
  11. 15. Opioid Treatment for Chronic Pain <ul><li>10) An opioid treatment trial should be discontinued if the goals are not met and opioid treatment should be discontinued at any point if adverse effects outweigh benefits or if dangerous or illegal behaviors are demonstrated. </li></ul>
  12. 16. <ul><li>In 2011 it can be within the community standard of care to use opioids for chronic pain. </li></ul><ul><li>In 2011 the use of long term opioids for the treatment of persistent pain conditions is an elective practice. </li></ul><ul><li>There is no pain diagnosis for which the use of opioids is mandatory. </li></ul><ul><li>There is no pain diagnosis for which the necessity for using opioids outweighs the requirement for the patient to positively demonstrate their safe and legal use. </li></ul>
  13. 17. Conservative Opioid Prescribing
  14. 18. The Patient Already on Opioids <ul><li>Opioid tolerance is a medical condition. </li></ul><ul><li>If a worker sustains an injury while in an opioid tolerant condition the opioid tolerance is a pre-existing condition. </li></ul><ul><li>An opioid tolerant person who sustains a new injury will ALWAYS “need” to treat the new injury with increased opioid dose, even in injuries that can sometimes be treated without opioids in opioid naïve patients. </li></ul>
  15. 19. Case Study <ul><li>Mr. S., a 23-year-old man, falls while at work and dislocates his right shoulder. The clinical course includes 3 shoulder surgeries over the course of 3 years. The last surgery was on 9/8/08. On current presentation he is doing well but his shoulder pain continues to be a 3-4 out of 10. He was recently declared at MMI by his shoulder surgeon. </li></ul><ul><li>Past history includes chronic low back pain. Prior to and at the time of his work-related shoulder dislocation he was on OxyContin 20 mg t.i.d. and 30 tablets of Percocet 5 mg per month. Now, after 3 years of treatment with a shoulder surgeon he is on OxyContin 40 mg t.i.d., Percocet 10 mg 6 tablets per day. </li></ul><ul><li>Mr. S. is now on more than twice as much daily opioid medication. Is this because he is in twice as much pain? Is the worker's compensation insurance carrier now indefinitely responsible to provide opioids because of Mr. S’s chronic right shoulder pain? </li></ul>
  16. 20. The new chronic pain condition
  17. 21. Preexisting pain in the acute industrial injury <ul><li>ISSLS Prize winner: Early predictors of chronic work disability: a prospective, population-based study of workers with back injuries. SPINE: 1 December 2008, Volume 33, 25:2809-2818 </li></ul>
  18. 22. <ul><ul><li>Conclusion: Among workers with new lost work-time back injury claims, risk factors for chronic disability include radiculopathy, substantial functional disability, and to a lesser extent, more widespread pain and previous injury with extended time off work. </li></ul></ul>
  19. 23. <ul><li>SPINE Volume 33, Number 25, pp 2789–2800; 2008: Surgical Versus Nonoperative Treatment for Lumbar Disc Herniation Four-Year Results for the Spine Patient Outcomes Research Trial (SPORT) </li></ul><ul><li>“ Bothersomeness of sciatica” the most unequivocally positive outcome for surgery versus non-operative care for herniated disc with radiculopathy. </li></ul>
  20. 25. Principles of Conservative Opioid Prescribing <ul><li>Think beyond drugs. </li></ul><ul><li>Practice more strategic prescribing. </li></ul><ul><li>Maintain heightened vigilance regarding adverse effects. </li></ul><ul><li>Exercise caution and skepticism regarding new drugs. </li></ul><ul><li>Work with patients for a shared agenda. </li></ul><ul><li>Consider long-term, broader impacts. </li></ul>
  21. 26. Principles of Conservative Prescribing <ul><li>My idea--- Avoid prescribing practices that mimic the way addicts take opioids. </li></ul>
  22. 27. Universe of Addiction Universe of Chronic Pain Management Counterproductive use of opioids Frequent dose raising IV Heroin IV Oxycodone Actiq, Fentora Frequent dose raising Large amounts of short acting opioids such as Lortab, Percocet, OxyIR, Actiq, Fentora Rehabilitative use of opioids Methadone maintenance Suboxone maintenance Long acting opioids at moderate stable doses, such as methadone, long-acting morphine, fentanyl patches, buprenorphine.
  23. 34. Principles of Conservative Opioid Prescribing <ul><li>Avoid short acting opioids </li></ul><ul><li>Never prescribe, authorize or pay for transmucosal fentanyl (actiq, fentora) for chronic pain in injured workers. </li></ul><ul><li>Avoid dose raising as a strategy to try to defeat tolerance. </li></ul><ul><li>Monitor prescriber’s data base. </li></ul><ul><li>Perform unannounced urine drug screens. </li></ul>
  24. 35. <ul><li>Hydromorphone also known as Dilaudid or &quot;Dillies&quot; are &quot;Top of the food chain&quot; when it comes to pain medication in pill form! Its 8mgs pill is the strongest pain pill on the market. Oxycontin gives it a good run for the money! Msir 30mgs is in the mix also! If you can get a hold of Actiq, Fentanyl in lollipop form, your one lucky man...they pack a wallop!! –Dr. Dopenstein. </li></ul>
  25. 36. <ul><li>Consider overnight oximetry to screen for sleep apnea in chronic opioid use. </li></ul><ul><li>Opioids predictably suppresses serum testosterone in males. </li></ul><ul><ul><li>Topical testosterone gels are the treatment of choice for this. </li></ul></ul>
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