Pain mgtpdf

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Pain mgtpdf

  1. 1. Dear Physician: Physician education/training for a review of pain management is now available. This will involve: A. Complete the self-learning module that is attached. This is approved for 4 CME Category I credit. Instructions for completion include: 1. Review information in the booklet 2. Complete the written exam. 3. Complete evaluation. 4. Return written exam and evaluation form to Jayne Sheehan. 5. Upon receipt of required paperwork, a certificate of completion will be sent to P. Eppinger in the Medical Staff office in order to pursue credentialing of this service on your behalf. A copy will be sent to you only if requested. 6. J. Sheehan will record the CME credits. Thank you, Jayne Sheehan, RN, MSN, CRNP Director of Professional and Allied Health Education 07/09 rsharesoncmeendmatpainmanagement Please only print out pages 1-8 for your records and to complete the questions and evaluation. Please review the Power Points from this document. If you would like a print out of this Enduring Material, Please contact Lori Graham (x4050) or Jayne Sheehan (x4052). Thank you!
  2. 2. ENDURING MATERIAL JAMESON MEMORIAL HOSPITAL COMPREHENSIVE REVIEW COURSE IN PAIN MANAGEMENT FOR NON-SPECIALISTS COURSE DIRECTOR: VEERAIAH C. PERNI, M.D., ASSOCIATE CLINICAL PROFESSOR OF ANESTHESIOLOGY, NEOUCOM. ORIGINAL PROGRAM DATE: MAY 16, 2009 Chronic pain is a complex disease affecting more individuals than diabetes, heart disease, and cancer combined. There are approximately eighty million sufferers and it is the most common reason to seek medical help. Description: This four hour comprehensive review course on pain management is intended to describe and define the various types of pain that a primary care physician is confronted with on a regular basis. The course will offer methods to proper diagnosis and various aspects of pain management. In order to provide better outcomes with reduced side effects, the standard of care issues, protocols, schedules, and suggestions on timely transfer of care issues will be reviewed. Objectives: After this course, participants should be able to: 1. Describe the pain definition, classification and methods for understanding of proper diagnosis. 2. Describe the various methods of multidisciplinary pain management, including alternate, non-traditional methods. 3. Demonstrate understanding of the principles of pharmacologic methods for pain management, including side effects, abuse, governmental regulations, and accountability. 4. Describe the multiple aspects of interventional pain management techniques. 5. Post written test to evaluate the skills on pain management with 85% as a passing score.
  3. 3. Pain Management To receive CME credits for this test, you must mark your answers, complete the evaluation/enrollment information, and return them in the envelope provided to Jayne Sheehan or Lori Graham. Accreditation Statement Jameson Health System is accredited by the Pennsylvania Medical Society to sponsor continuing medical education for physicians. This CME activity was planned and produced in accordance with ACCME Essentials and Standards. Designation Statement Jameson designates this educational activity for maximum of 4.0 AMA PRA Category 1 credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Disclosure Statement All Faculty and CME Committee do not have any real or apparent conflict(s) of interest or other relationships related to the content of this presentation. We encourage participation by all individuals. If you have a disability, advanced notification of any special needs will help us better serve you. Original date: 05/09 Updated: Expires: 05/2011
  4. 4. THIS PAGE WAS INTENTIONALLY LEFT BLANK. PLEASE MOVE ON TO THE NEXT PAGE.
  5. 5. Questions for Pain Symposia True or False 1. Prescription opiates has overtaken heroin and cocaine as number one drug of abuse/addiction in the US. 2. The mid-1990s saw a major rise in the number of new non-medical users of therapeutics (all Classes). 3. The CAGE questionnaire is an instrument in identifying patient with potential addiction problems. 4. Pseudoaddiction describes the behavior of chronic pain patients who have inadequate pain treatment. Multiple Choice 5. Techniques that help suppress head and facial pain include: a. Trigeminal Nerve block b. Sphenopalatine block c. Cervical Nerve root block d. All of the above 6. Procedures which diagnose or improve sympathetic mediated pain include: a. Stellate injection b. Lumbar sympathetic block c. Sphenopalatine block d. Superior Hypogastric plexus and Celiac Plexus block e. All of the above 7. Which of the following is an example of neuropathic pain? a. Cancer Pain b. Postoperative pain c. Chronic low back pain d. Post herpetic neuralgia
  6. 6. 8. Which of these treatments is approved for migraine prophylaxis? a. Aspirin b. Lamotrigine c. Fluoxetine d. Topiramate 9. Which of the following is NOT involved in fibromyalgia? a. Long standing pain in 11 of 18 standardized areas b. Central nociception c. Rash and hair loss d. Psychological components 10. Which of the following have demonstrated some efficacy in treating fibromyalgia? a. Venlafaxine and selective serotonin reuptake inhibitors b. Tricyclic antidepressants (TCAS), pregabalin, tramadol c. Opioids d. Non-steroidal anti-inflammatory drugs (NSAIDS) and COX-2 specific inhibitors 11.Anticonvulsants have some efficacy in treating neuropathic pain. Which of the following is approved for treatment of post herpetic neuralgia? a. Carbamazepine b. Gabapentin c. Lamotrigine d. Topiramate 12. TCAs are effective for the treatment of low back pain, neuropathic pain, and migraine. Which of the following commonly limits their use? a. Cost b. Potential for addiction c. Formulary restrictions d. Anti-cholinergic side effects
  7. 7. 13. Nonselective NSAIDS are not recommended for preemptive Analgesia because________________________. a. they are ineffective b. prolonged clotting times are a concern c. no intravenous formulations are available d. postoperative nausea and vomiting are possible 14. Which of the following is highly suggestive of opioid addiction in patients? a. “Lost” prescriptions b. Evidence of deterioration in work or social life c. Concurrent alcohol or substance abuse d. All of these
  8. 8. Both pages of the evaluation must be filled out 1 Created 11/09 CME Program Evaluation: Enduring Material (Credits expire May 30, 2011) Evaluation must be completed and turned in for certificate. Program Title: Comprehensive Review Course in Pain Management for Non-Specialists Speaker/Presenter: Drs. Perni, Monroe, Ranieri, and Wrightson Learning Objectives: 1. Describe the pain definition, classification and methods for understanding of proper diagnosis. At the conclusion of the presentation, the participant should be able to: 2. Describe the various methods of multidisciplinary pain management, including alternate, non-traditional methods. 3. Demonstrate understanding of the principles of pharmacologic methods for pain management, including side effects, abuse, governmental regulations, and accountability. 4. Describe the multiple aspects of interventional pain management techniques. 5. Post written test to evaluate the skills on pain management with 85% as a passing score Please rate the following… Excellent Good Fair Poor Overall activity…     Clarity of session content…     Relevance of content to you…     Quality of visual aids/handouts…     Presenter’s overall performance…     Presenter’s knowledge of subject area…     Presenter’s presentation skills…     Presenter’s ability to respond to questions…     Location of CME activity…     Statement of changes this program has made on your practice. Some questions allow for more than one answer. 1. This activity will assist in improvement of: □ Competence □ Performance □ Patient Outcomes 2. I plan to make the following changes in my practice by: □ Modifying treatment plans. □ Changing my screening/prevention practice. □ Incorporating different diagnostic strategies into patient evaluation. □ Using alternate communication methodologies with patient and families. □ Other. □ None. This activity validated current practices. 3. What is your level of commitment to making the changes stated above? □ Very committed □ Somewhat committed □ Not very committed □ Do not expect to change practice
  9. 9. Both pages of the evaluation must be filled out 2 Created 11/09 4. What are the barriers you face in your current practice setting that may impact patient outcomes? □ Lack of evidence-based guidelines □ Lack of applicability of guidelines to current practice or patients □ Lack of time □ Organizational or Institutional □ Insurance or Financial □ Patient Adherence or Compliance □ Treatment related to adverse events □ Other: Explain 5. This activity supported achievement of the learning objectives. □ Strongly Agree □ Agree □ No Opinion □ Disagree □ Strongly Disagree 6. The material was organized clearly for learning to occur. □ Strongly Agree □ Agree □ No Opinion □ Disagree □ Strongly Disagree 7. The content learned from this activity will impact my practice. □ Strongly agree □ Agree □ No Opinion □ Disagree □ Strongly Disagree 8. The activity was presented objectively and free of commercial bias. □ Strongly agree □ Agree □ No Opinion □ Disagree □ Strongly Disagree If you answered Disagree or Strongly Disagree to any of the statements above, please explain your disagreement with the statement(s) in space below. Any other comments about today’s program can be made here also. Please print your name Specialty
  10. 10. THIS PAGE WAS INTENTIONALLY LEFT BLANK. PLEASE MOVE ON TO THE NEXT PAGE.
  11. 11. Pain Management for Non-Specialists “Introduction to Pain Management” Presented by: Veeraiah C. Perni, M.D. Director of Anesthesiology, Jameson Memorial Hospital Associate Professor of Clinical Anesthesiology Northeastern Ohio Universities College of Medicine
  12. 12. I, Veeraiah C. Perni do not have any conflicts of interest in relation to this presentation.
  13. 13. Evolution of Pain Medicine Pre- 20th Century 20th Century Pain Management Revolution in Pain Management Recent Development
  14. 14. Recent Developments in Pain Management Local anesthetic supplements Novel applications of opiates Non-opioid pharmacologic agents On-demand, patient-controlled analgesia Multi-model analgesia Regional analgesia techniques Pain as a “fifth vital sign” Future of Pain Medicine
  15. 15. Introduction to Pain Management Cont’d Epidemiology of Chronic pain ● Chronic Pain- a public health problem ● 30% of US population has chronic pain ● Prevalence of chronic pain increases with age ● Estimated economic cost for chronic pain at $100 billion per year
  16. 16. ● Pain not taken seriously by the physician ● Doctor’s lack of knowledge of chronic pain ● Inadequate Pain management Inadequacies in the treatment of pain
  17. 17. ● Inadequate medical education ● Healthcare system not recognizing pain relief as a quality of life priority ● Therapy related side effects ● Compliance and regulatory issues ● Increased life expectancy leads to increase in painful chronic medical condition Barriers to appropriate Pain Management
  18. 18. ● 50% of elderly living at home and 80% at long term care facilities have persistent pain ● Physical and psychological toll leading to depression ● Non-adherence to analgesics exacerbates pain ● Shift the goal of pain treatment to functional improvement from decreased suffering ● Patients on combination treatments fare best Barriers to appropriate Pain Management Cont’d
  19. 19. ● Musculoskeletal - ● Neuropathic - ● Visceral pain - ● Metabolic - ● Other - arthritic fractures Diabetic, post herpetic neuralgia Constipation, urinary Retention, CAD Vitamin D deficiency, osteoporosis, Paget’s Disease Fibromyalgia, cancer, PVD, dental Common sources of pain in the elderly
  20. 20. Rickie K. Monroe,M.D. Staff Anesthesiologist Jameson Memorial Hospital
  21. 21. I, Rickie K. Monroe, do not have any conflicts of interest in relation to this presentation.
  22. 22. Goal is painless or nearly painless surgery Anesthesiologist are committed to explore mechanisms for acute postoperative pain
  23. 23. Quantifying clinical postoperative pain Visual analogue scale(VAS) or verbal score Recovery room nurses and floor nurses use this score to quantify acute pain Most adult patients can report a verbal pain score using the range “0” for no pain “10” as the worse pain imaginable.
  24. 24. After nearly all surgeries, pain with activities is much greater than at rest! Pain with activities persist much longer after most surgery than pain at rest.
  25. 25. Parenteral opiods have limited effects on pain after surgery only decreasing the baseline pain at rest In general, the only group of drugs that consistently reduces pain responses is local anesthesics
  26. 26. Epidural analgesia decreases pain with activities Continuous regional analgesic techniques like femoral nerve blocks and brchial plexus block decrease activity pain!
  27. 27. International Association for the Study of Pain defines pain as: “unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” Pain is subjective and emotional experience
  28. 28. Pain implies perception of a number of biochemical and physiologic processes We treat pains of different types because they vary remarkable in response and effective drugs depending on the type of pain being treated.
  29. 29. Peripheral noxious stimulus stimulates specialized receptors on small myelinated and unmyelinated fibers (A gamma , C fibers) Excitatory molecules are released in spinal cord dorsal horn Excited neuron sends signals supraspinally where sensory information is integrated and perceived as pain
  30. 30. Various reflexes are also excited including activation of sympathetic nervous system Regulation takes place by descending excitatory and inhibitory pathways
  31. 31. Signifies the presence of a noxious stimulus that produces actual tissue damage Implies a properly working nervous system Associated with autonomic hyperactivity, i.e. hypertension, tachycardia, sweating Short-lived
  32. 32. Pain from : 1. Recent Surgery 2. Recent Injury 3. Medical Illness Can be managed immediately Usually gets better in short time
  33. 33. Copyright © 2003 American Society of Anesthesiologists. All rights reserved
  34. 34. VISERAL COMPONENT –internal organs heart ,liver intestine SOMATIC COMPONENT-involving skeletal muscle
  35. 35. METHOD OF TREATMENT NSAID’S Opioids Side effects: Intense sedation Respiratory Depression Urinary retention Inhabition of bowel function
  36. 36. Regional Anesthesia 1. Continuous epidural infusion of local anesthetic 2. Spinal administration of morphine(Duramorph) or Fentanyl(Sublimaze) 3. Peripheral nerve block with local anesthesic (Marcaine, Naropin) 4. NSAIDS act to inhibit inflammatory-related pain
  37. 37. “ Do not mix pain prescription drugs with over-the –counter pain relievers without consulting your doctor”
  38. 38. Non-aspirin Pain Relievers Acetaminophen (Tylenol) Dosing (325 -1000 mg po Q4-6hr) Can relieve headaches and minor pain
  39. 39. Nonsteroidal Anti-inflammatory drugs Inhibit the synthesis of prostaglandins Prostaglandins mediate components of the inflammatory response including fever, pain and vasodilatation.
  40. 40. NSAID’S Aspirin (Anacin, Bayer) 325-650 mg po Q 4 prn Coated or Buffered Aspirin (Ascripton , Bufferin) Aspirin with Acetaminophen (Excedrin) Diclofenac (Voltaren)- CV risk, 50 mg po BID- TID
  41. 41. NSAID’s Ketoprofen (Orudis) 75 mg po TID May increase risk of serious and potentially fatal cardiovascular thrombotic event,MI, and stroke Used to reduce swelling and irritation as well as pain Limit no more than 10 days without talking to doctor
  42. 42. Naproxen (Aleve) Over the counter, 250-500mg po q 12 hr Used to relieve pain, inflammation and fever Finding which drugs work is a trial & error process There is no “magic bullet” We try different drugs or combinations until we arrive at what is optimal Individual treatment
  43. 43. NSAID’s Side Effects 1. Induced asthma 2. Renal impairment 3. Reduced platelet aggregation with bleeding risks 4. Risks of peptic ulcer disease 5. Edema 6. Hypertension
  44. 44. Cylo-oxygenase (COX) inhibitors Are effective analgesics in both inflammatory and surgical conditions Decrease opiod reqirements by 30%-50% There is a central site of action Increased risk for cardiovascular events such as MI and stroke : (Vioxx) rofecoxib , (Bextra) valdecoxib
  45. 45. Pain is severe Work on nerve cell’s pain receptors Controversial for chronic pain There is risk of addiction, the risk is decreased if used appropriately Combining medications lets physicians reduce the amount of narcotics
  46. 46. Commonly administered to treat surgical pain Should be administered for treatment of moderate to severe postoperative pain Opioids in the setting of chronic pain management have guidelines in all 50 states
  47. 47. Dispensing physicians should become familiar with the guidelines and maintain appropriate documentation of compliance Treatment agreement between the physician and patient are vital!!! An understanding of tolerance(increasing amount of drug needed to produce the same effect) ,or physical dependence(abrupt cessation of drug will lead to a withdrawl syndrome) as opposed to addiction(where drug is used for reasons other than pain relief)
  48. 48. Respiratory depression CNS depression Hypotension Syncope Shock Seizures Paralytic ileus Dependence, abuse Respiratory arrest Bradycardia Muscle rigidity Cardiac arrest
  49. 49. Codeine Fentanyl Morphine Oxycodone
  50. 50. Morphine (MS Contin)(15-30 mg po q8-12hrs) Avinza – once daily dosing(30,45,60,75,90 ,120 ER) Methadone - inexpensive mu agonist Duration 6-8 hours 2-4 times more potent than morphine Oxycontin(oxycodone) -2 times more potent than morphine Dosage (10,15,20,30,40,60,80 ER) No active metabolites Used in opioid tolerant patients
  51. 51. Morphine-like drugs prescribe d to treat acute pain or cancer pain Hydrocodone with acetaminophen (Vicodan, Lortab, Norco) Acetaminophen with codeine (Tylenol#3,etc.)
  52. 52. Duragesic transdermal skin patch- narcotic treatment for moderate to severe chronic pain Fentanyl delivery for 72 hours 25 mcg/hr patch ~60 mg per day morphine Actiq (Transmucosal 200 mcg times 1 Q 30 minute intervals) Fentora (buccal 100 mcg times 1 Q 30 minute intervals) Fast acting medications containing fentanyl Used for cancer patients who have breakthrough pain
  53. 53. Respiratory depression Respiratory arrest Bradycardia,severe Dependence,abuse Cardiac arrest Circulatory collapse Paralytic ileus
  54. 54. Allows patient to self administer an analgesic agent Incremental dose, lockout interval, maximum dose mg/hr and optional basal rate Preferred to use incremental dose of opioid with short lockout interval to allow frequent dosing ie, morphine 1.5 mg Q 8 min ; 12 mg/hr max. Basal rate usually used only following extensive and extremely painful surgery
  55. 55. Has been demonstrated to result in improved patient satisfaction due to decreased delay in treatment
  56. 56. Ultram(Tramadol) Non-narcotic drug that works on opiate receptors Indicated for moderate to severe chronic pain Less risk of addiction Dosing (50-100mg po q 4-6 hr prn)
  57. 57. Characteristics Drug Relieve certain pain Available only by prescription Used to help sleep better Adjust levels of brain chemicals( Serotonin, Norepinephine) Lower doses than that to treat depression Amitriptyline Elavil Pamelor Norpramin Cancer pain, nerve pain from diabetic neuropathy, post- herpetic neuralgia
  58. 58. Cymbalta Dosing 60 mg po qd Serotonin and norepinephrine reuptake inhibitor FDA approved for treatment of Diabetic Neuropathy and Fibromyalgia
  59. 59. Help some patients described as having “ shooting “ pain by decreasing abnormal painful sensations Still unclear as to how they control pain Post- herpetic neuralgia from shingles Tegretol (200-400 mg po bid) Gabapentin (Neurontin) (300-600 mg po tid) Pregabalin (Lyrica) (100-300 mg po bid-tid)
  60. 60. Neuaxial delivery of drugs will result in lower doses of medications need than systemic delivery Should result in less opiod related side effects
  61. 61. Copyright © 2003 American Society of Anesthesiologists. All rights reserved
  62. 62. I. Pruritis II. Urinary retention III. Hypotension I. Sensory or motor block sensation II. Respiratory depression
  63. 63. 1) Superficial infection 2) Epidural abscess 3) Epidural hematoma
  64. 64. Group of nerves or single nerve causing pain Typically using local anesthetic
  65. 65. Interventional Pain Medicine: Blocks and Procedures Thomas A Ranieri MD, FIPP
  66. 66. Disclosures I, Thomas Ranieri, do not have any conflicts of interest in relation to this presentation
  67. 67. Pain Physicians Fellowship Training in Interventional Techniques Certifications: “Special Qualifications” ABA Diplomat American Board of Pain Medicine Fellow of Interventional Pain Practice Diplomat of American Board of Interventional Pain Medicine
  68. 68. Purpose of Injection/infusion Therapy Diagnostic Therapeutic Prognostic Preemptive
  69. 69. Timeline 1. History and Physical 2. Data acquisition and review 3. Diagnostic testing 4. Physical and Behavioral Medicine Evaluation (Addictionology?) 5. Pharmacologic Intervention 6. Diagnostic/Prognostic/Therapeutic injections (Precision Localization) 7. Neuroablative Techniques 8. Neuroaugmentive Techniques (SCS,PNS,DAS) 9. Functional Restoration 10. Gainful Employment
  70. 70. Trigeminal Ganglion Block/Neurolysis Indications Trigeminal Neuralgia Cluster Headaches Ocular Pain Cancer Pain Surgical Anesthesia Contraindications Local Infection Sepsis Coagulopathy
  71. 71. Anatomy
  72. 72. Fluoroscopic Position
  73. 73. Cervical Nerve Root Indications A-A & A-O joint pain Occipital Headaches C/S radiculalgia Upper Cervical Pain Contraindications Local Infections Coagulopathies Vertical Metastasis Suboccipital craniotomy
  74. 74. Anatomy
  75. 75. Fluoroscopic Image
  76. 76. Sphenopalatine Ganglion Block Indications SPG Neuralgia Trigeminal Neuralgia Headaches Atypical Facial Pain Herpes Zoster Ophthalmicus Cancer Contraindications Infection Coagulopathy Relative Altered anatomy ie surgery, infection or genetic variations
  77. 77. Anatomy
  78. 78. Fluoroscopy
  79. 79. Sphenopalatine Block
  80. 80. Stellate Ganglion Block Indications Raynaud’s Disease Arterial Embolism Meniere`s disease Herpes Zoster Post-traumatic syndrome (CRPS I & II, Sudeck’s Disease) Pulmonary Embolism Contraindications Anticoagulant Pneumothorax & Pneumonectomy on the contralateral side Recent Cardiac Infarction Glaucoma Bradycardia
  81. 81. Anatomy
  82. 82. Stellate Block
  83. 83. Atlanto-Occipital Block Occipital Headaches Pain on rotation when performed protraction or retraction Contraindications: Local Infection Coagulopathy C/S instability
  84. 84. Anatomy
  85. 85. A-O Block
  86. 86. Atlanto-Axial Block Indications: Occipital Headaches – sub-occipital region C1-C2 Hypomobility Contraindications: Infections Surgical Fusion Cervical Surgery Relative: Arnold Chiari Mets to the Cervical Corpus Dens Fracture Bleeding disorder
  87. 87. Anatomy
  88. 88. A-A Block
  89. 89. Cervical Facets Indications: Whiplash Injuries Mechanical Neck Pain Cervical Sprain/Strain Cervicogenic Cephalgia Contraindications: Infections Coagulopathy
  90. 90. Anatomy
  91. 91. Cervical Facets
  92. 92. Cervical Discogram Indications: Persistent neck and arm pain Equivocal Findings on MRI Prior to Cervical Fusion S/P Fusion to ID transitional levels Cannot distinguish between scar and recurrent disk Contraindications: Infection Bleeding Immunocompromised
  93. 93. Anatomy
  94. 94. Cervical Discography
  95. 95. T2 and T3 Sympathetic Blocks Indications include upper extremity SMP and Vascular disease Contraindications: Absolute: Infection, bleeding & sepsis Relative: Thoracic aneurysm and Respiratory Insufficiency
  96. 96. Anatomy
  97. 97. Thoracic Sympathetic Block
  98. 98. Other Blocks and Procedures Intercostals – Injections/Cryo/RFL Thoracic – facets, disco, epidurals, SNRB – blocks/RFL/Discectomy Suprascapular – blocks and RFL Lumbar – Epidurals, SNRB, Disco, Facets/RFL/Annuloplasty/Perc-D Endoscopic Discectomy Percutaneous Facet Fusion Celiac and Splanchnic N Blocks/lysis/RFL
  99. 99. Disk Procedures Symptomatic Disk Disruption IDET Biaculoplasty, Disk-it, Stereotactic Disk Lesioning Intervertebral Disk Displacement Nucleoplasty - C/S, T/S, L/S DeKompressor – C/S, T/S, L/S SED – C/S, L/S, T12-L1 disk
  100. 100. IDET
  101. 101. Nucleoplasty
  102. 102. Nucleoplasty
  103. 103. Biaculoplasty
  104. 104. Stereotactic Radiofrequency Disk Lesioning
  105. 105. DeKompressor
  106. 106. Dekompressor
  107. 107. Endoscopic Discectomy Patient – Monitored Anesthesia Care Patient has failed all conservative measures Patient prefers not to undergo open discectomy Does not burn any bridges
  108. 108. Transforaminal Lumbar Discectomy (SED)
  109. 109. SED Procedure
  110. 110. YES Scope
  111. 111. TruFuse Facet Mediated Pain Failed all conservative measures including RFL Burns NO bridges Patients receive general anesthesia Addresses underlying problem
  112. 112. Indications Isolated Facet based back pain Minor instability Adjunct to motion limiting devices Augment posterior stabilization Contraindications Trauma, High Grade instability, Spondylolysis and Grade 2 or higher Spondylolisthesis
  113. 113. Trufuse Allograft Bone Dowels
  114. 114. Vertebral Augmentation Indications – VCFx due to osteoporosis, Tumor, angiomas Contraindications – infection, coagulopathy, vertebra Plana, Retropulsion, non- visualization Kyphoplasty – Balloon Tamp cavity creation, endplate elevator and PMMA delivery Vertebroplasty – PMMA delivery
  115. 115. Vertebroplasty
  116. 116. Kyphoplasty
  117. 117. Epiduroscopy Epidural steroid injections in patients with previous surgery Lysis of perineural adhesions Puncture and aspiration of synovial cysts and CSF inclusion cysts Irrigation of spinal canal after and extruded or sequestered disk fragment
  118. 118. Epidural Fibrosis
  119. 119. Procedure
  120. 120. Images
  121. 121. Spinal Cord Stimulation Indications: Failed Back Peripheral Vascular Disease and ischemic pain CRPS Post-Herpetic Neuralgia Visceral Pain – Angina, thoracic or AAA Deafferentiation Torticollis, MS and Cerebral Palsy Peripheral Nerve Stimulation
  122. 122. SCS Demonstrated relief with the temporary electrode ( 50% or greater) Cleared by Behavioral Medicine Failed all Measures including surgical Not addicted or in litigation
  123. 123. Drug Administration System • Indications: – Pain type and generator appropriate – Demonstrated opioid responsiveness – No untreated psychopathology – Demonstrated relief with trial catheter
  124. 124. DAS • Exclusion Criteria: – Aplastic Anemia and systemic infection – Known allergies to the materials in the implant – Known allergies to the medicines considered – Active intravenous drug use – Psychosis or dementia
  125. 125. Intrathecal Drug Administration
  126. 126. DAS
  127. 127. Summary • Interventions are performed to identify, treat and ablate pain generators • In depth knowledge of fluoroscopic anatomy is necessary • Each individual case presents its own problems relative patients own intentions i.e. secondary gain, depression,factitious • Each case must pass the “Yo Mama” test
  128. 128. Proper Opiate Prescribing Guidelines John D. Wrightson, M.D. FAAPMR Board Certified in Physical Medicine, Rehabilitation & Pain Management
  129. 129. I, John D. Wrightson, do not have any conflicts of interest in relation to this presentation.
  130. 130. Proper Opiate Prescribing Guidelines When is prescribing appropriate? What information is necessary before prescribing? What are the laws regarding prescription narcotic use? • For Physicians? • For Patients?
  131. 131. Proper Opiate Prescribing Guidelines What are the differences between dependence, tolerance, addiction and pseudo-addiction? How should the patient taking long-term opiate medication for chronic non-malignant pain be managed? • Treatment options? What are the requirements necessary to either discontinue prescription narcotic use or discharge a patient for either abuse or diversion?
  132. 132. Proper Opiate Prescribing Guidelines When is prescribing appropriate? Acute pain : Pain that comes on quickly, can be severe, but lasts a relatively short time. As opposed to chronic pain. Chronic pain: Pain (an unpleasant sense of discomfort) that persists or progresses over a long period of time. In contrast to acute pain that arises suddenly in response to a specific injury and is usually treatable, chronic pain persists over time and is often resistant to medical treatments. Pitfall: How can physicians be certain that a patient’s pain is legitimate and that the painful condition warrants the use of narcotics?
  133. 133. Proper Opiate Prescribing Guidelines What information is necessary before prescribing? More important for patient’s requiring chronic opiate management. What does the patient’s history & physical examination show? What is documented in diagnostic testing records? What documentation is appropriate? (Above, plus pharmacy records, urine drug screen)
  134. 134. Proper Opiate Prescribing Guidelines What are the laws regarding prescription narcotic use? • For Physicians? • For Patients?
  135. 135. Proper Opiate Prescribing Guidelines The Tenets of Lawful Prescribing A lawful prescription for a controlled substance must be: Issued for a legitimate medical purpose By an individual practitioner acting in the usual course of his or her professional practice. Physician-patient relationship exists. Documented in the medical records.
  136. 136. Proper Opiate Prescribing Guidelines Summary of Federal Law Federal law does not preclude the use of opioid’s as analgesics for legitimate medical purposes, including treating chronic pain and treating pain in addicts. Federal law does prohibit the use of opioids to maintain an addicted state without special registration as an NTP
  137. 137. Proper Opiate Prescribing Guidelines Patient responsibilities: Take medication as prescribed Do not share medication Do not accept medications from other people, physicians Essentially, adhere to pain management agreement
  138. 138. Proper Opiate Prescribing Guidelines What are the differences between dependence, tolerance, addiction and pseudo-addiction? Dependence Tolerance Addiction Pseudoaddiction
  139. 139. Proper Opiate Prescribing Guidelines Dependence: refers to a state resulting from chronic use of a drug that has produced tolerance and where negative physical symptoms of withdrawal result from abrupt discontinuation or dosage reduction.
  140. 140. Proper Opiate Prescribing Guidelines Tolerance: decrease in susceptibility to the effects of a drug due to its continued administration.
  141. 141. Proper Opiate Prescribing Guidelines ADDICTION: drug addiction, a condition characterized by an overwhelming desire to continue taking a drug to which one has become habituated through repeated consumption because it produces a particular effect, usually an alteration of mental status. Addiction is usually accompanied by a compulsion to obtain the drug, a tendency to increase the dose, a psychologic or physical dependence, and detrimental consequences for the individual and society. Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.
  142. 142. Proper Opiate Prescribing Guidelines Pseudoaddiction: Pattern of drug seeking behavior of pain patients receiving inadequate pain management that can be mistaken for addiction Cravings and aberrant behavior Concerns about availability “Clock-watching” Unsanctioned dose escalation **Can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.
  143. 143. Proper Opiate Prescribing Guidelines How should the patient taking long-term opiate medication for chronic non-malignant pain be managed? Monthly evaluations Random urine drug screens & pill counts Pain Management Agreement Opiate Informed consent
  144. 144. Proper Opiate Prescribing Guidelines How should the patient taking long-term opiate medication for chronic non-malignant pain be managed? • Treatment options? Poly-pharmacy, inclusive of NSAIDS, muscle relaxants, anti-convulsants, anti-depressants (TCA’s, SSRI’s, SNRI’s), opiates, etc… Physical therapy Occupational therapy Psychiatric therapy Cognitive-behavioral therapy Surgical intervention
  145. 145. Proper Opiate Prescribing Guidelines What are the requirements necessary to either discontinue prescription narcotic use or discharge a patient for either abuse or diversion? Repeated phone calls to the office requesting early narcotic refills. Unusual excuses to explain loss, theft or damage to narcotic medication. Tainted urine drug screens.
  146. 146. Proper Opiate Prescribing Guidelines Continued discharge criteria: Incorrect pill count Evidence of Doctor Shopping
  147. 147. Proper Opiate Prescribing Guidelines Physician obligation to patient: If discontinuing opiates only: letter outlining to the patient of such necessity Offer patient the opportunity to attend rehab If discharging a patient: Letter of discharge if patient being released from practice Offer patient opportunity to attend rehab One month supply of discharge or withdrawal medication
  148. 148. Proper Opiate Prescribing Guidelines Conclusion: It is often appropriate and necessary to prescribe narcotic based medications. As long as these guidelines are adhered to, physicians may prescribe them without fear of disciplinary action or prosecution.
  149. 149. Chronic Intractable Pain andChronic Intractable Pain and Opioids:Opioids: Relieve sufferingRelieve suffering Avoid addictionAvoid addiction Limit liabilityLimit liability Thomas A Ranieri MD, FIPP, DABIPPThomas A Ranieri MD, FIPP, DABIPP Allied Pain Treatment CentersAllied Pain Treatment Centers
  150. 150. DisclosuresDisclosures I, Thomas Ranieri, have no conflict of interest inI, Thomas Ranieri, have no conflict of interest in relation to this presentation.relation to this presentation.
  151. 151. Prescribing Controlled DrugsPrescribing Controlled Drugs A Question of BalanceA Question of Balance ““The underThe under--prescribing of controlled drugsprescribing of controlled drugs for acute, chronic and malignant pain, andfor acute, chronic and malignant pain, and (perhaps) anxiety is extremely widespread(perhaps) anxiety is extremely widespread and contributes to significant patientand contributes to significant patient morbidity.morbidity.”” 1988 AMA/White House Symposium1988 AMA/White House Symposium
  152. 152. Prescribing Controlled Drugs:Prescribing Controlled Drugs: A Question of BalanceA Question of Balance ““The overThe over--prescribing of controlledprescribing of controlled drugs contributes to societal substancedrugs contributes to societal substance abuse, iatrogenic dependence, increasedabuse, iatrogenic dependence, increased morbidity, and a risk managementmorbidity, and a risk management nightmare.nightmare.”” 1988 AMA/White House Symposium1988 AMA/White House Symposium
  153. 153. Number of U.S. TreatmentNumber of U.S. Treatment Admissions and EmergencyAdmissions and Emergency Department Mentions forDepartment Mentions for Narcotic Painkillers, 1995Narcotic Painkillers, 1995--20022002 1995 1996 1997 1998 1999 2000 2001 2002 30,000 40,000 50,000 60,000 70,000 80,000 90,000 100,000 110,000 Treatment Admissions Emergency Department Mentions
  154. 154. Unintentional Drug PoisoningUnintentional Drug Poisoning Paulozzi et al.Paulozzi et al. –– Pharmacoepidemiol Drug Saf. 2006 15(9):618Pharmacoepidemiol Drug Saf. 2006 15(9):618--627627 Average Mortality IncreasedAverage Mortality Increased 5%/year from 19795%/year from 1979--19901990 18%/year from 199018%/year from 1990--20022002 Opioid poisoning vs. Cocaine, Heroin from 1999Opioid poisoning vs. Cocaine, Heroin from 1999--20022002 91% inc. with Opioids91% inc. with Opioids 33% inc. with Cocaine33% inc. with Cocaine 12% inc. Heroin12% inc. Heroin 2002 Statistics2002 Statistics 32% Methadone32% Methadone 54% other opioids54% other opioids 13% synthetic Opioids13% synthetic Opioids
  155. 155. Number of new nonNumber of new non--medicalmedical users of therapeuticsusers of therapeutics (NSDUH, 2002)
  156. 156. Drug Abuse: An EpidemicDrug Abuse: An Epidemic Current illicit drug use in 2006(1 mo. Prior to survey) NSDUH SuCurrent illicit drug use in 2006(1 mo. Prior to survey) NSDUH Surveyrvey Among Populations aged 12 or olderAmong Populations aged 12 or older 20.4 million Americans or 8.3% of population20.4 million Americans or 8.3% of population Nearly 8,000 initiates per dayNearly 8,000 initiates per day Among population aged 12 o 17Among population aged 12 o 17 9.8% of population9.8% of population Among population aged 18 or olderAmong population aged 18 or older 18.5 million current users18.5 million current users 13.4 million (74.9%) employed part or full time13.4 million (74.9%) employed part or full time Lifetime useLifetime use –– 111.8 million111.8 million Past yearPast year –– 35.8 million35.8 million Illicit drug use other than marijuanaIllicit drug use other than marijuana Life time 72.9 millionLife time 72.9 million Past year 21.3 millionPast year 21.3 million Current 9.6 millionCurrent 9.6 million
  157. 157. Chronic intractable pain: theChronic intractable pain: the clinical challengeclinical challenge Be aware of theBe aware of the ““Heart SinkHeart Sink”” patient.patient. Remain within your area of expertise.Remain within your area of expertise. Utilize Interventional Pain Medicine to validateUtilize Interventional Pain Medicine to validate complaint (Injection and/or Differential infusions)complaint (Injection and/or Differential infusions) Stay grounded in you role:Stay grounded in you role: COMFORT ALWAYSCOMFORT ALWAYS THENTHEN…….... CURE SOMETIMESCURE SOMETIMES
  158. 158. Prescribing Controlled DrugsPrescribing Controlled Drugs The DoctorsThe Doctors PitfallsPitfalls ““I just donI just don’’t prescribe any controlled drugs in myt prescribe any controlled drugs in my practicepractice”” ““If patients abuse their medications, that is theirIf patients abuse their medications, that is their problem not mineproblem not mine”” ““I only prescribe controlled drugs in extremeI only prescribe controlled drugs in extreme situations, and only if pushedsituations, and only if pushed””
  159. 159. Chronic Pain Management:Chronic Pain Management: decisions regarding chronic opioiddecisions regarding chronic opioid therapytherapy What are the indication for considering chronicWhat are the indication for considering chronic opioids in chronic pain syndromes?opioids in chronic pain syndromes? IndicationIndication –– patient specific and disease specificpatient specific and disease specific ContraindicationsContraindications
  160. 160. Indications forIndications for possiblepossible chronicchronic opioidsopioids THE FIVE QUESTIONSTHE FIVE QUESTIONS Is there a clear diagnosis?Is there a clear diagnosis? Is there documentation of an adequate workIs there documentation of an adequate work--up?up? Is there impairment of function?Is there impairment of function? HasHas nonnon--opioid multi modal therapyopioid multi modal therapy failed?failed? Are contraindications to opioid therapy ruled out?Are contraindications to opioid therapy ruled out? Begin opioid therapyBegin opioid therapy……Document! Monitor!Document! Monitor! Avoid polyAvoid poly--pharmacypharmacy
  161. 161. Contraindications to chronicContraindications to chronic opioid prescribingopioid prescribing Allergy to opioid medications ~ relativeAllergy to opioid medications ~ relative Current addiction to opioids ~ ?Current addiction to opioids ~ ?absoluteabsolute Past addiction to opioids ~ ?Past addiction to opioids ~ ?absoluteabsolute Current /past addiction, opioids never involvedCurrent /past addiction, opioids never involved ~~ relative, ??absolute if cocainerelative, ??absolute if cocaine Severe COPD ~ relativeSevere COPD ~ relative
  162. 162. Prescription Drug AbusePrescription Drug Abuse The DrugsThe Drugs All euphoria producing drugs (EPDAll euphoria producing drugs (EPD’’s) haves) have abuse and dependence producing potentialabuse and dependence producing potential SedativeSedative--hypnotics / Stimulants / Opioidshypnotics / Stimulants / Opioids Totally DIFFERENT classesTotally DIFFERENT classes What do they have in common?What do they have in common? Acute release of DOPAMINE from the VTM toAcute release of DOPAMINE from the VTM to the frontal cortexthe frontal cortex
  163. 163. Chronic pain management:Chronic pain management: ruling out addictionruling out addiction Perform an AUDIT and CAGE.Perform an AUDIT and CAGE. Ask family or sig. other the fAsk family or sig. other the f--CAGE.CAGE. Perform one or more toxicology tests.Perform one or more toxicology tests. Inquire of prior physicians re: use of controlledInquire of prior physicians re: use of controlled prescriptions (fprescriptions (f--CAGE).CAGE). If history of current or prior addiction, everIf history of current or prior addiction, ever abused opioids?abused opioids?
  164. 164. Screening for Addiction: theScreening for Addiction: the CAGE and fCAGE and f--CAGECAGE CAGE =CAGE = CCut down on use? Comments byut down on use? Comments by friends and family about use that havefriends and family about use that have aannoyednnoyed you? Embarrassed bashful oryou? Embarrassed bashful or gguilty re: behaviorsuilty re: behaviors when using?when using? EEyeye--openers to get started in theopeners to get started in the mornings?mornings? FF--CAGE = Ask the patientCAGE = Ask the patient’’s significant others significant other the CAGE about the patientthe CAGE about the patient’’s use of alcohol,s use of alcohol, drugs or controlled prescriptions.drugs or controlled prescriptions.
  165. 165. Assessment of AddictionAssessment of Addiction Differentiate between misuse, abuse andDifferentiate between misuse, abuse and addiction behaviorsaddiction behaviors Distinguish between primary addictive diseaseDistinguish between primary addictive disease and pain underand pain under--treatmenttreatment Refer when neededRefer when needed-- Addictionology, PsychiatryAddictionology, Psychiatry and Interventional Pain (validation)and Interventional Pain (validation)
  166. 166. TERMSTERMS ToleranceTolerance: The development of a need to take increasing: The development of a need to take increasing doses of a medication to obtain the same effect;doses of a medication to obtain the same effect; tachyphylaxis is the term used when this processtachyphylaxis is the term used when this process happens quickly.happens quickly. DependenceDependence: The development of substance specific: The development of substance specific symptoms of withdrawal after the abrupt stopping of asymptoms of withdrawal after the abrupt stopping of a medication; these symptoms can be physiological onlymedication; these symptoms can be physiological only (i.e., absence of psychological or behavioral maladaptive(i.e., absence of psychological or behavioral maladaptive patterns).patterns).
  167. 167. TERMSTERMS AddictionAddiction: The development of a maladaptive pattern of: The development of a maladaptive pattern of medication use that leads to clinically significantmedication use that leads to clinically significant impairment or distress in personal or occupationalimpairment or distress in personal or occupational roles. This syndrome also includesroles. This syndrome also includes a great deal of timea great deal of time used to obtain the medication, use the medication, orused to obtain the medication, use the medication, or recover from its effects; loss of control over medicationrecover from its effects; loss of control over medication use; continuation of medication use after medical oruse; continuation of medication use after medical or psychological adverse effects have occurredpsychological adverse effects have occurred..
  168. 168. TermsTerms ““PseudoPseudo--addictionaddiction”” Definition: Patients with severe unrelieved painDefinition: Patients with severe unrelieved pain become intensely focused on obtaining relief, and canbecome intensely focused on obtaining relief, and can mimic aspects of drug seeking (aberrant) behavior.mimic aspects of drug seeking (aberrant) behavior. (Haddox, 1990)(Haddox, 1990) This behavior should resolve when adequate pain relief isThis behavior should resolve when adequate pain relief is provided, without evidence of loss of control, escalation,provided, without evidence of loss of control, escalation, binging, etc.binging, etc. Pseudoaddiction is a pseudoPseudoaddiction is a pseudo--diagnosis (ASIPPdiagnosis (ASIPP --2008)2008)
  169. 169. Tips for prescribing of chronicTips for prescribing of chronic opioidsopioids Factor in tolerance (already on opioids).Factor in tolerance (already on opioids). Start low/go slow (not already on opioids).Start low/go slow (not already on opioids). Slow release, long acting preparations.Slow release, long acting preparations. Fixed dosing, avoid prnFixed dosing, avoid prn’’s.s. Avoid opioids forAvoid opioids for ““breakthroughbreakthrough”” pain.pain. Avoid polyAvoid poly--pharmacy involvingpharmacy involving controlledcontrolled drugsdrugs!!!!!!
  170. 170. Prescription Drug AbusePrescription Drug Abuse Drugs to Avoid & AlternativesDrugs to Avoid & Alternatives Controlled drugs to avoid prescribingControlled drugs to avoid prescribing Side effectSide effect meperidine, propoxyphene, butalbitalmeperidine, propoxyphene, butalbital Narrow toxic/therapeuticNarrow toxic/therapeutic secobarbital, pentobarbital, meprobamate,secobarbital, pentobarbital, meprobamate, ethchlorvynolethchlorvynol Lack of efficacyLack of efficacy carisoprodol (Soma), propoxyphenecarisoprodol (Soma), propoxyphene
  171. 171. Prescription Drug AbusePrescription Drug Abuse Drugs to Avoid & AlternativesDrugs to Avoid & Alternatives ALTERNATIVES:ALTERNATIVES: Meperidine =Meperidine = anyany other CII medication!other CII medication! Butalbital = DHE / compazine / tramadol / etcButalbital = DHE / compazine / tramadol / etc Sedative Hypnotics =Sedative Hypnotics = anyany benzodiazepinebenzodiazepine Soma = baclofen / skelaxin / flexeril / etcSoma = baclofen / skelaxin / flexeril / etc Propoxyphene = other opioids / NSAIDS (cox I orPropoxyphene = other opioids / NSAIDS (cox I or II) / acetaminophen / tramadolII) / acetaminophen / tramadol
  172. 172. Documentation when initiating aDocumentation when initiating a chronic opioid treatment planchronic opioid treatment plan Identify a clear diagnosisIdentify a clear diagnosis Document an adequate workDocument an adequate work--up.up. Ensure that nonEnsure that non--opioid therapy failed or is notopioid therapy failed or is not appropriate (appropriate (treatment rationaletreatment rationale).). Identify anticipated outcome (treatmentIdentify anticipated outcome (treatment goalgoal).). Strongly consider anStrongly consider an opioid agreementopioid agreement.. Consult a physician with expertise in the organ systemConsult a physician with expertise in the organ system involved.involved.
  173. 173. Rules Governing Prescription ofRules Governing Prescription of OpiatesOpiates State of Ohio Medical and Pharmacy BoardsState of Ohio Medical and Pharmacy Boards Cannot prescribe opiates to an addict with Chronic pain unless tCannot prescribe opiates to an addict with Chronic pain unless thehe patient is under the care of an addictionologistpatient is under the care of an addictionologist Patients being prescribed opiates for a documented Chronic painPatients being prescribed opiates for a documented Chronic pain diagnosis must also be evaluated and treated by Psychiatry and/odiagnosis must also be evaluated and treated by Psychiatry and/orr Clinical PsychologistClinical Psychologist Must adhere to the state medical rules governing controlled subsMust adhere to the state medical rules governing controlled substancetance prescriptionprescription
  174. 174. RulesRules These rules do not apply when prescribingThese rules do not apply when prescribing nonnon--narcotic medication for chronic painnarcotic medication for chronic pain
  175. 175. RulesRules Documentation of improvement of function ADLs,Documentation of improvement of function ADLs, employment, volunteering exerciseemployment, volunteering exercise Documentation of patient compliance and nonDocumentation of patient compliance and non-- diversiondiversion Documentation the patient is not an addictDocumentation the patient is not an addict Specialist can assume the care but is usually aSpecialist can assume the care but is usually a consultantconsultant Evaluate progress toward treatment objectivesEvaluate progress toward treatment objectives
  176. 176. What are the Rules?What are the Rules? Documentation of PathologyDocumentation of Pathology Validation of complaint by more than one source i.e.Validation of complaint by more than one source i.e. consultantsconsultants Identify and document pain mechanismIdentify and document pain mechanism Prescribe amounts within the PDRPrescribe amounts within the PDR’’s Recommendations Recommendation Documentation of continued needDocumentation of continued need Use mostly long acting medications unlessUse mostly long acting medications unless contraindicatedcontraindicated
  177. 177. DiagnosticsDiagnostics LaboratoryLaboratory Imaging and Nuclear StudiesImaging and Nuclear Studies NeurophysiologicNeurophysiologic Neural Scan, EMG/NCV, AutonomicNeural Scan, EMG/NCV, Autonomic Vascular StudiesVascular Studies Diagnostic InjectionsDiagnostic Injections ValidationValidation IdentificationIdentification SuppressionSuppression PrognosticPrognostic Reduction of InflammationReduction of Inflammation
  178. 178. Purpose of Injection TherapyPurpose of Injection Therapy Augment healingAugment healing –– steroids/ PFP is comingsteroids/ PFP is coming Promote normal physiologyPromote normal physiology –– Synvisc/PFPSynvisc/PFP Enhance central modulationEnhance central modulation –– 10%NACL/Phenol10%NACL/Phenol Validation of Pain complaintValidation of Pain complaint Identify Pain mechanism and pathwayIdentify Pain mechanism and pathway Limit consumption of psychoactive substanceLimit consumption of psychoactive substance Augment and enhance rehabilitationAugment and enhance rehabilitation
  179. 179. Monitoring strategy whenMonitoring strategy when prescribing chronic opioidsprescribing chronic opioids Document functional improvement.Document functional improvement. Titrate opioids to improved function.Titrate opioids to improved function. Monitor medications (pill counts).Monitor medications (pill counts). Avoid nonAvoid non--planned escalation.planned escalation. Monitor for scams (controlled drug consent)Monitor for scams (controlled drug consent) Perform occasional toxicology tests.Perform occasional toxicology tests. Document, document, document!Document, document, document!
  180. 180. Prescription Drug AbusePrescription Drug Abuse Scams #1Scams #1 Spilled the bottleSpilled the bottle The dog ate itThe dog ate it Lost the prescriptionLost the prescription Washed in laundryWashed in laundry Medications stolenMedications stolen Left somewhereLeft somewhere The PharmacistThe Pharmacist ““shortedshorted”” meme
  181. 181. Prescription Drug AbusePrescription Drug Abuse Scams #2Scams #2 Physician heal thyselfPhysician heal thyself Oh, by the wayOh, by the way You are the only one who understands...You are the only one who understands... Rx lifting/alteringRx lifting/altering Late calls/cross coverageLate calls/cross coverage John Hancock/John Hancock/““Dear DoctorDear Doctor””
  182. 182. Dealing with ScamsDealing with Scams PrinciplesPrinciples Cops vs Docs attitudesCops vs Docs attitudes No offense but...No offense but... Learn to recognize common scamsLearn to recognize common scams –– USE AUSE A CONTROLLED DRUG CONSENT!CONTROLLED DRUG CONSENT! Just say no (and mean it)Just say no (and mean it) Turn the tablesTurn the tables
  183. 183. Emergency contraindications toEmergency contraindications to continued controlled drug prescribingcontinued controlled drug prescribing (above all, first do no harm)(above all, first do no harm) Altering a prescription = FELONYAltering a prescription = FELONY Selling Rx. drugs = DRUG DEALINGSelling Rx. drugs = DRUG DEALING Accidental/intentional overdose = DEATHAccidental/intentional overdose = DEATH Threatening staff = EXTORTIONThreatening staff = EXTORTION Too many scams = OUT OF CONTROLToo many scams = OUT OF CONTROL
  184. 184. Emergency contraindications to continuedEmergency contraindications to continued controlled drug prescribingcontrolled drug prescribing (above all, first do no harm)(above all, first do no harm) What is a physician to do?What is a physician to do? 1) Identify the contraindicated behavior.1) Identify the contraindicated behavior. 2) Show where agreement was broken.2) Show where agreement was broken. 3) State that prescribing is inappropriate.3) State that prescribing is inappropriate. 4) Educate about withdrawal symptoms.4) Educate about withdrawal symptoms. 5) Instruct to go to the E.R. if withdrawal.5) Instruct to go to the E.R. if withdrawal. 6) Offer care with out Rx, and/or referral6) Offer care with out Rx, and/or referral..
  185. 185. Signs and symptoms of opioidSigns and symptoms of opioid withdrawalwithdrawal HEENT, CV, GI, MS, Neuro/Psych.HEENT, CV, GI, MS, Neuro/Psych. HEENTHEENT-- dilated pupils, lacrimation, rhinorrhea,dilated pupils, lacrimation, rhinorrhea, yawningyawning CVCV-- tachycardia, hypertensiontachycardia, hypertension GIGI-- nausea, vomiting, diarrhea, abd. crampsnausea, vomiting, diarrhea, abd. cramps MSMS-- piloerection, diaphoresis, myalgias,piloerection, diaphoresis, myalgias, arthralgias, bone painsarthralgias, bone pains N/PN/P--insomnia, anxiety, headache, dysphoriainsomnia, anxiety, headache, dysphoria
  186. 186. Are chronic opioids appropriate?Are chronic opioids appropriate? ReRe--documentdocument:: DiagnosisDiagnosis WorkWork--upup Treatment goalTreatment goal Functional statusFunctional status Monitor ProgressMonitor Progress:: Pill countsPill counts FunctionFunction Refill flow chartRefill flow chart Occasional urineOccasional urine toxicologytoxicology Adjust medicationsAdjust medications Watch for scamsWatch for scams Physical Dependence vs AddictionPhysical Dependence vs Addiction:: Chemical dependenceChemical dependence screeningscreening Toxicology testsToxicology tests Pill countsPill counts Monitor for scamsMonitor for scams Reassess forReassess for appropriatenessappropriateness Educate patientEducate patient on need toon need to discontinue opioidsdiscontinue opioids EmergencyEmergency?? ie: overdosesie: overdoses selling medsselling meds altering Rxaltering Rx NO!NO! 33--month self tapermonth self taper (document in chart)(document in chart) OKOK 1010--week structured taperweek structured taper OKOK Discontinue opioids atDiscontinue opioids at end of structured taperend of structured taper Pain Patient onPain Patient on Chronic OpioidsChronic Opioids ++ New PhysicianNew Physician YES!YES! UNSUREUNSURE NONO YES!YES! Discontinue opioidsDiscontinue opioids Instruct patient onInstruct patient on withdrawal symptomswithdrawal symptoms Tell to “go to ER”Tell to “go to ER” if withdrawal symptomsif withdrawal symptoms
  187. 187. Opioid w/d treatment optionsOpioid w/d treatment options Gradual self taper over three months**Gradual self taper over three months** 10 week structured taper**10 week structured taper** Abrupt discontinuation and detoxificationAbrupt discontinuation and detoxification MethadoneMethadone ClonidineClonidine BuprenorphineBuprenorphine TramadolTramadol UltraUltra--Rapid Opiate DetoxificationRapid Opiate Detoxification –– Consent &Consent & ComplianceCompliance ** =** = nonnon--emergency patientemergency patient with a legitimate pain diagnosis.with a legitimate pain diagnosis.
  188. 188. Chronic intractable pain: theChronic intractable pain: the clinical challengeclinical challenge Be aware of theBe aware of the ““Heart SinkHeart Sink”” patient.patient. Remain within your area of expertise.Remain within your area of expertise. Stay grounded in you roleStay grounded in you role Utilize Interventional Pain Physician forUtilize Interventional Pain Physician for Diagnostic/DifferentialDiagnostic/Differential -- Injections/InfusionsInjections/Infusions FIRSTFIRST…….DO NO HARM.DO NO HARM THENTHEN…….... CURE SOMETIMESCURE SOMETIMES COMFORT ALWAYSCOMFORT ALWAYS
  189. 189. Pain Management forPain Management for the Nonthe Non--SpecialistSpecialist Presented by: Veeraiah C. Perni, M.D. Director of Anesthesiology Jameson Memorial Hospital
  190. 190. I, Veeraiah C. Perni do not have any conflicts of interest in relation to this presentation.
  191. 191. Practical Pain Management forPractical Pain Management for NonNon--SpecialistsSpecialists Target clinical specialty Guideline objectives Assessment /Evaluation Management/Rehabilitation/Treatment Chronic low back pain: ACP/APS recommendations Special focus on Cancer pain and palliative medicine Tips on referrals to pain specialist How to get paid for Pain Management
  192. 192. Target Clinical SpecialtyTarget Clinical Specialty Family Practice Internal Medicine Pediatrics Physical Medicine and Rehabilitation Psychology Surgery Hospitals/Allied Health Personnel
  193. 193. Guideline ObjectivesGuideline Objectives Chronic Pain; scope/definition To improve by bio-psychosocial assessment The target is management not elimination Multidisciplinary team approach; the primary care physician as team leader The goal of treatment is to improve function through fitness and healthy lifestyle To improve the effective use of medications and interventional techniques
  194. 194. Key Points in the History of theKey Points in the History of the Chronic Pain PatientChronic Pain Patient Pain location, intensity, quality, onset, duration, effects of pain, and pain relief A general history and physical exam are essential A history of depression or other psychopathology Past or current physical, sexual, or emotional abuse A history of chemical dependency Patient self report is remarkable
  195. 195. Other Methods of AssessmentOther Methods of Assessment Diagnostic Testing - There is no diagnostic test for chronic pain - Plain radiography – musculoskeletal pain - CT/MRI for spine pathology - CT Myelography for pts. considered for surgery - Electromyography / nerve conduction studies for LMN dysfunction, nerve or nerve root pathology or myopathy Functional Assessment Pain Assessment Tools
  196. 196. Determination of BiologicalDetermination of Biological Mechanism of PainMechanism of Pain Pain classification and types of pain - Neuropathic Pain - Muscle Pain - Inflammatory Pain - Mechanical/compression pain Decades ago, all chronic pain was treated similarly Mechanism – specific treatment Pain usually has more than one mechanism
  197. 197. Neuropathic PainNeuropathic Pain Cause – damage or dysfunction of the nervous system - sciatica from nerve root compression - diabetic peripheral neuropathy - trigeminal / Post herpetic neuralgia Clinical Features - the setting; the first clue - the distribution; follows the nerve distribution - the character; burning, shooting, stabbing - findings of physical examination: numbness, coolness, and allodynia
  198. 198. Muscle PainMuscle Pain Causes - muscle pain of chronic pain - fibromyalgia syndrome and, - myofascial pain syndrome Common Clinical Features - sore, stiff, aching, painful muscles - fatigue, poor sleep, depression, headache, and irritable bowel syndrome - acute muscle pain occasionally - pain related disability is a challenge to the health care system
  199. 199. Fibromyalgia Syndrome - Widespread musculoskeletal disease Myofascial Pain Syndrome - regional muscle and soft tissue pain - trigger points refer pain - Widespread musculoskeletal disease
  200. 200. Causes - Tissue Injury, postoperative, osteo-arthritic pain, infection - same as nociceptive pain - inflammatory chemicals stimulate primary sensory nerves and carry information to the spinal cord Clinical Features - heat, redness, and swelling Inflammatory PainInflammatory Pain
  201. 201. Mechanical / Compression PainMechanical / Compression Pain Causes : muscle / ligament strain, degeneration of discs, facets or osteoporosis with compression fractures, fractures, dislocation, obstruction, and compression by bony tumors Same as nociceptive pain Aggravated by activity and usually relieved rest Radiology very helpful
  202. 202. Pain ManagementPain Management --AlgorithmAlgorithm Develop a written plan of care and set goals using the bio-psychosocial model All patients with chronic pain must participate in an exercise fitness program Set personal goals/restructuring life Improve sleep, manage stress Decrease pain Patients want quick fix, not temporary relief
  203. 203. Treatment Plan for Chronic PainTreatment Plan for Chronic Pain Rehabilitation/functional management Psychosocial management - Depression - Cognitive – Behavior therapy Pharmacologic management Interventional management Non-pharmacologic management Complementary medicine Referral to multi-disciplinary pain mgmt. Surgery for placement of a stimulator or pump
  204. 204. Management of Neuropathic PainManagement of Neuropathic Pain Eliminate the underlying causes of pain Local or regional therapies - Topical Capsaicin, 3 to 4 times daily - Lidocain cream or patch - Transcutaneous electrical nerve stimulator Pharmacologic management - Gabapentin: 300mgs TID (100% Renal) - Pregabalin: 50-100 mgs TID - Other Anticonvulsants: * Carbamazepine * Oxcarbazepine 150-300 mgs BID * Topiramate, Lamotrigine, Tiagabine * Benzodiazepine, Clonazepam
  205. 205. Pharmacologic ManagementPharmacologic Management (cont)(cont)-- Neuropathic PainNeuropathic Pain Tricyclic antidepressants - Amitriptyline, Notriptyline, Desipramine, Imipramine, and others - Potentiate descending inhibitory pathways - Pain reduction is independent of effect on depression - A screening EKG is required in elderly
  206. 206. Corticosteroids - Pain relief through membrane stabilization and anti-inflammatory effects - Short term control of neuropathic radicular pain caused by edema, tumor invading bone and acute or sub-acute disc herniation Opioids - not known for neuropathic pain but as potent analgesics - Methadone and Tramadol are more effective
  207. 207. Management of Muscle PainManagement of Muscle Pain Physical rehabilitation Behavioral management Drug therapy - Pain and sleep * Tricyclic antidepressants Nortriptyline low dose * Cyclobenzaprine - Depression and Pain * Duloxetine - Opioids rarely needed
  208. 208. Inflammatory Pain ManagementInflammatory Pain Management Physical rehabilitation Behavioral management Drug therapy - Pain and sleep * Tricyclic antidepressants Nortriptyline low dose * Carbobenzaprine (short term) - Depression and pain * Duloxetine - NSAIDS, immunologic drugs, other depressants
  209. 209. Mechanical / CompressiveMechanical / Compressive Pain ManagementPain Management Screen for serious medical pathology and refer to appropriate specialist Physical rehabilitation Behavioral management Drug therapy - Tricyclic antidepressants - NSAIDS - Other antidepressants
  210. 210. Pharmacologic Management of PainPharmacologic Management of Pain Key PointsKey Points A thorough medication history is critical Base the choice of medications on type and severity Medications are not the primary focus in managing pain Titrate doses for an optimal balance between analgesic benefit, side effects, and functional improvement
  211. 211. For Opioid therapy: - use a written Opioid agreement for long- term therapy - see the Federation of State Medical Boards at: http://www.fsmb.org for complete information
  212. 212. NonNon--Opioid AnalgesicsOpioid Analgesics AcetaminophenAcetaminophen To treat mild chronic pain or to supplement Lack anti-inflammatory effects Do not damage gastric mucosa May have chronic renal and hepatic side effects Dose; max 4gms./24 hrs. Caution: Patients with liver impairment
  213. 213. NonNon--Opioid Analgesics,Opioid Analgesics, NonNon--Steroidal AntiSteroidal Anti--Inflammatory DrugsInflammatory Drugs
  214. 214. To treat mild to moderate inflammatory or non-neuropathic pain NSAIDS inhibit prostaglandin synthesis by blocking the enzyme Cyclooxygenase (COX) COX-2 agents have fewer GI symptoms but higher cardiovascular effects. Use along with gastroprotective agent; Proton pump inhibitor (Misoprostol) Use caution in patients with risk of bleeding Ketorolac not for chronic pain NSAIDS have significant opioid sparing properties and reduce opioid-related side effects
  215. 215. Use of Opioids in Chronic PainUse of Opioids in Chronic Pain First get familiar with Federation of State Medical Board documents For neuropathic pain, not responding to first line therapies Opioids are rarely beneficial for inflammatory, mechanical / compressive pain Not indicated for chronic headache mgmt. Have better therapeutic index and low medical risks Close monitoring is essential and non-compliant pts. must be referred to pain or addiction specialist
  216. 216. Tricyclic AntiTricyclic Anti--DepressantsDepressants (TCAS)(TCAS) First line for neuropathic pain with insomnia, anxiety and depression Avoid tertiary amines (Amitriptyline, Imipramine) TCAS analgesic effects are with lower doses Maximum analgesic effect may take several weeks to be seen Baseline EKG is indicated for pts. at higher cardiac risk Common side effects: sedation, dry mouth, constipation, and urinary retention
  217. 217. Other AntiOther Anti--DepressantsDepressants Selective Serotonin re uptake inhibitors Less side effects compared to TCAS, but less efficient for neuropathic pain relief Bupropion, Venlafaxine, and Duloxetine are all efficient against neuropathic pain Duloxetine in doses of 60 mgs. BID is beneficial for fibromyalgia
  218. 218. Anticonvulsant or AntiepilepticAnticonvulsant or Antiepileptic DrugsDrugs Carbamazepine and Phenytoin: - effective for neuropathic pain - Carbamazepine well established for trigeminal neuralgia - unwanted CNS side effects Pregablin: - Diabetic neuropathy - Post herpetic neuralgia
  219. 219. Oxcarbazepine; good for neuropathic pain Gabapentin; excellent for all types of neuropathic pains. Titrate up gradually Lamotrigine; Trigeminal neuralgia, post- stroke pain and neuropathies of HIV infection
  220. 220. Topical AgentsTopical Agents 5% Topical Lidocaine patches; 12hrs on and 12hrs off - Excellent safety profile - Post herpetic neuralgia and other neuropathic pain syndromes Capsaicin: - Depletes the pain mediator substance-P from afferent nociceptive neurons - Good for arthritic pain and other neuropathic pain - Use at least for 6 wks. for benefits - Side effect – burning; becomes tolerant after a few weeks
  221. 221. Diagnosis and TreatmentDiagnosis and Treatment of Low Back Painof Low Back Pain Joint Practice Guidelines fromJoint Practice Guidelines from ACP and APSACP and APS RecommendationsRecommendations
  222. 222. Focused history and physical examination 1. Nonspecific low back pain 2. Back Pain with radiculopathy or spinal stenosis 3. Low back pain with other spinal cause Imaging not required for nonspecific LBP Imaging advised for neurological deficits or other underlying conditions Imaging before steroid injections or surgery
  223. 223. Advise patients to be active and self-care options First line drugs: Acetaminophen, NSAIDS Muscle relaxants for temporary relief of acute low back pain Tricyclic antidepressants for chronic LBP Use of opioids in selected patients Spinal manipulation for acute LBP, intense rehabilitation, acupuncture, yoga, cognitive behavioral therapy for sub-acute and chronic pain
  224. 224. JAMESON MEMORIAL HOSPITAL NEW CASTLE, PA 16105 IV PCA - PAIN CONTROL ORDERS (For Jameson Hospital Medical Staff Only) Medication □Morphine 1 mg/ml in 0.9% NSS □HYDROmorphone (Dilaudid) 0.2 mg/ml in 0.9% NSS □Morphine 5mg/ml (HIGH POTENCY) □HYDROmorphone (Dilaudid) 0.5mg/ml (HIGH POTENCY) Initiate the following pain control orders: SELECT ONE: □ PCA Mode □ Continuous Mode □ PCA & Continuous Typical Ranges * Consider patient age, renal status, comorbidities and history of opioid use. Morphine• IV fluids @ ml/hr HYDROmorphone • Continuous rate (Delivery): mg/hr Continuous 1-3 mg/hr 0.2 - 0.5 mg/hr• Loading dose: mg Loading 1-4 mg 0.3 - 0.5 mg• PCA dose: mg PCA dose 0.5- 2 mg 0.2 - 1 mg• Lock out time: minutes. (Typical lock out range 10-20 minutes) • One hour dose limit: mg • Decreased respiratory rate of less than 8 per min. and/or patient unarousable, administer Narcan 0.04 mg q 1 minute IV STAT, according to protocol. Then call ordering physician. • Bolus PRN dose: • RN may administer a bolus PRN dose of mg once per hour, if needed, until pain relief is achieved. • Monitor sedation, pain level & vital signs q ½ h for 2 hours, q 1 hr for 2 hours, then q 4 h. • Continuous Pulse Oximetry - chart q h. If unable to maintain sat above 94%, apply Nasal O2 at 3 liters and notify physician. • Notify PCP or ordering physician of inadequate pain relief or persistent nausea. • Verify all other narcotic medication/sedative orders with physician initiating PCA orders. • RN must clarify if conflicting orders are present. • Additional PRN medications: Physician Date/Time *Patients in terminal state may be exempt from these monitoring/intervention orders. Physician can cross out unapplicable orders and initial to eliminate this monitoring. 9/05; Revised 4/09 PHO-1019
  225. 225. JAMESON HEALTH SYSTEM NEW CASTLE, PA 16105 CONTINUOUS EPIDURAL INFUSION (Anesthesia Assoc., P.C. Orders ONLY) Epidural Infusion Only: • Final concentration: Fentanyl 2 mcg/ml Bupivacaine (0.125%) in 250 ml 0.9% NSS • Infusion to run @ ml/hr. • Use yellow striped tubing specifically for Epidural infusion. • Ambu and Oxygen immediately available. • Continuous Pulse Oximetry - chart q 1 hrs. Apply nasal O2 at 2 LPM while catheter in place. Call Anesthesia if unable to maintain sat above 90% and notify PCP or Surgeon. • Notify anesthesia immediately if patient complains of progressive heaviness in legs or inability to move legs. • For decreased respiratory rate of less than 8 per minute and/or patient unarousable, administer Narcan 0.04 mg q 1 minute IV STAT according to protocol, then call Anesthesia and notify PCP or Surgeon. • Monitor/record respirations q ½ hr x 2 then q 1 hr x 24 hrs. then q 4 hrs. • Monitor sedation, pain level, and vital signs q ½ hour for 2 hrs and q 1 hr for 2 hrs then q 4 hrs. • Whenever Epidural dosage increased, reinstate initial monitoring protocol. • Notify Anesthesia of inadequate pain relief, persistent nausea, sedation level 3 or greater, or respirations less than 8. Exception: For pts on ventilator - contact physician/service managing ventilator care. • Hold all other Narcotic medications/sedatives unless ordered by Anesthesia. • If intubated, Diprivan drip titrated to sedation level of 3 or greater. • RN must clarify if conflicting orders are present. • If patient has no IV order from surgeon or primary physician, patient is to have Lactated Ringers at 40 ml/hr. • Do not begin Lovenox, Coumadin, IV/SQ Heparin until at least 2 hrs. after epidural catheter has been removed due to risk of epidural hematoma/bleeding. • If IV/SQ Heparin, Lovenox, or Coumadin ordered, discontinue Epidural catheter and hold dose for 2 hrs following removal of catheter. • If air in volumetric infusion set, may disconnect from Epidural catheter, purge air and reconnect to catheter. • Patient may have: □ Morphine Sulfate 2 mg IV q 30 min PRN for breakthrough pain for pain level greater than 5 x 2 doses only. If pain level greater than 5 after 2 doses, notify Anesthesia OR □ Dilaudid 0.5 mg IV q 30 min prn up to 4 doses per 4 hr. period Call Anesthesia if pain level greater than 5 after 4 doses of Dilaudid • Epidural Bolus prn per Anesthesia. • □ For nausea, give Zofran 4 mg IV, wait 15 minutes. If nausea/vomiting continues, give Zofran 4 mg IV then continue Zofran 4 mg IV q 4 hrs prn for nausea/vomiting. Call Anesthesia for persistent nausea/vomiting. • □ If itching, administer Nubain 5 mg IV. May repeat Nubain 5 mg IV in 15 minutes, once. If itching persists, notify Anesthesia for further orders. Physician Date/Time Revised 7/05; 8/06; 2/07; 4/09 PHO-1005
  226. 226. JAMESON HEALTH SYSTEM NEW CASTLE, PA 16105 CONTINUOUS PERIPHERAL NERVE/ FEMORAL NERVE/LUMBAR PLEXUS/ SCIATIC NERVE CATHETER ORDERS (Anesthesia Assoc., P.C. Orders ONLY) Medication: □ Bupivacaine 0.05% (final concentration) in 250 ml NSS □ Bupivacaine 0.125% (final concentration) in 250 ml NSS • Infusion to run at ml/hour on CADD Solis Pain Management Pump. • Place peripheral nerve catheter infusion pump at the foot of the bed when used in conjunction with another pain delivery system. • Use yellow-striped tubing with tag indicating “Bupivacaine Infusion Only”. • If air in infusion set, may disconnect from the peripheral nerve catheter, purge air and reconnect to catheter. • IV Peripheral PCA for 24 hours (see physician Peripheral PCA Order Sheet). Start: Date Time Discontinue: Date Time • Call Anesthesia if patient is experiencing progressive motor block in extremity • Post-op care: Check site for dislodgement and hematoma, check extremity for circulation, motion and sensation, and check vital signs: q ½ hour for 2 hours, then q 1 hour for 2 hours, then q 4 hours until catheter removed. • Call Anesthesia if catheter dislodges. Physician Date/Time Revised 2/07; 4/14/09 PHO-1007
  227. 227. JAMESON HEALTH SYSTEM NEW CASTLE, PA 16105 IV PCA INFUSION PUMP ORDERS (Anesthesia Assoc., P.C. Orders ONLY) PCA ORDERS SHOULD BE ADJUSTED BY ANESTHESIA ONLY Medication □Morphine 1 mg/ml in 0.9% NSS □HYDROmorphone (Dilaudid) 0.2 mg/ml in 0.9% NSS □Fentanyl 10 mcg/ml - * in 0.9% NSS • CONTINUOUS Rate (Delivery): • BOLUS (Loading Dose): *Omit Bolus if narcotic given within last hour. • PCA Dose: • (Lockout): min • ONE HOUR LIMIT: • If pain is not adequately controlled: (pain scale 4 or greater) PCA dose may be increased to and the 1 hr limit increased to (one time only) • If pain level greater than 5 after PCA dose increased one time (pain reassessment), call Anesthesia. • Monitor sedation, pain level, and vital signs q ½ hour for 2 hrs then q 1 hr for 2 hrs then q 4 hrs. • Notify Anesthesia if sedation level 3 or greater. • For decreased respiratory rate of less than 8 per min. and/or patient unarousable, administer Narcan 0.04 mg IV STAT q 1 minute according to protocol, then call Anesthesia and notify PCP or Surgeon. • □ For nausea, give Zofran 4 mg IV, wait 15 minutes. If nausea/vomiting continues, give Zofran 4 mg IV then continue Zofran 4 mg IV q 4 hrs prn for nausea/vomiting. Call Anesthesia for persistent nausea/vomiting. • □ If itching, administer Nubain 5 mg IV. May repeat Nubain 5 mg IV in 15 minutes, once. If itching persists, notify Anesthesia for further orders. • Continuous Pulse Oximetry - chart q 1 hr. Apply nasal O2 at 2 LPM while PCA in place. Call Anesthesia if unable to maintain sat above 90% and notify PCP or Surgeon. • Whenever PCA dosage increased, reinstate initial monitoring protocol. • Hold all other Narcotic medications/sedatives unless ordered by Anesthesia. • RN must clarify if conflicting orders are present. • If patient has no IV order from surgeon or primary physician, patient is to have Lactated Ringers at 40 ml/hr. • Place PCA infusion pump at the head of the bed when used in conjunction with another pain delivery system. Physician Date/Time Revised 7/05; 8/06; 2/07; 4/09 PHO-1045
  228. 228. JAMESON HOSPITAL NEW CASTLE, PA 16105 POST-OP PAIN MANAGEMENT ORDERS AFTER INTRAOPERATIVE DURAMORPH (Anesthesia Assoc., P.C. Orders ONLY) • Patient received mg of intrathecal/epidural Duramorph at (time) intraoperatively. • Epidural discontinued at: Date Time • Patient may have: ( ) Morphine Sulfate 1 mg IV q 15 min prn for breakthrough pain up to 5 doses (pain level greater than 5) *If pain scale still greater than 5 despite prn Morphine, increase Morphine Sulfate to 4 mg IV x 1 dose *If no relief, notify Anesthesia ( ) a. Until date @ 7:00 a.m. OR ( ) b. During 18 hours post Duramorph injection. End of 18 hour time frame: Date Time OR ( ) Dilaudid 0.5 mg IV q 15 minutes prn up to 4 doses per 4 hour period *Call Anesthesia if pain level greater than 5 after 4 doses of Dilaudid ( ) a. Until date @ 7:00 a.m. OR ( ) b. During 18 hours post Duramorph injection. End of 18 hour time frame: Date Time • No other IV/IM/PO narcotic for 18 hrs post Duramorph injection unless ordered by Anesthesia. • Hold all other Narcotic medications/sedatives unless ordered by Anesthesia. • Notify Anesthesiologist for additional pain orders while Duramorph protocol in effect. • Monitor/record Respirations q ½ hr x 2, q 1 hr x 24 hrs then q 4 hrs. • Notify Anesthesia if sedation level 3 or greater. • Monitor sedation, pain level, and vital signs q ½ hour for 2 hrs then q 1 hr x 2 hrs then q 4 hours. • For decreased respiratory rate of less than 8 per minute and/or sedation level 3 or greater, administer Narcan 0.04 mg IV STAT q 1 minute according to guidelines, then call Anesthesia and notify PCP or Surgeon. • Continuous Pulse Oximetry - chart q 1 hr. until the Duramorph protocol completed. • Apply nasal O2 at 2 LPM for 18 hours following Duramorph injection until Duramorph protocol is completed. Call Anesthesia if unable to maintain sat above 90% and notify PCP or Surgeon. • If patient has no IV order from surgeon or primary physician, patient is to have Lactated Ringers at 40 ml/hr. • May anticoagulate 2 hrs following epidural discontinuation. • □ For nausea, give Zofran 4 mg IV, wait 15 minutes. If nausea/vomiting continues, give Zofran 4 mg IV then continue Zofran 4 mg IV q 4 hrs prn for nausea/vomiting. Call Anesthesia for persistent nausea/vomiting. • □ For itching, administer Nubain 5 mg IV. May repeat Nubain 5 mg IV in 15 minutes, once. If itching persists, notify Anesthesia for further orders. • RN must clarify if conflicting orders are present. • □ Toradol 30 mg IV q 8 hrs x 3 doses if not contraindicated. Physician Date/Time Rev. 7/05; 8/06; 2/07; 5/09

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