Risk Management and Patient     Assessment in Pain        Management    Hongbiao (Hank) Liu MD PhD          Luna Medical C...
Objectives Discuss chronic pain and its interplay with  addictive disorders Rational assessment of chronic pain patient ...
Chronic Pain Chronic Pain-Pain that persists beyond  normal tissue healing; assumed to be 3  months 77 million adults ov...
Are Opiates Effective? Universal acceptance in Acute and  Malignant Pain Chronic Non Cancer Pain (CNCP) Use has increase...
Are Opiates Harmful? Between 2004 and 2005 11.8 million people  reported using opiates non-medically and  2.2 where new u...
Are Opiates Harmful? Ameritox Study: Aberrancy rates noted to  be 70%  Couto, JE. Popul Health Manag. 2009; 12 (4): 185-1...
Long Term Opiate Therapy            Reconsidered                     Annals, Sept 6 2011 Long term data supporting effica...
Scope of the Problem Currently approximately 1000 patients in  Buffalo on Methadone treatment (more  patients with Suboxo...
Definitions Misuse: Use in a manner other than  intended without dysfunction Abuse: Behavioral abnormalities  associated...
 Physical Dependence: Withdrawal Tolerance: Need for increased dose for  same effect Pseudoaddiction: Aberrant behavior...
DSM IV Criteria Opiate Abuse ( 1 in 12 months) Failure to fulfill major role obligations Recurrent us in hazardous situat...
How to Proceed?
Universal Precautions Diagnosis with appropriate referral Psychological assessment including risk for  addiction Inform...
 Appropriate trial of opioid therapy Reassessment of pain and functional level Regular assessment of the 4 As (Analgesi...
Risk Assessment Biological Age <45 Family History Smoking History
 Psychological Substance use disorder Bipolar disorder PTSD Preadolescent sexual abuse Depression ADHD
 Social Prior legal problems History of MVA Poor family support Lack of involvement in recovery program
Physical Exam   Careful attention to pupils   Skin exam looking for track marks/scars   Directed toward pain complaints
Screening Tools SOAPP (Screener and Opioid Assessment  for Patients with Pain) Specific screen for  patients with chronic...
Screening Tools cont CAGE (Cut down/Annoyed/Guilt/Eye  opener) Urine Drug Testing
Trial of Opiate Therapy   Informed consent   Treatment agreement   Urine Drug Testing   Ongoing Assessment   Taper do...
Ongoing Assessment/Red Flags More Predictive of Addiction Selling prescriptions Forgery Stealing or borrowing another pts...
Red Flags Less Predictive    Aggressive complaining    Drug hoarding    Specific drug request    Acquisition from other m...
Toxicology Screening Should be a part of routine monitoring of  most if not all patients on opiate therapy Literature su...
Toxicology Screening Very important to understand testing  characteristics:  Some synthetic opiates may not be positive  ...
Point of Care Testing Primary advantage is to identify problematic  use in a timely fashion Disadvantages include:  – Va...
Interventions Maximally structured care for higher risk  patients Frequent visits Limited medication supply Primarily lon...
How are we doing? Three risk reduction strategies (Any urine tox,  regular office visit, restricted early refill) Five r...
Interventions Discharge May be necessary based on patient inability or unwillingness to comply with treatment plan All pa...
Treatment for Opiate Dependence   Medically supervised detox   Inpatient rehabilitation   Outpatient Treatment/Self Hel...
Treatment for Opiate Dependence “Traditional” abstinence based treatment is  plagued by high rates of relapse Ongoing us...
Opiate Agonist Therapy Suboxone Partial opiate agonist Requires special XU DEA number Indicated for treatment of opiate w...
Methadone Gold standard for treatment of opiate  dependence Full opiate agonist Can not be prescribed for treatment of ...
Other considerations Risk Management One pharmacy Proper prescription writing and storage Understanding controlled substa...
Other considerations Documentation  4 A’s: Analgesia/Adverse effects/     ADL’s/Aberrancy  Document everything
Resources STAR (Substance Treatment and Recovery) Amherst: 3730 Sheridan Drive, Amherst, 862-2059 St. Vincents: 1595 Bail...
Resources Clinical Guidelines for use of Chronic Opioid  Therapy in Chronic Non Cancer Pain    Journal of Pain. 2009; 10:...
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Dr liu 12 8-2012 updike-risk management and pt assessment in pm

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Dr liu 12 8-2012 updike-risk management and pt assessment in pm

  1. 1. Risk Management and Patient Assessment in Pain Management Hongbiao (Hank) Liu MD PhD Luna Medical Care Primary Care and Nuclear Medicine
  2. 2. Objectives Discuss chronic pain and its interplay with addictive disorders Rational assessment of chronic pain patient in whom opiate tx is considered How to approach pain management in a patient with a history of addiction How to monitor a patient on opiate tx What to do if problems arise
  3. 3. Chronic Pain Chronic Pain-Pain that persists beyond normal tissue healing; assumed to be 3 months 77 million adults over 20 experienced some pain,43 million had chronic pain (National Center for Health Care Statistics 2006) Healthcare expenditures for back pain alone exceed 1 billion annually
  4. 4. Are Opiates Effective? Universal acceptance in Acute and Malignant Pain Chronic Non Cancer Pain (CNCP) Use has increased dramatically over last 20 years Likely effective for decreasing pain for both nociceptive and neuropathic pain American Geriatrics Society Practice Guideline : Pharmacological Management of Persistent Pain in Older Persons; 2009
  5. 5. Are Opiates Harmful? Between 2004 and 2005 11.8 million people reported using opiates non-medically and 2.2 where new users Non-medical use of opiates increased 542% between 1992 and 2003 with resultant increases in mortality Prescription opiate abuse now equal to Heroin abuse in patients seeking treatment
  6. 6. Are Opiates Harmful? Ameritox Study: Aberrancy rates noted to be 70% Couto, JE. Popul Health Manag. 2009; 12 (4): 185-190Dunn, KM. Ann Intern Med. 2010 152: 85 Increased risk of overdose at higher doses of opiates Only 51 events out of 9940 cases reviewedOverdose rare in opiate naïve patients
  7. 7. Long Term Opiate Therapy Reconsidered Annals, Sept 6 2011 Long term data supporting efficacy is lacking Increasing public health consequences Safer prescribing called for – Better patient selection – Judicious opioid prescribing especially caution with escalating doses
  8. 8. Scope of the Problem Currently approximately 1000 patients in Buffalo on Methadone treatment (more patients with Suboxone) for opiate dependence. Generally only 10-20% of addicted patients are in treatment.
  9. 9. Definitions Misuse: Use in a manner other than intended without dysfunction Abuse: Behavioral abnormalities associated with interpersonal impairment leading to dysfunction Addiction: Greater degree of impairment with loss of control, preoccupation (cravings), social or occupational disruptions and use despite harm.
  10. 10.  Physical Dependence: Withdrawal Tolerance: Need for increased dose for same effect Pseudoaddiction: Aberrant behavior associated with poorly treated pain
  11. 11. DSM IV Criteria Opiate Abuse ( 1 in 12 months) Failure to fulfill major role obligations Recurrent us in hazardous situations Recurrent substance-related legal problems Use despite persistent social problemsOpiate Dependence (3 in 12 months) Tolerance Withdrawal Taken Longer than intended Persistent desire to cut down/control use Time spent obtaining/recovering Important activities reduced/given up Ongoing use despite harm
  12. 12. How to Proceed?
  13. 13. Universal Precautions Diagnosis with appropriate referral Psychological assessment including risk for addiction Informed consent Treatment agreement Pre and post-intervention assessment of pain level and function
  14. 14.  Appropriate trial of opioid therapy Reassessment of pain and functional level Regular assessment of the 4 As (Analgesia Aberrancy/ADL’s/Adverse effects) Periodic review Documentation Gourlay, Pain Mde. 2005:6(2) 107-112
  15. 15. Risk Assessment Biological Age <45 Family History Smoking History
  16. 16.  Psychological Substance use disorder Bipolar disorder PTSD Preadolescent sexual abuse Depression ADHD
  17. 17.  Social Prior legal problems History of MVA Poor family support Lack of involvement in recovery program
  18. 18. Physical Exam Careful attention to pupils Skin exam looking for track marks/scars Directed toward pain complaints
  19. 19. Screening Tools SOAPP (Screener and Opioid Assessment for Patients with Pain) Specific screen for patients with chronic pain being considered for opioid tx COMM (Current Opioid Misuse Measure) Identify risk in patients on opiate treatment
  20. 20. Screening Tools cont CAGE (Cut down/Annoyed/Guilt/Eye opener) Urine Drug Testing
  21. 21. Trial of Opiate Therapy Informed consent Treatment agreement Urine Drug Testing Ongoing Assessment Taper dose if there is no benefitIs there a maximum dose?
  22. 22. Ongoing Assessment/Red Flags More Predictive of Addiction Selling prescriptions Forgery Stealing or borrowing another pts drugs Non-medical sources Concurrent abuse of related illicit drugs Multiple unsanctioned dose increases Recurrent lost scripts
  23. 23. Red Flags Less Predictive Aggressive complaining Drug hoarding Specific drug request Acquisition from other medical sources Dose increases once or twice (unsanctioned) Unapproved use to treat another symptom Other psychic effects not intended by the clinicianPassik Clin J Pain. 2006:22(2):173-181
  24. 24. Toxicology Screening Should be a part of routine monitoring of most if not all patients on opiate therapy Literature support? Positive result can confirm compliance with treatment Negative result may indicate diversion Use of other substances identified
  25. 25. Toxicology Screening Very important to understand testing characteristics: Some synthetic opiates may not be positive (i.e. Methadone) Correlate with history (when was opiate last taken?) False positives probably rare but possible Sertraline (B), Quinolones (O), Antipsychotics (A,M), NSAIDs and PPI (C)
  26. 26. Point of Care Testing Primary advantage is to identify problematic use in a timely fashion Disadvantages include: – Variable performance between available products – Less support than laboratory testing – Limited testing menu – Lack of confirmation
  27. 27. Interventions Maximally structured care for higher risk patients Frequent visits Limited medication supply Primarily long acting opiates Judicious use of rescue meds UDT Pill counts Recovery Program/Structured setting Consultations
  28. 28. How are we doing? Three risk reduction strategies (Any urine tox, regular office visit, restricted early refill) Five risk factors (Age <45, drug, alcohol or tobacco use, MH dx) Mean duration of opiate use 1.9 years Urine tox-8%, Office visit-50%, Restricted refill- 76%, only 3% had all three Less than one quarter of patients with three or more risk factors had a urine tox Journal of Internal Medicine, September 2011
  29. 29. Interventions Discharge May be necessary based on patient inability or unwillingness to comply with treatment plan All patients suspected of diversion Structured taperManipulative Behaviors: Consistency/Say No
  30. 30. Treatment for Opiate Dependence Medically supervised detox Inpatient rehabilitation Outpatient Treatment/Self Help Medication Assisted Treatment
  31. 31. Treatment for Opiate Dependence “Traditional” abstinence based treatment is plagued by high rates of relapse Ongoing use of opiates for pain complaints needs to be considered very carefully and should not be done in the absence of a stable recovery generally
  32. 32. Opiate Agonist Therapy Suboxone Partial opiate agonist Requires special XU DEA number Indicated for treatment of opiate withdrawal and maintenance therapy Off label use for pain Category C in pregnancy
  33. 33. Methadone Gold standard for treatment of opiate dependence Full opiate agonist Can not be prescribed for treatment of addiction outside of a registered treatment program Can be prescribed for pain by any physician Category B
  34. 34. Other considerations Risk Management One pharmacy Proper prescription writing and storage Understanding controlled substance law Group practice agreements (i.e. no call ins/uniform practice agreements)
  35. 35. Other considerations Documentation 4 A’s: Analgesia/Adverse effects/ ADL’s/Aberrancy Document everything
  36. 36. Resources STAR (Substance Treatment and Recovery) Amherst: 3730 Sheridan Drive, Amherst, 862-2059 St. Vincents: 1595 Bailey Ave, Buffalo, 893-9350Pathways Methadone Clinic Benita 862-1565, 158 Holden St, BuffaloSuboxone Physician Locator
  37. 37. Resources Clinical Guidelines for use of Chronic Opioid Therapy in Chronic Non Cancer Pain Journal of Pain. 2009; 10: 113-130 American Academy of Pain Management www.aapainmanage.org American Academy of Pain Medicine American Academy of Addiction Medicine Urine Drug Testing in Clinical Practice Monograph

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