This document provides information about a continuing medical education (CME) program on pain management for physicians. It details:
1. A self-learning module that is attached for physicians to complete for 4 CME credits. It involves reviewing information, taking a written exam, and completing an evaluation.
2. Instructions for completing the module, submitting the required paperwork to Jayne Sheehan, and having CME credits recorded.
3. An enduring material on pain management from Jameson Memorial Hospital for physicians to review select pages from and complete related questions and evaluation. The material covers topics like the epidemiology and barriers to treatment of chronic pain, as well as techniques for acute postoperative pain management.
The document discusses clinical decision making in evaluating and treating patients. It involves gathering subjective and objective data from patients, determining appropriate goals and treatment plans based on evaluation findings and clinical judgment, monitoring patient progress, and determining discharge. Treatment plans are adjusted based on a patient's response. Frequent re-evaluations ensure treatment strategies remain appropriate.
Get Research Paper Assignment help sample solution by Phd level experts for Free. contact us 24/7 Live chat, free downloadable solution.
http://www.helpwithassignment.com/admin/filemanager/downloads/Research%20Paper%20Critique%20-%20sample.pdf
Decide treatment - a new approach to better healthØystein Eiring
Better treatment, better health! People often experience suboptimal health because treatment is not optimal. A new approach is being developed - enabling patients and doctors to improve treatment and improve health.
Motivational Enhancement Therapy in Addition to Physical
Therapy Improves Motivational Factors and Treatment
Outcomes in People With Low Back Pain: A Randomized
Controlled Trial
Patient counseling refers to providing patients information to help them appropriately use their medications. The goals of counseling include improving patient understanding of their illness and treatment, adherence to medications, and quality of life while reducing health care costs. Effective counseling requires strong communication skills and involves preparing, opening the session, discussing the medication counseling points, and closing by addressing patient questions and summarizing key points. Barriers to counseling can be patient-related, such as a language difference, or provider-related like a lack of counseling skills or time constraints. Overcoming these barriers is important to improve counseling.
Adherence therapy in psychiatric nursingMartin Ward
Increasingly Adherence Therapy (AT) is being encouraged for all types of mental health problems. Psychiatric nurses need to be aware both of its use as well as some of the reasons why so many patients relapse, in an attmpt to increase adherence to treatment programmes
This document outlines a 4-phase treatment plan: Phase 1 involves diagnostic assessment, medication selection, and psychosocial challenges. Phase 2 focuses on stabilization through monitoring, psychoeducation, and group therapy. Phase 3 emphasizes symptom remission and control through medication titration and behavior management. Phase 4 provides psychoeducation on relapse prevention, works on interpersonal skills, and assesses social support systems.
This document discusses patient adherence to medical treatment. It begins by noting estimates that 30-50% of medicines for long-term illnesses are not taken as directed, representing a loss for patients and the healthcare system. Common myths about non-adherence are debunked, and it is argued that patients' perceptions of their illness and prescribed treatment strongly influence adherence. Effective interventions should aim to improve the fit between patients' illness beliefs and treatment recommendations by addressing concerns about necessity and potential adverse effects through clear communication and education.
The document discusses clinical decision making in evaluating and treating patients. It involves gathering subjective and objective data from patients, determining appropriate goals and treatment plans based on evaluation findings and clinical judgment, monitoring patient progress, and determining discharge. Treatment plans are adjusted based on a patient's response. Frequent re-evaluations ensure treatment strategies remain appropriate.
Get Research Paper Assignment help sample solution by Phd level experts for Free. contact us 24/7 Live chat, free downloadable solution.
http://www.helpwithassignment.com/admin/filemanager/downloads/Research%20Paper%20Critique%20-%20sample.pdf
Decide treatment - a new approach to better healthØystein Eiring
Better treatment, better health! People often experience suboptimal health because treatment is not optimal. A new approach is being developed - enabling patients and doctors to improve treatment and improve health.
Motivational Enhancement Therapy in Addition to Physical
Therapy Improves Motivational Factors and Treatment
Outcomes in People With Low Back Pain: A Randomized
Controlled Trial
Patient counseling refers to providing patients information to help them appropriately use their medications. The goals of counseling include improving patient understanding of their illness and treatment, adherence to medications, and quality of life while reducing health care costs. Effective counseling requires strong communication skills and involves preparing, opening the session, discussing the medication counseling points, and closing by addressing patient questions and summarizing key points. Barriers to counseling can be patient-related, such as a language difference, or provider-related like a lack of counseling skills or time constraints. Overcoming these barriers is important to improve counseling.
Adherence therapy in psychiatric nursingMartin Ward
Increasingly Adherence Therapy (AT) is being encouraged for all types of mental health problems. Psychiatric nurses need to be aware both of its use as well as some of the reasons why so many patients relapse, in an attmpt to increase adherence to treatment programmes
This document outlines a 4-phase treatment plan: Phase 1 involves diagnostic assessment, medication selection, and psychosocial challenges. Phase 2 focuses on stabilization through monitoring, psychoeducation, and group therapy. Phase 3 emphasizes symptom remission and control through medication titration and behavior management. Phase 4 provides psychoeducation on relapse prevention, works on interpersonal skills, and assesses social support systems.
This document discusses patient adherence to medical treatment. It begins by noting estimates that 30-50% of medicines for long-term illnesses are not taken as directed, representing a loss for patients and the healthcare system. Common myths about non-adherence are debunked, and it is argued that patients' perceptions of their illness and prescribed treatment strongly influence adherence. Effective interventions should aim to improve the fit between patients' illness beliefs and treatment recommendations by addressing concerns about necessity and potential adverse effects through clear communication and education.
Brief interventions and motivational enhancement therapy for alcohol problemskavroom
Brief interventions involve short counseling sessions that provide feedback, advice, and support to motivate individuals to reduce risky drinking behaviors. MET is a client-centered counseling style based on motivational interviewing that aims to resolve ambivalence and increase intrinsic motivation for change. Both approaches are time-limited and focus on negotiating drinking reduction rather than requiring abstinence. Screening tools are used to identify hazardous drinkers who could benefit, with brief structured advice or extended brief counseling sessions depending on severity. Motivational strategies like FRAMES are employed to enhance engagement in the process of behavior change.
Ruthann Russo - Integrative Population Health Management - White Paper Part 1Ruthann Russo
The document discusses how implementing integrative health modalities (IHM) such as meditation, yoga, and massage therapy in inpatient hospital settings can improve patient satisfaction scores on the HCAHPS survey. Higher HCAHPS scores lead to increased hospital reimbursement from CMS. The document reviews research showing IHM is effective at reducing pain, anxiety, and depression in patients, thus enhancing the patient experience and satisfaction. The low cost of implementing IHM makes it a promising strategy for hospitals to boost HCAHPS scores and reimbursement while improving patient care.
Presentation on medication history interview and soap notessuchitrauppicherla
pharmacy practice is vital activity performed by pharmadians along with physicians to enhance the quality and span of life of patient .mediaction history interview is is an essential to know and presentation of case collected in universally accepted format .
The document discusses patient counseling in pharmacy from educational and counseling perspectives. It defines counseling, consulting, and education and differentiates the terms. Various counseling theories and models of patient-provider relationships are described. The document emphasizes that patient counseling involves both counseling and education, drawing from different theories depending on the situation and patient needs. The goals of patient counseling are to establish trust and help patients manage their medication and health, while educational goals involve providing tailored information to meet patient needs. An andragogical approach is recommended to align counseling with adult learning principles and make it most effective.
Patient Assessment And Clinical Interviewingdunerafael
The document provides guidance on common mistakes healthcare practitioners make in patient communication and assessment. It discusses the importance of greeting patients, understanding their concerns, asking open-ended questions, being attentive to verbal and non-verbal cues, avoiding judgements, and understanding cultural beliefs. It also outlines key information to collect during a patient assessment, including medical history, medications, allergies and social factors, and provides examples of documentation through a SOAP note.
Psychological Assessment For Implantable Therapies Dr Peter Murphyepicyclops
Psychological assessment is recommended for patients undergoing spinal cord stimulation (SCS) therapy based on evidence that it leads to better outcomes. A brief psychological evaluation can identify potential mental health issues like depression or anxiety that are common in chronic pain patients and associated with poorer prognoses. It also aims to ensure patients have realistic expectations of SCS and a plan for managing their pain should the treatment not achieve the desired level of relief. While certain personality traits alone may not predict outcomes, evaluations can help optimize patient selection and preparation for SCS.
This document discusses strategies to enhance patient adherence to preventive dental programs. It defines key terms like adherence and compliance. It outlines factors that influence patient adherence like patient characteristics and relationships with providers. It also examines protocols to assess adherence using indices and discusses monitoring adherence over time. Finally, it presents strategies to promote adherence like patient education, counseling, stage-based models, and motivational interviewing. The goal is to properly identify strategies tailored for each individual patient's needs.
This document discusses the development of therapeutic guidelines. It defines therapeutic guidelines as clinical practice guidelines written for prescribers to provide treatment recommendations based on current evidence. The document outlines the need for guidelines to improve patient care quality and consistency while controlling healthcare costs. It describes the composition of guideline development groups and the multi-step process involved, including identifying the problem and literature, obtaining expert opinions, reviewing evidence, and disseminating the completed guidelines. Potential limitations of guidelines like complexity and physician acceptance are also discussed.
Communication is the transfer of information meaningful to those involved. Interactive communication is a process that facilitates a dialogue to provide multiple opportunities to accurately interpret meaning and respond appropriately. An interactive model is similar to a discussion rather than a lecture.
For example, using an interactive model, a patient may be asked what they know about their medications. As the patient describes aspects of his or her medication therapy, the pharmacist can then respond to fill in knowledge gaps, correct misinformation and verify patient understanding, thus eliminating or minimizing misunderstandings.
Interactive communications are effective for many interpersonal situations, but are especially useful when working with patients to assure appropriate use of medications.
The document outlines principles of patient counseling and communicating bad news. It discusses the importance of obtaining consent from patients, providing information in a sensitive manner, and allowing patients to process information at their own pace. Guidelines are provided for setting up private discussions, assessing a patient's understanding, disclosing medical details with empathy, and developing future care strategies together. The goal is to fully inform patients while respecting their rights, emotions, and decisions throughout the counseling process.
Patient counseling provides several benefits but also faces challenges. It reduces errors, noncompliance, and adverse drug reactions while improving outcomes and patient satisfaction. Counseling is integral to providing pharmaceutical care and professional pharmacy services. However, pharmacists face challenges like lack of time, incentives, and an environment conducive to counseling. Regulations, acceptance by other providers, and patient factors can also impede counseling.
This document discusses patient compliance, which refers to how well a patient follows medical advice such as taking medications correctly. It notes that adherence is a more accurate term than compliance, as it implies patients actively participate in their own care rather than just following doctor's orders. The document outlines factors that affect compliance like education level and side effects, and notes the importance of compliance for conditions like diabetes or HIV. It also discusses methods to detect non-adherence, the role of pharmacists in improving compliance through education and counseling, and concludes that developing strong patient relationships can increase understanding and compliance.
This study examines the effects of an 8-week Mindfulness-Based Stress Reduction program on burnout and empathy in healthcare professionals. The author hypothesizes that the MBSR program will decrease burnout, as measured by lower scores on emotional exhaustion, depersonalization, and increased personal accomplishment on the Maslach Burnout Inventory. They also hypothesize that the program will increase empathy, as measured by higher scores on perspective taking, compassionate care, and understanding the patient's perspective on the Jefferson Scale of Empathy. The study uses quantitative pre- and post-test measures and qualitative program evaluations to analyze the impact of MBSR training on burnout and empathy in healthcare workers.
Asam criteria attc online module 2018_week 1 pptMike Wilhelm
This document provides an overview of the American Society of Addiction Medicine (ASAM) Criteria for assessing substance use disorders. It introduces the six dimensions for assessment: acute intoxication, biomedical conditions, emotional/behavioral complications, readiness to change, relapse potential, and living environment. It also outlines the different levels of care in the ASAM model from early intervention to intensive inpatient treatment. Participants are assigned a case study to complete the initial assessment using the six dimensions for next week's session.
This document defines patient counseling as a one-on-one interaction between a pharmacist and patient/caregiver to provide medication information. It discusses how counseling is undertaken during dispensing, disease management, and providing self-care advice. The pharmacist should educate patients on medication names, directions, interactions, intended effects, side effects and monitoring. Effective communication relies on active listening, questioning, responding, explaining and ensuring patient understanding. Counseling aims to improve patient outcomes and satisfaction.
Course Director Peter A. Lio, MD, and Robert Sidbury, MD, MPH, prepared useful Practice Aids pertaining to atopic dermatitis for this CME activity titled "Advances in the Management of Moderate to Severe Atopic Dermatitis: How Can We Address Unmet Medical Needs in Individual Patients to Optimize Long-Term Outcomes?" For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at http://bit.ly/2VJqSFq. CME credit will be available until June 19, 2020.
This document is a resume for Chantel Enger, an art teacher seeking employment. She received her Bachelor's degree in Education and Liberal Arts from Montana State University. Her student teaching experiences included middle school and high school levels. She is passionate about helping students find creative expression and hopes to prepare them to explore their full potential.
Material handling control system software extends supply chain visibilityARC Advisory Group
The document discusses material handling control system (MCS) software, which provides uniform interfaces for equipment in material handling systems. MCS software integrates automated material handling subsystems, provides routing and tracking of items, and allows communication with conveyors and automated vehicles. It is a key part of achieving high performance in supply chain execution and manufacturing by enabling efficient material movement and data collection.
Emmanuel has over 30 years of experience in supply chain and operations management in various industries and countries. He has a strong background in demand management, production planning, and contract manufacturer management. Some of Emmanuel's roles included supply chain manager, transition manager, and project leader for ERP implementations. He is skilled at process improvement, change management, and delivering effective solutions through data analysis. References highlighted Emmanuel's strong drive, adaptability, and ability to manage people and projects in changing environments.
Goh Kee Kok has over 10 years of experience in supply chain management across various industries and countries. He has held procurement and supply chain roles at Emerson Electric, General Motors, Singapore Technologies Kinetics, and Leeboy India Construction Equipment. His responsibilities have included strategic sourcing, supplier development, cost reduction, and inventory management. He has a degree in electronics from the National University of Singapore and is fluent in English with proficiency in Mandarin and several Chinese dialects.
Brief interventions and motivational enhancement therapy for alcohol problemskavroom
Brief interventions involve short counseling sessions that provide feedback, advice, and support to motivate individuals to reduce risky drinking behaviors. MET is a client-centered counseling style based on motivational interviewing that aims to resolve ambivalence and increase intrinsic motivation for change. Both approaches are time-limited and focus on negotiating drinking reduction rather than requiring abstinence. Screening tools are used to identify hazardous drinkers who could benefit, with brief structured advice or extended brief counseling sessions depending on severity. Motivational strategies like FRAMES are employed to enhance engagement in the process of behavior change.
Ruthann Russo - Integrative Population Health Management - White Paper Part 1Ruthann Russo
The document discusses how implementing integrative health modalities (IHM) such as meditation, yoga, and massage therapy in inpatient hospital settings can improve patient satisfaction scores on the HCAHPS survey. Higher HCAHPS scores lead to increased hospital reimbursement from CMS. The document reviews research showing IHM is effective at reducing pain, anxiety, and depression in patients, thus enhancing the patient experience and satisfaction. The low cost of implementing IHM makes it a promising strategy for hospitals to boost HCAHPS scores and reimbursement while improving patient care.
Presentation on medication history interview and soap notessuchitrauppicherla
pharmacy practice is vital activity performed by pharmadians along with physicians to enhance the quality and span of life of patient .mediaction history interview is is an essential to know and presentation of case collected in universally accepted format .
The document discusses patient counseling in pharmacy from educational and counseling perspectives. It defines counseling, consulting, and education and differentiates the terms. Various counseling theories and models of patient-provider relationships are described. The document emphasizes that patient counseling involves both counseling and education, drawing from different theories depending on the situation and patient needs. The goals of patient counseling are to establish trust and help patients manage their medication and health, while educational goals involve providing tailored information to meet patient needs. An andragogical approach is recommended to align counseling with adult learning principles and make it most effective.
Patient Assessment And Clinical Interviewingdunerafael
The document provides guidance on common mistakes healthcare practitioners make in patient communication and assessment. It discusses the importance of greeting patients, understanding their concerns, asking open-ended questions, being attentive to verbal and non-verbal cues, avoiding judgements, and understanding cultural beliefs. It also outlines key information to collect during a patient assessment, including medical history, medications, allergies and social factors, and provides examples of documentation through a SOAP note.
Psychological Assessment For Implantable Therapies Dr Peter Murphyepicyclops
Psychological assessment is recommended for patients undergoing spinal cord stimulation (SCS) therapy based on evidence that it leads to better outcomes. A brief psychological evaluation can identify potential mental health issues like depression or anxiety that are common in chronic pain patients and associated with poorer prognoses. It also aims to ensure patients have realistic expectations of SCS and a plan for managing their pain should the treatment not achieve the desired level of relief. While certain personality traits alone may not predict outcomes, evaluations can help optimize patient selection and preparation for SCS.
This document discusses strategies to enhance patient adherence to preventive dental programs. It defines key terms like adherence and compliance. It outlines factors that influence patient adherence like patient characteristics and relationships with providers. It also examines protocols to assess adherence using indices and discusses monitoring adherence over time. Finally, it presents strategies to promote adherence like patient education, counseling, stage-based models, and motivational interviewing. The goal is to properly identify strategies tailored for each individual patient's needs.
This document discusses the development of therapeutic guidelines. It defines therapeutic guidelines as clinical practice guidelines written for prescribers to provide treatment recommendations based on current evidence. The document outlines the need for guidelines to improve patient care quality and consistency while controlling healthcare costs. It describes the composition of guideline development groups and the multi-step process involved, including identifying the problem and literature, obtaining expert opinions, reviewing evidence, and disseminating the completed guidelines. Potential limitations of guidelines like complexity and physician acceptance are also discussed.
Communication is the transfer of information meaningful to those involved. Interactive communication is a process that facilitates a dialogue to provide multiple opportunities to accurately interpret meaning and respond appropriately. An interactive model is similar to a discussion rather than a lecture.
For example, using an interactive model, a patient may be asked what they know about their medications. As the patient describes aspects of his or her medication therapy, the pharmacist can then respond to fill in knowledge gaps, correct misinformation and verify patient understanding, thus eliminating or minimizing misunderstandings.
Interactive communications are effective for many interpersonal situations, but are especially useful when working with patients to assure appropriate use of medications.
The document outlines principles of patient counseling and communicating bad news. It discusses the importance of obtaining consent from patients, providing information in a sensitive manner, and allowing patients to process information at their own pace. Guidelines are provided for setting up private discussions, assessing a patient's understanding, disclosing medical details with empathy, and developing future care strategies together. The goal is to fully inform patients while respecting their rights, emotions, and decisions throughout the counseling process.
Patient counseling provides several benefits but also faces challenges. It reduces errors, noncompliance, and adverse drug reactions while improving outcomes and patient satisfaction. Counseling is integral to providing pharmaceutical care and professional pharmacy services. However, pharmacists face challenges like lack of time, incentives, and an environment conducive to counseling. Regulations, acceptance by other providers, and patient factors can also impede counseling.
This document discusses patient compliance, which refers to how well a patient follows medical advice such as taking medications correctly. It notes that adherence is a more accurate term than compliance, as it implies patients actively participate in their own care rather than just following doctor's orders. The document outlines factors that affect compliance like education level and side effects, and notes the importance of compliance for conditions like diabetes or HIV. It also discusses methods to detect non-adherence, the role of pharmacists in improving compliance through education and counseling, and concludes that developing strong patient relationships can increase understanding and compliance.
This study examines the effects of an 8-week Mindfulness-Based Stress Reduction program on burnout and empathy in healthcare professionals. The author hypothesizes that the MBSR program will decrease burnout, as measured by lower scores on emotional exhaustion, depersonalization, and increased personal accomplishment on the Maslach Burnout Inventory. They also hypothesize that the program will increase empathy, as measured by higher scores on perspective taking, compassionate care, and understanding the patient's perspective on the Jefferson Scale of Empathy. The study uses quantitative pre- and post-test measures and qualitative program evaluations to analyze the impact of MBSR training on burnout and empathy in healthcare workers.
Asam criteria attc online module 2018_week 1 pptMike Wilhelm
This document provides an overview of the American Society of Addiction Medicine (ASAM) Criteria for assessing substance use disorders. It introduces the six dimensions for assessment: acute intoxication, biomedical conditions, emotional/behavioral complications, readiness to change, relapse potential, and living environment. It also outlines the different levels of care in the ASAM model from early intervention to intensive inpatient treatment. Participants are assigned a case study to complete the initial assessment using the six dimensions for next week's session.
This document defines patient counseling as a one-on-one interaction between a pharmacist and patient/caregiver to provide medication information. It discusses how counseling is undertaken during dispensing, disease management, and providing self-care advice. The pharmacist should educate patients on medication names, directions, interactions, intended effects, side effects and monitoring. Effective communication relies on active listening, questioning, responding, explaining and ensuring patient understanding. Counseling aims to improve patient outcomes and satisfaction.
Course Director Peter A. Lio, MD, and Robert Sidbury, MD, MPH, prepared useful Practice Aids pertaining to atopic dermatitis for this CME activity titled "Advances in the Management of Moderate to Severe Atopic Dermatitis: How Can We Address Unmet Medical Needs in Individual Patients to Optimize Long-Term Outcomes?" For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at http://bit.ly/2VJqSFq. CME credit will be available until June 19, 2020.
This document is a resume for Chantel Enger, an art teacher seeking employment. She received her Bachelor's degree in Education and Liberal Arts from Montana State University. Her student teaching experiences included middle school and high school levels. She is passionate about helping students find creative expression and hopes to prepare them to explore their full potential.
Material handling control system software extends supply chain visibilityARC Advisory Group
The document discusses material handling control system (MCS) software, which provides uniform interfaces for equipment in material handling systems. MCS software integrates automated material handling subsystems, provides routing and tracking of items, and allows communication with conveyors and automated vehicles. It is a key part of achieving high performance in supply chain execution and manufacturing by enabling efficient material movement and data collection.
Emmanuel has over 30 years of experience in supply chain and operations management in various industries and countries. He has a strong background in demand management, production planning, and contract manufacturer management. Some of Emmanuel's roles included supply chain manager, transition manager, and project leader for ERP implementations. He is skilled at process improvement, change management, and delivering effective solutions through data analysis. References highlighted Emmanuel's strong drive, adaptability, and ability to manage people and projects in changing environments.
Goh Kee Kok has over 10 years of experience in supply chain management across various industries and countries. He has held procurement and supply chain roles at Emerson Electric, General Motors, Singapore Technologies Kinetics, and Leeboy India Construction Equipment. His responsibilities have included strategic sourcing, supplier development, cost reduction, and inventory management. He has a degree in electronics from the National University of Singapore and is fluent in English with proficiency in Mandarin and several Chinese dialects.
Chloe Lloyd is a political science and women's studies graduate of Chapman University who has held several leadership roles in student government and organizations. She has work experience in development and political internships. Her education includes a semester abroad studying political science and women's studies in 14 countries through Semester at Sea.
Charles Waite has over 20 years of experience in maintenance, including 14 years in the U.S. Navy as a maintenance technician and supervisor responsible for mechanical systems on ships. He currently works as a Maintenance Supervisor for P.H. Glatfelter, where he oversees 14 employees and ensures preventative and emergency maintenance. He has strong skills in mechanical, electrical, and process control systems, as well as leadership and computer programs like SAP, Word, Excel, and AutoCAD.
Charlene Weiss has over 5 years of experience as an assistant story editor and story producer for reality television shows aired on networks such as Lifetime, Oxygen, ABC, and VH1. She has worked on shows such as Project Runway, Bad Girls Club, Love Games, and Swerved. Her skills include string outs, research, editing scenes, writing interview questions, and working with editors on network notes to recognize and structure storylines.
The document summarizes the experience and qualifications of a Supply Chain Manager. It outlines 8 years of experience in manufacturing and trading supply chain management, as well as project management and process restructuring experience. It also lists education including an MBA in Supply Chain Management and training in areas like team management, SAP, Oracle, supply chain management, and warehouse management. Responsibilities included planning, purchasing, logistics, warehouse management, and customer support. Achievements highlighted optimization of costs, inventory levels, and on-time delivery.
This document summarizes a master's thesis on granulomatous inflammation. It begins with an introduction to granulomas and granulomatous diseases. It then discusses specific granulomatous conditions in more depth, including tuberculosis (TB), fungal infections, and parasitic infections. For tuberculosis, it covers epidemiology, central nervous system involvement, pathogenesis, and clinical presentations such as tuberculous meningitis. In summary, the document provides an overview of granulomatous inflammation and focuses on infectious etiologies like TB.
Hussein Nassar is a supply chain management professional seeking a new managerial position. He has over 15 years of experience managing logistics and supply chain operations for pharmaceutical companies in Saudi Arabia and the UAE. Nassar holds a CSCM certification and has a proven track record of improving forecast accuracy, reducing costs, and optimizing inventory levels. He is fluent in Arabic and English and skilled in SAP, logistics process management, and financial controlling.
Chandan Singh is a mechanical engineer seeking a position that utilizes his technical and analytical skills. He has a Bachelor of Engineering in Mechanical Engineering from Yadavrao Tasgaonkar Institude Of Engg. & Tech. in Mumbai. He has experience with CAD software including Creo, SolidWorks, Catia, and Autodesk Inventor. His final year project involved testing an eco-friendly vortex induced vibration energy converter. He is proficient in MS Office and has participated in various extracurricular activities and technical competitions during his studies.
US Wind Turbine Supply Chain Conference 2011 brochureTom
The document advertises the 2nd US Wind Turbine Supply Chain Conference in 2011 to be held in Detroit on April 5-6. The conference will provide insights into developing lean manufacturing strategies, reducing costs, and deepening supplier relationships to gain a competitive edge in the US wind turbine supply chain. It will feature over 25 expert speakers from leading wind energy companies and cover topics like matching supply to increasing demand, the latest federal and state policies, and OEM production plans for 2011-2012. Attendees will learn how to prepare their businesses for the growing US wind market opportunities in a cost-effective way.
Top 8 finance and administration manager resume samplesverijom
The document provides information about resume samples, tips, cover letters, interview questions, and other career resources for finance and administration managers. It lists top resume types including chronological, functional, curriculum vitae, combination, targeted, professional, new graduate, and executive resumes. It also provides links to interview questions, thank you letter samples, career development resources, and suggested fields and job levels related to finance and administration management careers.
Hardik Doshi has over 10 years of experience in finance and research. He holds an MBA in finance and investment banking and is a CFA Level 3 candidate. Currently he works as an equity research analyst covering the banking sector in India and Eastern Europe. Previously he has interned at financial firms in Dubai and worked as a systems executive, project engineer, and PeopleSoft consultant.
Mohamed Rady Mahfouz is a certified supply chain manager with over 6 years of experience managing supply chains in Egypt and Saudi Arabia. He holds several certifications including CSCM, CSCP, and CPIM. Currently he is a supply chain manager at Mashreq for Business Development in Egypt where he oversees supply chain operations and identifies areas for cost reduction. Previously he held supply chain planning roles at Americana Meat in Saudi Arabia where he improved inventory turnover and implemented a balanced scorecard system. He also has experience providing supply chain consulting and training.
S Bala Krishna is a certified international supply chain manager with over 21 years of experience managing supply chains across diverse organizations. He has extensive experience in vendor and supplier management, procurement, logistics, and inventory management. Currently he works as the supply chain manager for GGICO Gourmet Investment LLC in Dubai, where he oversees import operations and works with suppliers to meet business needs. Previously he held purchasing management roles at Saleh Bin Lahej Hospitality Division and First Food Services, developing supply strategies and negotiating contracts to optimize costs.
Ccn(Data communication and networking) edited solution-manual suitable to be ...Vishal kakade
This document provides solutions to review questions and exercises related to network models and data link control. It begins with solutions to review questions on network models, including definitions of the OSI and Internet models. It then provides solutions to exercises on typical network examples like telephone and cable networks. Finally, it discusses data link control protocols like Stop-and-Wait ARQ, Go-Back-N ARQ, and Selective-Repeat ARQ, and provides solutions to related exercises.
This job description is for a Supply Chain Manager II position at DuPont's Circuits and Packaging Materials Business (CPM). The responsibilities of the role include monitoring global supply chain performance, developing and executing supply chain strategies, balancing risks and costs, and leading supply chain improvement initiatives across North America, Europe, Taiwan, and China. Qualifications for the role include a bachelor's degree, 15+ years of supply chain experience, 5+ years of management experience, and certifications in APICS CPIM, Six Sigma, and SAP APO.
Clinical Skills Self-Assessment Everyone ought to have specifiWilheminaRossi174
Clinical Skills Self-Assessment
Everyone ought to have specific attributes, including their strengths and weaknesses. My experience as a nurse has equipped me with several skills that will come in handy when I start working as a psychiatrist. Recognizing the signs and symptoms of mental illness is one of my strengths, thanks to the knowledge and abilities I have gained over the years. On the other side, I must have a lot of weaknesses. The options for professional development that I need to investigate during my career to increase my skills in making use of the results of psychological tests. This paper will discuss three strengths and weaknesses and three clinical skills that a nursing student would like to become a professional before graduating from a nursing program. These strengths and weaknesses will be compared to three clinical skills that a nursing student would like to have.
PRAC 6665/6675 Clinical Skills
Self-Assessment Form
Desired Clinical Skills for Students to Achieve
Confident (Can complete independently)
Mostly confident (Can complete with supervision)
Beginning (Have performed with supervision or needs supervision to feel confident)
New (Have never performed or does not apply)
Comprehensive psychiatric evaluation skills in:
Recognizing clinical signs and symptoms of psychiatric illness across the lifespan
Differentiating between pathophysiological and psychopathological conditions
Performing and interpreting a comprehensive and/or interval history and physical examination (including laboratory and diagnostic studies)
Performing and interpreting a mental status examination
Performing and interpreting a psychosocial assessment and family psychiatric history
Performing and interpreting a functional assessment (activities of daily living, occupational, social, leisure, educational).
Diagnostic reasoning skill in:
Developing and prioritizing a differential diagnoses list
Formulating diagnoses according to DSM 5-TR based on assessment data
Differentiating between normal/abnormal age-related physiological and psychological symptoms/changes
Pharmacotherapeutic skills in:
Selecting appropriate evidence based clinical practice guidelines for medication plan (e.g., risk/benefit, patient preference, developmental considerations, financial, the process of informed consent, symptom management)
Evaluating patient response and modify plan as necessary
Documenting (e.g., adverse reaction, the patient response, changes to the plan of care)
Psychotherapeutic Treatment Planning:
Recognizes concepts of therapeutic modalities across the lifespan
Selecting appropriate evidence based clinical practice guidelines for psychotherapeutic plan (e.g., risk/benefit, patient preference, developmental considerations, financial, the process of informed consent, symptom management, modality appropriate for situation)
Applies age-appropriate psychotherapeutic counseling techniques with ...
This document discusses using progress monitoring and outcome measures to enhance counselling, psychotherapy, and other talking interventions for student mental health. It provides an overview of progress monitoring versus outcome assessment and lists desirable characteristics of outcome measures. The document discusses how outcome measures can be used therapeutically, to help practitioners improve, for clinical supervision, and to shape service delivery. It also provides examples of outcome measures used at the University of Cumbria's mental health and wellbeing service and tips for using patient-rated outcome measures.
The document discusses the role of physical therapists in patient/client management. It describes the five key elements of patient management as examination, evaluation, diagnosis, prognosis, and intervention. Evaluation involves creating a problem list for the patient. Diagnosis categorizes the problems into defined clusters or syndromes. Prognosis predicts the patient's expected improvement, timeline, and outcomes. Discharge and discontinuation processes determine when physical therapy services are concluded. Outcomes analyze the overall impact of interventions on the patient.
TEST BANK For Critical Thinking, Clinical Reasoning, and Clinical Judgment A ...robinsonayot
TEST BANK For Critical Thinking, Clinical Reasoning, and Clinical Judgment A Practical Approach 7th Edition by Rosalinda Alfaro-LeFevre, Verified Chapters 1 - 7, Complete Newest Version.pdf
TEST BANK For Critical Thinking, Clinical Reasoning, and Clinical Judgment A Practical Approach 7th Edition by Rosalinda Alfaro-LeFevre, Verified Chapters 1 - 7, Complete Newest Version.pdf
Three Mountains Regional Hospital· Medical and surgical facility.docxjuliennehar
Three Mountains Regional Hospital
· Medical and surgical facility.
· Offer outpatient and inpatient surgeries.
· Committed to providing high-quality health services.
Electronic Medical Record
Defined as medical records kept on a computer.
Records are kept by doctors, health care providers, hospital or medical office staff.
Contents of EMR
The records contain general patient information, such as:
· Health condition
· Diagnostic tests
· Prescriptions and
· Treatment
· Personal details like name, contacts, and date of birth
EMRs are safe and confidential.
Records can be shared securely through a network.
HIPPA/
Confidentiality
It is a U.S legislation that safeguards medical information.
The law provides privacy and security to health data.
It requires health care information to be handled with confidentiality.
Level of Confidentiality
High-levels of confidentiality assured when transferring, receiving, sharing, or handling protected health information.
Release of Information
To maintain patient confidentiality and comply with set laws, health information will only be released upon written authorization by the patient.
The process of requesting your health records at Three Mountains Regional hospital is as follows:
· Obtain, fill and submit Authorization for Release of Health Information Form
·
· Form must be completed and signed.
· Specify information to be released.
· Health practitioner to review request and clinical appropriateness for release.
· After approval, information is released.
NB:
The following Protected health information cannot be shared without patient permission:
· Test and laboratory results
· Demographic information
· Mental health condition
· Medical histories and
· Insurance information
Privacy Pledge
At Three Mountains Regional Hospital, we pledge to keep all your information private and confidentiality in compliance with the law and through our
You did a nice job with the brochure layout, as it looks very good and you made a nice use of graphics and language. Nice work on the EMR. You need to discuss the joint committee requirement and add a citation to show that you used the material. In the HIPPA section, good job defining how HIPPA provides privacy and security protection. You need to expand and tell the patient how HIPPA is used by the facility to ensure their privacy. Your release of information good and explains the process as nice use of steps a patient needs to do besides just contacting the facility to get a form . You need to draft a more developed privacy pledge that adds a goal to comply with all federal and state laws regarding privacy to your pledge.
specific privacy policies.
Title
ABC/123 Version X
1
Grading Guide for Issues of Substance Abuse and Addiction
CPSS 420
1
University of Phoenix Material
Week 5: Substance Abuse Treatment
Content (80%)
Points Earned:
· All key elements of the assignment are covered in a substantive way. Major points are stated clearly; are supporte ...
TEST BANK For Critical Thinking, Clinical Reasoning, and Clinical Judgment A ...rightmanforbloodline
TEST BANK For Critical Thinking, Clinical Reasoning, and Clinical Judgment A Practical Approach 7th Edition by Rosalinda Alfaro-LeFevre, Verified Chapters 1 - 7, Complete Newest Version.
TEST BANK For Critical Thinking, Clinical Reasoning, and Clinical Judgment A Practical Approach 7th Edition by Rosalinda Alfaro-LeFevre, Verified Chapters 1 - 7, Complete Newest Version.
TEST BANK For Critical Thinking, Clinical Reasoning, and Clinical Judgment A Practical Approach 7th Edition by Rosalinda Alfaro-LeFevre, Verified Chapters 1 - 7, Complete Newest Version.
The document describes a learning module on pharmacology for nursing students. It includes an overview of the module, learning outcomes, content topics, and activities. The module aims to teach students how to apply the nursing process, including assessment, planning, intervention, education, and evaluation, when administering drugs to patients. It focuses on important aspects like taking drug histories, interpreting medication orders, ensuring safety, and educating clients. A variety of teaching methods are outlined like discussions, case studies, skills practice, and quizzes to reinforce the concepts.
Evidence based practice in physiotherapy.pptxDrNamrataMane
The document discusses evidence-based practice (EBP) in physical therapy. It defines EBP as integrating the best research evidence, clinical expertise, and patient values and describes the 5 steps of EBP as formulating a question, finding evidence, appraising evidence, implementing evidence, and evaluating outcomes. The document also explores barriers to EBP, such as lack of time and understanding of statistics, and facilitators, like access to online research summaries.
This document summarizes a presentation about an interdisciplinary outpatient pain management program. The program was developed in response to high rates of chronic pain in post-acute populations and new regulations surrounding opioid prescriptions. The program utilizes 10 collaborating disciplines including physicians, psychologists, physical therapists, nurses, and social workers. Key aspects of the program include comprehensive assessments, a pain contract, urine drug screening, and emphasis on non-pharmacological treatments. Initial results after one year include improved capacity for adjunct treatments, integration of new specialists, and fewer demanding patients due to clear guidelines.
The document provides an evaluation tool for a pediatric clinical course taken by Emily Tarrell. It outlines the course description and evaluation standards. The evaluation covers six essential competencies for nursing: patient-centered care, systems-based practice, evidence-based practice, informatics, quality improvement, and teamwork/collaboration. For each competency, the evaluator provides comments and examples of how Emily demonstrated the competencies in her clinical work from June 3rd to June 12th. Overall, the evaluation indicates Emily met course expectations and showed improvement over the rotation.
Clinical Audit is a method of confirming the quality of clinical services and identify the need for improvement. A skill hospital administrator should learn and practice.
Running Head Case study1Case study 5Case Stud.docxtodd271
Running Head: Case study 1
Case study 5
Case Study
Walden University
Name
NURS – 6630N
March 9, 2019
Case Study
Optimizing the dosing of medicines for neonates and children remains a challenge. The importance of pharmacokinetic (PK) and pharmacodynamics (PD) research is recognized both in medicines regulation and pediatric clinical pharmacology, yet there remain barriers to undertaking high-quality PK and PD studies. While these studies are essential in understanding the dose–concentration–effect relationship and should underpin dosing recommendations, this review examines how challenges affecting the design and conduct of pediatric pharmacological studies can be overcome using targeted pharmacometric strategies. Model-based approaches confer benefits at all stages of the drug life-cycle, from identifying the first dose to be used in children, to clinical trial design, and optimizing the dosing regimens of older, off-patent medications. To benefit patients, strategies to ensure that new PK, PD and trial data are incorporated into evidence-based dosing recommendations are needed.
The client selected is an African American child having depression with normal development milestone. Other aspects reveal that the child has high ratings in depression scale. The criterion is used to diagnose the child.
Decision point one
In this case, we had to prescribe the first choice of drug to get an effective effect. Some Selective serotonin reuptake inhibitors (SSRIs) are the drugs of choice to use in children with depressive disorder. The best medicine is Zoloft having sertraline. Now we decided the starting dose and that was 25mg to be administered orally. According to Vitiello (2012), if the medicine does not work in starting dose, we need to increase the dose. The child had been prescribed Zoloft and he came back with no change in his mental health.
Decision point two
If the drug is not working in a low dose, we need to increase the dose. Decision point two involved increasing the dose from 25mg to 50mg.The purpose of increasing the dose was to lower the depressive symptoms. Being within the range, we expected minimal desired effects (Stahl, 2013). Giving a single dose is more likely to give persistent desired effects in client. The patient experienced 50 percent decrease in symptoms. Hence Zoloft was successful in managing the patient’s depression. You must be cautious about the side effects of sertraline. One of the major is suicidal thoughts.
Decision point three
Decision point three is to decide if the dose will be maintained or increased to get rid of symptoms completely. The best decision is to maintain the dose because if the patient has shown 50 percent improvement then he will show more with the passage of time. His dose had been maintained now he further experienced decrease in symptoms. The best treatment is the complete remission as it is the main aim in contemporary psychopharmacology (Stahl, 2013). Then I recommended.
Assessing Benefits and Harms of Opioid Therapy for Chr.docxfestockton
Assessing Benefits and
Harms of Opioid Therapy
for Chronic Pain
Clinician Outreach and
Communication Activity
(COCA) Call
August 3, 2016
Office of Public Health Preparedness and Response
Division of Emergency Operations
Accreditation Statements
CME: The Centers for Disease Control and Prevention is accredited by the Accreditation Council for Continuing Medical
Education (ACCME®) to provide continuing medical education for physicians. The Centers for Disease Control and Prevention
designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit
commensurate with the extent of their participation in the activity.
CNE: The Centers for Disease Control and Prevention is accredited as a provider of Continuing Nursing Education by the
American Nurses Credentialing Center's Commission on Accreditation. This activity provides 1.0 contact hour.
IACET CEU: The Centers for Disease Control and Prevention is authorized by IACET to offer 1.0 CEU's for this program.
CECH: Sponsored by the Centers for Disease Control and Prevention, a designated provider of continuing education contact
hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is
designed for Certified Health Education Specialists (CHES) and/or Master Certified Health Education Specialists (MCHES) to
receive up to 1.0 total Category I continuing education contact hours. Maximum advanced level continuing education contact
hours available are 0. CDC provider number 98614.
CPE: The Centers for Disease Control and Prevention is accredited by the Accreditation Council for Pharmacy Education as
a provider of continuing pharmacy education. This program is a designated event for pharmacists to receive 0.1 CEUs in
pharmacy education. The Universal Activity Number is 0387-0000-16-150-L04-P and enduring 0387-0000-16-150-H04-P course
category. Course Category: This activity has been designated as knowledge-based. Once credit is claimed, an unofficial
statement of credit is immediately available on TCEOnline. Official credit will be uploaded within 60 days on the NABP/CPE
Monitor
AAVSB/RACE: This program was reviewed and approved by the AAVSB RACE program for 1.0 hours of continuing education
in the jurisdictions which recognize AAVSB RACE approval. Please contact the AAVSB RACE Program at [email protected] if
you have any comments/concerns regarding this program’s validity or relevancy to the veterinary profession.
CPH: The Centers for Disease Control and Prevention is a pre-approved provider of Certified in Public Health (CPH)
recertification credits and is authorized to offer 1 CPH recertification credit for this program.
Continuing Education Disclaimer
CDC, our planners, presenters, and their spouses/partners wish to
disclose they have no financial interests or other relationships with
the manufacturers of commercial products, suppli ...
The document proposes a pilot study to investigate the feasibility of integrating behavioral health outcomes data into routine clinical practice. The study would measure how frequently providers collect outcomes data from patients and enter it into the health records system. It would also survey patients and providers on their perceptions of the value of receiving feedback on treatment progress. If found feasible, a follow-up study would assess the quality and cost impacts of incorporating outcomes monitoring more broadly.
The document discusses the nursing process and how it is used to create nursing care plans and concept maps. It outlines the 5 steps of the nursing process - assessment, diagnosis, planning, implementation, and evaluation. Assessment involves collecting comprehensive patient data. Diagnosis identifies the patient's problems or nursing diagnoses. Planning determines goals and interventions. Implementation puts the plan into action. Evaluation assesses outcomes and the effectiveness of the plan. Concept maps provide an innovative way to organize patient data using diagrams of problems and interventions.
The document discusses various aspects of planning in nursing, including types of planning like initial, ongoing, and discharge planning. It covers developing nursing care plans, which can be informal, formal, standardized, or individualized. Standardized care plans provide detailed interventions for common client needs. When planning, nurses prioritize problems, establish goals, select interventions, and write individualized plans. Goals should be specific and measurable client outcomes. Interventions are chosen based on eliminating causes of problems and achieving goals. The planning process is an essential part of the nursing process.
The document introduces the nursing process, which includes assessment, nursing diagnosis, planning, implementation, and evaluation. It is a systematic approach to providing nursing care. The nursing process allows nurses to identify patient health problems, plan and provide interventions, and determine the effectiveness of the care.
Write a 4-6 page evidence-based patient-centered care report on .docxjohnbbruce72945
Write a 4-6 page evidence-based patient-centered care report on the patient scenario presented in the Evidence-Based Health Evaluation and Application media piece. Base your report on the information provided by the traumatic brain injury expert from the population health improvement initiative (PHII) described in the media activity and your own evidence-based research on this population health issue.
In this assessment, you will apply evidence-based practice in patient-centered care and population health improvement contexts. You will be challenged to think critically, evaluate what the evidence suggests is an appropriate approach for a personalized patient care plan, and determine which aspects of the approach could be applied to similar situations and patients.
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
Competency 1: Apply evidence-based practice to plan patient-centered care.
Evaluate the outcomes of a population health improvement initiative.
Develop a personalized patient care plan that incorporates lessons learned from a population health improvement initiative.
Competency 2: Apply evidence-based practice to design interventions to improve population health.
Propose a strategy for improving the outcomes of a population health improvement initiative, or for ensuring that all outcomes are being addressed, based on the best available evidence.
Competency 3: Evaluate outcomes of evidence-based interventions.
Propose an evaluation strategy for the outcomes of personalized patient care plan and determine what aspects of the approach could be applied to similar situations and patients.
Competency 4: Evaluate the value and relative weight of available evidence upon which to make a clinical decision.
Identify the level of evidence and describe the value and relevance it brings to personalized care for your patient.
Competency 5: Synthesize evidence-based practice and academic research to communicate effective solutions.
Write clearly and logically, with correct grammar and mechanics.
Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.
Scenario
The charge nurse in your clinic has contacted you to assume primary care for a patient and develop a plan for follow-up care. The plan should be personalized for him based on evidence-based research provided by a community expert as well as your own research on the condition. You will also be challenged to determine which aspects of the traumatic brain injury (TBI) approach could be applied to similar situations and patients.
Your Role
You are a nurse who has been requested to provide primary patient care, including a follow-up care plan. You will revisit the interview with the community TBI expert and prepare a personalized health pl.
This document provides a student evaluation tool for physical therapist students to assess their clinical education experiences and clinical instruction. The tool was developed in response to requests from academic and clinical educators for a consistent approach for student feedback. It consists of two sections - the first assesses the clinical experience, and the second evaluates clinical instruction. The tool is intended to be used by students to provide formative and summative feedback on the quality of their learning experience and clinical instructors.
How to Fix the Import Error in the Odoo 17Celine George
An import error occurs when a program fails to import a module or library, disrupting its execution. In languages like Python, this issue arises when the specified module cannot be found or accessed, hindering the program's functionality. Resolving import errors is crucial for maintaining smooth software operation and uninterrupted development processes.
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
This presentation includes basic of PCOS their pathology and treatment and also Ayurveda correlation of PCOS and Ayurvedic line of treatment mentioned in classics.
Main Java[All of the Base Concepts}.docxadhitya5119
This is part 1 of my Java Learning Journey. This Contains Custom methods, classes, constructors, packages, multithreading , try- catch block, finally block and more.
How to Build a Module in Odoo 17 Using the Scaffold MethodCeline George
Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
Assessment and Planning in Educational technology.pptxKavitha Krishnan
In an education system, it is understood that assessment is only for the students, but on the other hand, the Assessment of teachers is also an important aspect of the education system that ensures teachers are providing high-quality instruction to students. The assessment process can be used to provide feedback and support for professional development, to inform decisions about teacher retention or promotion, or to evaluate teacher effectiveness for accountability purposes.
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
Strategies for Effective Upskilling is a presentation by Chinwendu Peace in a Your Skill Boost Masterclass organisation by the Excellence Foundation for South Sudan on 08th and 09th June 2024 from 1 PM to 3 PM on each day.
The simplified electron and muon model, Oscillating Spacetime: The Foundation...RitikBhardwaj56
Discover the Simplified Electron and Muon Model: A New Wave-Based Approach to Understanding Particles delves into a groundbreaking theory that presents electrons and muons as rotating soliton waves within oscillating spacetime. Geared towards students, researchers, and science buffs, this book breaks down complex ideas into simple explanations. It covers topics such as electron waves, temporal dynamics, and the implications of this model on particle physics. With clear illustrations and easy-to-follow explanations, readers will gain a new outlook on the universe's fundamental nature.
Executive Directors Chat Leveraging AI for Diversity, Equity, and InclusionTechSoup
Let’s explore the intersection of technology and equity in the final session of our DEI series. Discover how AI tools, like ChatGPT, can be used to support and enhance your nonprofit's DEI initiatives. Participants will gain insights into practical AI applications and get tips for leveraging technology to advance their DEI goals.
বাংলাদেশের অর্থনৈতিক সমীক্ষা ২০২৪ [Bangladesh Economic Review 2024 Bangla.pdf] কম্পিউটার , ট্যাব ও স্মার্ট ফোন ভার্সন সহ সম্পূর্ণ বাংলা ই-বুক বা pdf বই " সুচিপত্র ...বুকমার্ক মেনু 🔖 ও হাইপার লিংক মেনু 📝👆 যুক্ত ..
আমাদের সবার জন্য খুব খুব গুরুত্বপূর্ণ একটি বই ..বিসিএস, ব্যাংক, ইউনিভার্সিটি ভর্তি ও যে কোন প্রতিযোগিতা মূলক পরীক্ষার জন্য এর খুব ইম্পরট্যান্ট একটি বিষয় ...তাছাড়া বাংলাদেশের সাম্প্রতিক যে কোন ডাটা বা তথ্য এই বইতে পাবেন ...
তাই একজন নাগরিক হিসাবে এই তথ্য গুলো আপনার জানা প্রয়োজন ...।
বিসিএস ও ব্যাংক এর লিখিত পরীক্ষা ...+এছাড়া মাধ্যমিক ও উচ্চমাধ্যমিকের স্টুডেন্টদের জন্য অনেক কাজে আসবে ...
বাংলাদেশ অর্থনৈতিক সমীক্ষা (Economic Review) ২০২৪ UJS App.pdf
Pain mgtpdf
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. 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. 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
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. 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. 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. 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. 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
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. I, Veeraiah C. Perni do not have any
conflicts of interest in relation to
this presentation.
13. Evolution of Pain Medicine
Pre- 20th Century
20th Century Pain Management
Revolution in Pain Management
Recent Development
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. 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. ● 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. ● 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. ● 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. ● 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
21. I, Rickie K. Monroe, do not have any
conflicts of interest in relation to
this presentation.
22. Goal is painless or nearly painless surgery
Anesthesiologist are committed to explore
mechanisms for acute postoperative pain
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. 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. 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. Epidural analgesia decreases pain with
activities
Continuous regional analgesic techniques like
femoral nerve blocks and brchial plexus block
decrease activity pain!
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. 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.
30. 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
31. Various reflexes are also excited including
activation of sympathetic nervous system
Regulation takes place by descending
excitatory and inhibitory pathways
32. 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
33. Pain from : 1. Recent Surgery
2. Recent Injury
3. Medical Illness
Can be managed immediately
Usually gets better in short time
37. 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
38.
39. “ Do not mix pain prescription drugs with
over-the –counter pain relievers without
consulting your doctor”
41. Nonsteroidal Anti-inflammatory drugs
Inhibit the synthesis of prostaglandins
Prostaglandins mediate components of the
inflammatory response including fever, pain
and vasodilatation.
42. 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
43. 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
44. 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
45. 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
46. 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
47. 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
48. 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
49. 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)
52. 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
53. Morphine-like
drugs prescribe d
to treat acute pain
or cancer pain
Hydrocodone with
acetaminophen
(Vicodan, Lortab,
Norco)
Acetaminophen
with codeine
(Tylenol#3,etc.)
54. 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
56. 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
57. Has been demonstrated to result in improved
patient satisfaction due to decreased delay in
treatment
58. 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)
59. 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
60. Cymbalta
Dosing 60 mg po qd
Serotonin and norepinephrine reuptake
inhibitor
FDA approved for treatment of Diabetic
Neuropathy and Fibromyalgia
61. 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)
62. Neuaxial delivery of drugs will result in lower
doses of medications need than systemic
delivery
Should result in less opiod related side effects
69. 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
88. 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
94. 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
100. 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
101. 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
109. Endoscopic Discectomy
Patient – Monitored Anesthesia Care
Patient has failed all conservative
measures
Patient prefers not to undergo open
discectomy
Does not burn any bridges
113. TruFuse
Facet Mediated Pain
Failed all conservative measures
including RFL
Burns NO bridges
Patients receive general anesthesia
Addresses underlying problem
114. 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
119. 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
123. 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
124. SCS
Demonstrated relief with the temporary
electrode ( 50% or greater)
Cleared by Behavioral Medicine
Failed all Measures including surgical
Not addicted or in litigation
125.
126. Drug Administration System
• Indications:
– Pain type and generator appropriate
– Demonstrated opioid responsiveness
– No untreated psychopathology
– Demonstrated relief with trial catheter
127. 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
131. 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
133. I, John D. Wrightson, do not have any
conflicts of interest in relation to this
presentation.
134. 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?
135. 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?
136. 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?
137. 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)
139. 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.
140. 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
141. 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
142. Proper Opiate Prescribing
Guidelines
What are the differences between dependence,
tolerance, addiction and pseudo-addiction?
Dependence
Tolerance
Addiction
Pseudoaddiction
143. 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.
146. 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.
147. 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
148. 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
149. 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.
151. 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
152. 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.
153. 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
154. 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.
155. 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
156. 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
157. 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
158. 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
159. Number of new nonNumber of new non--medicalmedical
users of therapeuticsusers of therapeutics
(NSDUH,
2002)
160. 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
161. 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
162. 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””
163. 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
164. 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
165. 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
166. 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
167. 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?
168. 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.
169. 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)
170. 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).
171. 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..
172. 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)
173. 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!!!!!!
174. 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
175. 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
176. 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.
177.
178. 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
179. RulesRules
These rules do not apply when prescribingThese rules do not apply when prescribing
nonnon--narcotic medication for chronic painnarcotic medication for chronic pain
180. 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
181. 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
182. 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
183. 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
184. 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!
185. 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
186. 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””
187. 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
188. 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
189. 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..
191. 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
192. 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.
193. 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
194. Pain Management forPain Management for
the Nonthe Non--SpecialistSpecialist
Presented by:
Veeraiah C. Perni, M.D.
Director of Anesthesiology
Jameson Memorial Hospital
195. I, Veeraiah C. Perni do not have any
conflicts of interest in relation to this
presentation.
196. 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
197. Target Clinical SpecialtyTarget Clinical Specialty
Family Practice
Internal Medicine
Pediatrics
Physical Medicine and Rehabilitation
Psychology
Surgery
Hospitals/Allied Health Personnel
198. 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
199. 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
200. 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
201. 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
202. 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
203. 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
205. 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
206. 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
207. 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
208. 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
209. 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
210. 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
211. 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
212. 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
213. 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
214. 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
215. 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
216. 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
219. 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
220. 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
221. 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
222. 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
223. 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
224. 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
225. 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
226. 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
227. 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
228. 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
229. 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
230. 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
231. 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
232. 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
233. 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