I do not have access to the video cases you referenced. Could you please provide a brief summary of the key details in each case so I can try to understand and respond to your questions? Without more context it's difficult for me to analyze how the provider handled the situation or determine the diagnosis.
A lecture given to nurse practitioners, physician assistants and others on pain management. The aim of the talk is to review:
1- the principles of effective pain management;
2- the knowledge and/or resources to assist in indentifying patients at high risk for substance abuse, and
3- the importance of counseling patients about the side effects, addictive nature and proper storage and disposal of prescription medications.
*Disclaimer: Case presentation is made up of a combination of cases, and does not reflect the case of any one particular patient.
A lecture given to nurse practitioners, physician assistants and others on pain management. The aim of the talk is to review:
1- the principles of effective pain management;
2- the knowledge and/or resources to assist in indentifying patients at high risk for substance abuse, and
3- the importance of counseling patients about the side effects, addictive nature and proper storage and disposal of prescription medications.
*Disclaimer: Case presentation is made up of a combination of cases, and does not reflect the case of any one particular patient.
Pain Validity Test identifies drug seeking behavior. Stop opioid abuse. Prote...Nelson Hendler
Physician prescribing practices are under constant scrutiny. An Internet questionnaire will predict if a patient will have a medical test abnormality with 95% accuracy, and 100% if the patient will not. This Pain Validity Test can be used to detect drug seeking behavior in patients, at a far high level of accuracy than tests currently in use (34.4%-48.2% accuracy).. The Pain Validity test has been admitted as evidence in 30 cases in 9 states.
Providing quality pediatric pain management during end of life carecassidydanielle
Author: Danielle Cassidy, PharmD, BCPS
Audience: continuing education for hospice nurses
Background: describes common developmentally appropriate tools for assessing pain in children, general principles of pediatric pharmacology, common pharmacological interventions, side effects commonly associated with opioid medications & side effect management strategies.
Pain points - Overcoming the Opioid CrisisCompleteRx
Today, 11 percent of Americans experience daily chronic pain, for which opioids are frequently prescribed. Unfortunately, what started as standard prescribing practice has become detrimental, and due to their highly addictive nature, we’ve seen a quadrupling number of opioid overdose deaths from 1999 to 2015, killing more than 90 people per day. While state and national legislatures continue to search for ways to combat this epidemic, significant change can be made at the community level starting with medical staff, hospitals and health systems. This webinar will provide a comprehensive overview of the pain crisis and how it affects various patient populations, outline CDC guidelines on opioid use for chronic pain and identify strategies to positively impact the use of opioids and outcomes.
Sources: NCCIH, NPR
Key Takeaways:
- Recognize the relationship between opioid use on clinical and economic outcomes in various patient populations and the community
- Outline recommendations suggested by CDC guidelines on opioid use in chronic pain and new pain standards just released by TJC
- Identify strategies to impact multiple drivers of the opioid crisis
Pain Validity Test identifies drug seeking behavior. Stop opioid abuse. Prote...Nelson Hendler
Physician prescribing practices are under constant scrutiny. An Internet questionnaire will predict if a patient will have a medical test abnormality with 95% accuracy, and 100% if the patient will not. This Pain Validity Test can be used to detect drug seeking behavior in patients, at a far high level of accuracy than tests currently in use (34.4%-48.2% accuracy).. The Pain Validity test has been admitted as evidence in 30 cases in 9 states.
Providing quality pediatric pain management during end of life carecassidydanielle
Author: Danielle Cassidy, PharmD, BCPS
Audience: continuing education for hospice nurses
Background: describes common developmentally appropriate tools for assessing pain in children, general principles of pediatric pharmacology, common pharmacological interventions, side effects commonly associated with opioid medications & side effect management strategies.
Pain points - Overcoming the Opioid CrisisCompleteRx
Today, 11 percent of Americans experience daily chronic pain, for which opioids are frequently prescribed. Unfortunately, what started as standard prescribing practice has become detrimental, and due to their highly addictive nature, we’ve seen a quadrupling number of opioid overdose deaths from 1999 to 2015, killing more than 90 people per day. While state and national legislatures continue to search for ways to combat this epidemic, significant change can be made at the community level starting with medical staff, hospitals and health systems. This webinar will provide a comprehensive overview of the pain crisis and how it affects various patient populations, outline CDC guidelines on opioid use for chronic pain and identify strategies to positively impact the use of opioids and outcomes.
Sources: NCCIH, NPR
Key Takeaways:
- Recognize the relationship between opioid use on clinical and economic outcomes in various patient populations and the community
- Outline recommendations suggested by CDC guidelines on opioid use in chronic pain and new pain standards just released by TJC
- Identify strategies to impact multiple drivers of the opioid crisis
Using the 2011 Definition of Addiction of the American Society of Addiction Medicine as well as its historical roots, attendees will learn how addiction is not just about alcohol or other drugs, but it’s about brains; and how it’s not just about mesolimbic reward circuitry, but is about the role of other brain regions in the relationship that persons with addiction develop with sources of reward and relief.
Presentation was originally done at Group Health Cooperative’s National Summit on Opioid Safety: http://www.ghinnovates.org/?p=3502
Presentation by: Roger Chou, MD, Associate Professor of Medicine for Oregon Health & Science University
and Director of Pacific Northwest Evidence-based Practice Center.
iCAAD London 2019 - Mel Pohl - CHRONIC PAIN AND ADDICTION: HOW WE MISSED THE...iCAADEvents
Chronic Pain occurs as a complicated web of emotions and physical symptoms. The most common way to treat pain is to use opioid medications, which actually complicate the course of chronic pain.
Poster for the 2018 Society for Teachers of Family Medicine Annual Meeting: A...Christina Czuhajewski
Presented at the 2018 STFM Annual Meeting, entiteld: Adolescent Views on Prescription and Nonprescription Opioid Use: Findings from the MyVoice Longitudinal Mixed Methods Study
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
1. Safe & Effective Management of Chronic Pain:
A Primary Care Core Competency
Lemuel Shattuck Hospital Addiction Conference
March 2, 2015
ChristopherW. Shanahan, MD, MPH, FACP
Assistant Professor of Medicine
Boston University School of Medicine
Boston Medical Center
Certified: Internal Medicine (ABIM) & Addiction Medicine (ASAM )
No Conflicts of Interest
1
2. Learning objectives
•Understand the etiology & consequences of the U.S.
prescription opioid epidemic.
•Understand rationale for & methods to:
•Risk assess patients prior to treating pain with opioid
medications.
•Monitor benefit & risk associated with pain
management using opioid medications.
•Refer or discontinue opioid medications.
2
6. Drug overdose deaths by major type in U.S., 1999-2011
National Vital Statistics System 2014. 6
7. Source for Most Recent Nonmedical use (Past year users > 11 yo) 2012-2013
Where Pain Med Rx’s were obtained…
9SAMHSA, OAS, NSDUH data , 2013
8. Where are all these meds coming from?
•Legitimate Provider Rxs (acute & chronic pain):
•common source misused/diverted opioids
•Doctor shopping:
•Drug Users
•~ 0.7% of pts legitimately prescribed opioids.
•a/w ↑ mortality.
•Drug dealers also obtain Rx’s from physicians.
•Opioid Rx’s from ED & Day surgery (incl.
Dental & Podiatry) for acute pain- major source
Cicero TJ, et.al. J Drug Issues. 2011; Rigg KK, , et.al. Drugs. 2012.
McDonald DC, , et.al. PLoS One. 2013; Jena AB, , et.al. BMJ. 2014.
Peirce GL, , et.al. Med Care. 2012; Chapman CR, Korean Pain J. 2013 8
9. Factors leading to ↑ risk of overdose death
• 1/1/07 -12/31/11 (5 years)
• 30%Tennessee population
filled opioid Rx each year.
Risk Factor Adjusted Odds Ratio 95% CI
4 or more prescribers 6.5 5.1 - 8.5
4+ pharmacies 6.0 4.4 - 8.3
more than 100 MMEs 11.2 8.3-15.1
Persons w/ 1+ risk factor comprise 55% of all OD deaths
↑ risk of opioid-related OD death a/w:
Gwira Baumblatt, JAMA 2014
9
11. Context defines Pain type,Treatment
goals & Overall outcomes & Risks
Acute & Post-
operative Pain
• Moderate to good Evidence.
• Guidelines?
• Standard of Care
Chronic Non-
Cancer Pain
• Insufficient evidence
for role of opioids
• Guidelines exist.
• Standard of Care?
Cancer Pain
• Role of opioids
• Strong Evidence
• Clear Guidelines
• Standard of Care
11
Chou R, Ann Intern Med. 2015 The
Effectiveness and Risks of Long-Term
Opioid Therapy for Chronic Pain: A
Systematic Review for a National
Institutes of Health Pathways to
Prevention Workshop
Chou R et.al. Research gaps on use of
opioids for chronic non-cancer pain:
findings from a review of the evidence for
an American Pain Society and American
Academy of Pain Medicine clinical
practice guideline. J Pain. 2009
Hegmann KT, et.al. ACOEM practice
guidelines: opioids for treatment of acute,
sub-acute, chronic, and
postoperative pain. J Occup Environ
Med. 2014
13. Wait, wait…. How did we get here?
• Historically, under-treatment of disorders appropriate for opioid
therapy: cancer pain, pain at the end-of-life, & acute pain
• Small, non-RCT studies of safety & efficacy of opioids for
chronic non-cancer pain (CNP) suggesting moderate effectiveness.
• Treatment of pain in general prioritized (5th Vital sign: American Pain Society in
1995, JACHO, 1999)
• Aggressive marketing of opioids forCNP citing these studies.
• Use of opioids to treat CNMP increased & incorporated into clinical guidelines
becoming an accepted, but non-evidence-based standard of care.
• Portenoy & Foley, 1986; Nyswander & Dole, 1986)
• “TheTragedy of Needless Pain”, (Melzack, 1990)
• Many of the original medical proponents have been investigated for industry
ties and conflicts of interest.
• Finally as overdoses and addiction explode – the clothes of the emperor are
being critically considered. 13
14. Critical research gaps in treatment of
chronic non-cancer pain using opioids
• Lack of effectiveness on long-term benefits in context of known
harms of opioids (incl. drug abuse, addiction, & diversion)
• Insufficient evidence for optimal approaches to risk stratification,
monitoring, or initiation & titration of opioid therapy
• No evidence on:
• Utility of informed consent & opioid management plans
• Utility of opioid rotation
• Benefits & harms of methadone or high dose opioids
• treatment of patients with chronic non-cancer pain at higher risk
for drug abuse or misuse.
14
Chou R J Pain. 2009
15. Chronic Pain and the Unexpected
• 66 yo ♂ here for follow-up Primary Care.
• Hx: LongstandingT2DM, HTN, OSA and Severe diabetic neuropathy
confirmed by Neurology.
• Ibuprofen & Acetaminophen tried with no or limited effect.
• Pt still requesting treatment for lower extremity pain.
• New meds prescribed:
• Oxycodone (5 mg) / APAP (325 mg). 1 tab po qid X 28 days; Disp: #112.
• Gabapentin 300 tid (tapered start).
• FU visit in 1 month.
• 12 days later patient calls:
• Out of pain medication & requesting oxycodone refill.
• Took more pills than Rx’d b/o inadequate pain relief.
• Pain is 12/10.
• Not taking gabapentin because “Doesn’t do anything”.
Case
15
16. Goals
•Goal 1: Avoid / Mitigate this situation.
• Set expectations - Informed consent
• Assess for risk.
•Goal 2: Maximize Benefit (Safety & Quality of Care).
•Pain management plan.
•Goal 3: Minimize risk.
• Prepare for the unexpected.
• Establish monitoring plan.
16
Case
17. Setting expectations - Informed consent
Set Expectations:
• “Pain free” is not a realist expectation.
• Treatment as a “Trial” – Reserving the right to stop the
medications if response is inadequate or unsafe.
Patient Responsibilities:
• Communication if unacceptable levels of post-operative pain,
Medication Disposal, No sharing.
Discuss Benefits & Risks Opioids (Focus: Safety)
• Benefits
• Pain relief, Increased function, Quality of Life.
• Risks
• Side effects: physical dependence; sedation.
• Misuse, abuse, addiction, overdose, death.
• Drug interactions. Paterick et al. Mayo Clinic Proc. 2008 17
Case
18. Pre-prescribing opioid risk assessment
1.Screen for Risk Substance Use
• Single Item Drug & Alcohol
2.Check Massachusetts
Prescription Medication
Program (PMP)
3.Use Opioid RiskTool (ORT)
18
Case
Don’t Forget!!!!
What you are treating?
Establish pain etiology.
19. Single item drug & alcohol risk screening
Drug
• “How many times in the past year have you used an illegal drug or
used a prescription medication for non-medical reasons?”
• If asked to clarify meaning of “non-medical reasons”, add "for instance
because of the experience or feeling it caused"
• = Response >0
100% sens., 74% spec. for Drug Use Disorder
93% sens. & 94% spec. for Past-year Drug Use
Alcohol (NIAAA):
• “Do you sometimes drink beer wine or other alcoholic beverages?
How many times in the past year have you had 5 (4 for women) or
more drinks in a day?”
• = Response >0
82% sens., 79% spec. for Alcohol Use Disorder
Smith PC, et.al. 2010.
NIAAA. CliniciansGuide to Helping
PatientsWho DrinkToo Much, 2007.
19
Case
20. Massachusetts Prescription Medication Program (PMP)
• A secure website supporting
safe prescribing & dispensing.
• A licensed prescriber or
pharmacist may obtain
authorization, to view the
prescription history of a
patient for the past year.
• MA Online PMP assists state &
federal agencies address
prescription drug diversion
…supports ongoing, specific
controlled substances-related
investigations.
20
http://www.mass.gov/eohhs/gov/commissions-and-initiatives/vg/
Case
21. Before Prescribing:The Opioid RiskTool (ORT)
♂ ♀
Family History of Substance Abuse Alcohol 3 1
Illegal Drugs 3 2
Prescription Drugs 4 4
Personal History of Substance Abuse Alcohol 3 3
Illegal Drugs 4 4
Prescription Drugs 5 5
Age (Mark box if 16 – 45) 1 1
h/o Preadolescent SexualAbuse If present 0 3
Psychological Disease h/o ADD, OCD, Bipolar, Schizophrenia 2 2
Depression 1 1
Total
LRWebster, 2005 21
Case
http://mytopcare.org/udt-calculator/opioid-risk-tool/
22. Pain management planning
•Non-opioid pain medications
• Adjunct Medications to Opioids.
• Acetaminophen / NSAIDS (Naprosyn).
• Tylenol with Codeine.
• Adjunct analgesics: Gabapentin, Amitriptyline.
• Local measures (heat / cold / massage, etc.).
• Non-medication basedTherapies.
• PhysicalTherapy / Counseling / Optimize transportation & housing.
•Plan for unexpected outcomes
• Develop & implement policies.
• Discuss policy pre-operatively with patient when consenting.
• Instruct patient when, how, & who to contact.
• Establish specific strategies for:
• Treatment escalation.
• Dealing w/ aberrant medication taking behaviors.
J Barden J, et.al. Cochrane Reviews 2004
CJ Derry et.al. Cochrane Reviews 2009
22
Case
23. “Ran out meds early” is a symptom.
1. It happens - it’s a risks of using opioid
medications - first talk with the patient.
•Review treatment agreement & clinic policy.
•Reset expectations.
2. Figure it out & make a Diagnosis.
•Unfounded patient expectations?
•Inadequate pain-management?
•Progression of disease?
•New disease process?
•Misuse? Addiction? Diversion? 23
Case
24. 24
4 yrs later: Managing chronic pain
• Pt (70 yo) stable on MS Contin 60 mg bid. (~3.5 ys.).
• Today: Monthly Follow-up visit for refills.
• Patient reports:
• Pain manageable. (PEG = 5 → 5).
• Feeling more anxious (PEG = 3 → 7).
• Less active. (PEG = 4 → 9).
• Increasingly forgetful.
• Recently fell & hit head.
• Despite repeated attempts, unable to taper opioid -
Pt states “its the only thing that works”.
Case
25. Risk - Benefit Framework
25
Case
Unintended consequences
Not all meds taken → Increased risk for Diversion
→ Misuse, abuse, addiction, overdose, death
26. Assessing benefit
PEG (Pain, Enjoyment, General activity) scale (0-10)
1. What number best describes your Pain on average in the
past week?
(No pain (0) - - - - - - - - - - - - - - Pain as bad as you can imagine (10))
2. What number best describes how, during the past week,
pain has interfered with your Enjoyment of life?
(Does not interfere (0)- - - - - - - - - - - - - - Completely interferes (10))
3. What number best describes how, during the past week,
pain has interfered with your General activity?
(Does not interfere (0) - - - - - - - - - - - - - - Completely interferes (10))
Krebs EE, et al. J Gen Intern Med. 2009
26
Case
27. Aberrant medication-taking behaviors
o Requests for increase opioid dose.
o Requests for specific opioid by name, “brand name only”.
o Non-adherence w/other recommended therapies (e.g., PT).
o Running out early (i.e., unsanctioned dose escalation).
o Resistance to change therapy despite AE (eg. over-sedation).
o Deterioration in function at home and work.
o Non-adherence w/monitoring (e.g. pill counts, UDT).
o Multiple “lost” or “stolen” opioid prescriptions.
o Illegal activities – forging scripts, selling opioid prescription.
Spectrum: to Flags
27
Case
29. Urine DrugTesting (UDT): Key to opioid prescribing
Why to do it:
• Provides objective information supporting safety (patient & public).
• Demonstrates med adherence. Is patient using the Rx?
• Shows substances that patient shouldn’t be using?
• Helps prevent abuse if pts know drug tests will occur.
How to Discuss UDTesting with Patients:
• Some providers feel awkward discussing UDT’ing.
• Frame as a personal & public health safety issue.
• Remind patients that:
• Opioid are dangerous & Providers can’t tell which pts will develop problems.
• Its the Standard of care for treatment with these medications.
• You monitor all your patients: Universal Precautions (No singling out).
When to Perform Urine DrugTesting:
• No clear standard: Regular scheduled basis vs. Random.
• Implement when concerns arise (e.g. aberrant behavior). 29
Case
31. When to refer
•Possible addiction or misuse.
•Addiction Specialist.
•SubstanceAbuseTreatment Program.
•Assistance with or discomfort with prescribing high
levels of chronic opioids.
•Pain Specialist.
•Assistance w/ tapering / discontinuing high doses of
opioid.
•Addiction Specialist.
•SubstanceAbuseTreatment Program.
31
Case
32. When to discontinue: Risks > Benefits
DO NOT have to prove diversion/addiction to stop opioid therapy.
Absolute Indications for Stopping OpioidTherapy.
• No benefit identified.
• Harms from treatment.
• Cannot keep medications safe.
• Unable / unwilling to comply w/ required monitoring.
• Active addiction (unstable).
• Illegal activity / medication diversion.
• Violent / abusive behaviors → practice staff/clinicians.
Relative Indications for stopping opioid therapy
• Based on clinical judgment (in absence of an absolute indication).
• Risks of opioid treatment outweigh potential benefits.
32
Case
34. Video Cases
https://www.scopeofpain.com/tools-resources/
Case Study II:
Assessing aberrant opioid taking behavior, increasing monitoring
Case Study III:
Addressing lack of opioid benefit and excessive risk, discontinuing
opioids
Case StudyV:
Established Patient with Evidence of Illicit Drug Use
34
Case
36. Summary
• Universal Precautions:
• Screen & assess risk for risk of substance misuse / abuse.
• Define the etiology of the pain.
• Provide informed consent
• Discuss Risks/Benefits of OpioidTherapy
• Set expectations - establish realistic Goals of Care.
• Consider & use all modes of pain management
• Opioids may not be of benefit and not be indicated.
• Start Low / Go Slow
• Use an outcomes-oriented trial-based mindset.
• Never stop monitoring.
• Functional Goals / Use the PEG.
• Urine DrugTesting & Pill Counts (Scheduled & Random).
• Make a diagnosis when the unexpected occurs.
• Discontinue opioids when Risks > Benefits.
• Access resources a/o ask for help. 36
Judge the
treatment not
the patient.