Transcript H. Lausen. DO

Chronic Pain Management
Harald Lausen, DO, MA
Objectives
• Introduce common definitions
• Review pharmacologic approaches
• Review management essentials
– FSMB Model Policy
– Pain Management Agreements
– 4 A’s of Pain Management
Pain
• An unpleasant sensory and emotional
experience associated with actual or potential
tissue damage or described in terms of such
damage.
Acute Pain
• The normal, predicted physiologic response
to a noxious chemical, thermal, or mechanical
stimulus and typically is associated with
invasive procedures, trauma, and disease.
• (Generally time-limited.)
Chronic Pain
• A state in which pain persists beyond the
usual course of an acute disease or healing of
an injury or that may or may not be
associated with an acute or chronic
pathologic process that causes continuous or
intermittent pain over months or years.
Physical Dependence
• A state of adaptation manifested by drug
class-specific signs and symptoms that can be
produced by abrupt cessation, rapid dose
reduction, decreasing blood level of the drug,
and/or administration of an antagonist.
• (Does not equate with addiction)
Addiction
• A primary, chronic, neurobiologic disease,
with genetic, psychosocial, and environmental
factors influencing its development and
manifestations. It is characterized by
behaviors that include the following: impaired
control over drug use, craving, compulsive use
and continued use despite harm.
Substance Abuse
• The use of any substance(s) for nontherapeutic purposes or use of medication for
purposes other than those for which it is
prescribed
Pseudoaddiction
• The iatrogenic syndrome resulting from the
misinterpretation of relief seeking behaviors
as though they are drug-seeking behaviors
that are commonly seen with addiction.
• The relief seeking behaviors resolve upon
institution of effective analgesic therapy
Tolerance
• A physiologic state resulting from regular use
of a drug in which an increased dosage is
needed to produce a specific effect, or a
reduced effect is observed with a constant
dose over time.
• Tolerance may or may not be evident during
opioid treatment and does not equate with
addiction
World Health Organization
Pain Pyramid
Strong Opioid – Schedule 2
Mild to Moderate Opioid – Schedule 3
Non-Opioid Analgesics – Schedule 4 or less
Pharmacologic Approaches
• Strong Opioid
– Oxycodone, Hydromorphone, Fentanyl, Morphine,
Oxymorphone, Methadone, Meperidine
• Mild to Moderate Opioid
– Codeine, Propoxyphene, Hydrocodone, Tramadol
• Non-Opioid Analgesics
– Acetaminophen, Ibuprofen, Naproxen
Pharmacologic Approaches
• Long – acting Opioids
– Chronic pain management
– Specific acute pain management
– May be crushed, sniffed, injected for abuse
• Short – acting Opioids
– Acute pain management
– Breakthrough pain in chronic pain management
– Dose titration
Pharmacologic Approaches
• Adjuvant Therapy for Opioids
– Non-opioid analgesics
– Muscle relaxants
– Anti-emetics
– Anti-seizure medications
– Anti-depressants
– Sleep agents / Anxiolytics
Pharmacologic Approaches
• Managing adverse effects
– Constipation
– Sedation
– Nausea
– Pruritis
– Dizziness
– Dry mouth
Pharmacologic Approaches
• Serious adverse effects
– Anaphylaxis
– Respiratory depression
– Confusion
– Urinary retention
– Hallucination
– Persistent mild adverse effects
Clinical Management
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Patient Evaluation
Treatment Plan
Informed Consent
Periodic Review
Consultation
Medical Records
Compliance with Laws and Regulations
Patient Evaluation
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Complete history and physical exam
Thoroughly assess pain
Assess risk and history of abuse
Identify coexisting conditions
Obtain records for all previous treatments,
studies, exams, interventions, visits, etc
Treatment Plan
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Document treatment goals
Include any further diagnostic evaluation
Document medication adjustments
Consider other treatment plans such as
physical therapy or counseling.
Informed Consent
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Discuss risks and benefits of treatment
Rules of informed consent apply
No treatment is an option
Review Pain Management Agreement in Detail
Informed Consent
Pain Management Agreement
• Not a contract
• Risks, benefits, alternatives
– Misuse, abuse, dependence, addiction
– Serious and common adverse effects
• Expectations – specific
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Illegal drugs, sell, trade, share
Refills, early, stolen, lost, times, place, directions
Random drug screening
Disclosure of additional information
Violations, discharge, exit strategy
Periodic Review
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Treatment goals
Treatment course
Etiology of pain
4 A’s of Pain management
– Analgesia
– Activities of daily living
– Adverse effects
– Aberrant behavior
Periodic Review
Aberrant Behavior
• Less Indicative
– Drug hoarding
– Acquiring similar meds
form other medical sources
– Aggressive complaining for
higher doses
– Unapproved use for
another symptom
– Unapproved dose increase
1 or 2 times
– Requesting specific drugs
– Reporting psychic effects
• More indicative
– Prescription forgery
– Concurrent abuse of
related drugs
– Recurrent prescription loss
– Selling prescription drugs
– Multiple unapproved dose
increases
– Stealing or borrowing
another patient’s drugs
– Acquiring similar meds
from non-medical sources
Consultation
• Refer the patient as necessary
• Identify high risk patients
• Confirmation of appropriate treatment
Medical Records
• Complete and Accurate Records
– History and physical
– Diagnostic, therapeutic, lab results
– Evaluations and consultations
– Treatment goals
– Informed consent with management
agreement
– Medications
– Periodic reviews
Compliance with Laws and Regulations
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State license
Federal and State DEA
Appropriate treatment
Comply with regulations
Must offer an exit strategy for patients