Transcript Pain Procedures and Medications: What You Need to Know

Medications for Pain:
What You Need to Know for Treatment
in Workers’ Compensation
Suzanne Novak, MD, PhD
5/17/07
Outline
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Opioids in general
Adderall
Actiq
NSAIDS
Benzodiazepines
Barbiturates
Soma
Anti-depressants
Prialt
Opioids: How did they get so popular?
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These drugs were noted to treat both acute
pain and cancer pain effectively
This was extended to treatment of chronic
pain
Addiction was thought to arise only rarely
during legitimate treatment of pain
Tolerance could be overcome by dose
escalation
Opioids: What we learned
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50% of patients abandon treatment in trials
because they don’t work or they have side
effects
Patients become refractory to treatment
These drugs have significant neuroendocrine
effects
Behavioral problems, and often, frank
addiction interfere with treatment
Opioids: Failed Treatment
Is there evidence of failed treatment?
- Opioid hyperalgesia
- Frank tolerance
What did we do in the past?
- Increase the dose until tolerance is overcome
Opioids: How to avoid failed treatment
Start to address the use of opioids early in
treatment
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Rule Out Risk Factors for Possible Misuse
Cage Questionnaire
Screener and Opioid Assessment for
Patients with Pain
History of substance abuse
Legal problems
Cravings
Heavy Smoking
Mood Swings
Opioids: How to avoid failed treatment
Start to address the use of opioids early in
treatment
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Consider a Psychological Evaluation
Diagnoses that have a poor outcome with
opioid therapy:
Conversion disorder
Somatization disorder
Pain disorders associated with depression
and/or anxiety
Additional Steps Before a Trial
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Set treatment goals
Document baseline pain and functional
assessments
Function assessments (social, physical,
psychological, daily and work activities)
Could the claimant be weaned?
Treatment agreement
Once started: What to look for
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Prescriptions from a single practitioner and
single pharmacy
Ongoing review:
Current pain
Least/most pain
Average pain
How long before relief
How long it lasts
Once started: What to look for
The 4 A’s for Ongoing Monitoring
 Pain Relief
 Side Effects
 Physical and Psychosocial Function
 Occurrence of Aberrant/non-adherent
Behavior
Opioids: Side Effects
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Constipation
Nausea
Dizziness
Somnolence or Drowsiness
Vomiting
Dry Skin
Itching/Pruritis
Opioids: When to continue and when
to discontinue
Continue: Don’t stop if it’s working
 Improved pain and function
 Return to work
Discontinue
 No overall improvement in function
 Continuing pain with intolerable adverse
effects
Opioids: When to continue and when
to discontinue
Illegal activities: diversion; forgery; arrest
related to drugs
 Suicide attempts
 Threatening behavior in the office
Repeated slips from the drug agreement:
Suggest a consult with a physician trained in
addiction
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Treatment of Opioid-Related Sedation:
Most Common Initially and With Dose
Increases
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Eliminate unnecessary medications
Rest
Exercise
Timing
Opioid rotation
Reducing the dose
Psychostimulants for Management of
Sedation: Adderall
Not recommended
Data supporting the use of this treatment
is lacking in clinical trials.
Actiq
Ongoing review: Current pain, Least/most pain,
Average pain, How long before relief, How
long it lasts
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Not recommended for musculoskeletal
pain
Recommended for breakthrough cancer
pain
NSAIDs
There is no current evidence for long-term
effectiveness for pain or function
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There is a risk of gastrointestinal and
cardiovascular side effects
GI/no CV: Non-selective +PPI or Cox-2
CV: Naproxyn if required
Benzodiazapenes
Not recommended for long-term use
(No more than 4 weeks)
Tolerance develops rapidly
Barbituates
Not recommended
The potential for drug dependence is high
No evidence of clinically important
analgesic effect
Soma
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Metabolized to meprobamate: anxiolytic
Main effect may be due to sedation
Withdrawal symptoms may occur with abrupt
withdrawal
Soma-Coma: Street-drug name when used
with opioids
Anti-depressants
First-line treatment for neuropathic pain
 Possible for non-neuropathic pain
 Analgesia occurs within a few days
Tricyclic anti-depressants
SNRIs: Effexor (venlafaxine) and Cymbalta
(duloxetine)
Wellbutrin (bupropion)
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Prialt
Not recommended until all other intrathecal
medication options have been exhausted
Advantage: Considered non-addictive
Disadvantage: Possible side effects including
severe psychiatric symptoms and
neurological impairment
Use with caution in patients with history of
depression and psychosis
Questions