Transcript Medication Use in Pain Management

Managing the Opioid Epidemic:
Medication Use in Pain Management
A Panel Discussion
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Today’s Panelists
■ Steven Moskowitz, MD, Senior Medical Director, Paradigm, panel moderator
■ Carmen Ferguson, Global Risk Manager, Donaldson Company
■ Cheryl Tabbert, Technical Claim Specialist, Liberty Mutual Group
■ Julia Uehling, Workers’ Compensation Consultant, Hays Companies
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Chronic Pain and Rx Abuse are Chronic Problems
Pain medications are prescribed regularly, and the potential for abuse is significant.
■ Pain medications are the most commonly prescribed class of drugs in the U. S.
■ Hydrocodone is top prescribed medication in the U.S.
■ Admission rates for abuse of opiates other than heroin—including prescription painkillers—rose
by 400% from 1998-2008
■ Drug overdose deaths in the United States have more than tripled since 1990
■ 100 people die from drug overdoses every day in the U. S.
■ 76 million Americans suffer from chronic pain, according to the NIH
■ 80% of physician office visits are due to pain
■ 20% of workers’ compensation medical costs of fully developed claims are spent on prescription
drugs; narcotics account for 34% of drug costs
■ The rest of medical costs are non-pharmaceutical
■ Avoid “opioid myopia” when planning solutions
Source: Centers for Disease Control Prescription Painkiller Overdoses Policy Impact Brief, 2011
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The Cost of Chronic Pain in the Workforce
The estimated annual cost in the United States of healthcare, lost income, and lost
productivity due to chronic pain is $100 billion, according to the NIH.
■ To combat the problem, in 2010 the Minnesota Board of Pharmacy implemented the MN
Prescription Monitoring Program (MN PMP) to monitor prescription drug use in an effort to
promote public health and welfare by detecting diversion, abuse and misuse of certain
controlled substances www.pmp.pharmacy.state.mn.us
■ Minnesota is one of 36 states with an operational PMP
■ Per Minnesota PMP, as of November 2012, 7,116,260 controlled substance prescriptions have
been collected
■ Minnesota’s 2008 drug overdose rate was 7.2 per 100,000 prescriptions
■ Minnesota has 3.7 to 5.9 kilograms of prescription painkillers sold per 10,000 people
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Opioids Remain a Critical National Problem
In 2008, there were 14,800 prescription painkiller deaths
www.cdc.gov/homeandrecreationalsafety/rxbrief Nov 2011
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How do I determine which
treatments are effective, which
are hurtful, and which tools can I
use to monitor a treatment plan?
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Why are these medications prescribed?
An introduction and investigation
Steven Moskowitz, MD
Senior Medical Director, Paradigm Outcomes
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Why Do We See So Many Poor Outcomes?
■ Estimated 40-67% incidence of inaccurate or incomplete
diagnosis in patient presenting to a pain treatment centers.
■ Effectiveness of many treatments unproven.
– High dose COT
– Polypharmacy
– Spinal fusion
– Spinal Cord Stimulator
■ Behavioral aspects of chronic pain are often not taken properly
into account.
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Why Do Doctors Prescribe Medications for Chronic Pain?
And why intent and outcome are not always in balance.
Intent
Reasons for poor outcome
■ To help patients
■ Helping chronic pain patient requires more than prescriptions
■ To relieve symptoms/quick fix
■ Symptoms are by nature subjective
■ Convenience/simplicity
■ It is easier to prescribe than talk and negotiate
■ To satisfy desire for quick fix
■ Doctors and patients believe in quick fixes
■ Efficiency-education and coaching take time and
resources
■ Even a medication prescription requires educations and training
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How Do We Interrupt a Maladaptive Cycle?
Patient
Illness conviction
 Catastrophizing
Unrealistic expectations
avoidance
 Fear
Catastrophizing
Quick fix seeking
 Quick fix seeking
Maladaptive
Coping
Lack of objective
 Quick fixes
measures
Quick
fixesapproach
 Trial and
error
Trial and error
 Escalating
interventions
approach
Maladaptive
Treatment
Poly-pharmacy
Escalating
interventions
Doctor
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The Story of Two Treatment Philosophies
!
!
■ The biomedical approach assumes
■ The biopsychosocial approach:
that all pain symptoms have a specific
chronic pain is a complex and dynamic
physical cause and attempts to eradicate
interaction among biological,
the cause directly by identifying and
psychological, and social factors that
rectifying the presumed pathophysiology.
perpetuates and may even worsen the
clinical presentation. It usually includes
deconditioning and poor flexibility, fear
avoidance, maladaptive coping.
The biopsychosocial model is consistent
with rehabilitation principles.
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A Proactive Approach
Case Study #1
Panel Discussion
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Case 1
DOI less than 1 year
■ 40 year old female attacked by patient on 1/24/2012
■ Resulting bilateral shoulder rotator cuff injuries, neck strain, back strain
■ Treated with bilateral arthroscopic shoulder surgeries; findings of bilateral tear and degenerative changes
■ Continued multiple pain complaints in shoulders, headaches, neck, low back. Continues to look for solutions,
even surgical.
■ Psychiatric evaluations noted severe depression and “mired in a self-defeating passivity and isolation”.
■ Current medications:
Oxycodone 5/325 2 per day
Cymbalta 30 mg daily
Nucytna 200 mg twice per day
Fiorinal COD 30-50-325-40 twice per
day
Vicoprofen 7.5/200 twice per day
Lunesta 2 mg at night
Robaxin 500 mg twice per day
Flector patch 1.3% as directed
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Ask the Panel
We have a case where the current medications plan appears unsuccessful
■ How do you determine effectiveness of the current treatment?
■ How do you influence a change in plan?
■ What tools do you use?
■ What challenges do you encounter with managing these cases?
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Long Term Chronic Pain Treatment
Case Study #2
Panel Discussion
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Case 2
An old simmering case with complications, side effects
■ 45 year old male injured worker
■ >10 years post injury
■ On multiple medications including high dose opioids ; 27,000 daily morphine equivalent
■ On medications to treat opioid complications: Ex, Amitiza, Provigil, Testosterone, Alfuzocin
■ History of infections from spinal cord stimulator, morphine pump
■ In hospital with infection of clavicle
■ Overly solicitous spouse
■ Medications
Hydromorphone
Hydrocodone
Prozac
Celebrex
Wellbutrin XL
Alprazolam
Nortriptyline
Flomax
Urecholine
Prilosec
Dulcolax
Lasix
Tylenol
Lasix
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Ask the Panel
We have a case where medication plan is unsuccessful and harmful
■ How do you determine when the medications are harmful?
– What tools do you use to identify they are harmful?
■ What tools do you use to rectify harmful usage?
■ What challenges do you encounter with managing long-term cases?
– How can you turn around such an old case?
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Conclusion
Steven Moskowitz, MD
Senior Medical Director, Paradigm Outcomes
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Universal Precautions in Pain Management
■ Make a Diagnosis With Appropriate Differential following a comprehensive evaluation
■ Psychological Assessment, Including Risk of Addictive Disorders and stratification.
■ Informed Consent
■ Treatment Agreement
■ Pre- or Post Intervention Assessment of Pain Level and Function.
■ Appropriate Trial of Opioid Therapy With or Without Adjunctive Medication
■ Reassessment of Pain Score and Level of Function
■ Regularly Assess the "A's" of Pain Medicine (analgesia, activities of daily living, adverse side effects, and
aberrant drug-taking behaviors); “adherence” and “affect” (observed mood) might also be added.
■ Urine Toxicology
■ Periodically Review Pain Diagnosis and Comorbid Conditions, Including Addictive Disorders
■ Documentation
REF: “Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain,” Douglas
L. Gourlay, MD, et al, Volume 6 • Number 2 • 2005.
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Conclusions
Try to get provider to help define a rational approach
■ What are appropriate reasons for which medications should be prescribed?
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To improve impairment and function (restorative)
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To help relieve specific defined symptoms
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As part of a biopsychosocial plan to help an injured worker manage and relieve their symptoms
■ What are appropriate measures of success/effectiveness?
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Measures of impairment and function (ODG reference)
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Decrease need for other treatments or for more toxic medications
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Measures for toxicity: mental status, lab studies, UDT
■ What are appropriate strategies to influence the prescribing/attending physician?
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Ask specific for outcome measures for a particular RX and how injured worker will measure it
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Help avoid multiple simultaneous interventions so outcome can be measured
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Remind provider of side effects and negative outcomes
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Share any information about inconsistencies
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