Transcript The Opioid Epidemic

Headache to Heroin
The Opioid
Epidemic
“Current Best Practice Prescribing
and Supporting the Patient”
Solution Focused CEU Programs
Definition- Webster’s Dictionary
Definition of EPIDEMIC
1.: affecting or tending to affect
a disproportionately large number of
individuals within a population, community, or
region at the same time <typhoid
was epidemic>
2: characterized by very widespread growth
or extent : of, relating to, or constituting an
epidemic <the practice had
reached epidemic proportions>
1
Why this Training?
From the January 28th 2016 CMCS (Center for
Medicaid and CHIP Services) Bulletin:
I. “According to CDC, opioid medication deaths
have quadrupled from 1999 to 2011.”
II. "Of the 43,982 drug overdose deaths in 2013,
37% were associated with prescription opioid
analgesics.”
2
Why this Training? (continued)
III. “A Primary Driver of the rapid rise in opioid
overdose was increased prescriptions for opioid
pain medications, especially prescriptions
associated high doses, longer course of treatment
and in conjunction with benzodiazepine use”.
3
Why this Training? (continued)
IV. “Inappropriate opioid prescribing can also
result in costly medical complications such
as nonfatal overdoses, falls and fractures,
drug-drug interactions and neonatal
conditions. These complications result in costly,
preventable healthcare expenditures and cause an
incalculable amount of emotional suffering.”
4
Why this Training? (continued)
V. “Research shows the opioid epidemic has a
disproportionate impact on Medicaid
beneficiaries. Medicaid beneficiaries are
prescribed painkillers at twice the rate of nonMedicaid patients and are three-to-six times the
risk of prescription opioids. One study from the
state of Washington found that 45 percent of
people who died from prescription opioid
overdoses were Medicaid enrollees.”
5
Why this Training? (continued)
From Center for Disease Control and Prevention 2016:
I. An estimated 20% of patients presenting to physician offices
with non-cancer pain symptoms or pain-related diagnoses
(including acute and chronic pain) receive an opioid
prescription.”
II. In 2012, health care providers wrote 259 million
prescriptions for opioid pain medication, enough for every
adult in the United States to have a bottle of pills.
III. 1999 to 2014, more than 165,000 persons died from
overdose related to opioid pain medication in the United States.
6
Why this Training? (continued)
IV. The Drug Abuse Warning Network estimated that
>420,000 emergency department visits were
related to the misuse or abuse of narcotic pain
relievers in 2011, the most recent year for which data are
available ”
V. In 2013, on the basis of DSM-IV diagnosis criteria, an
estimated 1.9 million persons abused or were
dependent on prescription opioid pain medication
7
Why this Training? (continued)
Pill Mill Story
From Medscape Medical News January 21, 2016
Physician Who Ran Pill-Mill 'Zoo' Gets
12 Years in Prison
8
Why this Training? (continued)
Dr. Lowe owned and operated a string of clinics in New
York City called AstraMed, but only the two clinics where
Dr. Terdiman and Dr. Virey worked were involved in the
pill-mill conspiracy, according to prosecutors.
Court records describe a brazen criminal enterprise. Drug
traffickers known as crew chiefs commanded fake patients,
who paid $300 for an office visit lasting only a minute or
two. There were no tests or physical examinations. Crew
chiefs footed the bill and gave their fake patients nominal
sums for their role-in cash.
9
Why this Training? (continued)
The fake patients obtained oxycodone prescriptions, had
them filled, and turned over the pills to their crew chiefs,
who sold them on the street for $30 apiece in New York
City and for more elsewhere. Independent drug dealers and
addicts lined up for prescriptions after paying admission
fees as high as $1600 apiece in New York City and for more
elsewhere.
10
Why this Training? (continued)
Practice management for this kind of clinic sometimes
turned violent. Crew chiefs and their bouncers were not
above throwing a wayward clinic patron through a window
or an uncooperative employee against the wall. Prosecutors
alleged that members of the conspiracy murdered at least
two individuals who got in their way. Physicians were
pressured — and in one instance threatened at gunpoint —
to prescribe oxycodone at outrageously high volumes.
11
Why this Training? (continued)
The gangster-style persuasion appeared to work. Between
January 2011 and February 2014, AstraMed physicians
wrote nearly 35,000 unnecessary prescriptions for
oxycodone, totaling some 5.5 million tablets. Their street
value topped $165 million. During this period, Dr. Lowe
collected more than $7 million in cash for bogus office
visits, prosecutors said.
"The defendant's clear greed — and his willingness to use
his medical training to turn his clinics into drug dens and
his doctors into drug dealers — weighs very strongly in
favor of a substantial sentence.”
12
Acute Pain
Acute Pain
Acute pain begins suddenly and is usually sharp in quality.
It serves as a warning of disease or a threat to the body.
Acute pain might be caused by many events or
circumstances, including: surgery, broken bones, dental
work, burns or cuts labor and childbirth.
13
Chronic Pain
Chronic Pain
Chronic pain persists despite the fact that the injury has
healed. Pain signals remain active in the nervous system for
weeks, months, or years. Physical effects include tense
muscles, limited mobility, a lack of energy, and changes in
appetite. Emotional effects include depression, anger,
anxiety, and fear of re-injury. Such a fear might hinder a
person's ability to return to normal work or leisure
activities. Common chronic pain complaints include:
14
Chronic Pain
Headache, Low Back Pain, Cancer Pain, Arthritis Pain,
Neurogenic pain (pain resulting from damage to
nerves),Psychogenic pain (pain not due to past disease or
injury or any visible sign of damage inside)
Chronic pain might have originated with an initial
trauma/injury or infection, or there might be an ongoing
cause of pain. However, some people suffer chronic pain in
the absence of any past injury or evidence of body damage.
**Dr. Ghorbani adds that it is a more diffused pain
meaning that it spreads out in the body vs. a pinpoint area.
15
Non-Medicinal Pain Management
Heat: Heat helps decrease pain and muscle spasms. Apply
heat to the area for 20 to 30 minutes 3-4 times per day as
needed. ** Dr. Ghorbani adds that one needs to be very
careful not to burn yourself.
Ice: Ice helps decrease swelling and pain. Ice may also help
prevent tissue damage. Use an ice pack or put crushed ice
in a plastic bag. Cover it with a towel and place it on the
area for 15 to 20 minutes every hour as directed.
Massage therapy: This may help relax tight muscles and
decrease pain.
16
Non-Medicinal Pain Management
Physical therapy: This teaches you exercises to help
improve movement and strength, and to decrease pain. It
can help relieve chronic and acute pain.
Transcutaneous electrical nerve stimulation
(TENS): This is a portable, pocket-sized, battery-powered
device that attaches to your skin. It is usually placed over
the area of pain. It uses mild, safe electrical signals to help
control pain.
Spinal cord stimulation (SCS): An electrode is
implanted near your spinal cord during a simple procedure.
The electrode uses mild, safe electrical signals to relax the
nerves that cause your pain.
17
Non-Medicinal Pain Management
Aromatherapy: This is a way of using scents to relax,
relieve stress, and decrease pain. Aromatherapy uses oils,
extracts, or fragrances from flowers, herbs, and trees. They
may be inhaled or used during massages, facials, body
wraps, and baths.
Guided imagery: This teaches you ways to put pictures in
your mind that will make pain less intense. It may help you
learn how to change the way your body senses and
responds to pain.
Laughter: Laughter may help you let go of stress, anger,
fear, depression, and hopelessness.
18
Non-Medicinal Pain Management
Music: This may help increase energy levels and improve
your mood. It may help reduce pain by triggering your body
to release endorphins. These are natural body chemicals
that decrease pain.
Biofeedback: This teaches your body to respond
differently to the stress of being in pain. Caregivers may use
a biofeedback machine to help you know when your body is
relaxed. Biofeedback is a technique you can use to learn to
control your body's functions, such as your heart rate. With
biofeedback, you're connected to electrical sensors that
help you receive information (feedback) about your body
(bio).
19
Non-Medicinal Pain Management
Self-hypnosis: This is a way to direct your attention to
something other than your pain. For example, you might
repeat a positive statement about ignoring the pain or
seeing the pain in a positive way.
Acupuncture: This therapy uses very thin needles to
balance energy channels in the body. This is thought to help
reduce pain and other symptoms.
20
NSAIDs (Non-Steroidal Anti-Inflammatory
Drugs
Generic
Brand Name
Bromfenac
Diclofenac
Diflunisal
Etodolac
Fenoprofen
Flurbiprofen
Prolensa, Bromday
Cataflam, Voltaren, Zipsor
Dolobid
Lodine, Lodine XL
Nalfon
Ansaid
Ibuprofen
Advil, Cramp End, Dolgesic, Excedrin IB, Genpril, Haltran,
Ibren, Ibu, Ibuprin, Ibuprohm, Ibu-Tab, Medipren, Midol IB,
Motrin, Nuprin, Pamprin-IB, Q-Profen, Rufen, Trendar
Indomethacin
Indocin, Indocin SR, Tivorbex
Ketoprofen
Ketorolac
Meclofenamate
Mefenamic Acid
Meloxicam
Nabumetone
Actron, Orudis, Oruvail
Toradol, Sprix
Meclomen
Ponstel
Mobic, Vivlodex
Relafen
Aleve, Anaprox,
Anaprox DS, EC-Naprosyn, Naprelan, Naprosyn
Daypro
Cotylbutazone
Feldene
Clinoril
Tolectin, Tolectin DS
Naproxen
Oxaprozin
Phenylbutazone
Piroxicam
Sulindac
Tolmetin
21
Other Medications
Non-Narcotic Analgesics
Generic
Brand Name
Acetaminophen
Tylenol
COX-2 Inhibitors
Generic
Brand Name
Celecoxib
Celebrex
Central Analgesics
Generic
Brand Name
Tramadol
Ultram
Tramadol and
Acetaminophen
Ultracet
22
Opioids
Generic
Brand Name
Buprenorphine
Buprenex, Butrans transdermal patch
Butorphanol
Codeine
Hydrocodone
Stadol
Hydromorphone
Levorphanol
Meperidine
Methadone
Dilaudid, Dilaudid-5, Dilaudid-HP, Hydrostat IR,
Exalgo ER
Levo-Dromoran
Demerol
Dolophine, Methadose
Morphine
Astramorph PF, AVINZA, Duramorph, Kadian,
M S Contin, MSIR, Oramorph SR, Rescudose,
Roxanol
Nalbuphine
Nubain
Oxycodone
OxyContin, Roxicodone, Oxecta
Oxymorphone
Pentazocine
Propoxyphene
Tapentadol
Numorphan
Talwin
Cotanal-65, Darvon
Nucynta
23
Opioid Combinations
Generic
Brand Name
Butalbital, Acetaminophen, and Caffeine
Femcet, Fioricet, Esgic, Esgic-Plus
Butalbital, Aspirin, and Caffeine
Fiorinal
Butalbital, acetaminophen, caffeine, and
codeine
Fioricet with Codeine
Hydrocodone and Ibuprofen
Hydrostal IR, Vicoprofen
Morphine/Naltrexone
Pentazocine/Naloxone
Narcotic Analgesics and Acetaminophen
Embeda
Talwin NX
Acetaminophen and Codeine
Capital with Codeine, Margesic #3, Phenaphen with
Codeine, Tylenol with Codeine
Dihydrocodeine, Acetaminophen, and
Caffeine
DHCplus
Hydrocodone and Acetaminophen
Allay, Anexsia 5/500, Anexsia 7.5/650, Dolacet,
Dolagesic, Duocet, Hycomed, Hydrocet, Hydrogesic, HYPHEN, Lorcet 10/650, Lorcet-HD, Lortab, Panacet 5/500,
Panlor, Stagesic, T-Gesic, Ugesic, Vicodin, Zydone
Oxycodone and Acetaminophen
Endocet, Percocet, Roxicet, Roxilox, Tylox; Xartemis XR
Pentazocine and Acetaminophen
Talacen
Propoxyphene and Acetaminophen
Darvocet-N 50,
Darvocet-N 100, E-Lor, Propacet 100
24
Opioids and Aspirin
Narcotic Analgesics and Aspirin
Aspirin, Caffeine, and
Dihydrocodeine
Synalgos-DC
Aspirin and Codeine
Empirin with Codeine
Hydrocodone and Aspirin
Damason-P, Lortab ASA,
Panasal 5/500
Oxycodone and Aspirin
Endodan, Percodan,
Percodan-Demi, Roxiprin
Pentazocine and Aspirin
Talwin Compound
Propoxyphene, Aspirin,
and Caffeine
Darvon Compound-65,
PC-Cap, Propoxyphene
Compound-65
25
Topicals
Topical Analgesics
Generic
Brand Name
Capsaicin
ArthriCare, ARTH-RX, Axsain,
Capsagel, Dura-Patch, Methacin,
Qutenza, Zotrix, Zotrix-HP
Topical Anesthetics
Generic
Brand Name
Benzocaine
Americaine, Endocaine, Lagol
Benzocaine / Menthol
Benzocol, Butyl Aminobenzoate, Dermoplast
Dibucaine
Cinchocaine, Nupercainal Cream,
Nupercainal Ointment
Lidocaine
LidaMantle, Lidoderm, Lignocainem,
Xylocaine
Lidocaine/ Prilocaine
EMLA
26
Tricyclic Antidepressants
• Tricyclic antidepressants are the most
common type of antidepressant used for
pain. They include:
• Amitriptyline
• Imipramine (Tofranil)
• Clomipramine (Anafranil)
• Doxepin
• Nortriptyline (Pamelor)
• Desipramine (Norpramin)
27
Anticonvulsants
Generic Name
carbamazepine
Brand Name
Epitol, Tegretol
gabapentin
oxcarbazepine
pregabalin
topiramate
Gralise, Neurontin
Trileptal
Lyrica
Topamax
28
Cannabis as Painkiller
Cannabinoids have shown significant promise in basic
experiments on pain. Peripheral nerves that detect pain
sensations contain abundant receptors for
cannabinoids, and cannabinoids appear to block
peripheral nerve pain in experimental animals. Even
more encouraging, basic studies suggest that opiates
and cannabinoids suppress pain through different
mechanisms. If that is the case, marijuana-based
medicines could perhaps be combined with opiates to
boost their pain-relieving power while limiting their side
effects…….
29
Cannabis as Painkiller
…But because of the ethical and logistical difficulties of
conducting pain experiments on human volunteers,
marijuana's potential to relieve pain has yet to be conclusively
confirmed in the clinic. Only a few such studies have been
conducted. Most tested the ability of cannabinoids to relieve
chronic pain in people with cancer or acute pain following
surgery or injury. Unfortunately, few of these studies are
directly comparable because the methods used to conduct
them varied greatly and in some cases appear to have been
less than scientifically sound. ***Dr. Ghorbani adds that he is
very wary about marijuana’s interaction with other drugs that
treat pain. He will not prescribe pain medicine for a patient
using marijuana.
30
Cannabis-Diversion of Opioids
A major reason doctors do not prescribe opiates if
a patient tests positive for cannabis…
What do you pay your drug dealer with to get your
marijuana if you have no money, but you have pain
medicine?
31
Opiates Dangerous Combinations
Benzodiazepines, such as alprazolam (Xanax®),
diazepam (Valium®), clonazepam (Klonopin®),
and lorazepam (Ativan®), depress central nervous
system (CNS) activity and are used to relieve
symptoms of anxiety, panic attacks, and seizures.
However, when combined with other drugs that
depress CNS activity, such as alcohol or opioid
pain relievers benzodiazepines may present serious
or even life-threatening problems.
32
Opiates Dangerous Combinations
Being Prescribed Opiates while also being in an
opiate replacement drug treatment with
Buprenorphine (Suboxone) or Methadone.
33
Evaluating Morphine Equivalent Dosing (MED)
The standardized measurement for the amount of opiate
medication is calculated via a conversion of any opiate
medication to its equivalent in morphine. This is
Morphine Equivalent Dosing (MED)
The following are excerpts from best practice guidelines
from leaders in the field of opiate treatment of chronic pain.
MED is an essential component in these guidelines:
• The American Pain Society
• Washington State Agency Medical Directors’ Group (AMDG)
34
Best Practice American Pain Society
2009 Clinical Guidelines from the
American Pain Society
“The guideline defines high dose opioid therapy as >200 mg daily
of oral morphine (or equivalent). These doses are outside the ranges
evaluated in randomized trials and prescribed in only a small minority of
patients in observational studies. When opioid doses reach this
threshold, more frequent and intense monitoring is recommended.
Clinicians should consider weaning or discontinuation of chronic
opioid therapy if assessments indicate reduced analgesia,
function, or quality of life; aberrant drug-related behaviors;
or the presence of intolerable adverse effects.”
35
Best Practice Washington State
Washington State Agency Medical
Directors’ Group
“While there is evidence that opioids can provide significant pain
relief in the short term, there is little evidence for sustained
improvement in function and pain relief over longer periods of time.
Chronic Opioid Analgesic Therapy (COAT) is associated with the
development of tolerance, a decrease in analgesic effect with
the same dose over time. Providers must pay attention to the
development of tolerance and avoid ongoing dose escalation to
overcome this effect.
36
Best Practice Washington State (continued)
The 2010 edition recommended a 120 mg/day MED
threshold to seek consultation with a pain specialist
as a strategy to prevent serious adverse outcomes, including
fatal overdoses. Group Health Cooperative (GHC), which
implemented the best practices from the 2010 edition, has
demonstrated a reduction in opioid doses for their COAT
patients. For the last quarter of 2014, less than one-quarter
of COAT patients seen by GHC providers received 50
mg/day MED or greater and only 7.3% exceeded 120
mg/day MED.
37
Best Practice Washington State (continued)
38
Best Practice Washington State (continued)
Overdose risk approximately doubles at doses between 20
and 49 mg/day MED, and increases nine-fold at doses of
100 mg/day MED or more (Figure C). Although the 2015
guideline maintains the 120 mg/day MED threshold for
consultation and some guidelines have lower dose
thresholds ranging from 50 to 90 mg/day MED, there is
no completely safe opioid dose.
There is a correlation between the amount of opioids
prescribed for patients and their potential availability for
diversion, with associated risks for individuals in the
community.”
39
Provider Education-CDC Guideline for prescribing
Opioids for Chronic Pain-United States 2016
An 50 page book from the CDC that has
detailed information in best practice in
prescribing opiates for chronic pain and
research to back it up.
12 points of emphasis
“Hot off the press”-March
18th 2016.
Newest Best Practice
Guideline
http://www.cdc.gov/mmwr/volumes/65/rr/rr650
1e1.htm
40
Provider Educational Material
Best Practice CDC 12 points
***Dr. Ghorbani stresses that these are guidelines. He
stresses that these are not a substitute for clinical
judgement. There are many intricacies in treating
chronic pain. There are time consuming office policies
and measures that should be in place. Dr. Ghorbani
feels that if a pain specialist is available, they should be
treating chronic pain with narcotics (if appropriate) with
other modalities of treatments that are non-narcotics
and non-medicinal.
41
Provider Educational Material
Best Practice CDC 12 points (continued)
1. Nonpharmacologic therapy and nonopioid
pharmacologic therapy are preferred for chronic
pain. Clinicians should consider opioid therapy only if
expected benefits for both pain and function are
anticipated to outweigh risks to the patient. If opioids
are used, they should be combined with
nonpharmacologic therapy and nonopioid
pharmacologic therapy, as appropriate.
42
Best Practice CDC 12 points (continued)
2. Before starting opioid therapy for chronic pain,
clinicians should establish treatment goals with all
patients, including realistic goals for pain and function,
and should consider how opioid therapy will be
discontinued if benefits do not outweigh risks.
Clinicians should continue opioid therapy only if there is
clinically meaningful improvement in pain and function
that outweighs risks to patient safety.
Written Pain Treatment Agreement
preferred in other agency best practice
documents.
43
Best Practice CDC 12 points (continued)
3. Before starting and periodically during opioid therapy,
clinicians should discuss with patients known risks
and realistic benefits of opioid therapy and patient
and clinician responsibilities for managing therapy.
44
Best Practice CDC 12 points (continued)
4. When starting opioid therapy for chronic pain,
clinicians should prescribe immediate-release
opioids instead of extended-release/long-acting
(ER/LA) opioids.
45
Best Practice CDC 12 points (continued)
5. When opioids are started, clinicians should
prescribe the lowest effective dosage. Clinicians
should use caution when prescribing opioids at any
dosage, should carefully reassess evidence of
individual benefits and risks when considering
increasing dosage to ≥50 morphine milligram
equivalents (MME)/day, and should avoid increasing
dosage to ≥90 MME/day or carefully justify a decision to
titrate dosage to ≥90 MME/day.
Consultation/referral to pain management
preferred in other agency best practice
documents when high MED.
46
Best Practice CDC 12 points (continued)
6. Long-term opioid use often begins with treatment of
acute pain. When opioids are used for acute pain,
clinicians should prescribe the lowest effective dose of
immediate-release opioids and should prescribe no
greater quantity than needed for the expected duration
of pain severe enough to require opioids. Three days
or less will often be sufficient; more than seven
days will rarely be needed.
47
Best Practice CDC 12 points (continued)
7. Clinicians should evaluate benefits and harms with
patients within 1 to 4 weeks of starting opioid therapy
for chronic pain or of dose escalation. Clinicians should
evaluate benefits and harms of continued therapy with
patients every 3 months or more frequently. If benefits
do not outweigh harms of continued opioid therapy,
clinicians should optimize other therapies and work
with patients to taper opioids to lower dosages or to
taper and discontinue opioids.
48
Best Practice CDC 12 points (continued)
8. Before starting and periodically during continuation of
opioid therapy, clinicians should evaluate risk factors for
opioid-related harms. Clinicians should incorporate into
the management plan strategies to mitigate risk,
including considering offering naloxone when factors
that increase risk for opioid overdose, such as history
of overdose, history of substance use disorder,
higher opioid dosages (≥50 MME/day), or
concurrent benzodiazepine use, are present.
***Dr. Ghorbani is adamantly against non-professionals
using naloxone. He feels it enables patients to push the
limits of taking higher quantities****.
49
Best Practice CDC 12 points (continued)
9. Clinicians should review the patient’s history of
controlled substance prescriptions using state
prescription drug monitoring program (PDMP) data to
determine whether the patient is receiving opioid
dosages or dangerous combinations that put him or her
at high risk for overdose. Clinicians should review
PDMP data when starting opioid therapy for chronic
pain and periodically during opioid therapy for chronic
pain, ranging from every prescription to every 3
months.
50
Best Practice CDC 12 points (continued)
10. When prescribing opioids for chronic pain, clinicians
should use urine drug testing before starting opioid
therapy and consider urine drug testing at least annually
to assess for prescribed medications as well as other
controlled prescription drugs and illicit drugs.
***Dr. Ghorbani “at least annually” is ridiculous”*** It
needs to be done much more often on a random basis.
He adds, if the patient can’t provide a sample, then no
medication.
Pill Counting is also part of other best
practice documents.
51
Urine Drug testing Continued(continued)
Dr. Ghorbani adds that Quantitative tests, not just
qualitative (just + or -, not amounts) need to be done.
There are false negative results associated with
qualitative (cups) and quantitative measurement gives a
better idea of how much of the prescribed medication is
being consumed (detect diversion better).
52
Best Practice CDC 12 points (continued)
11. Clinicians should avoid prescribing opioid pain
medication and benzodiazepines concurrently
whenever possible.
***Dr. Ghorbani feels benzodiazepines should only be
prescribed by a psychiatrist.
53
Best Practice CDC 12 points (continued)
12. Clinicians should offer or arrange evidence-based
treatment (usually medication-assisted treatment with
buprenorphine or methadone in combination with
behavioral therapies) for patients with opioid use
disorder.
54
CDC Provider Educational Materials
7 provider educational materials based
on-CDC Guideline for prescribing
Opioids for Chronic Pain-United States
2016
http://www.cdc.gov/drugoverdose/prescribi
ng/resources.html
55
Additional Provider Educational Materials
Helping to insure adherence to Medication Treatment Plan.
• The Prescription Drug Monitoring Program (cornerstone 1)
• Sample Patient-Doctor Pain Treatment
Agreement(cornerstone 2)
• Pill Counting Procedure (cornerstone 3)
• Urine Drug Testing (cornerstone 4)
56
Prescription Drug Monitoring Program (PDMP)
The PDMP is a database that houses
the controlled medication
prescription information for the State
of Maryland. Information and
registration is available at:
https://crisphealth.org/CRISP-HIESERVICES/Prescription-DrugMonitoring-Program-PDMP
The first cornerstone of best practice is
registering and using the PDMP to
know exactly the controlled
medications a patient has filled.
57
Sample Patient-Doctor Pain Treatment Agreement
A two page example of a pain treatment
agreement developed by
American Academy of Pain Medicine
http://www.painmed.org/files/agreement-oncontrolled-substances-therapy.pdf
The second cornerstone of best practice
is creation, use, and enforcement of a
patient-doctor pain treatment
agreement.
58
Pill Count Procedure
A two page pill count procedure
developed by The State of Maine
Quality Counts Division
https://www.mainequalitycounts.org/image_upload
/Pill_Count_Procedure_PCHC.pdf
The third cornerstone is the use of
pill counting.
59
Urine Testing Guide (Saliva also now used)
A ten page document regarding urine
drug testing published on OpioidRisk
website (http://www.opioidrisk.com)
The fourth cornerstone is the use
urine drug testing.
A negative test means something too!
60
When High Dose Opioids are Part of Life
• Pain has become not having the medicine. The body and
mind seem to work together to combine a craving sensation with
the pain relief.
• Opioid-induced hyperalgesia (OIH) is defined as a
state of nociceptive sensitization caused by exposure to opioids.
The condition is characterized by a paradoxical response
whereby a patient receiving opioids for the treatment of pain
could actually become more sensitive to certain painful stimuli.
The type of pain experienced might be the same as the
underlying pain or might be different from the original underlying
pain. OIH appears to be a distinct, definable, and characteristic
phenomenon that could explain loss of opioid efficacy in some
patients.
61
When New Best Practice Meets the Patient
Doctor decides to follow best practice (Training, DEA
worries, Other Professionals, and/or Insurance Company
Pressures)
• The patient was diverting the medicine (should be found out if drug tests
were being performed as best practice would dictate). Withdrawal should
not be an issue (obviously).
• The patient doctor shops. Hopefully, other doctors will follow best practice
and refer patient back to the previous doctor.
• The prescribing doctor refers patient to pain management office who should
be following best practice.
• The patient now must taper if doctor or pain management practice feels this
is the best practice for the patient’s treatment.
62
Tapering or discontinuing opioids
From Washington State:
Not all patients benefit from opioids, and a prescriber
frequently faces the challenge of reducing the opioid dose
or discontinuing the opioid altogether. From a medical
standpoint, weaning from opioids can be done safely by
slowly tapering the opioid dose and taking into account the
following issues:
63
Tapering or discontinuing opioids (continued)
• A decrease by 10% of the original dose per week is usually
well tolerated with minimal physiological adverse effects.
Some patients can be tapered more rapidly without
problems (over 6 to 8 weeks). „
•
If opioid abstinence syndrome is encountered, it is rarely
medically serious although symptoms may be unpleasant.
• Symptoms of an abstinence syndrome, such as nausea,
diarrhea, muscle pain and myoclonus can be managed
with clonidine 0.1 – 0.2 mg orally every 6 hours or
clonidine transdermal patch 0.1mg/24hrs (Catapres TTS1™) weekly during the taper while monitoring often. In
some patients it may be necessary to slow the taper
timeline to monthly, rather than weekly dosage
adjustments.
64
Tapering or discontinuing opioids (continued)
• Symptoms of mild opioid withdrawal may persist for six months
after opioids have been discontinued. Rapid reoccurrence of
tolerance can occur for months to years after prior chronic
use. „
• Consider using adjuvant agents, such as antidepressants to
manage irritability, sleep disturbance or antiepileptics for
neuropathic pain. „
• Do not treat withdrawal symptoms with opioids or
benzodiazepines after discontinuing opioids. „Referral for
counseling or other support during this period is recommended
if there are significant behavioral issues. „
• Referral to a pain specialist or chemical dependency center
should be made for complicated withdrawal symptoms.
65
Supporting the Tapering Patient
The tapering patient now enters your life and is your client:
Social Worker, Therapist, Psychologist, Nurse, Nurse Practitioner, Physician’s
Assistant, Physician, Certified Addiction Counsellor, Case Manager, Others in
the Helping Professions.
How to Support the Client in this difficult Situation:
My four pronged fused approach: 1)Humanism, 2)Education, 3)Solution
Focused Therapy and 4)Motivational Interviewing
Every therapist and client relationship is different. It’s not science but
more of the art in fusing these four techniques to help the client achieve the
goal of a proper medical treatment plan with healthy coping and
internal locus of control.
66
Humanism
• Humans have free will; not all behavior is determined.
• All individuals are unique and have an innate (inborn) drive to
achieve their maximum potential.
• A proper understanding of human behavior can only be achieved by
studying humans - not animals.
• One should study the individual case rather than the average
performance of groups.
67
Humanism (continued)
EMPATHY
• Remember, there is good chance the person before you put their faith in a
doctor to treat them for their pain. There is good chance the doctor
prescribed high dose of medicine because this was their best practice at the
time.
• Can’t you see yourself in the same position as the
person before you?
• This is humanism. Rogers (key figure in the Humanistic Movement) found
that the client/therapist relationship accounted for 80% of the
client’s progress and, 20% was accounted for by the therapists choice of
therapy and expertise.
• Be genuine, transparent, and caring. You client will feel joined in the pursuit
of mental well being during their shift of medical treatment.
68
Education
• Talk about the things we have been discussing in the previous slides.
• Especially that society and government is forcing doctor’s to
prescribe less and lower doses of opioids.
• Present the information at the understanding level of the client.
• Be very matter of fact.
• Always move forward and do not get caught in discussing the past.
• Eventually get to the point where the client realizes that the opioid
dose is going to come down, so let’s work on it together.
69
Solution Focused Therapy
• Change is constant and inevitable
• Clients are the experts and define goals
• Clients have resources and strengths to solve problems
• Future orientation - history is not essential
• Emphasis is on what is possible and changeable
• Short term
• Clients want change
• Throw away the “AH HA” goal of therapy
70
Solution Focused Therapy (continued)
The Miracle question
De Shazer's (1988) miracle question: "Suppose that one night, while you are asleep,
there is a miracle and the problem that brought you here is solved. However, because
you are asleep you don't know that the miracle has already happened. When you wake
up in the morning, what will be different that will tell you that the miracle has taken place?
What else?"
Erickson's original version of the question involved asking his client to look into the
future and see themselves as they wanted to be, problems solved, and then to explain
what had happened to cause this change to come about. He might also ask clients to
think of a date in the future, then worked backwards, asking them what had happened at
various points on the way.
O'Hanlon suggests other variations of the question:
•a time machine
•crystal ball
•rainbow bridge
•a letter from a future self
71
Solution Focused Therapy (continued)
Building on the miracle question:
• What difference would you (& others) notice?
• What are the first things you notice?
• Has any of this ever happened before?
• Would it help to recreate any of these miracles?
• What would need to happen to do this?
• What else?
72
Solution Focused Therapy (continued)
Exception Questions
•
Has anything been better since the last appointment? What's changed? What's better?
•
Can you think of a time in the past (month/year/ever) that you did not have this
problem?
•
What would have to happen for that to occur more often?
•
When doesn't the problem happen?
•
What's different about those times?
•
What are you doing or thinking differently during those better times?
•
When have you been able to stop doing....?
•
Are there times when you expect to...but you remember something that helps you
calm down?
•
What else?
73
Solution Focused Therapy (continued)
Coping Questions
• How do you cope with these difficulties?
• What keeps you going?
• Who is your greatest support?
• What do they do that is helpful?
• What do you do that stops the problem getting worse?
• When you've had this problem before, what helped you get through then?
• How did you manage to solve the problem?
• What advice would you give to someone else who has this problem?
• What else?
74
Solution Focused Therapy (continued)
Scaling questions
• On a scale of 1 to 10 where 1 is the worst it's ever been and 10 is after
the miracle has happened, where are you now?
• Where do you need to be?
• What will help you move up one point?
• How can you keep yourself at that point?
• What would be the first sign that you had moved on one point
further?
• Who would be the first person to notice you've moved one point up?
What would they notice?
• What else?
75
Solution Focused Therapy (continued)
•De Shazer's Skeleton Keys
•Between now and next time....observe what works - notice what is going
well in your situation that you would like to continue (keep doing what works)
•Do something different
•Pay attention to when.....(an exception happens)
•Write, read, and burn thoughts
•Write about what is bothering you for 15 minutes each night, at the same
time.
•When you've fully expressed everything you think needs to be expressed,
read it over each night until you really think it's complete…….
and you've got it all out, then burn the paper you've written on
76
Motivational Interviewing
Motivational interviewing is practiced by licensed
therapists and substance-abuse counselors. Initially defined
in 1983 by William Miller, motivational interviewing is used
as a form of therapy to help treat people dealing with
addictions, including drug and alcohol. During the
treatment, interpersonal processes patients use to continue
or change certain addictive behaviors are examined. It is
the five principles of motivational interviewing,
principles that focus on empowering patients, that make
the treatment different from more traditional therapies..
77
Motivational Interviewing (continued)
1. Express and Show Empathy Toward Clients
Counselors or psychologists express and demonstrate
empathy when discussing behaviors, thoughts and life
events that clients regularly engage in. By expressing
empathy, counselors can start to build rapport and trust
which, in turn, may help clients to become more open,
sharing more of their personal history, struggles and
concerns. This principle also accepts that clients might be
ambivalent during counseling sessions, especially at the
start of counseling. Skillful and active listening that reflects
what the client shares is another component of this
principle counselors practice.
.
78
Motivational Interviewing (continued)
2. Support and Develop Discrepancy
During motivational interviewing, clients give reasons for
changing their behavior -- instead of viewing counselors as
authority figures with the right answers. For example,
clients might decide to stop taking so much pain medicine
to build healthy relationships with their children. If clients
are exhibiting behaviors and making choices that take them
away from their goals, counselors gradually point out this
gap between behaviors and goals to clients.
.
79
Motivational Interviewing (continued)
3. Deal with Resistance
When clients resist changing their behavior, counselors do
not confront the client’s resistance. Instead, counselors
avoid struggling to get client’s to see their point of view. As
discussions continue, counselors work with clients to get
them to see and examine different viewpoints, allowing
clients to choose which points of view they want to stick
with. Furthermore, resistance, when it occurs, is a sign for
counselors to alter their approach to the talk therapy.
80
Motivational Interviewing (continued)
4. Support Self-Efficacy
Clients are made to feel that they are capable of achieving
the change they want. This principal involves counselors
discussing and pointing out previous behavioral and life
successes clients have experienced. For example,
counselors might remind clients recovering from drug
addiction that they have kept a job for two years and have
been drug-free for six months. Current or previous
strengths and skills clients possess are also discussed,
thereby increasing the clients’ belief that they can change.
81
Motivational Interviewing (continued)
5. Autonomy
Counselors demonstrate to clients that the authentic power
for them to change comes from within, not from the
counselor. This emphasizes the thought that there is no one
way to achieve the change that clients want. It is also
expressed to clients that they are ultimately responsible for
changing their behavior. Additionally, counselors listen as
clients develop a list of action steps they can take to change
their behavior.
82
Resources
www.scopeofpain.com
www.anthem.com/painmanagement
www.americanhumanist.org
www.solutionfocused.net
www.motivationalinterviewing.org/
www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
www.drghorbani.com
83
Thanks
Lonny Samuels, LCSW-C
[email protected]
(410)804-5097
84