Transcript What Our Patients Look Like

What Our Patients Look Like
70-year-old retired banker with advanced osteoarthritis
84-year-old grandmother with COPD and severe back pain
51-year-old machinist with failed back syndrome
36-year-old female retail sales associate with chronic back pain
Case 1
• 70-year-old retired banker with advanced
osteoarthritis of the knees, not a surgical
candidate due to congestive heart failure.
• Prescribed Lortab 10/325 6x/day with pain
relief and improved quality of life.
Discussion Case 1
• Discussion points of conversion to long acting
opiate medications, lessening of
acetaminophen dosage and management of
a compliant low risk opiate candidate
• Utilization of the UDS, opiate contract,
frequency of visits, ongoing monitoring
Opiate Risk Tool
Managing Opioid Therapy
Assess Benefit:
• Discuss realistic goals and expectations of opioid therapy
• Discuss importance of focusing on functional improvements
• Assess benefit periodically using scales to assess pain,
function, quality of life
• “Exit” Strategy
Boston University: http://www.opioidprescribing.com/
Review of Treatment Form
Name ___________________________ DOB_______
New life stressors to discuss today?
Any NEW ISSUES since your last visit? Only if YES, circle below
(separation, loss of job, death, other)
YES
Surgery since your last visit?
YES
Emergency Room visits since your last visit? YES
Injections since your last visit?
YES
Imaging studies since your last visit?
YES
Rate your pain on a 0-10 scale
General Health
Main Complaint_____________________________
NO
NO
NO
NO
NO
worse____ best____
fever, fatigue, weight loss or night sweats
chest pain or shortness of breath
chronic cough or shortness of breath
diarrhea, bloody stool, constipation, nausea
painful urination, bloody urine
Numbness, muscle weakness, joint swelling
abnormal bruising, bleeding or rashes
Crying, hallucinations, or hearing voices
Dizziness, numbness, tingling or headache
Since your last visit, HAVE You…
Changed pharmacy?
Gotten pain meds from anyone else?
Used any illegal drugs?
Drank alcohol since last visit?
Given/shared or sold medication?
Taken medications as prescribed?
Has your treatment/medication helped you
To be able to work?
To be in a better mood?
To be more active?
To sleep better?
Yes No
Yes No
Yes No
Yes No
DO YOU FEEL THREATENED AT HOME?
Have you fallen since your last visit?
Yes No
Yes No
Yes No
Yes No
Yes no
Yes No
YES NO (If yes, give packet and offer Case Management info)
YES NO If yes, explain_____________________________________.
Are you feeling depressed or have you ever had an emotional or mental illness?
Have you thought of harming yourself within the past week? ( If yes, notify RN or Provider )
Do You Have Medicare Part D insurance coverage?
YES NO
YES NO
Yes
No
Do you have any questions about your medications, treatments or diagnosis?
Yes
Shade the area below where you hurt
Clinical Notes Only
No
Front
BP______
Back
Pulse____ Resp_______
WEIGHT_____ (stated) VAS____(present)
Clinical Sign/Date/Time______________________________________
Provider Sign/Date/Time_____________________________________
06/2015
Review of Treatment Form
Tab: Review of Treatment Form
Page: 1 of 1
Inventory #:
Revision Date: 06/2015
Weight loss, fever, fatigue, night sweats
Monitoring Opioid Therapy
• Use "Universal Precautions" to monitor and document any harm
(e.g., aberrant medication taking behavior). Use consistent
approach, but set level of monitoring to match risk.
• Agreements/informed consent, “Contract”
• Urine drug testing
• Pill counts
• Frequent visits initially, then follow-up visits at least every 3
months
• Review Prescription Monitoring Program; NCCSRS showing
controlled medications
Boston University: http://www.opioidprescribing.com/
Case 2
• 84-year-old grandmother with COPD on
supplemental oxygen and chronic pain related
to severe lumbar DDD and facet arthropathy
• Patient’s granddaughter living in the home is
addicted to Crystal Meth
Discussion Case 2
• Discussion of importance of addressing social
factors. Issues of narcotic management in
the elderly with respiratory compromise,
medication diversion, elder abuse
Discussion
Treatment Challenges:
Age related physiologic changes
- Decreased renal function
- Decreased volume of distribution secondary to
reduced lean muscle mass
- Decreased liver activity and metabolizing
enzymes
- Decreased serum protein concentrations
- Decreased pulmonary function
Case 3
• 51-year-old employed machinist with chronic
back pain and radiculopathy with a history of 3
back surgeries including a multilevel fusion 5
years ago
• Relocating from West Virginia and needing to
establish pain management
• Prescribed Oxycontin 60 mg three times a day,
Oxycodone 15 mg every four hours and Valium 10
mg three times a day
• Has benefited from periodic lumbar epidural
steroid injections
Discussion Case 3
• Discussion points of assumption of care in
regards to opiate pain medications, possible
specialist referral, continuing appropriate
screening, addressing possible opiate induced
hyperalgesia, medication weaning,
consideration of alternative therapies
including a SCS implant.
Opiates and Benzodiazepines
• Both CNS depressant medications
• High risk combination due to accentuation of
side effects
• Recommendations are to avoid prescribing
together
• Minimize dosage and quantity
Opiate Induced Hyperalgesia
• Patients on chronic high dose opiate
medications develop diffuse pain of vague
quality, pain medications “not working”
• Condition related to up regulation of pain
receptors, sensitization of afferent neurons
and activation of central glutamate
• Therapeutic approach is tapering of opiate
medication dosage
Case 4
• 36-year-old female retail sales associate with a history
of a 2-level lumbar fusion
• Prescribed Oxycodone 15 mg every four hours from
prior pain clinic and travelling from Charlotte for
evaluation
• Requesting Fentanyl patch
• NCCSRS showing opiate prescriptions from multiple
prescribers over last 3 months. Outside records
indicating patient has been discharged from multiple
pain clinics
• UDS results from ED visit last year positive for cocaine
Discussion Case 4
• Discussion points of the utility of the NCCSRS,
opiate misuse/abuse, addiction, referral to
appropriate community services
Addiction vs. Dependence
• Addiction: a chronic neurobiological disease involving reward,
motivation, and memory circuits, reflected in pathological pursuit
of reward and/or relief by substance use
• Pseudo-addiction- Inadequate pain management leading to
addiction-typical behavior like dose escalation and drug-seeking,
but which ceases upon adequate pain control.
• Physical Dependence- A state of adaptation manifested by drug
class- specific withdrawal triggered by abrupt cessation, rapid dose
reduction, decreasing blood levels, and/or administration of
antagonist
• Tolerance: A state of adaptation resulting in a diminution of a drug’s
effects over time at a given dose.
Addiction