Transcript Core Components of Comprehensive Services

Managing Chronic Pain
Clinical Pearls and Practical Tools
Dan Berland, MD, ABAM, FACP
Departments of Medicine and Anesthesiology
What You Need to Take Away
• Take a history. You’ll get the
answers.
• Med removal and psychology do
work, but it’s hard.
• Utilize practice tools that are
available to you.
• Stay within your capability.
• Do no harm.
Steps For Approaching Chronic Pain
• Get records
• Identify / treat any local pain generators
• Promote healthy behaviors, increased
physical activity
• Find and treat comorbid psychiatric illness
• Restore sleep
• Use adjuvant medical therapies
• Consider opioid initiation or continuation
Clinician – Patient Communication
About Treating the Pain
• Likely outcomes of treatment
• Unlikely outcomes of treatment
• Past experiences, influences on outcomes
• Role of social / psych / adjuvant therapies
over opioids and sedatives – “I don’t have
a miracle pill for you.”
• Roles and expectations of both of you
Relative Effectiveness of
Chronic Pain Treatments
• Physical fitness
30-60%
• CBT / Mindfulness
30-60%
• TCAs / AEDs / SNRIs
30-50%
• Opioids
30-50% ?
• Acupuncture
10%
Cochrane Collaboration
Phases of Opioid Management
And “Universal Precautions”
• Decision – risks vs. benefits
Patient selection: Who? Who not?
Indications? Contraindications?
• Initiation / continuation / trial phase
• Maintenance phase
• When to stop, taper, get help
Necessary Steps For Initiation
Trial or Continuation
• Records
• Red Flags
• MAPS
• Toxicology Testing
• Treatment agreements – aka, “contracts”
– informed consent and set expectations.
Don’t patients object?
Controlled Medication Management
Understand equianalgesic opioid dosing
Drug
Dose
Rel. Potency
• Morphine (MS)
30 mg
MS
• Hydrocodone
30 mg
= MS
• Oxycodone
20 mg
1.5 x MS
• Oxymorphone
7.5 mg
4
x MS
• Hydromorphone
6 mg
5
x MS
• Fentanyl
15 mcg
“2 x” MS
• Methadone
variable
up to 20 x
Controlled Medication Management
• Use or continued use of opioid should be a trial
• What opioid to use – the case for morphine
• What not to use: Demerol, Stadol; Opana?
Fentanyl? OxyContin? Hydrocodone? Tramadol?
• Consolidate treatments: Do not mix and match
opioids. A role for opioid rotation?
• Avoid prolonged use of short-acting meds. Role
for ER meds? “Rescue” PRN dosing means per
month!
• Say no to benzodiazepines, carisoprodol (Soma)
Safe and effective practice
• Use the practice tools in the UM guideline:
o Initial and return visit checklists
o Assessment scales
o Dosing and conversion tables
• Practice processes (policies?):
o MAPS, testing, agreement
• Documentation – how many, when, how…
• Prescription management – exact fill dates,
28 day rx’s, no after-hours refills
When and Why To Taper or Remove
• Lack of a functional benefit – ignore pain
scores!
• Opioid induced hyperalgesia / toxicity
• Non-compliance with evaluation, meds, etc.
• Suspicion for misuse of medication
• Excessive total dosing ≥ 100 MED ?
o Morphine > 90 mg/day
o Oxycodone > 60 mg/day
o Fentanyl > 50 mcg/hr
o Methadone > 30 mg/day
Landing the Plane
• Slow and fast tapers
• Drug rotation?
• The 10% rule
• 25% tapers
An evolving role for buprenorphine
• Butrans® You should know about it
• Suboxone® / Subutex ® / Zubsolv /
generic bup/naloxone
What about “medical” MJ ?
Case Discussions
Case 1
45 y/o man new to you, his former doc, a Dr.
Oscar, recently “left practice” and he will soon
need refills. History of fairly good health, but
chronic headaches, neck pain and spasm now 5
years after a MVA. No hx surgery, physical
therapy. Pain managed well on meds he needs
refilled before they run out this week. He
works part-time, smokes cigarettes. Asking for
carisoprodol 350 mg – 1 TID, OxyContin 80
mg BID and Norco 5/325 – 2 QID. Exam –
NAD, friendly, non-specific exam.
Managing Case 1
• Obtain info – are opioids indicated?
• Universal Precautions – No kissing on
the 1st date !
• Giving the news – no rx today
• Getting the urine, what to order
• Prescription Monitoring Program?
• Soma? A role for “muscle relaxants?”
• Mixing opioids. OxyContin ?
Case 2
45 year old woman seen by you tomorrow (after
this conference). You have been giving her MS-ER
30 mg TID, HC/APAP 10/325 x 8/d, sometimes
takes 12 and Xanax 2 mg TID for chronic
abdominal pain and anxiety. She is divorced,
unemployed, is worried about her bills and cannot
sleep at night. Pain 8/10. She has never had
unexpected drug test results, but occasionally runs
out of her meds, calls early for more, cries every
time seen.
Managing Case 2
• Opioids and benzos
• Benzos and anxiety
 benzo.org.uk – Ashton Manual
• Adjuvant therapy, improve sleep
• Are opioids indicated?
• Moving to a long-acting regimen
• Psych, Social Work interventions
Case 3
45 year old woman with longstanding DM2, s/p
renal transplant, DM neuropathy, AVN and
chronic ankle pain, burning pain in legs.
Prescribed MS-ER 60 TID, Norco 7.5/325 one
QID PRN “breakthrough.” Also on
pantoprazole, lisinopril, glipizide, glargine,
tacro. She is divorced, lives with her troubled
teen, has not worked in years. Exam: 165#,
evidence of peripheral neuropathy. Tender with
mild allodynia.
Managing Case 3
• Neuropathic pain and methadone
• Hyperalgesia, allodynia
• Adjuvant tx and sleep restoration
• Converting, then taper ?
• Educating the patient
Managing Case 3
She turns to the Dark Side:
• Drug EIA → + cocaine, MJ;
negative opioid
• GCMS → + cocaine; +
methadone
• Methadone level 22 ng/ mL
(predicted: 88/176 on 25 mg
divided to TID)
Red flags = STOP !! vs. taper
Case 4
Dr. Phil calls you for advice: His patient is a 75 y/o
woman with a history of complex GI issues
including abdominal pain, visceral hypersensitivity,
esophageal spasm, recurrent SBO s/p multiple,
multiple surgeries, chronic constipation, myofascial
back pain, degenerative arthritis, falls, ?confusion.
Her next appt is in a few days. Dr. Phil would like
to work out a tapering strategy for her opioid
medications, which consist of MS-ER 30 mg 2-3
times per day and oxycodone 20-40 mg per day.
She has been on gabapentin and nortriptyline
previously, but non-compliant because they put her
to sleep.
Case 4 Management
• Why one opioid
• Rare PRN use. Other
“breakthrough” pain options
• Consolidation of treatment
• Adjuvants
• How to taper
• Prescription management
• Documentation
Remember…
• All roads do not lead to opioids.
Opioids often don’t work and
should not be a first or a last
resort.
• Iatrogenic addiction does not
help pain.
• Take a history. You’ll get the
answers.
• Med removal and psychology do
work. It’s hard, but rewarding.
Stay Grounded In Your Role:
FIRST…
THEN…
Do No Harm
Cure Sometimes
Comfort Always
Essential Reading
• CDC Opioid Guideline 2016 www.cdc.gov
• UM Chronic Pain/Opioid Guideline
available at guidelines.gov
• Heather Ashton Manual
benzo.org.uk
• The Body Keeps The Score – van der Kolk
My email: [email protected]