Transcript decode the opiod

David Saxon, MD
Conflict of Interest Disclosures
I have NO affiliations with or involvement in any organization or
entity with any financial interest (such as honoraria; educational
grants; participation in speakers’ bureaus; membership,
employment, consultancies, stock ownership, or other equity
interest; and expert testimony or patent-licensing
arrangements), or non-financial interest (such as personal or
professional relationships, affiliations, knowledge or beliefs) in
the subject matter or materials discussed in this lecture.
However, anyone interested in paying me to do this lecture I would be happy to talk with afterwards.
Learning Objectives
The participants should be able to:
• 1) Understand the role the provider has in the
current epidemic of opioid use in America.
• 2) Recognize opioid substance abuse and
characteristics of drug seeking behavior.
• 3) Understand compassionate management
of opioid abusers.
Reason # 1
Reason # 2
An independent, not-for-profit organization, The Joint Commission
accredits and certifies nearly 21,000 health care organizations and
programs in the United States. Joint Commission accreditation and
certification is recognized nationwide as a symbol of quality that
reflects an organization’s commitment to meeting certain performance
standards.
Our Mission: To continuously improve health care for the public, in
collaboration with other stakeholders, by evaluating health care
organizations and inspiring them to excel in providing safe and
effective care of the highest quality and value.
Vision Statement: All people always experience the safest, highest
quality, best-value health care across all settings.
Reason # 3
Reason # 4
• Studies have shown that the United States, with
~ 5% of the world’s population, uses 81% of the
global supply of oxycodone and 99 percent of
the world's hydrocodone.
• Health care providers wrote 259 million
prescriptions for painkillers in 2012, enough for
every American adult to have a bottle of pills.
• The prescribing rates for prescription opioids
among adolescents and young adults nearly
doubled from 1994 to 2007.
• Changes organizations view of pain and how
it should be treated
• Added pressure to the provider to “cure”
pain
• When we start tying our reimbursement on
how patients feel about their treatment and
the provider or nursing staff we have lost
control of the practice of medicine
• This is just a shift of burden from the
primary provider to a “specialist” so the
primary provider doesn’t have to deal with
the constant pressure to provide pain
medications.
• This is not a fix but a temporary-at-best
solution.
• Why do patients come to the clinic or ER for
pain medications?
• Legal (no illegal consequences)
• Easy Provider
• Stressed Providers
• Gambling
• True pain from acute injury
• Don’t preconceive all pain medication
requests as being drug-seeking
• Even drug seekers have acute pain and severe
illness
• Clean Slate Concept
•
•
•
•
•
•
•
Hx of the patient (frequent visits)
Community reputation
Clinic or ER reputation
History of acute pain
Exam consistent with Hx
Objectifiable quality to pain
Since nurses are at the frontline when it comes to
pain management in all settings, it is important for
them to know the physiology of pain, myths and
misconceptions about pain, and ethical issues in pain
management
Complaint of headaches
Complaint of back pain
Complaint of dental pain
Request for narcotic, benzodiazepine, or muscle relaxant medication by
name
Requesting a refill of narcotic, benzodiazepine, or muscle relaxant
medication
Reporting that narcotic, benzodiazepine, or muscle relaxant medication had
been lost or stolen
Reporting being out of narcotic, benzodiazepine, or muscle relaxant
medication
Reporting ten-out-of-ten pain
Reporting greater than ten-out-of-ten pain
Requesting medication IV
Studied behavior
Total
% of total visits
interval
Complaint of 10/10 pain
724
29.1
Complaint of headache
539
21.7
Complaint of back pain
516
20.8
Medication by name
377
15.2
Complaint of out of medication
235
9.5
Chief complaint of refill
174
7.0
Request for IV administration
106
4.3
Complaint of dental pain
45
1.8
Complaint of 10+ pain
44
1.8
Complaint of lost medication
15
0.6
•
West J Emerg Med. 2012 Nov; 13(5): 416–421.
95% Confidence
27.3–30.9
20.1–23.3
19.2–22.4
13.8–16.6
8.3–10.6
6.0–8.0
3.5–5.1
1.3–2.3
1.3–2.3
0.3–0.9
• Drug seeking is an addictive behavior and
thus it is an illness
• Fool me once shame on you, fool me twice
shame on me.
• Say No to Drugs!
• Help you colleagues to say No!
• Drug Monitoring Program
• Confront the patient with concern.
• Do not allow to leave without a responsible
person willing to take responsibility for them
• If they become unruly call 911, especially if
they drove to the clinic by themselves
• If goes unresponsive CPR as needed and call
911
• Develop a pain policy for the clinic or ER
• Be willing to be uncomfortable but do not
allow the patient to be threatening
• Suggest help or provide “Hot Line” numbers
for addiction, addiction programs
• Refer to Pain Management
• Dismissal of the Patient
• The “System” is broken and is part of the
problem
• We as providers and medical care workers
are part of the problem
• The patient is part of the problem
• Have compassion
• Learn to say No!