What Our Patients Look Like - PowerPoint Presentation

Slide1

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 painSlide2

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.

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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 Slide4

Opiate Risk ToolSlide5
Slide6

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/Slide7
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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/Slide9

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 Slide10

Discussion Case 2

Discussion of importance of addressing social factors.

Issues of narcotic

management in the

elderly with respiratory compromise, medication diversion, elder abuse Slide11

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 functionSlide12

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 dayHas benefited from periodic lumbar epidural steroid

injections Slide13

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. Slide14

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 quantitySlide15

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 Slide16

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 Slide17

Discussion Case 4

Discussion points of the

utility of the NCCSRS

, opiate misuse/abuse, addiction, referral to appropriate community

services Slide18
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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.Slide20

Addiction