A Scientific Approach Christopher Dietrich MD Scope of the Problem 42 of Emergency Room Visits Pain Problems Estimated 44 million pain related visits made to US emergency departments annually ID: 780294
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Slide1
Prescribing Pain MedicationsA Scientific Approach?
Christopher Dietrich MD
Slide2Scope of the Problem42% of Emergency Room Visits – Pain Problems
Estimated 44 million pain related visits made to US emergency departments annually
30%-40% of adults experience back pain
Pletcher MJ, Kertesz SG, Kohn MA, Gonzales R. Trends in opioid prescribing by race/ethnicity
for patients seeking care in US emergency departments. JAMA. 2008;299:70-78.
Verhaak PFM, Kerssens JJ, Decker J, et al. Prevalence of chronic benign pain disorder
among adults: A review of the literature. Pain 1998; 77:231-239.
Slide3Slide4Slide5Traditional Treatments
Slide6Normal Pain Pathway
Slide7Approach to Patient with PainDetailed Patient History
Location, quality, timing, severity, exacerbating, palliative factorsMechanism of injury
Acute vs chronic“6 months”Physical Examination
Motor
Detailed Neurological exam
Provocative
tests
Imaging Studies
EMG
Slide8Identify Type of PainAcute vs Chronic
“6 months” Nociceptive Somatic
VisceralNeuropathic
Slide9Nociceptive Pain
Direct stimulation of pain receptors/nociceptorsTypically involves direct tissue injurySharp, aching, throbbing
Worse with movement
Slide10Slide11Somatic Pain
Nociceptive PainBone, Soft tissue, muscle, skin
Aching, throbbingEasy to locate/describe
A-delta fiber stimulation
Slide12Most Responsive Treatments
Acetaminophen
Cold Packs
Local Anesthetic
Topical
Infiltrated
Corticosteroids
NSAIDS
Opioids
Slide13Visceral Pain
Nociceptive pain that involves cardiac, lung, gastrointestinal, or genitourinary tissuesDifficult to localize painDifficult to describe
“Dull”“Deep”
C-delta fibers
Slide14Most Responsive Treatments
CorticosteroidsNSAIDsOpioids
Slide15Opioids Action
•
presynaptic inhibition of production of neurotransmitters
• postsynaptic suppression of evoked activity in nociceptive
path
• increased transmission of the descending inhibition of spinal nociceptive
conduction
Slide16Neuropathic Pain
Compression, transection, ischemia, or metabolic injury to a nerveBurning, tingling, shooting, stabbing, electrical
Slide17Most Responsive Treatments
AnticonvulsantsGabapentin, PregabalinCorticosteroids
Nerve BlockNSAIDsOpioids
Tricyclic Antidepressants
Slide18Slide19Slide20Tramadol
Surgical & Other
Interventions
Scheduled Narcotics
Use before
scheduled narcotics
in adults who require
around-the-clock treatment for
an extended period of time
Mild
Moderate
Severe
Acetaminophen
Non-Prescription NSAIDs
ULTRAM ER
Prescription NSAIDs
COX-2 Inhibitors
Modified Pain Treatment Ladder
Topical Agents
Physical therapy, Modalities
Neuropathic Pain Agents
Slide21Central SensitizationNervous system changes
Nociceptive neurons in the dorsal horn of spinal cord“Wind-up”, pain threshold changesMaintains pain after initial insult has resolved
Slide22Central Sensitization
Slide23Slide24Approach to Patient with PainIdentify type of painNociceptive, Neuropathic
Acute vs ChronicPeripheral vs Central SensitizationIdentify pain generator
Review aggravating/ameliorating factors Develop initial treatment planReview/modify treatment if necessary
Slide25How to Identify/Prevent Problems
Slide26Prescription Drug Abuse Statistics
6.2 Million Americans who are current non-medical users of Psycho-therapeutic DrugsGreater than the number of those abusing cocaine, hallucinogens, and heroin combined
Non-medical use of prescription drugs ranks 2nd only to marijuana
Slide27Prescription Drug Abuse Statistics
Slide28Prescription Drug Abuse Statistics
Slide29Prescription Drug Abuse Statistics
Slide30Prescription Drug Abuse Statistics
Slide31Abuse Statistics
Pain Med 2008
May-Jun;9(4):444-59.What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review.Fishbain DA
,
Cole B
,
Lewis J
,
Rosomoff HL,
Rosomoff RS.3.27% rate of addiction/abuse (all study patients)
0.19% - rate of addiction – when eliminate all prev abuse pts
11.5% Adverse Drug Related Behaviors
0.59% ADRB
when eliminate all prev abuse pts
Slide32Risks/problems associated with prescribing controlled substancesConcern about patients
Fear of addictionFear of Drug AbuseConcerns about diversion
Concern about safety of medicationsIdentifying “doctor shoppers”Tolerance
Dose Escalation
Regulatory concern
Concern about DEA scrutiny
Rules vs myths
Prescribing Logistics
Monthly prescription refillsDrug Testing
Opiate Agreements
Slide33How to Decrease Risk when Prescribing Controlled SubstancesDocumentation – 4As
Written Opiate treatment Agreements – “not contracts”Drug screensICD-9 = V58.69 Chronic Med Use
Adequately treat pain & identify patients at risk for abuse/diversionSOAPP-R (Screener and Opioid Assessment for Patients with Pain – Revised)Determine how often to monitor, who to monitor
Patient Database/registry
Prescription Drug Monitoring Program(PDMP)
Slide34Documentation4 A’s – Criteria looked at by DEA/Reviewers
Analgesia – documented pain scoreActivity/Function – ADLs, functional outcomes
Adverse events – side effects, complicationsAberrant Behavior – drug seeking, abnormal drug screens, should have explanations, plan, course of action
Slide35Narcotic AgreementAgreement to Treat with Narcotics
Not a contractContract implies service or product for $$Include terminology that allows
:Prescriber to communicate with pharmacy, primary care MD, ERPrescriber to obtain drug screens when clinically indicated
Patient only uses one pharmacy
Agrees to take medications exactly as prescribed
Slide36Drug ScreensDrug screens
Codes/What to order:RCRH Lab – UDS panel – confirm positive opiates
ClinLab – 764819Sanford Lab – drugs of abuse panel with expanded opiate panel – 38081N- 9907ICD-9 = V58.69 Chronic Med Use
Drug Screen/Test Specifics
Look at Creatinine level (way to determine if valid test)
Make sure test includes synthetic opiates
Slide37When to use/screenInitial assumption of care
Scheduled basisDetermined by clinician
Determined by SOAP-RRandom systemSOAPP-R (Screener and Opioid Assessment for Patients with Pain – Revised)
Drug Screens
Slide38Slide39SOAPP-R
Slide40SOAPP-R ScoringHigh Risk = 22 or greaterModerate Risk = 10 – 21
Low Risk = < 9
Slide41Prescription Drug Monitoring Program(PDMP)
Program designed to deter prescription drug abuse
Keeps track of all dispenser/prescriber recordsReports can be requested to aide prescribers, dispensers, and law enforcement“Allow clinicians to adequately treat legitimate pain patients and identify and curb inappropriate non-medical use of controlled substances, stop doctor shoppers, and decrease prescription drug diversion”
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