Download Dr. Kris Zeller Seminar Material

+/- Opioid Management
Kristen Zeller, M.D.
Interventional Pain Management Specialist
• Pain – “Unpleasant sensory and emotional experience associated with
actual or potential tissue damage or described in terms of such
damage.”
*1994 International Association for the Study of Pain
Basic Neuroanatomy of Pain
Biochemical mediators of the Dorsal Horn
• Excitatory Neuromediators
-Excitatory amino acids-glutamate and aspartate
-Neuropeptides-substance P (SP) and calcitonin
gene-related peptide (CGRP)
-Growth Factor-brain-derived neurotrophic factor
(BDNF)
• Inhibitory Neuromediators
-Endogenous opiods, such as enkephalin and
B-endorphin
-Gamma-aminobutyric acid (GABA)
-Glycine
Yin/Yang
1. Excitation occurs in an injury
2. A patient needs counter balance or pain can be out of control
3. Patients have natural inhibition
4. Opioids particularly in an acute injury function as inhibition in the pain
pathway
Target Sites for Pain Therapies
Individual Pain Experience
Nociception
Suffering
Cancer
Depression
Fear
Perception of Pain
Pain Behavior
Secondary Gain
Nociception
Perception of Pain
Pain Behavior
Suffering
Fear
Perception of Pain
Nociception
Suffering
Depression
Pain Behavior
Secondary Gain
High Pathology
ACUTE PAIN
CHRONIC PAIN
Low Pathology
OPIOID MANAGEMENT
PAIN
DIAGNOSIS
OPIOIDS
OPIOID MANAGEMENT
DIAGNOSIS ?
SOMATIC (Acute post-op,
NEUROPATHIC (RSD, Neuroma,
VISCERAL (Distention of hollow
Fractured bone, Cancer
Peripheral Neuropathy, Radiculopathy,
etc.
viscous, SBO, etc.
metastasis to the bone, etc)
Very Helpful
? Utility
?Utility
OPIOID MANAGEMENT
• AGE ? - Is tolerance going to be an issue
• Pathology ? - Chronic benign pain with low pathology
• Chemical Dependency ? – Denial - Urine Screen
• Functional ability ? – Coach Potatoes
• Long Term Goals ? – Briefly use opioids to facilitate rehabilitation and then taper off
• Personality Disorders/Psychiatric issues/Psychosocial issues ?
OPIOID MANAGEMENT
• Difficult medications to manage - Utility
• Physical Dependence
• Hyperalgesia state with withdrawal
• Potential for a paradoxical effect with chronic use
Education
• 1. If rapid tolerance develops unlikely to be a long-term solution to the
patients pain state.
• 2. If the patient has an injury that needs time to heal if they take opioids
they may not get the proper feedback on biophysical pain mechanisms.
• 3. Opioids are typically not a solution to a pain state, so to use opioids
ONLY without other treatments will likely lead to tolerance and
increasing doses……..poor pain control
• 4. Long-term use seems to loose its efficacy and the side effects of
opioid remain. (cognitive delay, constipation)
• 5. I do not want to see you suffer and I will treat your pain, but I want
you to understand the risks and limitations of these medications.
Rehabilitation
Over Activity
PAIN
Middle Road of Activity
Under Activity
PAIN
TIME
Urine Drug Screen
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Needs to be random
Test temperature of urine
Most Urine Drug screens were developed for illicit use of drugs
More challenges and more variables when testing for compliance of narcotic use
(hydration, dosing, metabolism, body mass, urine pH, duration of use, drug’s pharmacokinetics)
Urine drug screen
• Opiates
• Codiene
• Hydrocodone
• Hydromorphone
• Morphine
• Semi-synthetic opiates
• Oxycodone
• Oxymorphone
• Synthetic-methadone, Fentanyl, Tramadol
• Benzodiazapines-Alprzolam, Nordiazepam
• Illicit Drug-Methamphetamine, Cocaine metabolites, THCA/marijuana, Heroin metabolite
Urine Drug Screen
• Immunoassay
• Susceptible to false positives
• Gas Chromatography-Mass Spectrometry (GC/MS)
• When a positive result is on Immunoassay then need to go to GC/MS. GC/MS is an confirmation
assay that is highly reliable and specific test with rare interferences.