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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 pain 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. 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 Opiate Risk Tool 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/ Review of Treatment Form Name ___________________________ DOB_______ New life stressors to discuss today? Any NEW ISSUES since your last visit? Only if YES, circle below (separation, loss of job, death, other) YES Surgery since your last visit? YES Emergency Room visits since your last visit? YES Injections since your last visit? YES Imaging studies since your last visit? YES Rate your pain on a 0-10 scale General Health Main Complaint_____________________________ NO NO NO NO NO worse____ best____ fever, fatigue, weight loss or night sweats chest pain or shortness of breath chronic cough or shortness of breath diarrhea, bloody stool, constipation, nausea painful urination, bloody urine Numbness, muscle weakness, joint swelling abnormal bruising, bleeding or rashes Crying, hallucinations, or hearing voices Dizziness, numbness, tingling or headache Since your last visit, HAVE You… Changed pharmacy? Gotten pain meds from anyone else? Used any illegal drugs? Drank alcohol since last visit? Given/shared or sold medication? Taken medications as prescribed? Has your treatment/medication helped you To be able to work? To be in a better mood? To be more active? To sleep better? Yes No Yes No Yes No Yes No DO YOU FEEL THREATENED AT HOME? Have you fallen since your last visit? Yes No Yes No Yes No Yes No Yes no Yes No YES NO (If yes, give packet and offer Case Management info) YES NO If yes, explain_____________________________________. Are you feeling depressed or have you ever had an emotional or mental illness? Have you thought of harming yourself within the past week? ( If yes, notify RN or Provider ) Do You Have Medicare Part D insurance coverage? YES NO YES NO Yes No Do you have any questions about your medications, treatments or diagnosis? Yes Shade the area below where you hurt Clinical Notes Only No Front BP______ Back Pulse____ Resp_______ WEIGHT_____ (stated) VAS____(present) Clinical Sign/Date/Time______________________________________ Provider Sign/Date/Time_____________________________________ 06/2015 Review of Treatment Form Tab: Review of Treatment Form Page: 1 of 1 Inventory #: Revision Date: 06/2015 Weight loss, fever, fatigue, night sweats 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/ 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 Discussion Case 2 • Discussion of importance of addressing social factors. Issues of narcotic management in the elderly with respiratory compromise, medication diversion, elder abuse 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 function 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 day • Has benefited from periodic lumbar epidural steroid injections 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. 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 quantity 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 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 Discussion Case 4 • Discussion points of the utility of the NCCSRS, opiate misuse/abuse, addiction, referral to appropriate community services 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. Addiction