Download Providing Compassionate Care While Avoiding Common Mistakes

Understanding State Board Regulations:
Providing Compassionate Care While
Avoiding Common Mistakes
Joe Y. Kim, MD
Water’s Edge: Memorial’s Pain Relief Institute
Washington State
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Follows Model Policy on the Use of Opioid
Analgesics in the Treatment of Chronic Pain
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Federation of State Medical Boards
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July 2013 (1997, 2003)
Washington State
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Since 2004
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1 in 4 in primary care settings, pain limits ADL’s
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Undertreatment of pain is serious public health
problem
Inappropriate Management
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Inadequate initial assessment for clinical indication
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Inadequate monitoring
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Inadequate attention to patient education/consent
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Unjustified dose escalation: risks? alternatives?
Discipline
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“Physicians should not fear disciplinary action
from the Board for ordering, prescribing,
dispensing or administering controlled
substances, including opioid analgesics, for a
legitimate medical purpose and in the course of
professional practice, when current best clinical
practices are met.”
Discipline
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“The Board will not take discplinary action against
a physician for deviating from this Model Policy
when contemporaneous medical records show
reasonable cause for such a deviation.”
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“The board will judge the validity of the
physician’s treatment of a patient on the basis of
available documentation, rather than solely on
the quantity and duration of medication
administered”.
Guidelines
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Understanding Pain:
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Patient Evaluation and Risk Stratification
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Development of a Treatment Plan/Goals
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Informed Consent/Treatment Agreement
Guidelines
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Initiating an Opioid Trial
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Ongoing Monitoring and Adapting the
Treatment Plan
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Periodic Drug Testing
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Consultation and Referral
Guidelines
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Discontinuing Opioid Therapy
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Medical Records
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Compliance with Controlled Substance Laws
and Regulations
Methadone
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Increased rate of methadone related deaths
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QTc: pre, 3days, annual
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450-500 ms discuss (debate)
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“No evidence has been found to support the
use of the EKG for preventing cardiac
arrhythmias in methadone-treated opioid
dependents” Cochrane investigators
Methadone
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Follow up sooner after:
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Initiation or increase
Pharmacodynamics/kinetics
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Analgesic action 6 hrs (morphine is opposite)
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Full analgesic effects
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Morphine conversion median 5 days (range 4-13)
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May be 1-2 weeks
Long half-lfe/accumulation ==> delayed toxicity
Methadone
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Equianalgesic for repetitive dosing smaller than
single-dose
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65 y/o decreased clearance
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No liver adjustments
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Metabolites do not accumulate with renal failure
Methadone
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Increased rate of methadone related deaths
What is the ideal opioid?
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half-life, side effects, metabolites, etc…
What is the ideal opioid?
Oxycodone
No ceiling dose
Minimal side effects
Absence/minimal activce metabolite
Easy titration
Rapid onset
Short half-life
Long duration
Predictable pharmacokinetics
Random Considerations
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T3/T4: ceiling effect 60mg/dose, max 360mg/day
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Hyrdocodone: maximal daily 60mg/day?
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Morphine: renal failure (M6G); rectal?
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Oxymorphone: hepatic impairment
Random Considerations
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Tapentadol (Nucynta): seizures, ICP, asthma
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inhibit serotonin/NE reuptake
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Tramadol: 5HT, cardiovascular, seizures, addiction
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TCA/MSO4: synergistic CNS/respiratory depression
Guidelines
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Patient Evaluation and Risk Stratification
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Indication/Evaluation
Assessment
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Nature, intensity, treatments, comorbidities, function.
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ROS, SH, FH (abuse), PE, labs?, SOAPP-R, ORT
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All patients should be screened for depression/mental
health
Guidelines
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Assessment
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History of substance abuse: failure/harm
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If possible, consult before therapy initiated.
Current abuse
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Established in treatment/recovery program
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Co-managed with addictions specialist
Terms
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Tolerance
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Dependence
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Abuse
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Addiction
Guidelines
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Assessment
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Brings in own pile of records
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ask for records directly
PMP
Guidelines
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Development of a treatment plan/goals
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Goals
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Improvement of pain and function
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Improvement of pain associated symptoms
Avoidance of unnecessary/excessive use of meds
Revisited regularly
Guidelines
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Development of a treatment plan/goals
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Individualized
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Supports selection of treatment
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Objectives to evaluate progress
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pain relief
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physical/psychosocial function
Guidelines
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Informed consent
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Risks/benefits
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Why change
Treatment agreement
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Goals
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Patient’s/physician’s responsibilities
Guidelines
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Informed consent/Treatment agreement
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Shared decision
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Store/disposal
Guidelines
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Initiating an Opioid Trial
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Present as a trial (e.g. 90 days)
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Evaluate benefit (pain/fxn/QOL) vs. harm
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Lowest possible start dose
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Short acting
Guidelines
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Ongoing Monitoring and Adapting the
Treatment Plan
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Collateral information: family, close contacts,
PMP
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More frequently at first
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Five A’s: Analgesia, Activity, Adverse Effects,
Aberrancy, Affect/mood
Guidelines
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Ongoing Monitoring and Adapting the
Treatment Plan
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Continue?
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Progress towards goals (pain, fxn, QOL)
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Absence of risks/adverse events
More meds
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Psychotherapy
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Rehabilitative
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Injection
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Surgery
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Medications
More meds
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Anti-inflammatory
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Antidepressants
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Membrane stabilizers
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Muscle relaxants
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Opioids
Escalations
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Can be a sign of use disorder/diversion
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Good time to get UDS
“halftime” rule
High doses
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200mg (MED) in 2010, lower now
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Concerns
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Hyperalgesia
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Neuroendocrine
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Immunosuppression
Guidelines
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Periodic Drug Testing/Screening
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Clinical judgement > recommendations
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Discuss in supportive fashion
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Pill count “useful”
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PMP “highly recommended”
Opioid Rotation
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Intolerable side effects
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Inadequate benefit
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25-50% reduction
Rotation
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Total 24-hour dose
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Calculate new dose
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50-65% got incomplete cross-tolerance
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Consider rescue
Rotation
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Fentanyl 50% decrease in 17 hours
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Calculate new dose
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50-65% got incomplete cross-tolerance
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Consider rescue
Guidelines
Periodic Drug Testing/Screening
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Unsatisfactory progress
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Intervention needed:
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early refill
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multiple lost/stolen rx
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physician shopping
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intoxication/impairment
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pressuring/threatening behavior
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illicit/unprescribed drugs
Guidelines
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Periodic Drug Testing/Screening
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Intervention needed:
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Behavior suggesting RECURRING misuse
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self-increase dose
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deteriorating function
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failure to comply to the treatment plan
Guidelines
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Periodic Drug Testing
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“Firm response”
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Forgery
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Obvious impairment
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abusive/assaultive behavior
Transit times (inexact)
Rapid:
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EtOH 7-12 hrs
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Pentobarbitol (24h)
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Propoxyphene 6-48 hrs
Transit times
Fast:
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(Meth) Amphetamine 48 hrs
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Codeine 48 hrs
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Heroine 48 hrs
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Cocaine metabolites 2-4 days
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Hydromorphone 2-4 days
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Methadone 3 days
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Short-acting BZ’s 3days
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Long-term/heavy 30 d
Transit times
Long
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PCP 8 days
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Phenobarbital 3 wks
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Long-acting BZ’s 30 days
Guidelines
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Consultation and Referral
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Pain, psychiatry, addiction, or mental health specialist “if
needed”
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History of substance abuse
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Co-occuring mental health disorder
Know treatment options in treatment programs for
addictions
Guidelines
Discontinuing Opioid Therapy
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Regularly weigh benefits/risks
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Discontinue
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resolution
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intolerable side effects
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inadequate analgesia
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failure to improve QOL
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significant aberrancy
Guidelines
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Discontinuing Opioid Therapy
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Structured tapering regimen
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Withdrawal
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Addiction specialist or physician
Not the end (direct care or referral)
Weaning off
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Repeated aberrant drug-related behaviors
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Diversion
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Intolerable side effects
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No progress towards goals
“More Serious”
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Repeatedly non adherent
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Cocaine
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Unprescribed opioids
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Doctor Shopping
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Unprescribed opioids
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Morphine example
“Non-serious”
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1-2 unauthorized dose escalations
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Alcohol
Wean off
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Rehabilitation setting ideal
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Addiction
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Addiction treatment made available
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Follow-up
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Non-opioid pain management
Wean off
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Slow: 10%/ week
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Rapid: 25-50% every few days
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At higher doses, can be more rapid
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When get to lower doses, slow down
Guidelines
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Medical Records
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Copies of the signed informed consent and treatment agreement
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Patient’s medical history
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Results of physical exam and laboratory tests
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Results of risk assessment (e.g. screen tools)
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Description of treatments provided
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Instructions to the patient (e.g. risks, benefits)
Guidelines
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Medical Records
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Results of ongoing monitoring of patient progress
(pain/fxn)
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Notes on evaluation/consultations of specialists
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Any other supporting information to support
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Authorization of release of information
Universal Precautions
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1. Make a diagnosis with an appropriate differential
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2. Conduct a patient assessment, including risk for substance
use disorders
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3. Discuss the proposed treatment plan with the patient and
obtain informed consent
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4. Have a written agreement that sets forth the expectations
and obligations of both the patient and treating physician
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5. Initiate an appropriate trial of opioid therapy, with or
without adjunctive medications
Universal Precautions
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6. Perform regular assessments of pain and function.
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7. Reassess the patient’s pain score and level of function
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8. Regularly evaluate the patient in terms of the “5 A’s”
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9. Periodically review the pain diagnosis and any comorbid
conditions (including substance use disorders) and adjust
the treatement regimen accordingly
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10. Keep careful and complete recored of the initial
evaluation and each follow up visit.
State Website
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Can I drink alcohol while taking pain medication?
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“Talk to your healthcare provider. Alcohol may have
unintended consequences…”
If a patient has been at 140 mg MED for several years,
do I need to consult a pain specialist?
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“No, For a patient with stable pain and function, on a
non-escalating dosage of opioids, the consultation
requirement would not be required as long as the
practitioner documents these items.”
Scoping the Addict
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Most strongly predictive factor:
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personal/family history of alcohol/drug abuse.
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Younger
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Psychiatric history
Scoping the Addict
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Travel
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Escalation of dose
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Focus on one medication
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Affect
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End of week refill
The “High Risk Patient”
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History of drug abuse
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Psychiatric issues
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Serious aberrant drug-related behaviors
The “High Risk Patient”
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Benefits outweigh risks
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“Strongly Consider”
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Mental health specialist
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Addiction specialist
The “High Risk Patient”
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Referral/change/discontinue
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Precise prescription
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4 strikes and you’re out:
How often to visit with?
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Stable, Low risk: 3-6 months
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High risk: up to weekly
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addictive disorder
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job requiring mental acuity
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elderly
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social/psychiatric/medical
The “High Risk Patient”
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Change
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More frequent/intense
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Tapering (permanent/temporary)
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Psychological therapies
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Nonopioid treatment
The “High Risk Patient”
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Discontinue
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Diversion, forgery, stealing/buying
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Serious aberrant behavior
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Injecting oral meds
Dangerous/suicidal behavior
Driving
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Effects (Especially at first, with increases, or
mixed)
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Somnolence
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Clouded mentation
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Decreased Concentration
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Slower reflexes/incoordination
Studies don’t show increase accidents
Driving
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A person is guilty of driving while under the
influence of intoxicating liquor or any drug if the
person drives a vehicle within this state:
While the person is under the influence of or
affected by intoxicating liquor or any drug; or
While the person is under the combined influence of
or affected by intoxicating liquor and any drug.
Driving
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A person is guilty of negligent driving in the first degree
if he or she operates a motor vehicle in a manner that is
both negligent and endangers or is likely to endanger any
person or property, and exhibits the effects of having
consumed liquor or an illegal drug.
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However, legal entitlement to use the drug is a defense to
the charge of “negligent driving” [§46.61.5249 (1)(a)] if
the defendant had a valid prescription for the drug
consumed and had been consuming the drug according
to the prescription directions and warnings.