Download Pain Management in Today`s Legal Environment

Pain Management in Today’s
Legal Environment
J.K. Lilly M.D. M.S.
Appalachian Pain Therapy
4407 MacCorkle Ave. S.E.
Charleston, WV 25304
[email protected]
304-925-2922
Pain Management in Today’s Legal
Environment
Objectives
Enjoy the “Signs of the
Time” images
Recognize capability,
competency and currency
in therapy
Recognize “Best Practices”
for Compliance and
Compassion
Recognize the “5 Ps”
Pain Management in Today’s Legal
Environment
Preparation
Capability
Residency – ACGME
approved
Licensure – Practice and
Dispensing
Certification – Specialty,
Subspecialty Board
Competency – Critical Skill
Maintenance
Currency – CME,
Literature, Mentoring
Pain Management in Today’s Legal
Environment
Professionalism
Collegiality – Networking,
Organizations, Instruction
Conduct –
Polite, Attentive, Timely,
Communication –
Reasonable, Rational,
Responsible, Available,
Affable, Assertive
Validation- Never claim to
be something you’re not!
Pain Management in Today’s Legal
Environment
Privacy
Documentation
(HIPPA compliant)
Telephone
(Logs, Notes, Response Sheets)
Office Policy & Procedure
(On Hire & Recurrent)
Computers
(Memos, HDs, VPNs, Tech
Reps, Security, Encryption)
Personnel
(Skill Sets, Recruitment &
Training, Chaperones)
Pain Management in Today’s Legal
Environment
Proof
Nationally Published
Guidelines
(i.e. Dx-based, VA-SCI, COEs )
Professional Society
Standards of Care and
Ethical Behavior
State Regulatory Agencies
Peer-reviewed Efficacy/
Outcome-validated
Literature
Personal Practice Data
Pain Management in Today’s Legal
Environment
Permission
General Consent to
Examine and Treat
Procedural Informed
Consent (~10%)
Opioid Access Agreements
Off-Label Treatment
Statements
“Second Chance” Noncompliance Form
Communication Qualifiers
on Fax & E-mail
Pain Management in Today’s Legal
Environment
Chronic Pain Control Plan
• Pain lasts longer than six months
• Persists disproportionately beyond the initial cause
• May not respond in the same way as acute pain to
techniques and medications
• Cause may not be resolvable!
• May require combined treatment modalities
• Long Term Opioid Therapy (LTOT) may be the final
therapeutic (last/ best) alternative
• Chronic Pain Syndrome and its attendant behavior ARE
NOT equivalent to Addiction Disorder or Drug Diversion
Pain Management in Today’s Legal
Environment
Pain Taxonomy
• Acute Paintissue injury, distention or
inflammation
• Episodic Painrelated to activity
recurrent, breakthrough,
incident
• Chronic Painconstant and unremitting
waxes & wanes but
seldom subsides
Pain Management in Today’s Legal
Environment
Analgesic Selection
1st & 2nd line
Mu (m) Opioid Receptor Activators – most
familiar to clinicians as to effects and sideeffects; best for initiating opioid therapy for
moderate to severe pain (VAPS 5-10/10).
Morphine, Hydromorphone, Oxycodone,
Hydrocodone, Fentanyl, Codeine,
Hydrocodeine, Levorphanol, Methadone,
Meperidine.
Pain Management in Today’s Legal
EnvironmentAnalgesic Selection
3rd & 4th line
• Limited Proven
Analgesic Efficacy
• Adverse Effects
• Drug-to-Drug
Interaction
• Toxic Metabolites
• Organ-limited
Elimination
Pain Management in Today’s Legal
Environment3rd & 4th line analgesics
• Propoxyphene equianalgesic to Extra Strength Tylenol in
blind studies (VAPS 1-3/10 = mild)
norpropoxyphene- cardio & neurotoxic
• Tramadol weak m agonist but primarily active on spinal
adrenergic receptors similar to tricyclics (VAPS 4-5/10 =
moderate)
• Meperidine short acting (45-90 mins), metabolites
accumulate within 48 hrs, side-effects common
normeperidine- cardio & neurotoxic
• Codiene effective pain relief (equianalgesic o
Meperidine) but many side-effects at analgesic doses
• Hydrocodiene isn’t routinely monitored on UDS
• NSAIDs, APAP and AEDs, TCAD are “co-analgesics”
Pain Management in Today’s Legal
Environment
Summary
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Pain relief is defined as a primary care (PCP) function
Remain reasonable, rational, responsible and available
Examine thoroughly and review regularly
Utilize LTOT Informed Consent to Treat and Opiate Access
Agreement
Document & define providers & pharmacy
Require patient to notify all providers of Opiate Access
Agreement participation
Monitor compliance (pill counts, UDS, etc.) and response to
therapy (functional assessments, charts, diaries, surveys, etc.),
Review OAA violation consequences regularly
Match the tool to the problem- SR opioid for continual pain, IR
for recurrent pain; pick analgesics sensibly
Pain Management in Today’s Legal
Environment
Summary (continued)
Plan if Addiction is Recognized
Be Humane - Intervene and Wean to withdrawal
-Evaluation, treatment and extended recovery care by
addiction professionals is optimal
-Know community and regional resources for treatment &
extended recovery care when initiating LTOT
-Prescribing opioids to treat addiction (Methadone Clinics)
is advisable only for specially certified addiction medicine
and psychiatry physicians,
-Buprenorphine Addiction Treatment (Subtex) requires
additional training and additional DEA certification…too
new to assess.
Pain Management in Today’s Legal
Environment
Summary (continued)
• Consult and co-manage appropriately
• Require formal behavioral assessment periodically
• Stipulate that verified non-clinical information may be
considered when deciding whether to continue LTOT
• Beware of 90 day prescription “Prescription Drug Benefit
Plan Requirements” -cost saving scheme that may be
technically illegal for opioids; i.e.. unmonitored and
unlicensed warehousing of Schedule II & III medications
in homes not supported by law or regulation
• Recognize that LTOT may be the therapy of last resort
Pain Management in Today’s Legal
Environment
Take Home Thoughts
The Main Thing is to
keep the Main Thing
the Main Thing.
(Stephen Covey)
What we don’t need is
another way
to do things poorly.
(Balfour Mount)
Pain Management in Today’s Legal
Environment
“Signs of the Time”
Thanks for your
attention!!
Hope to see you
again soon.