Download Evaluation of Chronic Pain Patients for Narcotic Therapy: Cautions and Controversies

Evaluation of Chronic Pain Patients
for Narcotic Therapy: Cautions and
Controversies
C. Marcus Cooper, Ph.D., D. N. H.
Director Of Psychological Services
Pain Medicine Associates
Johnson City, Tennessee
Disclosure Statement of Financial
Interest
I, Marc Cooper, Ph.D., DO have a financial
interest/arrangement or affiliation with one or more
organizations that could be perceived as a real or
apparent conflict of interest in the context of the subject
of this presentation, they are:
Affiliation/Financial Interest:
Interest: Director of Psychological Services
Name of Organization:
Organization: Pain Medicine Associates
Disclosure Statement of
Unapproved/Investigative Use
I, Marc Cooper, Ph.D.,
Do Not anticipate discussing the
unapproved/investigative use of a commercial
product/device during this activity or presentation.
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Evaluation of the Chronic Pain Patient
• History and Subjective Data
Pain history
Medical history
Surgical history
Social history
Family history
Current Medications / Allergies
Complete Review of Systems
VAS, Pain Drawing, Pain Disability Index
• Physical and Objective Data
Complete Physical Exam
Radiology and Laboratory
Assess for Pre-morbid Function
• What did the person do prior to the pain problem?
• Note
N previous
i
llevell off function
f
i in
i all
ll areas off life.
lif See
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Pain Disability Index Questionnaire
• What does the person do behaviorally to help the pain?
Assess for function: How is pain
interfering with the patients life? Pain
Disability Index.
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Family/home
y
responsibilities
p
Recreation
Social Activities
Sexual Behavior
Self-care
Sleeping
Occupation
Indications for Chronic Opiate
Therapy
• Consider narcotic therapy when the patient suffers from
severe daily pain caused by a disorder for which all
accepted medical treatments have failed or are otherwise
contraindicated and when the pain is significant interfering
with the person’s function and quality of life.
• Is there a pain problem verified by objective diagnostic
studies? (Fibromyalgia)
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Contra-indications or Risk Factors
for Narcotic Therapy
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Pre-existing Psychiatric Disorders vs. co-existing factors
Personality and/or behavioral health concerns
Social/environmental factors
No surgical, alternative, non-opioid or nonpharmacological strategies have been attempted
• Age
Personality Characteristics, Preexisting Functional Issues prior to
pain problem, and other variables.
• Morbid obesity
• Deconditioning and sedentary life style
• Sleep issues
• Nicotine Dependence
• Resistance to making any personal changes
• Age
Pre-existing Psychiatric Disorders vs.
Co-Morbid Psychiatric Disorders
• Major Depression and/or Bipolar Disorder
• Personality Disorders: Axis II (especially
Borderline)
• Unstable Marital Relationship
• History of Alcohol Addiction or current problems
• Drug Addiction or misuse (including marijuana)
• Panic Disorder/Anxiety
Social risk factors for compliance
and successful treatment with
opioids
• Social security
sec rit disability
disabilit issues
iss es
• Litigation/workman’s compensation issues
• Living environment (who is living in the home
and why)
• Area code/local neighborhood
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General Guidelines for Opioid Therapy
Evaluation of Opioid Therapy:
Monitoring Outcomes: Is it Working?
Critical outcomes: The “Four A’s”
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Have all other strategies for Pain Management been tried?
Having evaluated the patient from a physical, psychological,
social and spiritual point of view (thoroughly evaluating risk
social,
factors) proceed with caution.
Start low and go slow
Remember that all opioid treatment is a trial: not an “entitlement”
program
Typically convert to long acting medications
Please use caution regarding “break through” medications
• Analgesia
Is pain relief meaningful?
• Adverse
Ad
events
Are side effects tolerable?
• Activities
Has functioning improved?
• Aberrant drug-related behavior
4. Passik SD, Whitcomb L, Kirsch K, et al. Pain outcomes as assessed with a pain assessment and monitoring tool in
chronic non-malignant pain patients treated with opioids: results of final analyses. Paper presented at: The
International Conference on Pain and Chemical Dependency; June 6-8, 2002; New York, NY.
Monitoring Outcomes: Analgesic
• Is the visual analogue scale improving?
• Is there meaningful pain relief?
• Is
I there
h improvement
i
in
i functional
f
i l activities?
i ii ?
Note: Remember to document findings
Monitoring Outcomes of Opioid
Therapy: Side Effects
Common:
Constipation and somnolence
Less common
Nausea
Amenorrhea
Sexual dysfunction
Urinary retention
Myoclonus
Headache
Itching
Sweating
Cognitive Impairment
5. Portenoy RK. Opioid prescribing to patients with and without chemical dependency. Presented at: The International
Conference on Pain and Chemical Dependency; June 6-8, 2002: New York, NY.
11. Portenoy RK, Coggins C. Management of opioid side effects. Presented at: The International Conference on Pain and
Chemical Dependency; June 6-8, 2002; New York, NY.
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Monitor Outcomes of Opioid
Therapy: Aberrant Behaviors?
1. Preference for short acting medications
2. Running
g out of medications
early/unsanctioned dose escalations
3. Obtaining pain medications from other
physicians
4. Borrowing or family member’s medication
(drugs)
Monitoring Outcomes: Functional
Improvement
More severe aberrant behaviors
1. Obtaining prescription drugs from nonmedical sources (on the street)
2. Concomitant abuse of related illicit drugs
(marijuana or other?)
3. Recurrent prescription losses
4. Selling prescription drugs
5. Injecting oral formulation
6. Prescription forgery
Controversies in Narcotic Therapy for
Pain Management
Improvement in Pain Disability Index
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Family/home responsibilities
Recreation
Social activities
Sexual behavior
Self-care abilities
Sleeping
Occupation
On might even consider physiological measures like bmi,
cardiovascular function, bp, hr, or weight loss
• Improvement in test scores on depression and anxiety
(BDS and BAI)
• Providing narcotics to a high risk population
• Pseudo-addiction issues
• When do you make pain medication contingent on
behavioral health changes: stop smoking, weight
loss, regular exercise program, etc?
• Resistance and negotiating compliance. Patients
not attending other prescribed pain treatments like
physical therapy, acupuncture, etc.
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Controversy #1: Interventional
Strategies especially for moderate to
high risk patients
• Medication agreement
• Adequate medical management of pain
• Adequate management of co-morbid anxiety and
depression: multi-disciplinary approach
• Periodic random urine drug screens
• Pill counts for all controlled substances at all
patients visits
Controversy #2: “Pseudoaddiction”
• Pattern of drug-seeking behavior of pain patients
receiving inadequate pain management that can
be mistaken for addiction
Cravings and some types of aberrant behavior
Concerns about availability
“Clock-watching”
Unsanctioned dose escalation
• Resolves with re-establishing analgesia
• Involve self-help and alternative strategies for pain
management
14. Weissman DE, Haddox JD. Opioid pseudoaddiction — an iatrogenic syndrome. Pain. 1989;36:363-366.
Controversies #3: Crazy, lazy or
just non-compliant/resistant?
When to Refer to a Multidisciplinary Pain Program
• When do you make continuing narcotic therapy
dependent upon behavioral health changes.
Gaining the cooperation of the patient to make
changes to reduce their pain.
• Resistance issues: Pain medication contingent
upon patients actively participating in their own
care by following though with prescribed medical
care: diagnostic studies and adjunctive treatments.
• Age and Financial Factors
• Depends on your personal level of comfort,
supportt staff
t ff andd clinical
li i l operations
ti
andd policies
li i
• Pre-existing significant psychological factors
• Are there any therapies (injections or nonpharmacological approaches that you do not offer)
that warrant further consideration?
• Practitioner/patient conflicts
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Conclusions
• Chronic pain affects the quality of life of many patients
which can be improved with opioids.
• Healthcare providers need to try first try non-narcotic
approaches for pain prior to medications. Narcotics are not
an “entitlement”.
• Health care providers need to gain the cooperation of the
patient in their own recovery process.
• Healthcare providers need to appropriately assess, treat,
and reassess chronic pain, patient compliance and
functional improvement.
• Successful pain management for the moderate to high risk
patients includes the utilization of a multi-disciplinary
approach, e.g. interventional procedures, medical
management, psychological evaluations, alternative
strategies, physical therapy, and good rational for
treatments.
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