The Role of Opioid Medication in Chronic Pain
ManagementLorraine Widdall, MS APRN BC
Interventional Spine and Pain Center
Effective December 15, 2013
Emergency rule that temporarily adds provisions under P.L. 185-2013 (SEA246) regarding physicians prescribing opioids for chronic pain.
Under Title 844 Medical Licensing Board of Indiana
Indiana Prescribing Guidelines
Patients with chronic pain. Chronic Pain is defined in this document
as: A state in which pain persists beyond the
usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years.
Included:
Patients with a terminal condition Residents of a healthcare facility Patients enrolled in a hospice program Patients enrolled in an inpatient or
outpatient palliative care program of a hospital
Excluded:
Patient has been prescribed:
1. More than 60 opioid containing pills a month; or
2. A morphine equivalent dose of more than 15 mg per day;
for more than 3 consecutive months
Guidelines apply when:
Evaluation and Risk stratification Education of the patient as to risks and
benefits of opioid therapy as well as expectations related to prescription requests and proper medication use
Continual monitoring and evaluation of therapy
DOCUMENTATION
Also included
Indiana legislature passed a law, in compliance with a federal mandate for states, requiring the Indiana Medical Licensing Board to develop an emergency opioid prescribing rule.
Proliferation of “pill mills” Prescription drug abuse has become a
bigger problem than all other illicit street drugs
Pain has been treated as “5th Vital Sign”
Why?
The US comprises 4% of the world’s population yet consumes 85% of the opioid medication.
CDC
Is there a problem?
Detox in Lake County Jail exploding from prescription drugs (10:1 RX to heroin)
Sheriff has established the High Intensity Drug Trafficking Task Force (Seized over $7M in RX drugs in 2013, already over that for 2014)
New trend: heroin cut with BZA Wellbutrin and Gabapentin snorted together
mimic heroin.
Lake County, IN
17th in US for RX drug deaths
Porter county #1 in IN for heroin deaths
In 2013, the OAG filed disciplinary complaints against 15 physicians for overprescribing pain medication; so far in 2014 they have already surpassed that number
Indiana
Procedures Physical therapy/Aquatic therapy Lifestyle changes NSAID Adjuvant medications Psychological counseling Alternative treatments
Opioid Free Treatment
Epidural Steroid Injections Joint injections Steroid/Hyaluronate (Synvisc or Hyalgan) Trigger Point Injections Scar Neuroma Injections Nerve Blocks (Chemical/Thermal) Chemodenervation (Botox)
Procedures
Aquatic Therapy
Land Based
Home exercise program
Physical Therapy
Weight loss Smoking Cessation Activity pacing Back to work (work
hardening/conditioning/restrictions) Exercise
Lifestyle Changes
OTC ibuprofen and naproxen Prescription Mobic, Celebrex, Motrin, Diclofenac Tylenol Topical preparations Pennsaid, Voltaren Gel, Flector patches
NSAID’s
Antidepressants: Nortriptyline, Amitriptyline, Effexor, Cymbalta, Savella
Antiseizures: Gabapentin, Lyrica, Topamax, Lamitcal, Tegretol, Gralise
Muscle Relaxants: Baclofen, Tizanadine, Flexeril, Zanaflex, Robaxin, Skelaxin, (Exclude Soma)
Sedative/Antianxiety: Valium, Xanax, Klonopin
Topical: Lidoderm
Adjuvant Medications
Evaluation is ALWAYS appropriate Treat underlying issues that are closely
related to pain such as depression and sexual abuse
Biofeedback Relaxation/meditation Imagery Music therapy
Psychological Counseling
Acupuncture Acupressure Massage Hypnosis
Alternative Treatments
Evaluation and risk stratification History and physical
Obtain and review records from other providers
Objective pain assessment tool
Risk for substance abuse tool (SOAPP)
Establish working diagnosis and tailor a treatment plan
Managing Opioid Therapy
Risks/benefits and expectations Discuss alternative modalities to opioids
Simple and clear explanation to help patient understand the key elements of their treatment plan
Discuss with females ages 14-55 with childbearing potential possible risks to the fetus
Managing Opioid Therapy
Review and sign a treatment agreement which shall include at least the following:
1. Goals of treatment 2. Consent to drug testing*****(delayed
until 1/1/15 due to ACLU lawsuit filed 1/8) 3. Physician prescribing policies which
must include (at least) that the medication be taken as prescribed and not shared with anyone else.
Managing Opioid Therapy
4. A requirement that the patient inform the physician about any other controlled substances prescribed or taken.
5. Permission for random pill counts 6. Reasons that the opioid therapy may be
discontinued or changed by the physician.*A copy of this agreement is to be retained in
the patient’s chart.
Periodic scheduled face to face visits Stable medication regime: at least every 4
months Changed medication regime: at least every 2
months During the visit, evaluate progress and
compliance and set clear expectations along the way (such as participation in physical therapy)
Managing Opioid Therapy
INSPECT At the outset of an opioid treatment plan
and at least annually thereafter. Document in chart the consistency with
physician’s knowledge of patient’s controlled substance history
Managing Opioid Therapy
Drug Testing At the outset of opioid treatment plan and at
least annually thereafter. Doesn’t specify serum, urine or saliva Must include confirmatory test results Inconsistencies or presence of illicits require
review of treatment plan. Documentation of revised plan and
discussion with patient must be recorded in chart.
Managing Opioid Therapy
When a patient’s opioid dose reaches a morphine equivalent of 60 mg/day:
Face to face review of treatment plan Consideration of referral to specialist If continuing therapy, there must be a
revised assessment and plan for therapy Documented assessment of increased risk
for adverse outcomes, including death.
Managing Opioid Therapy
Short acting: Tylenol with codeine, Tramadol, hydrocodone, oxycodone, hydromorphone, Nucynta
Long acting: MS Contin, Fentanyl, Opana, Oxycontin, (Zohydro)
Methadone Demerol Intrathecal opioid therapy
Appropriate Use of Opioids
THE HOLY TRINITY
Hydrocodone Muscle Relaxant (Soma) Benzodiazepine
Red flag for DEA
Appropriate Use of Opioids
PRN vs. Scheduled Treat flares and return to baseline It’s OK to say “no.” Be aware of trends and fads (Adderall) Stay informed and aware www.opiophile.org
Appropriate Use of Opioids
Lake County Drug Task Force 219-755-3822 www.deadiversion.udsoj.gov Scott Nowland (219) 681-7000 x128 www.cdc.gov www.bitterpill.IN.gov (Indiana AG office) www.supportprop.org (Physicians for
Responsible Opioid Prescribing)
Resources