1. Prescribing Pain Medications A Scientific Approach? Christopher Dietrich MD

2. Scope of the Problem 42% of Emergency Room Visits – Pain Problems Estimated 44 million pain related visits made to US emergency departments annually 30%-40% of adults experience back pain Pletcher MJ, Kertesz SG, Kohn MA, Gonzales R. Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA. 2008;299:70-78. Verhaak PFM, Kerssens JJ, Decker J, et al. Prevalence of chronic benign pain disorder among adults: A review of the literature. Pain 1998; 77:231-239.

5. Traditional Treatments

6. Normal Pain Pathway

7. Approach to Patient with Pain Detailed Patient History –Location, quality, timing, severity, exacerbating, palliative factors –Mechanism of injury –Acute vs chronic “6 months” Physical Examination –Motor –Detailed Neurological exam –Provocative tests Imaging Studies EMG

8. Identify Type of Pain Acute vs Chronic –“6 months” Nociceptive Somatic Visceral Neuropathic

9. Nociceptive Pain Direct stimulation of pain receptors/nociceptors Typically involves direct tissue injury Sharp, aching, throbbing Worse with movement

11. S omatic Pain Nociceptive Pain Bone, Soft tissue, muscle, skin Aching, throbbing Easy to locate/describe A-delta fiber stimulation

12. Most Responsive Treatments Acetaminophen Cold Packs Local Anesthetic –Topical –Infiltrated Corticosteroids NSAIDS Opioids

13. Visceral Pain Nociceptive pain that involves cardiac, lung, gastrointestinal, or genitourinary tissues Difficult to localize pain Difficult to describe –“Dull” –“Deep” C-delta fibers

14. Most Responsive Treatments Corticosteroids NSAIDs Opioids

15. Opioids Action presynaptic inhibition of production of neurotransmitters postsynaptic suppression of evoked activity in nociceptive path increased transmission of the descending inhibition of spinal nociceptive conduction

16. Neuropathic Pain Compression, transection, ischemia, or metabolic injury to a nerve Burning, tingling, shooting, stabbing, electrical

17. Most Responsive Treatments Anticonvulsants –Gabapentin, Pregabalin Corticosteroids Nerve Block NSAIDs Opioids Tricyclic Antidepressants

20. Tramadol Surgical & Other Interventions Scheduled Narcotics Use before scheduled narcotics in adults who require around-the-clock treatment for an extended period of time Mild Moderate Severe Severe Acetaminophen Non-Prescription NSAIDs ULTRAM ER Prescription NSAIDs COX-2 Inhibitors Modified Pain Treatment Ladder Topical Agents Physical therapy, Modalities Neuropathic Pain Agents

21. Central Sensitization Nervous system changes Nociceptive neurons in the dorsal horn of spinal cord “Wind-up”, pain threshold changes Maintains pain after initial insult has resolved

22. Central Sensitization

24. Approach to Patient with Pain Identify type of pain –Nociceptive, Neuropathic –Acute vs Chronic –Peripheral vs Central Sensitization Identify pain generator Review aggravating/ameliorating factors Develop initial treatment plan Review/modify treatment if necessary

25. How to Identify/Prevent Problems

26. Prescription Drug Abuse Statistics 6.2 Million Americans who are current non-medical users of Psycho-therapeutic Drugs Greater than the number of those abusing cocaine, hallucinogens, and heroin combined Non-medical use of prescription drugs ranks 2 nd only to marijuana

27. Prescription Drug Abuse Statistics

31. Abuse Statistics Pain Med 2008 May-Jun;9(4):444-59. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Fishbain DA, Cole B, Lewis J, Rosomoff HL, Rosomoff RS.Fishbain DACole BLewis JRosomoff HLRosomoff RS –3.27% rate of addiction/abuse (all study patients) –0.19% - rate of addiction – when eliminate all prev abuse pts –11.5% Adverse Drug Related Behaviors –0.59% ADRB when eliminate all prev abuse pts

32. Risks/problems associated with prescribing controlled substances Concern about patients –Fear of addiction –Fear of Drug Abuse –Concerns about diversion –Concern about safety of medications –Identifying “doctor shoppers” –Tolerance –Dose Escalation Regulatory concern –Concern about DEA scrutiny –Rules vs myths Prescribing Logistics –Monthly prescription refills –Drug Testing –Opiate Agreements

33. How to Decrease Risk when Prescribing Controlled Substances Documentation – 4As Written Opiate treatment Agreements – “not contracts” Drug screens –ICD-9 = V58.69 Chronic Med Use Adequately treat pain & identify patients at risk for abuse/diversion –SOAPP-R (Screener and Opioid Assessment for Patients with Pain – Revised) –Determine how often to monitor, who to monitor Patient Database/registry –Prescription Drug Monitoring Program(PDMP)

34. Documentation 4 A’s – Criteria looked at by DEA/Reviewers –Analgesia – documented pain score –Activity/Function – ADLs, functional outcomes –Adverse events – side effects, complications –Aberrant Behavior – drug seeking, abnormal drug screens, should have explanations, plan, course of action

35. Narcotic Agreement Agreement to Treat with Narcotics –Not a contract –Contract implies service or product for $$ –Include terminology that allows : Prescriber to communicate with pharmacy, primary care MD, ER Prescriber to obtain drug screens when clinically indicated Patient only uses one pharmacy Agrees to take medications exactly as prescribed

36. Drug Screens Drug screens –Codes/What to order: RCRH Lab – UDS panel – confirm positive opiates ClinLab – 764819 Sanford Lab – drugs of abuse panel with expanded opiate panel – 38081N- 9907 –ICD-9 = V58.69 Chronic Med Use Drug Screen/Test Specifics –Look at Creatinine level (way to determine if valid test) –Make sure test includes synthetic opiates

37. When to use/screen –Initial assumption of care –Scheduled basis Determined by clinician Determined by SOAP-R Random system –SOAPP-R (Screener and Opioid Assessment for Patients with Pain – Revised) Drug Screens

39. SOAPP-R

40. SOAPP-R Scoring High Risk = 22 or greater Moderate Risk = 10 – 21 Low Risk = < 9

41. Prescription Drug Monitoring Program (PDMP) Program designed to deter prescription drug abuse Keeps track of all dispenser/prescriber records Reports can be requested to aide prescribers, dispensers, and law enforcement “Allow clinicians to adequately treat legitimate pain patients and identify and curb inappropriate non- medical use of controlled substances, stop doctor shoppers, and decrease prescription drug diversion”