What Our Patients Look Like 70-year-old retired banker with advanced osteoarthritis 84-year-old grandmother with COPD and severe back pain 51-year-old machinist with failed back syndrome 36-year-old female retail sales associate with chronic back pain

Case 1 70-year-old retired banker with advanced osteoarthritis of the knees, not a surgical candidate due to congestive heart failure. Prescribed Lortab 10/325 6x/day with pain relief and improved quality of life.

Discussion Case 1 Discussion points of conversion to long acting opiate medications, lessening of acetaminophen dosage and management of a compliant low risk opiate candidate Utilization of the UDS, opiate contract, frequency of visits, ongoing monitoring

Opiate Risk Tool

Managing Opioid Therapy Assess Benefit: Discuss realistic goals and expectations of opioid therapy Discuss importance of focusing on functional improvements Assess benefit periodically using scales to assess pain, function, quality of life “Exit” Strategy Boston University: http://www.opioidprescribing.com/

Monitoring Opioid Therapy Use "Universal Precautions" to monitor and document any harm (e.g., aberrant medication taking behavior). Use consistent approach, but set level of monitoring to match risk. Agreements/informed consent, “Contract” Urine drug testing Pill counts Frequent visits initially, then follow-up visits at least every 3 months Review Prescription Monitoring Program; NCCSRS showing controlled medications Boston University: http://www.opioidprescribing.com/

Case 2 84-year-old grandmother with COPD on supplemental oxygen and chronic pain related to severe lumbar DDD and facet arthropathy Patient’s granddaughter living in the home is addicted to Crystal Meth

Discussion Case 2 Discussion of importance of addressing social factors. Issues of narcotic management in the elderly with respiratory compromise, medication diversion, elder abuse

Discussion Treatment Challenges: Age related physiologic changes - Decreased renal function - Decreased volume of distribution secondary to reduced lean muscle mass - Decreased liver activity and metabolizing enzymes - Decreased serum protein concentrations - Decreased pulmonary function

Case 3 51-year-old employed machinist with chronic back pain and radiculopathy with a history of 3 back surgeries including a multilevel fusion 5 years ago Relocating from West Virginia and needing to establish pain management Prescribed Oxycontin 60 mg three times a day, Oxycodone 15 mg every four hours and Valium 10 mg three times a day Has benefited from periodic lumbar epidural steroid injections

Discussion Case 3 Discussion points of assumption of care in regards to opiate pain medications, possible specialist referral, continuing appropriate screening, addressing possible opiate induced hyperalgesia, medication weaning, consideration of alternative therapies including a SCS implant.

Opiates and Benzodiazepines Both CNS depressant medications High risk combination due to accentuation of side effects Recommendations are to avoid prescribing together Minimize dosage and quantity

Opiate Induced Hyperalgesia Patients on chronic high dose opiate medications develop diffuse pain of vague quality, pain medications “not working” Condition related to up regulation of pain receptors, sensitization of afferent neurons and activation of central glutamate Therapeutic approach is tapering of opiate medication dosage

Case 4 36-year-old female retail sales associate with a history of a 2-level lumbar fusion Prescribed Oxycodone 15 mg every four hours from prior pain clinic and travelling from Charlotte for evaluation Requesting Fentanyl patch NCCSRS showing opiate prescriptions from multiple prescribers over last 3 months. Outside records indicating patient has been discharged from multiple pain clinics UDS results from ED visit last year positive for cocaine

Discussion Case 4 Discussion points of the utility of the NCCSRS, opiate misuse/abuse, addiction, referral to appropriate community services

Addiction vs. Dependence Addiction: a chronic neurobiological disease involving reward, motivation, and memory circuits, reflected in pathological pursuit of reward and/or relief by substance use Pseudo-addiction- Inadequate pain management leading to addiction-typical behavior like dose escalation and drug-seeking, but which ceases upon adequate pain control. Physical Dependence- A state of adaptation manifested by drug class- specific withdrawal triggered by abrupt cessation, rapid dose reduction, decreasing blood levels, and/or administration of antagonist Tolerance: A state of adaptation resulting in a diminution of a drug’s effects over time at a given dose.

Addiction