Current Concepts in Pain Management How physical therapy can help CDC Guidelines for Chronic Pain Management Melanie Mailand, PT, DPT Lori Poss, APNP

Objectives Overview of prescription rates, economic cost, statistics Review of 12 CDC recommendations for chronic pain management Discuss April Wisconsin mandate

Pain 5th Vital sign

An estimated 20% of patients presenting to providers offices for noncancerous issues, leave with or receive an opioid prescription. In 2012, Health Care Providers (HCP) wrote 259 million prescriptions for opioid pain management. One American dies every 19 minutes from opioid or heroin overdose. The economic impact of drug and alcohol misuse and addiction amounts to $442 billion each year. In 2016, opioid drug overdoses doubled.

Chronic pain is defined as pain which lasts > 3 months or past the time of normal tissue healing. These guidelines are recommendations for the outpatient setting OUTSIDE of active cancer treatment, palliative care and end of life care.

Guideline #1 Nonpharmacological therapy and nonopioid pharmacology therapy are preferred for chronic pain. NSAIDS Joint injections Selective antidepressants Selective anticonvulsants PT Pain school Mental Health Referral Aquatic exercising Weight loss CBT

Guideline #2 Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function and should consider how opioid therapy will be discontinued if benefits do not outweigh the risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.

Pain Scale

Guideline#3 Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinicians responsibilities for managing therapy. There is no good evidence that opioids improve pain or function with long term use. Complete pain relief is unlikely.

Guideline#4 When starting opioid therapy, clinicians should prescribe immediate release instead of long acting opioids. This is change since 2014. Prior to that, ER/LA was recommended.

Guideline #5 When opioids are started, clinicians should prescribe the lowest effective dose. Clinicians should use caution when prescribing at ANYdose but patients should not be started on any dose higher than 50 morphine milligram equivalent (MME)/day. The CDC strongly discourages daily doses greater than or equal to 90 MME/day.

Guideline #6 Long term opioid use often begins with treatment for acute care. Use lowest effective dose Shortest amount of time **** 3-7 days for acute injury

Guideline #7 Clinicians should evaluate benefits and harms with patients within 1-4 weeks of starting opioid therapy for chronic pain or if dose escalation. Contextual evidence review found that patients who did not have pain relief at 1 month are unlikely to have pain relief at 6 months.

Guideline #8 Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid related harms and incorporate strategies to mitigate risk. Previous hx of drug misuse Pregnancy Renal or hepatic insufficiency Age > 65 Associated Mental Health conditions

Guideline #9 Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring (PMDP) data to determine whether the patient is receiving other opioids or dangerous combinations that put him or her at risk for overdose. Clinicians should review PMDP when initiating opioid therapy and periodically as well.

Guideline #10 When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs or illicit drugs.

Guideline #11 Clinicians should avoid prescribing opioid pain medication and benzodiazepines together. Concurrent use can triple the risk of overdose.

Guideline #12 Clinicians should offer or arrange medication assisted treatment of buprenorphine or methadone in combination with behavioral therapies in patients with opioid use disorder. Methadone clinics - clinicians must be trained to use/prescribe methadone.

April 2017 Wisconsin state law will require prescribers to review the PDMP before prescribing ANY controlled substance for greater than a 3 day supply. dsps@Wisconsin.gov