Pain Management JEFFREY TAN HO, D.O.

Initial Visits For New patients (Opioid Naive patients) Appropriate History Appropriate Exams Appropriate Imaging(s) if necessary Treatments: Physical therapy Acupuncture Manual Manipulation/Chiropractic Therapeutic Yoga Tai Chi

Initial Visits Treatment Medications NSAIDS Tylenol Gabapentin, TCA (nortriptyline), Topamax Tramadol Tapentadol(Nucynta) Buprenophine medications (Belbuca, Butrans) AVOID OPIOIDs as first line treatment

Initial Visits New Patients (Already on Opioid) Appropriate H&P Appropriate Imagings for reason of pain and justification for being on Opioid Xrays for DJDs MRIs for Spinal Issues EMG/NCV for neuropathy pain

Initial Visits New Patients (Already on Opioid) Consider CBT CURES (Controlled Substance Utilization Review and Evaluation System) Point of care UDT Pain Contract Opioid Risk Assessment Consider CBT Dietary Modifications More Vegetables and less animal based diet

Documentations Documentations Failure of non-opioid meds 4 A’s Adverse Side-effect Aberrant Behavior Affect ADLs

Things to Avoid Avoid opioid/benzodiazepine combo Avoid Soma Avoid 90MME or greater Avoid Fentanyl Patch for chronic non-cancer pain Avoid Methadone

CURES It’s mandatory to check CURES as of 10/2/18 Must check the first time prescribing a controlled substance At time of care or within 24hrs before Every 4 months there after

CURES Exemptions While being admitted to or during an emergency transfer clinic or medical facility In an Emergency Department (ER) Can get up to 7 days supply NO Refills Post-surgical care Up to a 5 days supply Patient receiving Hospice care

CURES Exemptions Unable to access CURE Do not have time Technical difficulties Or the time it takes to access CUREs will cause patient to missed getting their med refill Must documents, documents and documents Can only prescribe 5 DAYS of medications NO Refills

Urine Drug Testing Needs it on initial visit if patient is on a controlled substance or will be prescribed one Use point of care UDT At least once a year as per CDC guideline Additional testing is at discretion of providers History of drug abuse High Risk on Opioid Risk Assessments Tobacco Smokers

AB2760 Naloxone or another drug approved by FDA for the complete or partial reversal of opioid depression 90MME Opioid and Benzodiazepine History of overdose History of Substance Abuse Patient return to high dose of opioid which they can no longer tolerant

AB2760 Requires prescribers to provide education on overdose prevention and use of naloxone or similar products Patients Person designate by patient Parents of minors on opioid or guardian

AB2760 Applies to prescriber but is not limited to prescriber only Does not need to write Rx if patient declined Must offer patient Naloxone “anytime the specified condition is present” Education is good for 24 months Does not exempt Home Hospice care pts Does not apply to Inpatient

Chronic Opioid Patients Needs Cures every 4months Needs UDT at least annually More frequently if indicated Use POC UDT Consider naloxone or equivalent product High Risk patients 90MME or greater Opioid and Benzo History of Overdose History of substance abuse High risk on Opioid Risk Assessment Patient going back to high dosage but has less tolerant