1. 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

2. 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.

3. 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

4. Opiate Risk Tool

6. 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:

8. 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:

9. 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

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

11. 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

12. 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

13. 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.

14. 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

15. 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

16. 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

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

19. 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.

20. Addiction