1. Pain Management JEFFREY TAN HO, D.O.

2. 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

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

4. 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

5. 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

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

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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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