1. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 1 The Role of Adjuvant Medications in the Treatment of the Injured Worker Benjamin G Benner, MD, FACS Neurosurgery Specialists, Tulsa

2. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 2 Introduction Today we want to review the role of traditional and non-traditional medications in the initial and subsequent treatment period. Explore proposed mechanism of actions, effectiveness, complications, and costs Place emphasis on the antineuritics class

3. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 3 General Treatment Options Accupunture Chiropractic Injections Medications Physical Therapy Surgery

4. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 4 Medication Classes Anti-inflammatory Pain Relievers Muscle relaxants Tranquilizers Antidepressants Antineuritics Stimulants

5. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 5 Anti Inflammatory Work on a number of enzyme paths to reduce swelling and irritation. Main side effects are GI irritation, fluid retention, and bleeding Include steroidal (use only for short periods) and non-steroidal class. Effectiveness varies and cost related more to newness

6. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 6 Pain Relievers Best in short term format. Problems with habituation and dependence. Work generally at the brain level to block pain perception. Narcotic and non-narcotic classes Side effects may include impaired judgment, increase risk of injury, reduced motivation. Costs are mainly related to the patent status and newness or complexity of the drug

7. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 7 Muscle Relaxants Reduce muscle and ligament pain Reduce “tension” Variable costs Use with caution in the elderly Confusion Dizzyness Dryness and constipation

8. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 8 Accupunture Several review articles indicate a limited benefit for accupunture or accupressure. Difficult to establish credentials or locate well trained practioners Essentially no significant side effects

9. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 9 Tranquilizers Represents multiple families of medicines which all aim to reduce anxiety and agitation thus improving the effectiveness of other class medicines and healing. Minor: anxiolytic Major: antipsychotic Variable cost Dependence and withdrawal issues

10. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 10 Anti Depressants Since most injuries result in some element of diminished worth and future, depression is common. A more positive outlook results in more patient engagement in care. Some antidepressants actually have a specific pain relieving effect such as Cymbalta.

11. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 11 Anti Neuritics Collection of anticonvulsants, analgesics, and vitamins which help neuropathic pain. Most helpful in nerve injury, diabetic neuropathy, and radicular pain. Common side effects include fatigue, weight gain, swelling.

12. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 12 Stimulants Have been shown to improve the effectiveness of pain meds when given together. More common use is to combat the sedative side effects of other prescribed medication. Has high abuse and diversion potential.

13. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 13 Neurontin, (gabapentin) 90 % off label use Diabetic neuropathy Post-herpetic npathy Relatively cheap Rare dependence Slow habituation Dizziness Fatigue Weight gain Peripheral edema Sexual dysfunction Watch with renal impairment. $$ $250/mo

14. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 14 Lyrica (pregabalin) 2 nd Gen Neurontin Diabetic, post-herp Epilepsy Fibromyalgia Ca channel stabliz Small abuse potential. Dizziness Drowsiness Withdrawal symptoms Depression $$$ $230/mo Generic in 2018

15. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 15 Tegretol (carbamazepine) Anticonvulsant Mood stabilizer Epilepsy partial Bipolar disorder Neuropathic pain Trigeminal neuralgia Stabilizes Ca channel $$ $100 Teratogenic Drowsiness Headache GI effects Blood dyscrasias ^ Hypothyroidism Requires lab tests ^ Myoclonis Stevens-Johnson

16. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 16 CYMBALTA (duloxetine) Major depression Generalized anxiety disorder Neuropathy Fibromyalgia Stress Incontinence SNRI action Nausea Insomnia Withdrawal ^ Suicide < 25 yo $$$ $250/mo

17. 6th Annual EOOC/NSS Workers' Comp Seminar 2/26/2015 17 Thank You For Your Attention ! Questions ? Samples ??