1. Medications for Pain: What You Need to Know for Treatment in Workers’ Compensation Suzanne Novak, MD, PhD 5/17/07

2. Outline Opioids in general Adderall Actiq NSAIDS Benzodiazepines Barbiturates Soma Anti-depressants Prialt

3. Opioids: How did they get so popular? These drugs were noted to treat both acute pain and cancer pain effectively This was extended to treatment of chronic pain Addiction was thought to arise only rarely during legitimate treatment of pain Tolerance could be overcome by dose escalation

4. Opioids: What we learned 50% of patients abandon treatment in trials because they don’t work or they have side effects Patients become refractory to treatment These drugs have significant neuroendocrine effects Behavioral problems, and often, frank addiction interfere with treatment

5. Opioids: Failed Treatment Is there evidence of failed treatment? - Opioid hyperalgesia - Frank tolerance What did we do in the past? - Increase the dose until tolerance is overcome

6. Opioids: How to avoid failed treatment Start to address the use of opioids early in treatment Rule Out Risk Factors for Possible Misuse Cage Questionnaire Screener and Opioid Assessment for Patients with Pain History of substance abuse Legal problemsHeavy Smoking CravingsMood Swings

7. Opioids: How to avoid failed treatment Start to address the use of opioids early in treatment Consider a Psychological Evaluation Diagnoses that have a poor outcome with opioid therapy: Conversion disorder Somatization disorder Pain disorders associated with depression and/or anxiety

8. Additional Steps Before a Trial Set treatment goals Document baseline pain and functional assessments Function assessments (social, physical, psychological, daily and work activities) Could the claimant be weaned? Treatment agreement

9. Once started: What to look for Prescriptions from a single practitioner and single pharmacy Ongoing review: Current painLeast/most pain Average painHow long before relief How long it lasts

10. Once started: What to look for The 4 A’s for Ongoing Monitoring Pain Relief Side Effects Physical and Psychosocial Function Occurrence of Aberrant/non-adherent Behavior

11. Opioids: Side Effects Constipation Nausea Dizziness Somnolence or Drowsiness Vomiting Dry Skin Itching/Pruritis

12. Opioids: When to continue and when to discontinue Continue: Don’t stop if it’s working Improved pain and function Return to work Discontinue No overall improvement in function Continuing pain with intolerable adverse effects

13. Opioids: When to continue and when to discontinue Illegal activities: diversion; forgery; arrest related to drugs Suicide attempts Threatening behavior in the office Repeated slips from the drug agreement: Suggest a consult with a physician trained in addiction

14. Treatment of Opioid-Related Sedation: Most Common Initially and With Dose Increases Eliminate unnecessary medications Rest Exercise Timing Opioid rotation Reducing the dose

15. Psychostimulants for Management of Sedation: Adderall Not recommended Data supporting the use of this treatment is lacking in clinical trials.

16. Actiq Ongoing review: Current pain, Least/most pain, Average pain,How long before relief, How long it lasts Not recommended for musculoskeletal pain Recommended for breakthrough cancer pain

17. NSAIDs There is no current evidence for long-term effectiveness for pain or function There is a risk of gastrointestinal and cardiovascular side effects GI/no CV: Non-selective +PPI or Cox-2 CV: Naproxyn if required

18. Benzodiazapenes Not recommended for long-term use (No more than 4 weeks) Tolerance develops rapidly

19. Barbituates Not recommended The potential for drug dependence is high No evidence of clinically important analgesic effect

20. Soma Metabolized to meprobamate: anxiolytic Main effect may be due to sedation Withdrawal symptoms may occur with abrupt withdrawal Soma-Coma: Street-drug name when used with opioids

21. Anti-depressants First-line treatment for neuropathic pain Possible for non-neuropathic pain Analgesia occurs within a few days Tricyclic anti-depressants SNRIs: Effexor (venlafaxine) and Cymbalta (duloxetine) Wellbutrin (bupropion)

22. Prialt Not recommended until all other intrathecal medication options have been exhausted Advantage: Considered non-addictive Disadvantage: Possible side effects including severe psychiatric symptoms and neurological impairment Use with caution in patients with history of depression and psychosis

23. Questions