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55 Cards in this Set
- Front
- Back
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What is the main goal of treatment of chronic non-malignant pain? |
Improve quality of life while decreasing pain |
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How can you try to overcome the challenges of prescribing opioids for chronic pain? |
Follow the Federation of State Medical Boards guidelines: - Random urine drug screening - Monitoring for aberrant behaviors - Anticipate adverse effects |
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What can increase the risk of substance abuse of opioids? |
When psychiatric comorbidities are present |
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How common is chronic pain in the U.S.? |
More than 50 million Americans have chronic pain |
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What is the definition of chronic non-malignant pain? |
Pain that is unrelated to cancer that persists beyond the usual course of disease or injury; it may or may not be associated with a pathologic process |
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What is the estimated annual costs related to chronic pain? |
$85-90 billion |
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How can you classify a patient's pain during your evaluation? |
- Nociceptive (tissue injury) - Neuropathic (neurologic response to neural or non-neural injury) - Mixed |
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Why should you do a thorough social and psychiatric history when evaluating a patient with chronic pain? |
To identify any issues, such as current or past substance abuse, developmental history, depression, anxiety, or other factors, that may interfere with achieving treatment goals |
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What tool can be used to identify a patient with higher risk of opioid abuse? |
Opioid Risk Tool
Screener and Opioid Assessment for Patients with Pain (Revised) |
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What is the utility of using tools to identify patients at higher risk for opioid abuse (e.g., opioid risk tool and the screener and opioid assessment for patients with pain? |
Not to deny a patient pain meds, but to help develop a plan for medication monitoring (or whether to refer to a pain specialist) |
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What should a written plan for treating chronic pain include? |
- Objectives to determine success - State if further diagnostic tests are indicated - Address psychosocial and physical function - Adjust therapy to meet the needs of the patient - Use non-drug treatment modalities in addition to medication |
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What should patients taking long-acting opioids for chronic non-malignant pain also be started on? |
Combination stimulant / softener laxative for constipation prevention
With anti-nausea medication |
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What should the note prior to starting opioid therapy document? |
- The circumstances leading to the decision to treat with long-term opioids - Diagnosis - Quality of pain (what palliates and provokes it, radiation, severity, type, temporal sequence) - Region of pain - Treatments (current and previous) - Referrals - Studies ordered - Patient risk factors - Any psychiatric or social considerations |
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What is the definition of "addiction"? |
Neurobiologic, multifactorial disease characterized by impaired control, compulsive drug use, and continued use despite harm |
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What is the definition of "physical dependence"? |
Normal adaptive state that results in withdrawal symptoms if the drug is abruptly stopped or decreased |
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What is the definition of "pseudo-addiction"? |
Relief-seeking behaviors misinterpreted as drug-seeking behaviors that resolve upon institution of effective analgesic therapy |
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What is the definition of "substance abuse"? |
Use of any substance for purposes that are non-therapeutic or are not those for which it is prescribed |
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What is the definition of "tolerance"? |
Physiologic state from regular drug use in which an increased dosage is needed to produce the same effect |
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What is the first step in the assessment of chronic non-malignant pain? |
- H&P exam - Pain evaluation and description - Functional and social assessment tools - Pain and visual analog scales |
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What are possible causes of neuropathic (burning/stabbing/shooting) pain? |
- PNS conditions: complex regional pain syndrome, phantom pain, metabolic - CNS conditions: Parkinson disease, MS, myelopathies, stroke - Fibromyalgia |
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What are possible causes of musculoskeletal (aching/soreness/stiffness) pain? |
- Fibromyalgia - Myofascial pain syndrome - Trauma |
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What are possible causes of inflammatory (aching/swelling/erythema/heat) pain? |
- Arthropathies (rheumatoid arthritis, ankyosing spondylitis) - Infection - Post-op pain - Tissue injury |
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What are possible causes of mechanical compression (aching, soreness, stiffness) pain? |
- Low back pain - Musculoskeletal pain - Visceral pain - Muscle, tendon, ligament pain |
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What do non-pharmacologic treatment modalities for pain require? |
Patient participation and motivation |
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What are the benefits of non-pharmacologic treatment modalities for pain? |
Improve physical mobility, fitness, mood, sleep, and general health |
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What non-opioid meds should be tried initially for chronic pain? |
- Amitriptyline (tricyclic anti-depressant) - Acetaminophen - NSAIDs - Salicylates (Aspirin) |
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What is the reason for reluctance about using long-term opioids? |
- Concerns about abuse, addiction, diversion, and adverse effects - Inadequate knowledge - Fear of regulatory scrutiny |
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What are the non-pharmacologic treatment options for chronic nonmalignant pain? |
- Lifestyle modifications: cessation of tobacco products, weight loss - Physical: exercise, manipulation, physical therapy, stretching/yoga, surgical therapies (nerve blocks, trigger point injections, spinal infusions or stimulation), transcutaneous electric nerve stimulation - Psychologic: biofeedback, cognitive behavior therapy, counseling, hypnosis, music, relaxation - Complementary or alternative: acupuncture, herbal remedies, massage, mindfulness meditation, reflexology - Occupational: occupational therapy, work conditioning programs |
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What are the pharmacologic treatment options for chronic nonmalignant pain? |
- Non-opioid analgesics: acetaminophen, NSAIDs, salicylates (aspirin) - Opioids: combination opioid and non-opioid meds or non-combination/"strong" opioid meds - Adjuvant meds: anticonvulsants, antidepressants, topical lidocaine, others |
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What are the combination opioid and non-opioid meds? |
With acetaminophen, aspirin, or NSAID: - Codeine - Hydrocodone - Oxycodone
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What are the non-combination or "strong" opioid meds? |
- Morphine - Butorphanol - Codeine - Fentanyl - Hydrocodone - Hydromorphone - Levorphanol - Methadone - Oxycodone |
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What are the anticonvulsant meds that can be used to treat chronic nonmalignant pain? |
- Carbamazepine (Tegretol) - Gabapentin (Neurontin) - Lamotrigine (Lamictal) - Phenytoin (Dilantin) - Pregabalin (Lyrica) - Valproic Acid (Depakene) |
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What are the antidepressants meds that can be used to treat chronic nonmalignant pain? |
- SSRIs - Tricyclics - Atypicals (duloxetine (cymbalta), venlafaxine (effexor)) |
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If you decide to stop using non-opioid pain meds in favor of opioids what should you document? |
Document the ineffectiveness of non-opioid options
There must be a legitimate medical purpose for opioid use
Anticipated benefits must outweigh the risks |
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What is the use of short-acting opioids for chronic non-malignant pain? |
Typically discouraged but may be used for breakthrough pain and acute exacerbations of pain |
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What are the six A's for monitoring patients with chronic non-malignant pain taking controlled substances? |
- Analgesia (assess pain relief) - Affect (evaluate mood) - Activities (evaluate ADLs, function, QOL) - Adjuncts (non-pharmacologic or non-opioid treatments) - Adverse effects (side effects of treatments) - Aberrant behavior (tolerance, dependence, addiction) |
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What is the utility of periodic review of patients taking controlled substances? |
Monitor the treatment effectiveness, non-pharmacologic treatment compliance, and patient behaviors that may indicate violation of the opioid agreement or medication misuse
Provides direction for further treatment and goal revision |
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What should you do for patients at high risk of diversion and abuse? |
Consider routine use of random urine drug screens to assess for presence of prescribed meds and absence of illicit substances |
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How long can morphine be detected in the urine? |
1 - 1.5 days |
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What do standard urine drug screens test for? |
Opiates (eg, heroin, codeine, morphine) THC Cocaine Phencyclidine Barbiturates Amphetamines/methamphetamines
* Must test for synthetic controlled substances (opioids) separately |
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What does codeine break down into? What will a urine drug screen be positive for in a patient taking this? |
- Breaks down into morphine - Test positive for both codeine and morphine
- If taken in HIGH amounts, will also break down and be positive for hydrocodone |
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What does hydrocodone break down into? What will a urine drug screen be positive for in a patient taking this? |
- Breaks down into hydromorphone (deluded) - Test positive for both hydrocodone and hydromorphone |
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Before urine drug screening, what should a physician explain to their patient? |
Explain policy for a positive result --> may not necessarily result in dismissal of the patient, but it must be addressed (eg, referral for substance abuse counseling or treatment and refusal to prescribe further controlled substances) |
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What does "aberrant behavior" refer to? |
Medication misuse - use of pain meds other than for pain treatment, impaired control (of self or of med use), compulsive use of meds, continued use of meds despite harm (or lack of benefit), and craving or escalation of use
Selling or altering prescriptions, stealing or diverting meds, calls for early refills, losing prescriptions, drug-seeking behaviors (e.g., doctor shopping), or reluctance to try non-pharmacologic interventions |
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How common is a lifetime psychiatric diagnosis in patients with chronic non-malignant pain (2/2 low back pain)? Vs. general population? |
77% (in those with psychiatric diagnosis) vs 46% (in general population) |
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How common is an active/current psychiatric diagnosis in patients with chronic non-malignant pain (2/2 low back pain)? Vs. general population? |
59% (in those with psychiatric diagnosis) vs 26% (in general population) |
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What are common psychiatric disorders in those with chronic non-malignant pain? |
- Anxiety - Mood disorders - Personality disorders - Somatoform disorders - Substance abuse |
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What are the most common adverse effects of opioids? |
- Somnolence - Nausea - Sedation (tolerance or resolution usually develops within 10 days)
- Constipation (no tolerance or resolution develops) |
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How long should combination stimulant/softener laxative be used in patients being treated with opioids long-term? |
10 days (because tolerance or resolution usually develops in 10 days)
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What causes constipation in patients taking opioids? |
Slowing of stool transit time - avoid stool bulking agents (as this may worsen constipation) |
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When should you refer a patient to a pain management specialist? |
- When pain problems remain intractable and unremitting - When there are psychosocial indications such as history of substance abuse or interpersonal dynamics that complicate the treatment of pain - When a patient's dosage has increased to ≥120 morphine mg equivalents per day w/o substantial improvement in pain/function |
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In what circumstances should you consider random, periodic, targeted urine testing for opioids and other drugs? |
Any patient <65 years old w/ non-cancer pain who is being treated with opioids for >6 weeks |
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Are long-acting or controlled-release opioids good for treating acute pain? |
No - avoid using oxycontin, fentanyl patches, and methadone for acute pain |
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How can you tell if your patient is receiving opioids from other providers? |
Periodically request a report from your state prescription drug monitoring program on the prescribing of opioids to your patients by other providers |
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What is the foundation for effective chronic non-cancer pain management? |
Self-care |
