Pain Management in Today’s Legal Environment

Pain Management in Today’s Pain Management in Today’s Legal EnvironmentLegal Environment

J.K. Lilly M.D. M.S.J.K. Lilly M.D. M.S.Appalachian Pain TherapyAppalachian Pain Therapy4407 MacCorkle Ave. S.E.4407 MacCorkle Ave. S.E.

Charleston, WV 25304Charleston, WV [email protected]@msn.com

304-925-2922304-925-2922

Pain Management in Today’s Legal Pain Management in Today’s Legal EnvironmentEnvironment

ObjectivesEnjoy the “Signs of the

Time” images

Recognize capability, competency and currency in therapy

Recognize “Best Practices” for Compliance and Compassion

Recognize the “5 Ps”


PreparationCapability Residency – ACGME approved Licensure – Practice and DispensingCertification – Specialty, Subspecialty Board

Competency – Critical Skill Maintenance

Currency – CME, Literature, Mentoring


ProfessionalismCollegiality – Networking,

Organizations, Instruction Conduct –

Polite, Attentive, Timely, Communication –

Reasonable, Rational, Responsible, Available, Affable, Assertive

Validation- Never claim to be something you’re not!


PrivacyDocumentation

(HIPPA compliant)Telephone

(Logs, Notes, Response Sheets)

Office Policy & Procedure (On Hire & Recurrent)

Computers (Memos, HDs, VPNs, Tech Reps, Security, Encryption)

Personnel(Skill Sets, Recruitment & Training, Chaperones)


ProofNationally Published

Guidelines (i.e. Dx-based, VA-SCI, COEs )

Professional Society Standards of Care and Ethical Behavior

State Regulatory AgenciesPeer-reviewed Efficacy/

Outcome-validated Literature

Personal Practice Data


PermissionGeneral Consent to

Examine and TreatProcedural Informed

Consent (~10%)Opioid Access AgreementsOff-Label Treatment

Statements“Second Chance” Non-

compliance FormCommunication Qualifiers

on Fax & E-mail


Chronic Pain Control PlanChronic Pain Control Plan• Pain lasts longer than six months• Persists disproportionately beyond the initial cause• May not respond in the same way as acute pain to

techniques and medications• Cause may not be resolvable!• May require combined treatment modalities• Long Term Opioid Therapy (LTOT) may be the final

therapeutic (last/ best) alternative• Chronic Pain Syndrome and its attendant behavior ARE

NOT equivalent to Addiction Disorder or Drug Diversion

Pain Management in Today’s Legal Pain Management in Today’s Legal EnvironmentEnvironment Pain TaxonomyPain Taxonomy

• Acute Pain-tissue injury, distention or inflammation

• Episodic Pain- related to activityrecurrent, breakthrough, incident

• Chronic Pain- constant and unremittingwaxes & wanes but seldom subsides


Analgesic Selection Analgesic Selection 11stst & 2 & 2ndnd line line

Mu () Opioid Receptor Activators – most familiar to clinicians as to effects and side-effects; best for initiating opioid therapy for moderate to severe pain (VAPS 5-10/10).

Morphine, Hydromorphone, Oxycodone, Hydrocodone, Fentanyl, Codeine, Hydrocodeine, Levorphanol, Methadone, Meperidine.

Pain Management in Today’s Legal Pain Management in Today’s Legal Environment- Environment-

Analgesic SelectionAnalgesic Selection

33rdrd & 4 & 4thth line line • Limited Proven

Analgesic Efficacy• Adverse Effects• Drug-to-Drug

Interaction• Toxic Metabolites• Organ-limited

Elimination

Pain Management in Today’s Legal Pain Management in Today’s Legal Environment-Environment-

33rdrd & 4 & 4thth line analgesics line analgesics• Propoxyphene equianalgesic to Extra Strength Tylenol in

blind studies (VAPS 1-3/10 = mild)norpropoxyphene- cardio & neurotoxic

• Tramadol weak agonist but primarily active on spinal adrenergic receptors similar to tricyclics (VAPS 4-5/10 = moderate)

• Meperidine short acting (45-90 mins), metabolites accumulate within 48 hrs, side-effects commonnormeperidine- cardio & neurotoxic

• Codiene effective pain relief (equianalgesic o Meperidine) but many side-effects at analgesic doses

• Hydrocodiene isn’t routinely monitored on UDS• NSAIDs, APAP and AEDs, TCAD are “co-analgesics”


Summary• Pain relief is defined as a primary care (PCP) function• Remain reasonable, rational, responsible and available• Examine thoroughly and review regularly• Utilize LTOT Informed Consent to Treat and Opiate Access

Agreement • Document & define providers & pharmacy • Require patient to notify all providers of Opiate Access

Agreement participation• Monitor compliance (pill counts, UDS, etc.) and response to

therapy (functional assessments, charts, diaries, surveys, etc.), • Review OAA violation consequences regularly • Match the tool to the problem- SR opioid for continual pain, IR

for recurrent pain; pick analgesics sensibly


SummarySummary (continued) (continued)

Plan if Addiction is RecognizedPlan if Addiction is Recognized

Be Humane - Intervene and Wean to withdrawal-Evaluation, treatment and extended recovery care by

addiction professionals is optimal-Know community and regional resources for treatment &

extended recovery care when initiating LTOT-Prescribing opioids to treat addiction (Methadone Clinics)

is advisable only for specially certified addiction medicine and psychiatry physicians,

-Buprenorphine Addiction Treatment (Subtex) requires additional training and additional DEA certification…too new to assess.


SummarySummary (continued) (continued)• Consult and co-manage appropriately • Require formal behavioral assessment periodically• Stipulate that verified non-clinical information may be

considered when deciding whether to continue LTOT• Beware of 90 day prescription “Prescription Drug Benefit

Plan Requirements” -cost saving scheme that may be technically illegal for opioids; i.e.. unmonitored and unlicensed warehousing of Schedule II & III medications in homes not supported by law or regulation

• Recognize that LTOT may be the therapy of last resort


Take Home ThoughtsTake Home ThoughtsThe Main Thing is to

keep the Main Thing

the Main Thing.

(Stephen Covey)

What we don’t need is another way

to do things poorly.

(Balfour Mount)


“ “Signs of the Time”Signs of the Time”

Thanks for your attention!!

Hope to see you

again soon.

Pain Management in Today’s Legal Environment

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