Prescribing Pain MedicationsA Scientific Approach?

Christopher Dietrich MD

Scope of the Problem

• 42% of Emergency Room Visits – Pain Problems• Estimated 44 million pain related visits made to US

emergency departments annually

• 30%-40% of adults experience back pain

Pletcher MJ, Kertesz SG, Kohn MA, Gonzales R. Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA. 2008;299:70-78.

Verhaak PFM, Kerssens JJ, Decker J, et al. Prevalence of chronic benign pain disorder among adults: A review of the literature. Pain 1998; 77:231-239.

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Self-medication

Persistent Pain Treatment Ladder

Scheduled OpioidsScheduled Opioids

Surgical & OtherSurgical & OtherInterventionsInterventions

Mild

Mild

Moder

ate

Moder

ate

Sev

ere

Sev

ere

HCP intervention

HCP intervention

HCP intervention

AcetaminophenAcetaminophenNonNon--Prescription NSAIDsPrescription NSAIDs

COXCOX--2 Inhibitors2 InhibitorsPrescription NSAIDsPrescription NSAIDs

TramadolTramadol

HCP = Healthcare Professional

Traditional Treatments

Normal Pain Pathway

Approach to Patient with Pain

• Detailed Patient History– Location, quality, timing, severity,

exacerbating, palliative factors– Mechanism of injury– Acute vs chronic

• “6 months”• Physical Examination

– Motor– Detailed Neurological exam– Provocative tests

• Imaging Studies• EMG

Identify Type of Pain

• Acute vs Chronic– “6 months”

• Nociceptive • Somatic• Visceral• Neuropathic

Nociceptive Pain

• Direct stimulation of pain receptors/nociceptors

• Typically involves direct tissue injury

• Sharp, aching, throbbing• Worse with movement

Somatic Pain

• Nociceptive Pain• Bone, Soft tissue, muscle, skin• Aching, throbbing• Easy to locate/describe

• A-delta fiber stimulation

Most Responsive Treatments

• Acetaminophen• Cold Packs• Local Anesthetic

– Topical– Infiltrated

• Corticosteroids• NSAIDS• Opioids

Visceral Pain

• Nociceptive pain that involves cardiac, lung, gastrointestinal, or genitourinary tissues

• Difficult to localize pain• Difficult to describe

– “Dull”– “Deep”

• C-delta fibers

Most Responsive Treatments

• Corticosteroids• NSAIDs• Opioids

Opioids Action

• • presynaptic inhibition of production of neurotransmitters• postsynaptic suppression of evoked activity in nociceptive path• increased transmission of the descending inhibition of spinal nociceptive conduction

Neuropathic Pain

• Compression, transection, ischemia, or metabolic injury to a nerve

• Burning, tingling, shooting, stabbing, electrical

Most Responsive Treatments

• Anticonvulsants– Gabapentin, Pregabalin

• Corticosteroids• Nerve Block• NSAIDs• Opioids• Tricyclic Antidepressants

Tramadol

Surgical & OtherInterventions

Scheduled Narcotics

Use before scheduled narcotics in adults who require around-the-clock treatment for an extended period of time

Mild

Mod

era

te S

evere

AcetaminophenNon-Prescription NSAIDs

ULTRAM ER

Prescription NSAIDsCOX-2 Inhibitors

Modified Pain Treatment Ladder

Topical Agents

Physical therapy, Modalities

Neuropathic Pain Agents

Central Sensitization

• Nervous system changes

• Nociceptive neurons in the dorsal horn of spinal cord

• “Wind-up”, pain threshold changes

• Maintains pain after initial insult has resolved

Central Sensitization

Approach to Patient with Pain

• Identify type of pain– Nociceptive, Neuropathic– Acute vs Chronic– Peripheral vs Central Sensitization

• Identify pain generator• Review aggravating/ameliorating factors • Develop initial treatment plan• Review/modify treatment if necessary

How to Identify/Prevent Problems

Prescription Drug Abuse Statistics

• 6.2 Million Americans who are current non-medical users of Psycho-therapeutic Drugs

• Greater than the number of those abusing cocaine, hallucinogens, and heroin combined

• Non-medical use of prescription drugs ranks 2nd only to marijuana

Prescription Drug Abuse Statistics

Prescription Drug Abuse Statistics

Prescription Drug Abuse Statistics

Prescription Drug Abuse Statistics

Abuse Statistics

• Pain Med 2008 May-Jun;9(4):444-59.• What percentage of chronic nonmalignant pain patients exposed to chronic

opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review.

• Fishbain DA, Cole B, Lewis J, Rosomoff HL, Rosomoff RS.

– 3.27% rate of addiction/abuse (all study patients)– 0.19% - rate of addiction – when eliminate all prev

abuse pts– 11.5% Adverse Drug Related Behaviors – 0.59% ADRB when eliminate all prev abuse pts

Risks/problems associated with prescribing controlled substances

• Concern about patients

– Fear of addiction– Fear of Drug Abuse– Concerns about

diversion– Concern about safety

of medications– Identifying “doctor

shoppers”– Tolerance– Dose Escalation

• Regulatory concern

– Concern about DEA scrutiny

– Rules vs myths• Prescribing Logistics

– Monthly prescription refills

– Drug Testing– Opiate Agreements

How to Decrease Risk when Prescribing Controlled Substances

• Documentation – 4As• Written Opiate treatment Agreements – “not contracts”• Drug screens

– ICD-9 = V58.69 Chronic Med Use• Adequately treat pain & identify patients at risk for

abuse/diversion– SOAPP-R (Screener and Opioid Assessment for Patients

with Pain – Revised)– Determine how often to monitor, who to monitor

• Patient Database/registry – Prescription Drug Monitoring Program(PDMP)

Documentation

• 4 A’s – Criteria looked at by DEA/Reviewers– Analgesia – documented pain score– Activity/Function – ADLs, functional outcomes– Adverse events – side effects, complications– Aberrant Behavior – drug seeking, abnormal drug screens,

should have explanations, plan, course of action

Narcotic Agreement

• Agreement to Treat with Narcotics– Not a contract– Contract implies service or product for $$– Include terminology that allows:

• Prescriber to communicate with pharmacy, primary care MD, ER• Prescriber to obtain drug screens when clinically indicated• Patient only uses one pharmacy• Agrees to take medications exactly as prescribed

Drug Screens• Drug screens

– Codes/What to order:• RCRH Lab – UDS panel – confirm positive opiates• ClinLab – 764819• Sanford Lab – drugs of abuse panel with expanded

opiate panel – 38081N- 9907

– ICD-9 = V58.69 Chronic Med Use

• Drug Screen/Test Specifics– Look at Creatinine level (way to determine if valid

test)– Make sure test includes synthetic opiates

• When to use/screen– Initial assumption of care– Scheduled basis

• Determined by clinician• Determined by SOAP-R• Random system

– SOAPP-R (Screener and Opioid Assessment for Patients with Pain – Revised)

Drug Screens

SOAPP-R

SOAPP-R Scoring

• High Risk = 22 or greater• Moderate Risk = 10 – 21• Low Risk = < 9

Prescription Drug Monitoring Program(PDMP)

• Program designed to deter prescription drug abuse• Keeps track of all dispenser/prescriber records• Reports can be requested to aide prescribers,

dispensers, and law enforcement• “Allow clinicians to adequately treat legitimate pain

patients and identify and curb inappropriate non-medical use of controlled substances, stop doctor shoppers, and decrease prescription drug diversion”