Opioid Abuse in Chronic Pain… Another day, another strategy

 

Read and heed.

A recent review article in the New England Journal of Medicine by Nora Volkow, MD and A. Thomas McLellan, PhD, succinctly sums up the state of affairs surrounding the use of opioids for chronic pain.

Yes, I agree with most everything their article says.

And…

As I read their litany of legitimate negatives, I wonder if anyone has recently taken the time to study “successful” chronic pain management with opioids.

Actually, I wonder if anyone in a position of authority believes it is even possible to be successful treating chronic pain with opioids.

Full disclosure: I am not a researcher. I am a clinician. I am on the front line.

As review articles, guidelines, policies, regulations, and laws keep popping up, I keep reading. And as I read it occurs to me that defining “success” is as subjective as defining pain itself.

The International Association for the Study of Pain has defined pain as

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

So maybe success in treating chronic pain with opioids could be defined as:

A regulatory and emotional experience associated with actual or potential benefit, or described in terms of such benefit.

And I’ll offer the other side this definition of failure:

A regulatory and emotional experience associated with actual or potential harm, or described in terms of such harm.

Take home point: All three definitions are subjective.

So, as I prepare for another day on the front line of chronic pain care my inherent duty is to:

Follow the regulations, but

Find the truth contained therein, and use it to

Facilitate my patient’s journey to success.

 

Success is a journey. Not a destination.

 

New England Journal of Medicine, consider this my open invitation to any researcher interested in exploring the possibility that one might be able to successfully prescribe opioids for chronic pain.

The doctor will see you now.

Will you see the doctor?

 

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Success is counted sweetest
By those who ne’er succeed.
To contemplate a nectar
Requires sorest need.
Emily Dickinson

 

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Chronic Pain Management for Survivors of Torture

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The most preventable form of human pain is that inflicted in the form of torture 
World Medical Association

Pain is a universal human experience, however each human experiences pain uniquely.

So, when I was asked to team with Psychiatrist, Sarah Acland, MD, to talk about pain management for survivors of torture, I thought I could cover the topic well by simply falling back on the standard approach I’ve used in treating all my patients with chronic pain – a BIO-PSYCHO-SOCIAL approach.

biopsychosocial

But as I researched more about the profound struggles survivors of torture face, I began to question whether or not another approach was necessary for this group of patents.

In the end, I returned to the realization that a (1) biological + (2) psychological + (3) sociological approach is well-suited to care for the survivors of torture, as long as caregivers are thorough in evaluating, understanding, and optimizing each of the three elements.

Pain is defined as: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (IASP)

Pain is a necessary body system that, while unpleasant, protects us from harm. But in survivors of torture, this “useful pain” can be hijacked by a damaged nervous system, heard through the amplified megaphone of psychological distress, and experienced in a prison of cultural barriers.

To understand how best to help these survivors, one must have some understanding of how the body’s pain system is wired. It’s not as simple as two points connected by a nerve. When trauma is inflicted, pain receptors transmit multiple nerve impulses toward the brain (i.e. the “ascending” pathways). These sensory impulses travel up different tracks at different speeds to not just one, but to several areas of the brain – both “conscious” and “unconscious.” At the same time, the nervous system will try to dampen (“modulate”) the ascending pain impulses by releasing chemicals and sending impulses downward (i.e. the “descending” pathways).

pain pathways

Granted, my explanation grossly oversimplifies the complex interactions between the ascending (pain) and descending (anti-pain) pathways, but it lays the foundation for understanding how we can treat pain.

Use treatments that (a) enhance the descending anti-pain pathways, such as:

  • Some antidepressants
  • Endorphins (exercise)
  • Physical therapy/occupational therapy
  • Psychotherapy

And (b) treatments that dampen the ascending painful pathways:

  • Physical medicine (e.g., ice/heat)
  • NSAIDs
  • Stimulators (e.g. TENS)
  • Some anti-epileptics (e.g., gabapentin)
  • Nerve blocks
  • Opioids

As Bing would say… You have to accentuate the positive and eliminate the negative.

bing

Effective treatment also depends upon knowing the degree to which the pain is nociceptive (“normal”) or neuropathic (“abnormal”).

Types of Pain (IASP)

Nociceptive pain occurs when diseased or traumatized tissue activates the nervous system and its receptors (i.e. nociceptors). On the other hand, neuropathic pain is when disease or trauma (i.e. pathology) to the nervous system itself causes pain. Nociceptive pain is usually sharp, acute, and localized. Neuropathic pain is usually dull, burning, aching, chronic, and poorly localized. Nociceptive pain is usually associated with defined tissue damage. Neuropathic pain can persist long after the traumatized tissue has healed and there are no physical findings.

To varying degrees, all pain syndromes (acute and chronic) have some combination of both neuropathic and nociceptive pain. Neuropathic pain is actually the most prevalent type of pain in developing nations and prominently results from torture. Neuropathic pain is difficult to cure, and generally must be “managed” with measures to augment activity in descending modulating pain pathways.

By design, torture often doesn’t physically “leave a mark” after the acute injuries have healed. Most common is blunt trauma, especially to soles of feet (“falanga”), often leading to chronic neuropathic pain.

Also common is suspension of the body, i.e. stretching nerves, leading to musculoskeletal joint/soft tissue damage and “plexopathy.”

Regardless of the physical signs left by torture, the marks left by psychological trauma is nearly universal, i.e., PTSD.

Obviously, my presentation to this point has primarily focused on biological (i.e., physical) aspects of pain and pain treatment. The psychological and social aspects are equally important, but are beyond the scope of this brief overview. Suffice it to say, effective pain care requires a team approach (i.e., multidisciplinary). Mental health issues (e.g., PTSD, depression, anxiety) almost always co-exist with chronic pain and lead to, or are influenced by, social/family/cultural circumstances. The following lists offer some insight into just how challenging it can be to treat pain in survivors of torture.

Treatment barriers to overcome include:

  1. Language/communication
  2. Cultural barriers
  3. Memories of helplessness fear & shame
  4. Impaired recollection
  5. Survivors may not offer information unless asked
  6. Non-compliance with treatment
  7. Reticent to use meds due to past forced use

Findings suggestive of torture:

  1. Multiple chronic pains
  2. Multiple physical scars
  3. Complex injuries
  4. Musculoskeletal pain
  5. Headaches
  6. Neuritis
  7. Depression
  8. Anxiety
  9. PTSD
  10. Neuropathic pain

Effective treatment augmented by:

– Trust and communication
– Evaluate in a calm atmosphere
– Be thorough
– Offer detailed explanations
– Obtain informed consent
– Allow the patient to have control
– Minimize exhaustive visits for tests & specialists
– Identify potentially treatable disorders
– Ask patients about their beliefs about the pain
(e.g., Pain may be assumed to signal ongoing damage)
– Set realistic and clear goals/expectations
– Stepwise approach to treatment
– Avoid reinforcing/addictive drugs
– Injections might trigger flashbacks

Summary:

In all individuals, to varying degrees, pain has biological, psychological & sociological elements. All three elements feature prominently in torture survivors. Effective treatment must address all three (i.e., a bio-psycho-social treatment model), and is best achieved by using a multidisciplinary approach (i.e., psychotherapy, physical medicine & traditional clinical medicine). Establishing trust and effective communication can be challenging but is crucial.

Pain can be effectively managed in survivors of torture in the same thorough step-wise manner used to treat other patients as long as caregivers work as a team to fully address all three elements in the bio-psycho-social treatment model.

Another final point, among the many, I took away from this interactive presentation with my colleagues on that April Friday morning was this one I initially took for granted, but was so eloquently emphasized by Dr. Acland… That they are victims cannot be overlooked, but that they are survivors can never be forgotten.

 

Pain has an element of blank;
It cannot recollect
When it began, or if there were
A day when it was not. 

– Emily Dickinson

 

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Pain Management:
Implications for Caring for Refugee & Immigrant Survivors of Torture
Survivors of Torture Recovery Center
Kent School of Social Work
University of Louisville
April 8, 2016
James Patrick Murphy, MD, MMM
 

CeggdUdW4AIvDvS 

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Beware the GuIDES of March… The CDC Releases Pain Guidelines*

*Note: This blog post was updated on March 16, 2018caesarCDC recommendations for prescribing opioids for chronic pain outside of active cancer, palliative, and end-of-life care

Released: March 15, 2016

The following was copied directly from the CDC website: https://www.cdc.gov/drugoverdose/prescribing/guideline.html

cdc

Determining When to Initiate or Continue Opioids for Chronic Pain

  1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.
  2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.
  3. Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.

Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation

  1. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.
  2. When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.
  3. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.
  4. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.

Assessing Risk and Addressing Harms of Opioid Use

  1. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present.
  2. Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.
  3. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
  4. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
  5. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.

* All recommendations are category A (apply to all patients outside of active cancer treatment, palliative care, and end-of-life care) except recommendation 10 (designated category B, with individual decision making required); see full guideline for evidence ratings.

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Unlike Marc Antony, I recommend an open mind…

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The CDC Guidelines Memory Aid (mnemonic)

 C – D – C – G – U – I – D – E – L – I – N – E

(#REC)

(#5)      Caution at any dose (dosing limits)

When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.

(#9)      Database (PDMP)

Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.

(#3)      Consent (informed consent)

Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.

(#2)      Goals (function)

Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.

(#10)      Urine drug testing

When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.

(#4)      Immediate release when starting (avoid ER/LA drugs)

When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.

(#11)      Don’t use benzodiazepines

Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.

(#7)      Evaluate in 1-4 weeks (periodic review)

Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.

(#6)      Lowest effective dose for acute pain (and time limited)

Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.

(#8)      Incorporate risk evaluation and mitigation strategies (i.e. REMS)

Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present.

(#1)      Non-opioid therapy (maximize use before turning to opioids)

Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.

(#12)      Evidence based addiction treatment (when opioid use disorder is discovered)

Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.

CDC-Opioids-Pills

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I wouldn’t give 2 cents for the CDC opioid guidelines?

The world has until 11:59 pm EST today (January 13, 2016) to comment on the proposed United States Centers for Disease Control Guideline and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain. I got my two cents in just under the wire…

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Here are the twelve draft “Recommendations” from the CDC website along with my suggestions in italics.

 CDC RECOMMENDATIONS

Section (1) Determining When to Initiate or Continue Opioids for Chronic Pain

 

  1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Providers should only consider adding opioid therapy if expected benefits for both pain and function are anticipated to outweigh risks to the patient.

The phrase “pain and function” should be “pain or function.” Sometimes pain relief is reason enough to prescribe opioids. And “risks to the patient” should be “harm to the patient.” (The word “benefit” is very often coupled with “risk” when it more correctly should be coupled with “harm.”)

 

  1. Before starting opioid therapy for chronic pain, providers should establish treatment goals with all patients, including realistic goals for pain and function. Providers should not initiate opioid therapy without consideration of how therapy will be discontinued if unsuccessful. Providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.

The last phrase should be “…only if there is meaningful improvement in pain or function that outweighs harm to the patient.” The word “clinically” is ambiguous and unnecessary.

 

  1. Before starting and periodically during opioid therapy, providers should discuss with patients known risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.

The word “known” is unnecessary and ambiguous (i.e. Known by whom?)

 

Section (2) Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation

 

  1. When starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.

The phrase “providers should prescribe” should be “providers should strongly consider prescribing…” (When starting opioid therapy there can be clinical scenarios where prescribing a ER/LA opioid would be the best course of action.)

 

  1. When opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, should implement additional precautions when increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should generally avoid increasing dosage to ≥90 MME/day.

The use of the arbitrary thresholds (50 mgms and 90 mgms) is acceptable here because the flexible helping verb “should” is used instead of the inflexible verb “shall.” This allows the provider some flexibility for clinical judgment.

 

  1. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, providers should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three or fewer days usually will be sufficient for most nontraumatic pain not related to major surgery.

This is reasonable as written.

 

  1. Providers should evaluate benefits and harms with patients within 1–4 weeks of starting opioid therapy for chronic pain or of dose escalation. Providers should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, providers should work with patients to reduce opioid dosage and to discontinue opioids.

Change the first two sentences to: “Soon after starting or escalating opioid therapy, providers should evaluate patients in order to gauge any benefits or harms associated with the treatment plan. This initial reevaluation is usually within the first four weeks. Providers generally should evaluate benefits and harms of continued opioid therapy every 3 months – and more frequently or less frequently depending upon the clinical course.”

 

Section (3) Assessing Risk and Addressing Harms of Opioid Use

 

  1. Before starting and periodically during continuation of opioid therapy, providers should evaluate risk factors for opioid-related harms. Providers should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, or higher opioid dosage (≥50 MME) are present.

The second sentence should read: “Providers should incorporate into the management plan strategies to mitigate risk. One such risk mitigation strategy worth of consideration is offering naloxone when…”

 

  1. Providers should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving high opioid dosages or dangerous combinations that put him or her at high risk for overdose. Providers should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.

Change to: “Providers should review the patient’s history of controlled substance prescriptions by way of prescription drug monitoring program (PDMP) data, such as those offered by most states. This data can allow insight into aberrant and risky behaviors, such as when a patient is receiving high opioid dosages or dangerous combinations that put him or her at high risk for overdose. Providers should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months or longer – depending upon clinical and regulatory circumstances.”

 

  1. When prescribing opioids for chronic pain, providers should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.

Change to: “When prescribing opioids for chronic pain, providers should consider appropriate biologic tissue drug testing before starting opioid therapy. Additional drug testing should occur randomly and when clinically indicated.”

 

  1. Providers should avoid prescribing opioid pain medication for patients receiving benzodiazepines whenever possible.

Change to: “Providers should exercise caution when prescribing opioid pain medication for patients receiving benzodiazepines.”

 

  1. Providers should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.

Change to: “Providers should offer or arrange evidence-based treatment (such as medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.”

 

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Overall, I am impressed with the amount of detail and collaborative effort that went into creating this impressive document. There are no easy answers and no universally accepted dictums – all the more reason to allow flexibility for clinical judgment. I hope we can continue to seek truth with open minds and open hearts. That’s my real recommendation, my two cents worth. 
The CDC draft is available at:
http://www.cdc.gov/drugoverdose/prescribing/guideline.html

My comments were posted to the CDC website and can be viewed at:
http://www.regulations.gov/#!documentDetail;D=CDC-2015-0112-4296

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The Least Meaningful Time of the Year

‘Twas the week before Christmas, and all through the clinic,
My patients were fuming, and I was a cynic.

My hopes had been dashed by “Affordable Care.”
I’d thought the ridiculous rules might be fair.

But patients were desperately seeking their meds,
‘Cause benefits had been curtailed by the feds.

The managed care mischief and benefits cap,
That sounded so good, was merely a trap.

Then out in the foyer arose such a clatter,
Someone’s co-pay was the crux of the matter.

Away to the window I flew like a flash,
Shut down the computer and asked him for cash.

He wasn’t abreast of his new plan in place,
That cut off his nose just in spite of his face.

When what to my wondering eyes did appear,
But a government man, somewhat tiny and weird.

He asked for an audit so detailed and quick,
That I prayed to the Lord, “This must be a trick.”

More than just illegal, this wasn’t a game.
And he whistled and shouted transgressions by name…

“You downcode! You miscode! You don’t even fix ‘em!
You’re sloppy! You’re stupid! More crooked than Nixon!”

“I’ll file my report! From on top you will fall!
Now cash you’ll pay! Cash you’ll pay! Cash you’ll pay! All!”

As dry heaves, that before a wild emesis fly,
When faced this obstacle, I thought I would die.

So onto his ribcage, my fingers they flew,
Which gave him no joy. He ain’t ticklish too.

And then in a twinkling, he wanted the proof,
And documentation for each little goof.

So I drew in my head what I thought would astound,
But this audit’s ridiculous claims did abound.

He addressed all inferred, and he read what was put,
In our policy manual, which was thick as a foot.

Our bundles of charges he said was a ruse,
And he scoffed at our data on Meaningful Use.

Then his knee! How it bucked! …It’s simple, so very.
It started to hemorrhage and looked rather scary.

It no-mattered at all was he friend or a foe,
For the loss of his blood made his suffering show.

So his stump of a leg I held tight, no conceding.
And my hands they encircled his thigh to stop bleeding.

He’d had a bad cut, from his leg to his belly.
But his bandage was only petroleum jelly.

I asked why he’d done oh so little to soothe.
“ ‘Cause that’s all,” he replied, “that my plan would approve.”

An i.v. for some fluids and lowering his head,
Soon gave him to know he had nothing to dread.

He asked why I’d saved him, though he’d been a jerk?
Physicians just do this. It’s just how we work.

Then thinking about his life saved, I suppose,
Giving a nod, from the stretcher he rose.

He then took his report, his scathing epistle,
And into the trash, threw it down like a missile.

And I heard him exclaim, as he drove out of sight,
“Don’t you ever give up. We need you in the fight.”

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Acute Pain Management for the Patient on Chronic Opioid Therapy

Screen Shot 2015-12-01 at 10.24.50 AMPatients benefitting from the therapeutic effects of chronic opioid therapy generally fall into two categories: (1) chronic pain treatment and (2) addiction “medication assisted treatment.” Both groups will at times need additional pain care measures to address acute issues, such as: trauma, surgery, and hospitalizations. Care providers, in trying to find the right balance between too much and too little, can find these situations challenging.

IMG_1713

Today (December 1, 2015)  I am traveling to Leitchfield, Kentucky to conduct a seminar at Twin Lakes Regional Medical Center on acute pain management for the patient on chronic opioid therapy. Below are the slides that I prepared, followed by the references. My hope is that, whether you are a healthcare provider or recipient, as you peruse this information and explore the references and links a better understanding will emerge and your comfort level will improve. 

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Guidelines for Perioperative Management of Buprenorphine

http://www.theapms.com/sitePagesContent/stephens-docs/SuboxoneInfoStephens.pdf

 

ASAM Definition of Addiction

https://www.naabt.org/documents/APS_consensus_document.pdf

 

Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1892816

 

Acute & Chronic Pain Management (requiring opioid analgesics) in Patients Receiving Pharmacotherapy for Opioid Addiction

http://www.thci.org/Opioid/June11docs/Session8_ALFORD%20MAT%20pain%20management%206-9-11%20FINAL.pdf

 

Clinical Opiate Withdrawal Scale

https://www.drugabuse.gov/sites/default/files/files/ClinicalOpiateWithdrawalScale.pdf

 

Perioperative Pain Management for Patients on Chronic Buprenorphine: A Case Report

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3846172/

 

Methadone Dose Conversion Guidelines Adapted from AAHPM Palliative Care Primer, 2010 edition with permission from Timothy Quill M.D.

http://www.compassionandsupport.org/pdfs/professionals/pain/Methadone_Dose_Conversion_Guidelines.051810_.pdf

 

Buprenorphine Hydrochloride Injection

http://www.hospira.com/en/images/EN-2088_tcm81-5649.pdf

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http://buprenorphine.samhsa.gov/Bup_Guidelines.pdf

 

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A stellar time at Bellarmine

Bellarmine-705159

On Thursday, September 24, 2015, I had the pleasure of serving as a guest “professor” for about sixty or so students at Bellarmine University, Louisville, KY. I promised them I would post some of the major points discussed along with some links for reference.

Here we go…

(1) We have a big problem in this country with drug abuse. To illustrate, a recent 2014 government survey found that about 1 in 10 Americans (12 years or older) have used an illicit drug in the past thirty days! About two-thirds of the abuse drugs are pharmaceuticals.

Ref: http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf

(2) Drug overdose deaths continue to increase and are now the leading cause of deaths from injury in the United States, even outpacing deaths due to motor vehicle accidents.

Ref: http://www.medscape.com/viewarticle/846636

(3) While drug overdose deaths have been on the rise for the past two decades, the number of drug overdose deaths from heroin use has skyrocketed recently – up by 39% over the past 3 years.

Ref: http://www.cnn.com/2015/01/14/health/heroin-deaths-increase

(4) Obviously, prescription drugs help many people. Take for example the most abused class of drugs – opioids (i.e., morphine-like drugs). Opioids are powerful painkillers that many suffering people need to have any quality of life. Pain is a big problem in this country too. Here are some pain facts, courtesy of our government:

-Pain affects more Americans than diabetes, heart disease and cancer combined.

-Pain is cited as the most common reason Americans access the health care system.

-One in every four Americans, have suffered from pain that lasts longer than 24 hours and millions more suffer from acute pain.

-Chronic pain is the most common cause of long-term disability.

Ref: http://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=57

Note: There is evidence to suggest treating previously drug-naïve chronic pain patients with opioids is associated with a very low risk of addiction. The presence of ongoing pain appears to lower rather than increase the risk of opiate addiction.

Ref: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073133

(5) The majority of individuals abusing opioids (usually young people) are getting “high” taking grandma’s Oxycontin, stealing it or buying it from their friends or relatives and do not get them from their physician.

Ref: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073133

(6) Words matter. Here are some important words to understand:

Tolerance– the body adapts to the drug, requiring more of it to achieve a certain effect

Physical dependence– the body adapts to the drug, eliciting drug-specific physical or mental symptoms if drug use is abruptly ceased (withdrawal). This can happen with the chronic use of many drugs—including many prescription drugs, even if taken as instructed. Thus, physical dependence in and of itself does not constitute addiction, but it often accompanies addiction.

Ref: http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/there-difference-between-physical-dependence

Addiction—or compulsive drug use despite harmful consequences—is characterized by an inability to stop using a drug; failure to meet work, social, or family obligations; and, sometimes (depending on the drug), tolerance and withdrawal.

ADDICTION: a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

The FOUR C’s of ADDICTION

CONTROL, LOSS OF

COMPULSIVE USE

CONTINUED USE DESPITE HARM

CRAVING

Ref: http://www.asam.org/for-the-public/definition-of-addiction

(7) Risk factors of developing addiction:

Genetics: Addiction tends to run in families. Heredity is a major risk factor for addiction. In fact, scientists estimate that 40 to 60 percent of a person’s risk for addiction is based on genetics.

Age: The younger the user is, the more likely he or she is to become addicted.

Environment: Where one lives, works, and plays can be factors.

Mental health: Underlying mental health issues can increase the risk of addiction.

Drug of choice: The object of the addiction can play a role.

Speed to reach the brain: Drugs that are smoked or injected into the body tend to be more addictive than those that you swallow.

Ref: http://www.healthline.com/health/addiction/risk-factors#Overview1

These are just some of the major points that were covered. The class was engaged, attentive, and focused. I am certain I was speaking to future leaders and policymakers as well. I truly believe that the world in which I will soon live belongs to them. I feel this group now better understands the complexity of balancing preventive and therapeutic drug control with the necessity to allow effective pain care for the suffering.

I humbly thank the students for their earnest attention and their professor, Dr. Marylee Jamesfor the invitation.

I look forward to their thoughts and actions.

FullSizeRender (14)

And thanks for the Bellarmine swag!

Go KNIGHTS!

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