2011 passey treatment chronic pain

Treatment of Injured Treatment of Injured Workers on Chronic Pain Workers on Chronic Pain

MedicationsMedications

Mark Miles Passey MDMark Miles Passey MD

Utah Spine and Joint SpecialistsUtah Spine and Joint Specialists

801 314-2308801 314-2308

• Review State of the Art for long term Review State of the Art for long term opioid use for managing chronic painopioid use for managing chronic pain

• Review Standard of Care for long term Review Standard of Care for long term opioid use for managing pain in injured opioid use for managing pain in injured workersworkers

• Conservative Opioid PrescribingConservative Opioid Prescribing

State of the Art and the State State of the Art and the State of our Understandingof our Understanding

Until there's more scientific evidence, Until there's more scientific evidence, doctors "should not continue to prescribe doctors "should not continue to prescribe high-dose opioids" for chronic non-cancer high-dose opioids" for chronic non-cancer pain. Narcotic drugs for short-term relief of pain. Narcotic drugs for short-term relief of pain are fine, but Katz says there's pain are fine, but Katz says there's insufficient evidence to support their use insufficient evidence to support their use over the long haul.over the long haul.

Reinecke H. et al., S3 guideline LONTS: Long-Reinecke H. et al., S3 guideline LONTS: Long-Term Administration of Opioids for on-Tumor Term Administration of Opioids for on-Tumor

Pain, Pain, SchmerzSchmerz, 2009;23(5):440-7, 2009;23(5):440-7

• There is evidence that opioid therapy relieves There is evidence that opioid therapy relieves pain in the 3 weeks to 3 months timeframe.pain in the 3 weeks to 3 months timeframe.

• There is evidence that opioids can improve the There is evidence that opioids can improve the level of physical functioning for neuropathic pain, level of physical functioning for neuropathic pain, joint pain, and back pain.joint pain, and back pain.

• Randomized controlled trials examining the long-Randomized controlled trials examining the long-term effects of opioids do not exist.term effects of opioids do not exist.

Current Opinions in Anesthesiology, Current Opinions in Anesthesiology, 2010;23:598-6012010;23:598-601

• ““Many argument [in favor of opioids] are solely Many argument [in favor of opioids] are solely based on traditions, expert opinions, practical based on traditions, expert opinions, practical experience and uncontrolled anecdotal experience and uncontrolled anecdotal observations.”observations.”

“ “The consensus now is that some patients The consensus now is that some patients with chronic pain should be considered as with chronic pain should be considered as candidates for long-term opioid therapy, candidates for long-term opioid therapy, and some will gain great benefit from this and some will gain great benefit from this approach.” -approach.” -Russell Portenoy MD, 2004Russell Portenoy MD, 2004

• G.S. is a 42 y.o. male who has been my G.S. is a 42 y.o. male who has been my patient since October 2003. Works full-patient since October 2003. Works full-time as a research biologist at the U of U.time as a research biologist at the U of U.

• Anterior L5-S1 fusion April 2003. Residual Anterior L5-S1 fusion April 2003. Residual 5/10 low back and left lower extremity 5/10 low back and left lower extremity pain.pain.

• Methadone 10 qid, soma 1 nightly, Methadone 10 qid, soma 1 nightly, amitriptylene 25mg hs, ibuprofen and amitriptylene 25mg hs, ibuprofen and CPAP machine.CPAP machine.

Standard of Care for long term Standard of Care for long term opioid use for managing pain in opioid use for managing pain in

injured workersinjured workers

• Medical care is provided for all necessary Medical care is provided for all necessary and reasonable medical services which and reasonable medical services which are needed to help the employee heal are needed to help the employee heal from their work injury.from their work injury.

• Community standardCommunity standard

In the absence of adequate evidence to In the absence of adequate evidence to determine the true benefits and best determine the true benefits and best practices in use of these medications, practices in use of these medications, these Guidelines were developed to assist these Guidelines were developed to assist physicians who choose to use opioids to physicians who choose to use opioids to treat patients with pain to manage that treat patients with pain to manage that treatment as safely as possible.treatment as safely as possible.

Opioid Treatment for Chronic Opioid Treatment for Chronic PainPain

10) An opioid treatment trial should be 10) An opioid treatment trial should be discontinued if the goals are not met and discontinued if the goals are not met and opioid treatment should be discontinued at opioid treatment should be discontinued at any point if adverse effects outweigh any point if adverse effects outweigh benefits or if dangerous or illegal benefits or if dangerous or illegal behaviors are demonstrated.behaviors are demonstrated.

• In 2011 it can be within the community standard of In 2011 it can be within the community standard of care to use opioids for chronic pain. care to use opioids for chronic pain.

• In 2011 the use of long term opioids for the In 2011 the use of long term opioids for the treatment of persistent pain conditions is an elective treatment of persistent pain conditions is an elective practice.practice.

• There is no pain diagnosis for which the use of There is no pain diagnosis for which the use of opioids is mandatory.opioids is mandatory.

• There is no pain diagnosis for which the necessity There is no pain diagnosis for which the necessity for using opioids outweighs the requirement for the for using opioids outweighs the requirement for the patient to positively demonstrate their safe and legal patient to positively demonstrate their safe and legal use.use.

Conservative Opioid PrescribingConservative Opioid Prescribing

The Patient Already on The Patient Already on OpioidsOpioids

• Opioid tolerance is a medical condition.Opioid tolerance is a medical condition.• If a worker sustains an injury while in an If a worker sustains an injury while in an

opioid tolerant condition the opioid tolerance opioid tolerant condition the opioid tolerance is a pre-existing condition.is a pre-existing condition.

• An opioid tolerant person who sustains a An opioid tolerant person who sustains a new injury will ALWAYS “need” to treat the new injury will ALWAYS “need” to treat the new injury with increased opioid dose, even new injury with increased opioid dose, even in injuries that can sometimes be treated in injuries that can sometimes be treated without opioids in opioid naïve patients.without opioids in opioid naïve patients.

Case StudyCase Study

Mr. S., a 23-year-old man, falls while at work and dislocates his right shoulder. Mr. S., a 23-year-old man, falls while at work and dislocates his right shoulder. The clinical course includes 3 shoulder surgeries over the course of 3 years. The clinical course includes 3 shoulder surgeries over the course of 3 years. The last surgery was on 9/8/08. On current presentation he is doing well but The last surgery was on 9/8/08. On current presentation he is doing well but his shoulder pain continues to be a 3-4 out of 10. He was recently declared at his shoulder pain continues to be a 3-4 out of 10. He was recently declared at MMI by his shoulder surgeon.MMI by his shoulder surgeon.

Past history includes chronic low back pain. Prior to and at the time of his Past history includes chronic low back pain. Prior to and at the time of his work-related shoulder dislocation he was on OxyContin 20 mg t.i.d. and 30 work-related shoulder dislocation he was on OxyContin 20 mg t.i.d. and 30 tablets of Percocet 5 mg per month. Now, after 3 years of treatment with a tablets of Percocet 5 mg per month. Now, after 3 years of treatment with a shoulder surgeon he is on OxyContin 40 mg t.i.d., Percocet 10 mg 6 tablets shoulder surgeon he is on OxyContin 40 mg t.i.d., Percocet 10 mg 6 tablets per day.per day.

Mr. S. is now on more than twice as much daily opioid medication. Is this Mr. S. is now on more than twice as much daily opioid medication. Is this because he is in twice as much pain? Is the worker's compensation insurance because he is in twice as much pain? Is the worker's compensation insurance carrier now indefinitely responsible to provide opioids because of Mr. S’s carrier now indefinitely responsible to provide opioids because of Mr. S’s chronic right shoulder pain?chronic right shoulder pain?

The new chronic pain The new chronic pain conditioncondition

Preexisting pain in the acute Preexisting pain in the acute industrial injury industrial injury

ISSLS Prize winner: Early predictors of ISSLS Prize winner: Early predictors of chronic work disability: a prospective, chronic work disability: a prospective, population-based study of workers with population-based study of workers with back injuries. SPINE: 1 December 2008, back injuries. SPINE: 1 December 2008, Volume 33, 25:2809-2818Volume 33, 25:2809-2818

Conclusion: Among workers with new lost Conclusion: Among workers with new lost work-time back injury claims, risk factors for work-time back injury claims, risk factors for chronic disability include radiculopathy, chronic disability include radiculopathy, substantial functional disability, and to a substantial functional disability, and to a lesser extent, more widespread pain and lesser extent, more widespread pain and previous injury with extended time off work.previous injury with extended time off work.

SPINE Volume 33, Number 25, pp 2789–2800; SPINE Volume 33, Number 25, pp 2789–2800; 2008: 2008: Surgical Surgical Versus Versus Nonoperative Nonoperative Treatment for Lumbar Disc Herniation Treatment for Lumbar Disc Herniation Four-Four-Year Results for the Spine Patient Outcomes Year Results for the Spine Patient Outcomes Research Trial (SPORT)Research Trial (SPORT)

“ “Bothersomeness of sciatica” the most Bothersomeness of sciatica” the most unequivocally positive outcome for surgery unequivocally positive outcome for surgery versus non-operative care for herniated disc with versus non-operative care for herniated disc with radiculopathy.radiculopathy.

Principles of Conservative Principles of Conservative Opioid PrescribingOpioid Prescribing

• Think beyond drugs. Think beyond drugs.

• Practice more strategicPractice more strategic prescribing. prescribing.

• MaintainMaintain heightened vigilance regarding heightened vigilance regarding adverse effects. adverse effects.

• Exercise caution and skepticismExercise caution and skepticism regarding regarding new drugs.new drugs.

• Work with patientsWork with patients for a shared agenda.for a shared agenda.

• Consider long-term, broader impacts. Consider long-term, broader impacts.

Principles of Conservative Principles of Conservative PrescribingPrescribing

My idea--- Avoid prescribing My idea--- Avoid prescribing practices that mimic the way practices that mimic the way addicts take opioids. addicts take opioids.

Universe of Addiction Universe of Chronic Pain Management

Counterproductive use of opioids

Frequent dose raising

IV Heroin

IV Oxycodone

Actiq, Fentora

Frequent dose raising

Large amounts of short acting opioids such as Lortab, Percocet, OxyIR, Actiq, Fentora

Rehabilitative use of opioids

Methadone maintenance

Suboxone maintenance

Long acting opioids at moderate stable doses, such as methadone, long-acting morphine, fentanyl patches, buprenorphine.

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Principles of Conservative Principles of Conservative Opioid PrescribingOpioid Prescribing

• Avoid short acting opioidsAvoid short acting opioids

• Never prescribe, authorize or pay for Never prescribe, authorize or pay for transmucosal fentanyl (actiq, fentora) for transmucosal fentanyl (actiq, fentora) for chronic pain in injured workers.chronic pain in injured workers.

• Avoid dose raising as a strategy to try to Avoid dose raising as a strategy to try to defeat tolerance.defeat tolerance.

• Monitor prescriber’s data base.Monitor prescriber’s data base.

• Perform unannounced urine drug screens.Perform unannounced urine drug screens.

Hydromorphone also known as Dilaudid or Hydromorphone also known as Dilaudid or "Dillies" are "Top of the food chain" when it "Dillies" are "Top of the food chain" when it comes to pain medication in pill form! Its comes to pain medication in pill form! Its 8mgs pill is the strongest pain pill on the 8mgs pill is the strongest pain pill on the market. Oxycontin gives it a good run for market. Oxycontin gives it a good run for the money! Msir 30mgs is in the mix also! the money! Msir 30mgs is in the mix also! If you can get a hold of Actiq, Fentanyl in If you can get a hold of Actiq, Fentanyl in lollipop form, your one lucky man...they lollipop form, your one lucky man...they pack a wallop!! –Dr. Dopenstein.pack a wallop!! –Dr. Dopenstein.

• Consider overnight oximetry to screen for Consider overnight oximetry to screen for sleep apnea in chronic opioid use.sleep apnea in chronic opioid use.

• Opioids predictably suppresses serum Opioids predictably suppresses serum testosterone in males.testosterone in males.− Topical testosterone gels are the treatment of Topical testosterone gels are the treatment of

choice for this.choice for this.