A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO, PGYͲ3 University of Kansas School of Medicine – Wichita Family Medicine Residency Program at Wesley April 10th , 2015 Objectives • Four serial chronic pain visits – Stepwise standardized approach • Monitoring and follow up • Pros and cons • Tips for adapting to your practice 2 Visit Overview Visit 1 • Information gathering • Screen for patient appropriateness Visit 2 • Physical exam • “Pain Inventory” Visit 3 • Recap • Treatment plan 3 Case • L.M., 61 year old white female • Medical History: – Chronic pain • Fibromyalgia • Diffuse neuropathy – Asthma – Depression – Osteoarthritis 4 A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO Family Medicine Spring Symposium April 10, 2015 1
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
A Standardized Approach for theChronic Pain PatientTraci Dieckmann, DO, PGY 3
University of Kansas School of Medicine – WichitaFamily Medicine Residency Program at Wesley
April 10th , 2015
Objectives• Four serial chronic pain visits
– Stepwise standardized approach
• Monitoring and follow up• Pros and cons• Tips for adapting to your practice
2
Visit Overview
Visit 1• Informationgathering
• Screen forpatientappropriateness
Visit 2• Physical exam• “PainInventory”
Visit 3• Recap• Treatmentplan
3
Case
• L.M., 61 year old white female• Medical History:
– Chronic pain• Fibromyalgia• Diffuse neuropathy
– Asthma– Depression– Osteoarthritis
4
A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO
Family Medicine Spring Symposium April 10, 2015
1
Chronic Pain Visit 1 of 3
• Information Gathering and Goal Setting– Review plan of care and expectations– Thorough review of patient’s history– History of abuse, legal problems and substanceuse
– Review of previous testing, imaging, work up, etc.– Collection of outside records
5
Chronic Pain Visit 1 of 3 cont’d• Screening
– PHQ 9 (Depression Screen)– Opioid Risk Tool– CAGE/CAGE AID (Adapted to Include Drugs)– Mania Self Reporting Tool
• Patient Appropriateness– DIRE (Diagnosis, Intractability, Risk, Efficacy Score)– SOAPP (Screener and Opioid Assessment forPatients with Pain)
6
Case• Long history of fibromyalgia• Diffuse neuropathy/weakness
– Work up negative for: MS, autoimmune, B12deficiency, and thyroid disease
• MRI brain, C and L spine, EMG/NCT and LP – nondiagnostic
• Previous Prescriptions:PregabalinGabapentinTramadolOxycodone
CitalopramLidocaine patchMorphine
7
Case
• Screening– PHQ 9: 17/37 (mod severe depression)
• On Citalopram– Opioid Risk Tool: 5/14 (Moderate)– CAGE/CAGE AID: Negative– Mania Self Reporting: Negative– DIRE score 18/21 (may be a candidate for longterm opioid analgesia)
8
A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO
Family Medicine Spring Symposium April 10, 2015
2
Chronic Pain Visit 1 of 3, cont’d
• Patient Education– Comparative Pain Scale– Set expectations
• Frequency monthly to bi annually• Rx only for 28 day supply until established• Random UDS
• Brief Pain Inventory– Used to follow patient throughout care plan
9
Chronic Pain Visit 2 of 3
• Physical exam• Review of information gathered since CPV #1• Kansas Tracking and Reporting of ControlledSubstances(KTRACS)
• Urine Drug Screen (UDS)• Brief Pain Inventory
10
Case
• Exam noted foot drop– Patient referred for bracing
• UDS obtained– Positive for oxycodone and tramadol
• Agreeable with current treatment regimen
11
Behavioral Group Visit• Led by psychologist• Group visit• Mind body education• Emphasis placed on relationship betweenpain and well being
• Lifestyle considerations
http://www.peanuts.com/characters/lucy/
12
A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO
Family Medicine Spring Symposium April 10, 2015
3
Chronic Pain Visit 3 of 3
• KTRACS and UDS as indicated• Brief Pain Inventory• Physical Functional Ability Questionnaire(FAQ5)– Score followed throughout care plan
• Evaluate need for/efficacy of current painregimen
13
Case
• Reviewed KTRACs – no aberrant behavior• Current pain meds:
– Tramadol and Oxycodone• Prescribed prn but taking regularly
– Pregabalin
• Transitioned to long term Fentanyl patch– Low dose oxycodone for breakthrough
• Switched to Fluoxetine for depression
14
Follow up
• Use screening tools to guide follow up• Prescriptions kept in lock box• Random UDS
15
Pros and Cons
• Patient fairness andequality
• Ensure safety forphysicians and patients
• Monitor compliance• Avoid abuse
• Time consuming• Uncomfortable for
established patients• Limited resources
(psychology)• Plan for patients that
are not appropriate
16
A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO
Family Medicine Spring Symposium April 10, 2015
4
Practice Tips
• Divide appointment time– Half with RN, half with doctor
• Contact community resources• More time for new patients• Establish cut off for appropriate patients
– DIRE– Morphine Equivalent Doses– SOAPP
17
References• Blackman K., Odom A., Identifying and Initiating Treatment for
Bipolar Disorder in the Family Medicine Office. STFMPreconference Workshop. 2010.
• Hooten WM, et al. Assessment and Management of ChronicPain. Institute for Clinical Systems Improvement. UpdatedNovember 2013.
• Kroenke, K, et al. The PHQ 9: validity of a brief depressionseverity measure. J Gen Intern Med. 2001 Sept. 16(9): 606 13.
• Moeller, K. et al. Urine Drug Screening: Practical Guide forClinicians.Mayo Clinic Proceedings; Jan 2008; 83 (1): 66 76
• PainEDU.org• Scanlan, T. Drug Testing: Overview. Clinical Topic.• Scanlan, T. Drug Testing: Interpreting Results. Clinical Topic.• Webster, LR and Webster, RM, Pain Med: 2005; 6:432 442
18
A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO
Family Medicine Spring Symposium April 10, 2015
5
Related Documents
