American Osteopathic College of Occupational and Preventive Medicine 2015 Mid Year Educational Conference, Ft. Lauderdale, Florida Guidelines and Recommendations “Federal and State Laws Relating to the 1. Standards For The Use Of Controlled Substances Prescribing of Controlled Substances”. For Treatment Of Pain; AHCA in consultation with The Florida Pain Commission, The Florida Board of • Walter B. Flesner III, D.O. Medicine, and The Florida Board of Osteopathic • Past President, FOMA, 1996-1997. Medicine, Revised 12-21-99. 2. JCAHO Standards 1999 3. Federation of State Medical Boards Joint Concensus • Past President, FOMA District XI, 2008-2010. 4. Federal Controlled Substances Act 1970 • Medical Director, ICP&R, Cape Coral, Fl. 5. DEA Statements. • Risk Management/Continuing Medical Education 6. Florida House/Senate Bills 7095,0462, and 2272, Florida Statute Chapter 893, 456.44, 459.0137,64B- American Osteopathic College of Occupational and 15-14.005. 7.Risk Evaluation Preventive Medicine Midyear Seminar. and Mitigation Strategy 8.E-Forcse-PDMP. 9. • Sunday, Sunday March 15th, Ft. Lauderdale, Fl. Lee County Coalition for a Drug-Free South West Florida. Walter B. Flesner III, D.O. Medical Director ICP&R Florida Statistics • 7 Floridians die daily from lethal overdoses. Additional 7 persons die daily with at least one prescription drug detected in combination with Addressing Prescription alcohol or other drugs. Florida led nation in sale of Pain Medicine Abuse & Misuse: Oxycodone with over 400,000,000 pills sold A Framework For Safe Prescribing annually! However down 20% in past year. How Prescription Drugs get to Floridians: 1. Physicians and Pharmacists- for profit, naïve, impaired. 2. Individuals- illegally obtain to satisfy addiction, traffic or divert for profit or to family or friend. 1. 3. Internet pharmacies- major difficult threat. Z-1 American Osteopathic College of Occupational and Preventive Medicine 2015 Mid Year Educational Conference, Ft. Lauderdale, Florida Solutions Be part of the solution, not part of the problem. You are here! Learn new guidelines, talk to your colleagues, consult specialists when indicated. Florida BOM, FBM, DEA, FDLA, State, County, Local law enforcement, State Attorney’s Off., FOMA, FMA, Specialty Societies- we all need to work together so legitimate acute, chronic, and terminal pain patients can have appropriate access to compassionate and multidisciplinary care. Urine drug testing, the Prescription Drug Monitoring Program (PDMP)- E-FORCSE.com, and patient-doctor opioid agreements have started to help. New Zoning Laws are coming for new Pain Clinics. Definition of Pain Definitions IASP definition:* • Tolerance Pain is “an unpleasant sensory and emotional experience Pseudotolerance associated with actual or potential tissue injury or Physical Dependence described in terms of such damage.” Addiction Importance of the patient’s self-report: Pseudoaddiction “Pain is whatever the experiencing person says it is, Substance Abuse existing whenever he/she says it does.”** Acute Pain Chronic Pain * IASP. Pain 1979;6:249-252. ** McCaffery M, Beebe A. Pain: Clinical Manual for Nursing Practice. St Louis: CV Mosby Company; 1989. Tolerance: Pseudotolerance: • the need for increased dosage of medication • need to increase dosage is not due to to produce same level of analgesia that tolerance, but due to other factors such as existed previously. Tolerance occurs also when disease progression, increased activity, drug a reduced effect is observed with constant interaction, new disease, other medication doses. Analgesic tolerance is not always seen changes, or deviant behavior. during opioid treatment and is not addiction. Z-2 American Osteopathic College of Occupational and Preventive Medicine 2015 Mid Year Educational Conference, Ft. Lauderdale, Florida Physical dependence: Addiction: • Occurrence of withdrawal • psychological dependence on the use of symptom/syndromes after opioid use is substances and their psychic effects and/or stopped abruptly or decreased without compulsive use of drugs over which patients titration. It can also occur if an antagonist is no longer have control, and continue to use administered. Physical dependence is NOT despite harm to themselves or others. addiction! It does not always occur with Addiction is a disease. opioid usage, but is a common phenomenon with opioid treatment. Pseudoaddiction: • drug-seeking behavior that may seem similar to addiction, but is due to unrelieved or incompletely relieved pain. Often after a dosage increase, the behavior stops once the pain is relieved. Substance Abuse: Acute Pain: • use of any substance for non-therapeutic • normal predicted physiological response to an purposes. adverse chemical, thermal, or mechanical stimulus and is associated with trauma, surgery, or acute illness. It usually resolves within 3 months. • Subacute Pain: 3-6 months. • Chronic pain: > 3-6 months. Z-3 American Osteopathic College of Occupational and Preventive Medicine 2015 Mid Year Educational Conference, Ft. Lauderdale, Florida Keys to Appropriate Pain Chronic Pain: Assessment • Complete initial assessment • • state in which pain is persistent and cannot be Use appropriate tools removed or otherwise cured. It usually has – patient self-report occurred for more than 6 months. – easily administered rating scales 456.44: Chronic nonmalignant pain means pain – documentation forms available to all clinicians: Pain unrelated to cancer or rheumatoid arthritis which Assessment and Documentation Tool/ PADT, Opioid Risk persists beyond the usual course of disease or the Tool, Screener and Opioid Assessment for Patients with Pain/SOAPP. injury that is the cause of the pain or more than • 90 days after surgery. Assess pain at regular intervals • Be aware of common pain syndromes • Risk Identification and Stratification Initial Pain Assessment: Medical History Initial or Ongoing Pain Assessment: Characterization of • Extent of disease Pain • Previous therapies: effective & failures • Location • Description • Treatment-related signs and • Intensity symptoms • Temporal nature • Other medical conditions – onset • Efficacy of previous – duration – chronic/acute/palliative therapy relationship to scheduled analgesic dose • Aggravating/alleviating factors • Efficacy of previous analgesic treatments • Effects on function Initial Pain Assessment: Initial Pain Assessment: Psychosocial Examination Physical Examination and Diagnostic Studies • Disease state: effects and understanding • Physical Examination: • Reactions to pain – Site of pain – meaning of pain – Adjacent sites (for referred pain) – coping strategies and support system – Sites of known disease/ tumor invasion – effects on function – effects on mood – Musculoskeletal and neurologic systems • Perceptions regarding analgesic therapy • Diagnostic Evaluation: – expectations, knowledge, and preferences – Laboratory studies/tumor markers – concerns regarding controlled substances – Radiologic studies • Financial concerns regarding therapy – Neurophysiologic testing *Assess whether low, medium, or high risk for abuse for – Urine drug screening chronic opioid therapy (COT). Z-4 American Osteopathic College of Occupational and Preventive Medicine 2015 Mid Year Educational Conference, Ft. Lauderdale, Florida Pain Assessment Tools: Intensity Simple Descriptive Pain Intensity Scale 0-10 Numeric Pain Intensity Scale 0 10 None Mild Moderate Severe Very Worst Severe Possible 0-10 Numeric Pain Intensity Scale 0 10 0 1 2 3 4 5 6 7 8 9 10 None Moderate Worst Possible Visual Analog Scale (VAS) 0 10 None Pain as bad as it could possibly be Faces scale reprinted with permission from Patt RB. Cancer Pain. Philadelphia: JB Lippincott Co.; 1993. Jacox A, et al. Management of Cancer Pain: Clinical Guideline No. 9. March 1994. AHCPR Publication No. 94-0592. SCREENER and OPIOID ASSESSMENT for PATIENTS with PAIN ( SOAPP), PAIN ASSESSMENT and DOCUMENTATION TOOL (PADT). OPIOID RISK TOOL. • SOAPP version 1.0 is an easy and relatively quick questionnaire to help physicians and providers evaluate patients’ risk for higher problems if long-term opioid therapy is to be considered. SOAPP is not a lie detector test. It is not intended for all patients. It is likely to predict which patients will need less or more close monitoring on long-term opioid therapy. Version 1.0 has 24 questions. Version 1.0 SF has 5 questions. 2 most important questions-Smoke and drink? PADT- Useful tool for clinicians evaluating care and outcomes during opioid therapy. Also Opioid Risk Tool. Z-5 American Osteopathic College of Occupational and Preventive Medicine 2015 Mid Year Educational Conference, Ft. Lauderdale, Florida Pharmacologic Management of Pain • Select the appropriate Drug. • Prescribe the appropriate Dose- do under or over treat. • Administer by the appropriate Route. • Schedule the appropriate dosing Interval- consider long acting for ATC, short acting for rescue/breakthrough. • Prevent Persistent pain/relieve Breakthrough pain. • Titrate doses aggressively. • Anticipate, prevent, and manage the Side Effects. • Use appropriate Adjuvant drugs when indicated. • Assess treatment response at regular intervals. Adapted from Levy MH. N Engl J Med 1996;335:1125. opioid Choice of Agent: The word opioid is a general term that Three-Step Analgesic Ladder refers to all compounds related to Morphine opium. The term narcotic(causing Opioid Fentanyl + Adjuvant Oxycodone narcosis) once used to refer to any Moderate/Severe 3 g + Nonopioid Hydromorphone n i s a e r drug