Purpose of Presentation. Medical and Psychological Management of the chronic back pain patient 10/24/2013

Transcription

1 Medical and Psychological Management of the chronic back pain patient Marc Cooper, PH.D. Director of Psychological and Behavioral Health Services Pain Medicine Associates Johnson City, Tennessee Disclosure Statement of Unapproved/Investigative Use I, C. Marcus Cooper, Ph.D. Do Not anticipate discussing the unapproved/ investigative use of a commercial product/device during this activity or presentation Purpose of Presentation 1. Help you as physicians decide whether you want to be in the pain management business, to what extent, and how to do it safely. 2. Help you understand the appropriate role of psychology in helping you with chronic pain patients. 1

2 History of Pain Management: Follow the Money (reimbursement) 1980 s to 1990 s: The Tollison Approach Physical Therapy (work hardening) and psychological support s to 2010 s: Injection Therapies, implant devices, and Medical Management and Beyond: 3rd Party Management and government oversight: Functional Improvement 2

3 3

4 4

5 5

6 Role Of Psychology in Chronic Pain Management 1. Help the physician assess the risk of misuse, abuse, or diversion of medication. 2. Establish behavioral health strategies and treatment approaches to involve the patient in their recovery process. 1. Evaluation of Risk: Special Consideration prior to initiating opioid therapy: Patient living in a Rural Area or have low income Medicaid population (Tenncare?) Patients who have already seen multiple providers for a pain problem in the past: doctor shopping Patients already on an abusable substance: benzodiazipine Patients with history of mental health problems Patient with history substance abuse problems 6

7 Dr. Cooper s Continuum of Risk: What places a patient in a high risk category from a psychological point of view Presence of past or present psychiatric disorders including major depression, bi-polar disorders, anxiety disorders, alcohol or drug history, and personality disorders. (The development of psychological problems prior to the pain problem increases risk as does poor treatment response to past psychiatric, drug or alcohol problems). Poorly controlled sleep disorder. Obesity and sedentary life style especially before injury. Nicotine Dependence Financial issues: Unemployment and no visible sign of income, social security disability, litigation, workman's compensation issues. Social Risk factors: Spouse's,children's, family member's, grand children's mental health and drug use history. 19 Dr. Cooper s Continuum of Risk: What places a patient in a low risk category The absence of the above personal risk factors in the patient. No overt drug/etoh problems in the patient's immediate social environment. Also positive factors include the fact that the patient has a stable and positive social network. Pain has not kept them from their social functioning, work, or activities. They may have modified them but they still are a functional person in the world Behavioral Health treatment in chronic pain patients Therapeutic strategies for the mental health/ drug concerns: 85% of chronic pain patients in our practice had a mental health disorder: e.g.. depression/anxiety. Therapeutic strategies sleep. Therapeutic strategies for nicotine dependence. Therapeutic strategies for obesity and deconditioning. 7

8 Goal of Psychological and Medical Pain Management Treatment: Improve cognitive, social, occupational, and ADL functioning. Patients who are passive in response to (threat) pain show greater distress and disability than patients who attempt to solve their problems. Patients who feel they can control their pain to some degree have less fear and disability. Snowturek Al, Norris MP, Tan G. Active and passive coping strategies in chronic pain patients. Pain 1996; 64: Psychological/Behavioral Health Treatment Options or Recommendations Individual psychotherapy, cognitive behavioral therapy, emotional freedom techniques. Marital and Family Therapy. Suggestions regarding psychotropic medications or referral to psychiatrist. Biofeedback, relaxation therapy, stress management, guided imagery, self-hypnosis training, meditation. Drug or ETOH outpatient/inpatient treatment. AA or NA Psychological/Behavioral Health Treatment recommendations Behavioral Strategies for Sleep Consideration for Physical Therapy: (Tens Unit, traction, ultrasound and e- stim, desensitization, therapeutic exercise, ice massage) Consideration of Home exercise program, silver sneakers or senior citizens group, yoga classes Weight loss programs Stop smoking program Diabetic cooking class or referral to dietitian/nutritionist Fibromyalgia Program/ anti-inflammatory diet Massage therapy, acupuncture, chiropractic, Theracane acupressure technique, Edward Casey s Violet Ray Technique. 24 8

9 What Do You Do First As a Physician Helping Chronic Pain: Guidelines for chronic Benign Pain Proper Diagnosis with history, physical exam, and appropriate diagnostic testing documented in chart. Rule out the need for surgical intervention. Attempt conservative treatments prior to initiating opioid therapy: physical therapy,nsaids, massage therapy, injection therapies, acupuncture. Professional Reminders The Extent of complaint and disability reported by the pain patient can not be explained by the extent of damage or disease. Pain (expression) is not a reliable indicator of tissue damage and tissue damage is not a reliable indicator of pain. Improved function is our primary goal, not absence of pain. British Journal of Anaesthesia: Vol. 87. Issue 1. pp Second: Professional Considerations prior to initiating long-term opioid medication management Do you want to do this type of work? What additional structures do you need to put in place to treat chronic back pain patient with opioids? At what level of opioid prescribing are you comfortable with? When do you refer to a pain specialist? 9

10 What tools, policies, and procedures will you need to set up to prescribe opioids Obtain validated risk assessment tool or formal psychological evaluation prior to considering opioid treatments Have written opioid agreement to be reviewed by provider and signed by patient. Have written informed consent documenting risk for the patient. Set up a monitoring compliance program: reviewing control substance monitoring database (CSMD), Urine Drug Screens (UDS) and pill counts and documentation of improved function in the chart. Risk Assessment Tools Pain Medication Questionnaire The Screener and Opioid Assessment for Patients with Pain (SOAPP) SOAPP (SOAPP-R) Opioid Risk Tool (ORT) 10

11 Multidisciplinary Treatment Recommendations Treatment recommendations are based on risk profile and other psychological, behavioral, and social variables revealed in testing and clinical interview. The decision to write for opioids are for the physicians to make, the pain psychologist role is to assist the physician in making that decision and how it should be done. 31 High Risk Treatment Recommendations Typically long acting medications only with no short acting medications or break threw medications. Medications should be written for one month only (no exceptions) with face to face clinic visit. No refills on hydrocodone (lortab) or tramadol (ultram) even though it is acceptable by guidelines. Patients should be required to bring in all medications (even from other doctors) at each visit or pill count. Check Tennessee Data Base at each visit. Current law is required twice per year. 3 to 4 urine screens each year and occasional calls for pill counts. Required adjunctive treatment with signed releases of information in chart so that all providers can communicate with each other in regards to patient s compliance. (psychiatry, physical therapy, psychotherapy, etc) Consideration can be given to making opioid treatment contingent upon behavior health changes. Monitor compliance and document improvement in function or discontinue opioid treatment. 32 Low Risk Treatment Options Long acting medications preferable, but short acting medications can be used. Pill counts only for pain clinics medications. Medications may be prescribed on a 3-month basis (depending on medication) after prescribing physician is comfortable with patient. Check Tennessee Data base as required by state statutes for opioids and benzodiazepines. Current law is once per year or when a change in medications occurs. (General providers). Urine screens only as required by state law (2 per year). No need for additional ones. Behavioral health changes or assistance is optional. No need for treatment team approach

12 Possible Future OpioidTreatment Prescribing Guidelines Documentation of objective need for opioids and failed improvement from other modalities. Validated risk assessment tool in chart Signed agreement form No suboxone prescribed for pain management. Methadone limited to 30 mg/ per day. No more than 1 type of short acting medication; no more combinations of 2 (like lortab and/or ultram) No more than 4 short acting medications per day. Use long acting medications if the patient is requiring higher levels and discontinue short acting. No break threw medications unless there is clear objective reasons. No concomitant pain medication written with a benzodiazepine without consultation with mental health provider and documented in chart. Psychological assessment required before adding a benzodiazepine. Prescription written only for 30 days with face to face visit. (Type 3 drugs like hydrocodone, tramadol, gabapentin, (possibly pregablin) are current exceptions but should only be written with 2 refills). Convert medications to morphine equivalent and consider referral to pain specialist above 100 mg. per day. Required referral to pain specialist above 200 mg equivalent. Psychological assessment may be considered and required prior to initiating any long term narcotic and especially when considering dosing above 100 mg. per day. 34 Consequences for Not Following opioid Prescribing guidelines Fines Revocation of license 35 Advantages for the New Guidelines The new guidelines provide an easier way to deal with your patients. The new guidelines provide you some protection from professional and legal problems. The new guidelines are easy to follow and set up in your office