9/28/2015. Approaches to the Treatment of Pain in an Environment of Diversion Friday October 3, Outline. Accuracy of Diagnoses

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1 Approaches to the Treatment of Pain in an Environment of Diversion Friday October 3, 2015 Michigan Pharmacists Association Michael P Notorangelo DO ABAM CMRO Outline 1. Accuracy of Diagnoses 2. Choice of Medications 3. Dispensing of Medications 4. Maximizing Delivery of Medication, Optimus Technique for Buprenorphine 5. Supervision of Medication 6. Nonpharmacologic Treatment 7. Behaviors to be aware of Accuracy of Diagnoses Opiate Use and Dependence are Complicated: (+) Are critically important for severe pain (+) Opiates are amazing antidepressants, anxiolytics, memory blockers (+) Often treat co occurring/underlying conditions, including; Depression, PTSD,( hugely underreported in the UP) GAD, OCD, ADHD 1

2 Accuracy of Diagnoses ( ) Opiates are the most addictive of substances ( ) By treating /obscuring Depression, PTSD, Anxiety, ADHD, complicates the diagnoses and patients willingness to D/C use of opiates ( )Opiate W/D mimics Depression, Anxiety, ADHD further complicating accurate diagnosis Prescribers historically are not taught addiction and most are not trained in Psychiatry Confounded further by the push to use Opiates CASE STUDY 30 yo wf, c/o diffuse pain, anxious all the time Norco D/C d, SSRI s don t work, bad side effects Only relief Xanax, she increased up to 1mg tid PMH past bullemia, PSH neg, All NKDA FH F alcoholic Soc Hx social drinker ROS acute Op/W/D, otherwise noncontributory Differential Dx:??? CASE STUDY Differential Dx: Opiate Dependence Acute Opiate W/D, + UDS(admits to buying opiates off the street ) Anxiety Opiate withdrawal anxiety? Anxiety Disorders? Alcohol Withdrawal? Stimulant Abuse/Dependence? ADHD? 2

3 Accuracy of Diagnoses Misdiagnoses are more common than we think!! EX: Hyperactive subcomponents of ADHD often misdiagnosed as Anxiety I m Anxious! will not respond to and poorly tolerate SSRI s (Noradrenergic based) often prescribed Benzo s, often become Dependent (predisposed to Addiction) Bottom Line: Doc s need to be MORE PRECISE with diagnosing!!! Choice of Medications Nonaddictive Medications work well for ADHD (Off Label = OL) Guanfacine (OL,A), Atomoxetine, Clonidine(OL,A), also possibly are Venlafaxine (OL), Buproprion (OL) Nonaddictive medication works well in PTSD for flashbacks Prazosin (OL) orthostasis limits use, Doxazosin (OL) Nonaddictive Medications work well for true Anxiety Disorders, the higher potentcy SSRI S, that necessitate longer periods of time to see the full response, 6 to 8 months, versus 1 2 for depression, As well as necessitating the higher range of dosing Dosing of Medication Lowest Effective Dose of Addictive Meds?? Very difficult if used to self medicate Must Identify and aggressively treat underlying Depression, Anxiety, ADHD, PTSD, to get there!! Buprenorphine provides some clarity in those Opiate dependent to diagnose underlying conditions, then treatment facilitates possible taper and D/C of Buprenorphine Aggressive SSRI s minimizes need for Benzo s 3

4 Dispensing of Medication I prescribe the exact # of CS to get to the next appointment at the lowest established effective dose. * No replacements under any circumstances. *Optimus Technique: Establishing lowest Effective dose of Suboxone, initiated during active opiate withdrawal. 1. No Nicotine or caffeine for 1 hour PTD 2. Rinse mouth with warmest tap water tolerable 3. put ¼ of 8mg strip under tongue and tilt head forward down, reading something/ tech neck for 15 minutes. 4. Wait at least 2 hours between doses, minimizing how much used, limited to 8mg strip over hours. Supervision of Medication Pill Counts, Pill Counts, Pill Counts!!! Pill Count form I devised in cooperation with Todd of Peoples Pharmacy in Escanaba. 1. Call patient at random to come in, in 24 hrs, with their Medication to the pharmacy # they provide 2. We call the Pharmacy, tell them we are doing a count, get their fax and contact person then fax our form. Pharmacy faxes back completed form 4

5 Use of Nonpharmacologic Treatment Accupunture / Accudetox Manipulation / Massage Meditation Biofeedback Exercise /Physical Therapy Psychotherapy Diet / Suppliments Behaviors to be aware of Obvious ones: Prescription doesn t look right MAP lights up More difficult: Girlfriend comes in and picks up his script, only they are no longer together Patient doesn t look right, sunken eyes, steely stare, scabs on face, twitchy, thin build = the look of Crystal Meth = could be psychotic enough to be dangerous Epidemiology Of 14,175 college students, from 26 campuses, 14.7% are diverting, including; stimulants(52.6%), anxiolytics (38.4%), antidepressants(17.4%) < 20% using Psychotropics with alcohol or other illicits told their HCP. Risk factors for misuse of stimulants included; heavy alcohol use, white race, fraternity sorority membership, low GPA, competitive University. 5

6 Conclusion Pain treatment is complicated by the complex Opiate/Pain /Psychiatry interface Accurate diagnosis and treatment of underlying psychiatric conditions is critical to minimize the carnage associated with addictive medications Nonaddictive alternatives offer effective relief Careful dosing, monitoring and supervision of controlled substances is critical for safety 6