Creating a Treatment Plan for Higher Risk Patients: A Case-Based Approach. Ted Jones, Ph.D. Pain Consultants of East Tennessee

Transcription

1 Creating a Treatment Plan for Higher Risk Patients: A Case-Based Approach Ted Jones, Ph.D. Pain Consultants of East Tennessee

2 Disclosures Consultant: Prescription Advisory Systems & Technology, Inc. (PAST) Contract with Ethos Laboratories regarding an electronic version of the Brief Risk Questionnaire (BRQ)

3 Learning Objectives Identify the essential pieces of information used to create an initial treatment plan Describe how to better choose opioid medications based on risk assessments results Explain the key pieces of behavioral information to use to determine patient risk Create appropriate treatment plans for high risk patients

4 Asks about oxycodone Smoker Pain at 45 degrees PMP shows HC from ER UDT appropriate Tender to palpation Failed gabapentin Cried once on exam Marital problems Prescribed HC 7.5 bid Records show one early refill Abused once as a child Smoked weed in college Labs normal Back pain Takes Elavil hs Empty nest starting last year Reflexes OK Taking Depakote Never had PT MRI shows L4-5 protrusion

5 Key Information The Initial Evaluation

6 The Essentials of an Initial Evaluation Pain complaint Physical exam Risk assessment Scans / Studies / Labs UDS / UDT / OFT Past medical records PMP information

7 Anyone? Got a good acronym? PEPURRS? Whatever.

8 A Quick Review Risk Assessment

9 Risk assessment is more than a form Sometimes it is easy to think that risk assessment is another form to complete and file. Another regulation. Risk should be integral to creating a treatment plan. Low, Medium, High risk means something and should impact treatment. And regulators are beginning to demand this.

10 Risk Assessment Tools

11 Risk assessment tools Screener and Opioid Assessment for Patients with Pain (SOAPP). (Butler, 2004) Pain Medication Questionnaire (PMQ). (Adams, 2004) Opioid Risk Tool (ORT). (Webster, 2005) Diagnosis, Intractability, Risk, Efficacy (DIRE). (Belgrade, 2006) Screener and Opioid Assessment for Patients with Pain - Revised (SOAPP-R). (Butler, 2008) Prescription Drug Use Questionnaire Self-report (PDUQp). (Compton, 2008) Brief Risk Interview (BRI). (Jones, 2013) Narcotic Risk Manager (NRM). (Gostine, 2014) Brief Risk Questionnaire (BRQ). (Jones, 2015)

12 Not a validated tool Your gut feeling about a patient / your own self-styled interview of a patient is not validated risk assessment tool. As good as it might be, you will have no data to support your use of this technique if you are ever questioned about it.

13 The Basics The Impact of Risk on Treatment Planning

14 Impact of risk on monitoring Monitoring The Four P s (apologies to Passik) Patient (visits) Pill Count PMP (pharmacy monitoring profile) Pee (UDT) The higher the risk the more frequently you should monitor in some or all of these ways.

15 OK, some rough specifics Low Risk: Some guidelines recommend urine drug screens (UDT s) at this risk level as two to four times a year (Chou et al, 2009). Once a year testing may be acceptable as well (Palmetto and WA state).

16 And Medium Risk: Guidelines tend to recommend that urine drug screens (UDT s) be administered more frequently than low risk, and might be four to six times a year. High Risk Guidelines tend to recommend that urine drug screens (UDT s) be administered as often as monthly or even weekly, with an apparent minimum of four times a year.

17 That said DON T take those slides to be gospel and a statement of what you should do in your practice. States vary. Regions vary. Practices vary. Check your state s regulations. Ask peers. Ask consultants. DON T say Ted Jones said this was what I was supposed to do. I didn t.

18 Impact of risk on medications Generally, the higher the risk the less you prescribe short-acting medications / a high number of doses. Generally, the higher the risk the less you prescribe rapid onset analgesics. Generally, the higher the risk the less you prescribe highly abuseable medications / medications that have a high street value.

19 Final impact of risk - referrals Generally, the higher the risk the more you should consider referrals to other specialists and support services, and get more help. That is, with higher risk you would more commonly refer for substance abuse evaluation / treatment, psychiatry, and psychotherapy. And you would be more likely to involve family / significant others as support.

20 UNIVERSAL PRECAUTIONS Med Options Monitoring More referrals High dose opioids? Low Risk Medium Risk High Risk

21 Putting it all together The initial treatment plan consists of: a working diagnosis referrals / diagnostics medication(s) to trial starting today monitoring schedule next visit should be in?

22 It s go time! Practice cases for you

23 Your task I will hand out some different cases. Each has a different color cover page so you can tell them apart. I will tell you how many cases to work up. You ll have a certain number of minutes to get your treatment plans done. What you will do is: Read the case information Create an initial treatment plan

24 You will have 1. A page for note taking and writing the treatment plan. 2. Presenting Complaint / Situation The patient is a 52-year-old male. He reports his primary pain is in his low back (with no radiation into his legs at this time). He has had

25 Physical Exam

26 X-rays / MRI s

27 Risk Assessment (3)

28 Summary of Other Medical Records The records from the previous pain clinic indicate that he was treated there for about one year and a half. He was titrated in his opioid dose the first several months but was on a stable dose after that..

29 UDT results

30 PMP Results (assume this is mid-march)

31 Again, the goal is to create An initial treatment plan that consists of: a working diagnosis referrals / diagnostics medication(s) to trial starting today monitoring schedule next visit should be in?

32 The cases There are different cases being distributed. Each has unique challenges. The focus here is not on having the best dx but to create a treatment plan that takes risk factors into account. There is no one right answer. Relax. Have fun. Go.

33 Go.

34 Stop.

35 Ann 37 yo female with DPN. Pain present five years. Tests confirm dx Has Bipolar Disorder and is not in treatment now. UDT shows nonprescribed oxycodone Opioids from multiple providers

36 The treatment plan created medications prescribed today treatments ordered, and any tests, assessments or referrals made today. monitoring schedule (UDT how often?) how long until the next visit

37 Betty 63 yo female with pervasive joint pain d/t RA as well as recent wound on hip Exam and hx supports her dx On low dose oxycodone now There is suspicion that her daughter is taking her medication

39 Carol 73 yo female with back and leg pain. Exam and scans support her dx. Shows some sleepiness Reports some trouble with falls UDT positive for metabolite for cocaine (yep, true case)

41 Diane 36 yo female with progressive MS. Pervasive pain, worse in legs. Hx and exam supports dx Former user of heroin. Clean 18 months. Hx of use of medical THC. Has gotten some medications from the street

43 Ethan 42 yo male, injured left shoulder and has had arm pain since. Scans and hx and exam supports his dx. Former alcoholic. Sober 11 years.

45 Frank 52 yo male with pain in his low back and both knees. Exam and scans support his dx. Discharged from his last pain clinic for two instances of medication aberrant behavior.

47 Grace 58 yo female with left foot pain. injured at work one year ago. Exam supports dx. UDT positive for THC. Smokes THC nightly.

49 Harry 38 yo male with low back pain with occasional radiation into the right leg. Past lumbar surgery. UDT positive for non-prescribed oxycodone Patient not honest about the use of oxycodone.

51 Irwin 40 yo male UDT with abdominal pain due to pancreatitis. Has been on high dose opioids from his gastroenterologist Past cocaine abuse 15 years ago Substance abuse treatment two years ago to try and go without opioids.

53 Jen 71 yo female with pain in her low back and both legs. Exam and scans support her dx. Medical High risk: elderly, bzd use, regular alcohol use, OSA and COPD.

55 To Summarize

56 Final Wrap-up Keys Do a PE as part of the initial evaluation Use scans / labs to document a diagnosis Use risk assessment information to Determine monitoring needs Help choose opioid medications Consider referrals and help Use all pieces of information to create a treatment plan. Don t assume safety

57 References

58 Chou R, Fanciullo GJ, Fine PG et al Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. Jrnl Pain 2009; 10(2) Katz NP, Sherburne S, Beach M, Rose RJ, Vielguth J, Bradley J, Fanciullo GJ. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg. 2003; Oct;97(4): Local Coverage Determination (LCD): Controlled Substance Monitoring and Drugs of Abuse Testing (L34398) CENTERS FOR MEDICARE AND MEDICAID SERVICES (Mar. 2013). +Administrators%2c+LLC+(18003%2c+DME+MAC)&DocType=AllProposed&DocStatus=Dr aft&cntrctrselected=140*2&lcntrctr=140*2&bc=agiaaaaaaaaaaa%3d%3d& New York State Office of Alcoholism and Substance Abuse Services. Clinical Practice Guidance Number : Guidance on Urine Drug Testing. April,

59 Passik SD. Issues in long-term opioid therapy: unmet needs, risks and solutions. Mayo Clin Proc 2009; 84(7): Peppin, J. F., Passik, S. D., Couto, J. E., Fine, P. G., Christo, P. J., Argoff, C., Aronoff, G. M., Bennett, D., Cheatle, M. D., Slevin, K. A. and Goldfarb, N. I. Recommendations for Urine Drug Monitoring as a Component of Opioid Therapy in the Treatment of Chronic Pain. Pain Medicine : Washington State Agency Medical Directors' Group. Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An educational aid to improve care and safety with opioid therapy 2010 Update. Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners Sunrise River Press, North Branch, MN.

60 Creating a Treatment Plan for Higher Risk Patients: A Case-Based Approach Thank you!