Options in Pain Management Alice Looney ANP-C Kreisberg Family Pain Management Center Saint Luke s Cornwall Hospital

Transcription

1 Options in Pain Management Alice Looney ANP-C Kreisberg Family Pain Management Center Saint Luke s Cornwall Hospital To decrease pain To improve lifestyle To decrease the need for drugs (including narcotics and other potentially hazardous medicines/medications) Goals of Pain Management When is it appropriate to refer to pain management? Conservative Therapies Interventional Options Medical Management What s New in the Regulations Topics 1

2 Chronic long standing pain Acute radicular pain and/or weakness Failed conservative therapy Complex pain not adequately managed in the Primary Care setting Neuropathic Pain/Shingles Metastatic Disease Referral Acute Post Operative Pain Short term Pain lasting only a few days or few weeks New pain of unknown origin Pain requiring urgent intervention Not for Pain Management Lumbar/Cervical radiculopathy Facet disease Sacro Ileac Joint disease Neck, back or Hip Pain Migraine Headaches Poorly controlled Fibromyalgia Sickle Cell Disease Long term pain post trauma Chronic Regional Pain Syndrome Neuropathy/Neuralgia/Post Herpetic Neuralgia Chronic Pancreatitis/long standing abdominal pain Metastatic Disease Diagnoses??? 2

3 Don t jump the gun!!! Time: 50% of acute back pain Resolves in 2 weeks and 80% in 6 weeks with rest With conservative treatment. Where to start??? Physical Therapy 4-6 weeks Stretching Strengthening Modalities : Heat/Ice, Traction, Ultrasound, TENS Non-Narcotic Medications NSAIDS Lidoderm Patches Muscle relaxers Neurontin/Lyrica Cymbalta (SNRI) Compounded Topicals Savella (SNRI) Conventional Options Psychiatric Evaluation May be needed 3

4 Chiropractor Acupuncture Reikki Therapy Massage Therapy Cold Laser Therapy Meditation/Biofeedback Off the Grid Facet Disease/Osteo Arthritis Facet Injections Lumbar/Cervical Patience is a virtue Radiofrequency Ablation Lasts 6-12 months Radicular Pain Disc Herniation Post Laminectomy Syndrome Stenosis Epidural Transforaminal Epidural Interventional Pain Management Chronic Regional Pain Syndrome Stellate Ganglion Block Lumbar Sympathetic Block Blocks are temporary, used to decrease pain to allow more aggressive Physical Therapy and desensitization to decrease loss of function. Usually combined with medications. Migraine Headaches/Occipital Neuralgia Occipital Nerve Block Cervical Facet Injections Botox Injections Interventional Pain Management 4

5 Sacroilitis: Sacro Ileac Joint Injections Chronic Pancreatitis: Celiac Plexus Block Myofacial Pain/Fibromyalgia: Trigger Point Injections OA of the Hip: Intra-articular hip injection Bursitis of the Hip: Bursa Injection Piriformis Syndrome: Piriformis Injection Other Injections Case by case basis. Needs referral Strict screening criteria Exhaust Non Narcotic Options Prior to prescribing narcotic medications Start low and go slow Medical Management Complete History and Physical Review of all prior pain management records Review the radiology No prescription on the first visit Urine Drug screen NYS Prescription monitoring system ISTOP Screening Criteria 5

6 Patient Safety Legal Ramifications Prevent Diversion of medications Requires use of one Pharmacy, random drug screens, single source of medications Defines reasons the contract would be cancelled Narcotics Contract Prescriptions are forged, sold, shared or misdirected in any way Other physicians prescribe my chronic pain medication or any other pain medication for me I do not keep my appointments in Pain Management, Physical Therapy or Psychology without a justifiable reason This Contract will be cancelled if: The Pain Management Provider will slowly reduce and stop my medication Additional narcotic medication will not be provided When appropriate, Non-narcotic alternatives will be suggested If appropriate referral to Detox or Rehab will be facilitated If cancellation of contract occurs 6

7 Tramadol/Ultrcet Butrans Tylenol with Codeine Hydrocodone/Hysingla/ZyhydroER Oxycodone/Oxycontin Dilaudid/Exalgo Nucynta/Nucynta ER MS Contin/MS IR/Embeda Fentanyl Patch/Actiq/Fentora Commonly Used Narcotic Medications Dependence Constipation Difficult Urination Drowsiness Nausea Itching Poor breathing Reduced Sexual Function Side Effects If fiber, increased fluids, stool softeners and a laxative are not effective.. Consider Relistor or Movantik Constipation 7

8 ISTOP * VA/Federal Government do not participate *Batching *Doesn t cross State lines * Fines Tamper Deterrent Technology Regulations Strict Screen Criteria Frequent Drug Screens Interviewing Skills Physical Exam Random Drug Screens NYS Prescription Monitoring System Weeding out the Drug Seekers Huge Allergy List!!!! I m allergic to everything except Oxy Specific Requests The only thing That works for me is Oxy 30 and I need at least 6 a day. Doctor shopping and hopping Frequent ER visits at multiple sites Inconsistent stories during interview Red Flags 8

9 Calling early for refills Missing or lost prescriptions Requesting Narcotics for elders in their care who continue to complain of pain More Red Flags Questions????? 9