Evaluation of Chronic Pain Patients for Narcotic Therapy: Cautions and Controversies C. Marcus Cooper, Ph.D., D. N. H. Director Of Psychological Services Pain Medicine Associates Johnson City, Tennessee Disclosure Statement of Financial Interest I, Marc Cooper, Ph.D., DO have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation, they are: Affiliation/Financial Interest: : Director of Psychological Services Name of Organization: : Pain Medicine Associates Disclosure Statement of Unapproved/Investigative Use I, Marc Cooper, Ph.D., Do Not anticipate discussing the unapproved/investigative use of a commercial product/device during this activity or presentation. 1
Evaluation of the Chronic Pain Patient History and Subjective Data Pain history Medical history Surgical history Social history Family history Current Medications / Allergies Complete Review of Systems VAS, Pain Drawing, Pain Disability Index Physical and Objective Data Complete Physical Exam Radiology and Laboratory Assess for function: How is pain interfering with the patients life? Pain Disability Index. Family/home responsibilities Recreation Social Activities Sexual Behavior Self-care Sleeping Occupation Assess for Pre-morbid Function What did the person do prior to the pain problem? Note previous level l of function in all areas of life. See Pain Disability Index Questionnaire What does the person do behaviorally to help the pain? Indications for Chronic Opiate Therapy Consider narcotic therapy when the patient suffers from severe daily pain caused by a disorder for which all accepted medical treatments have failed or are otherwise contraindicated and when the pain is significant interfering with the person s function and quality of life. Is there a pain problem verified by objective diagnostic studies? (Fibromyalgia) 2
Contra-indications or Risk Factors for Narcotic Therapy Pre-existing Psychiatric Disorders vs. co-existing factors Personality and/or behavioral health concerns Social/environmental factors No surgical, alternative, non-opioid or nonpharmacological strategies have been attempted Age Pre-existing Psychiatric Disorders vs. Co-Morbid Psychiatric Disorders Major Depression and/or Bipolar Disorder Personality Disorders: Axis II (especially Borderline) Unstable Marital Relationship History of Alcohol Addiction or current problems Drug Addiction or misuse (including marijuana) Panic Disorder/Anxiety Personality Characteristics, Preexisting Functional Issues prior to pain problem, and other variables. Morbid obesity Deconditioning and sedentary life style Sleep issues Nicotine Dependence Resistance to making any personal changes Age Social risk factors for compliance and successful treatment with opioids Social sec rit disabilit iss es Social security disability issues Litigation/workman s compensation issues Living environment (who is living in the home and why) Area code/local neighborhood 3
General Guidelines for Opioid Therapy Have all other strategies for Pain Management been tried? Having evaluated the patient from a physical, psychological, social, and spiritual point of view (thoroughly evaluating risk factors) proceed with caution. Start low and go slow Remember that all opioid treatment is a trial: not an entitlement program Typically convert to long acting medications Please use caution regarding break through medications Evaluation of Opioid Therapy: Monitoring Outcomes: Is it Working? Critical outcomes: The Four A s Analgesia Is pain relief meaningful? Adverse events Are side effects tolerable? Activities Has functioning improved? Aberrant drug-related behavior 4. Passik SD, Whitcomb L, Kirsch K, et al. Pain outcomes as assessed with a pain assessment and monitoring tool in chronic non-malignant pain patients treated with opioids: results of final analyses. Paper presented at: The International Conference on Pain and Chemical Dependency; June 6-8, 2002; New York, NY. Monitoring Outcomes: Analgesic Is the visual analogue scale improving? Is there meaningful pain relief? Is there improvement in functional activities? i i Note: Remember to document findings Monitoring Outcomes of Opioid Therapy: Side Effects Common: Constipation and somnolence Less common Nausea Amenorrhea Sexual dysfunction Urinary retention Myoclonus Headache Itching Sweating Cognitive Impairment 5. Portenoy RK. Opioid prescribing to patients with and without chemical dependency. Presented at: The International Conference on Pain and Chemical Dependency; June 6-8, 2002: New York, NY. 11. Portenoy RK, Coggins C. Management of opioid side effects. Presented at: The International Conference on Pain and Chemical Dependency; June 6-8, 2002; New York, NY. 4
Monitor Outcomes of Opioid Therapy: Aberrant Behaviors? 1. Preference for short acting medications 2. Running out of medications early/unsanctioned dose escalations 3. Obtaining pain medications from other physicians 4. Borrowing or family member s medication (drugs) More severe aberrant behaviors 1. Obtaining prescription drugs from nonmedical sources (on the street) 2. Concomitant abuse of related illicit drugs (marijuana or other?) 3. Recurrent prescription losses 4. Selling prescription drugs 5. Injecting oral formulation 6. Prescription forgery Monitoring Outcomes: Functional Improvement Improvement in Pain Disability Index Family/home responsibilities Recreation Social activities Sexual behavior Self-care abilities Sleeping Occupation On might even consider physiological measures like bmi, cardiovascular function, bp, hr, or weight loss Improvement in test scores on depression and anxiety (BDS and BAI) Controversies in Narcotic Therapy for Pain Management Providing narcotics to a high risk population Pseudo-addiction issues Pseudo-addiction issues When do you make pain medication contingent on behavioral health changes: stop smoking, weight loss, regular exercise program, etc? Resistance and negotiating compliance. Patients not attending other prescribed pain treatments like physical therapy, acupuncture, etc. 5
Controversy #1: Interventional Strategies especially for moderate to high risk patients Medication agreement Adequate medical management of pain Adequate management of co-morbid anxiety and depression: multi-disciplinary approach Periodic random urine drug screens Pill counts for all controlled substances at all patients visits Controversy #2: Pseudoaddiction Pattern of drug-seeking behavior of pain patients receiving inadequate pain management that can be mistaken for addiction Cravings and some types of aberrant behavior Concerns about availability Clock-watching Unsanctioned dose escalation Resolves with re-establishing analgesia Involve self-help and alternative strategies for pain management 14. Weissman DE, Haddox JD. Opioid pseudoaddiction an iatrogenic syndrome. Pain. 1989;36:363-366. Controversies #3: Crazy, lazy or just non-compliant/resistant? When do you make continuing narcotic therapy dependent upon behavioral health changes. Gaining the cooperation of the patient to make changes to reduce their pain. Resistance issues: Pain medication contingent upon patients actively participating in their own care by following though with prescribed medical care: diagnostic studies and adjunctive treatments. Age and Financial Factors When to Refer to a Multidisciplinary Pain Program Depends on your personal level of comfort, support staff and clinical i loperations and policies i Pre-existing significant psychological factors Are there any therapies (injections or nonpharmacological approaches that you do not offer) that warrant further consideration? Practitioner/patient conflicts 6
Conclusions Chronic pain affects the quality of life of many patients which can be improved with opioids. Healthcare providers need to try first try non-narcotic approaches for pain prior to medications. Narcotics are not an entitlement. Health care providers need to gain the cooperation of the patient in their own recovery process. Healthcare providers need to appropriately assess, treat, and reassess chronic pain, patient compliance and functional improvement. Successful pain management for the moderate to high risk patients includes the utilization of a multi-disciplinary approach, e.g. interventional procedures, medical management, psychological evaluations, alternative strategies, physical therapy, and good rational for treatments. 7