Addiction Treatment

From Clinicaltools.com

Contents 1 Course Alternative 6: Addiction Treatment 1.1 Need 1.2 Goal 1.3 Objectives 1.3.1 Objective A. Treat Patient in Addiction Treatment 1.3.2 Objective B. Prevent Abuse and Relapse 1.3.3 Objective C. Detect Abuse and Relapse 1.3.4 Objective D. Monitor Pain and Addiction 1.4 Case Study/Simulated Patients 1.4.1 Case 1 1.4.2 Case 2 1.4.3 Case 3 1.4.4 Case 4 1.4.5 Case 5

Course Alternative 6: Addiction Treatment

Managing Pain Patients Who Are In Addiction Treatment

Need

Clinicians need to know how to manage patients who are currently in addiction treatment who have acute and chronic pain.

Goal

The learner will manage pain and addiction treatment in order to provide appropriate dosing for pain and to prevent relapse among patients who are in addiction treatment.

Objectives

After completing this course, the learner will be able to:

Objective A. Treat Patient in Addiction Treatment

Determine optimum dosing and duration of pain treatment for patients who are currently in addiction treatment

1. Determine adequate dosing and duration of pain medication for patients who are currently in treatment for opioid addiction
2. Determine adequate dosing and duration of pain medication for patients who are currently in treatment for alcohol or other substances
3. Determine the lowest dose and duration of pain medication that is likely to be effective to treat the pain
4. Consider referral to a specialist if high doses of pain medication are required in a patient on buprenorphine or methadone
5. Employ non-opioid pain treatment strategies to treat pain and prevent relapse in patients who are in drug-free (abstinence) addiction treatment programs
6. Determine the appropriateness of non-opioid pain medications alone or in combination with opioids
7. Determine the appropriateness of non-pharmacological treatments, such as cognitive-behavioral therapy, physical therapy, and complementary and alternative medicine (CAM) treatments

Objective B. Prevent Abuse and Relapse

Employ strategies for preventing and recognizing abuse and relapse in someone who is in addiction treatment

1. Prescribe less-addicting pain medications
2. Determine the appropriateness of non-opioid pain medications
3. Determine the appropriateness of non-pharmacological treatments, such as cognitive-behavioral therapy, physical therapy, and complementary and alternative medicine (CAM) treatments
4. Recommend intensification of relapse prevention activities
5. Increase frequency of visits and decrease size of prescription

Objective C. Detect Abuse and Relapse

Employ strategies for preventing and recognizing abuse and relapse in someone who is in addiction treatment

1. Use sensitive interviewing techniques to inquire about patient's cravings or thoughts about using substances again
2. Identify behavioral red flags suggestive of substance abuse and/or relapse to addiction
3. Monitor pain medication use through pill counts

Objective D. Monitor Pain and Addiction

Provide ongoing care management of patients with substance use disorders co-occurring with pain

1. Obtain permission to share patient information with all parties involved including addiction and pain specialists, family members, and friends
2. Establish an agreement between primary care and specialist providers that that describes the care that each clinician will provide and includes a communication protocol and schedule of visits
3. Query patient about status of addiction treatment or recovery and treatment by other members of the treatment team at each visit
4. Query patient about status of pain at each visit and the extent to which the patient was able to follow directions
5. Continually re-assess risk and screen for substance abuse and refer back to the addiction specialist as needed
6. Co-manage patients with specialists and other healthcare providers (Covered in detail in core course)

Case Study/Simulated Patients

- IN DEVELOPMENT

Case 1

Nettie Knee Replacement on Addiction Treatment Maintenance Therapy: 52YOWF

• Chief Complaint: Pain in knee that needs replacement surgery.
• Narrative: Nettie needs a double knee replacement as soon as possible. She has a history of addiction to heroin and prescription opioids but has been successfully maintained on MMT for the past 8 years (with 1 relapse early in treatment) and recently switched to bup treatment (8 months ago). Nettie is concerned about having post-surgical pain but also afraid of relapsing back into addiction if she is prescribed pain meds.
• Objective Addressed: 1. Determine adequate dosing and duration of pain treatment for patients who are currently in addiction treatment
• Clinical Skills:

1. Determine adequate dosing and duration of pain treatment for patients who are currently in addiction treatment for opioid addiction
2. Determine the lowest dose and duration of pain medication that is likely to be effective to treat the pain

Case 2

A.A. Jones with Spinal Pain: 42 YOBM

• Chief Complaint: Spinal pain without detectable cause.
• Narrative: A.A. is in treatment for alcohol addiction. [more]

• Objective Addressed: 1. Determine adequate dosing and duration of pain treatment for patients who are currently in addiction treatment
• Clinical Skills:

1. Determine adequate dosing and duration of pain treatment for patients who are currently in addiction treatment for alcohol or other substance addiction
2. Determine the lowest dose and duration of pain medication that is likely to be effective to treat the pain

Case 3

Bill Badbreak in Treatment for Opioid Addiction: 19 YOWM

• Chief Complaint: Acute severe pain due to leg fracture.
• Narrative: Bill is in addiction treatment currently for prescription opioid addiction. He says he is not allowed to take any potentially addictive pain medications.
• Objective Addressed: 2. Employ pain treatment strategies to prevent relapse and treat pain in patients who are in drug-free (abstinence) addiction treatment programs
• Clinical Skills:

1. Choose less addicting pain medications
2. Consider non-opioid pain medications
3. Consider complementry and alternative medicine treatments
4. Consider intensive counseling treatment

Case 4

Stan Stable in Treatment With Chronic Post-Traumatic Musculoskelatal Pain: 29 YOBM

• Chief Complaint: Chronic pelvic pain from past crushing injury.
• Narrative: Stan has been in treatment for alcohol addiction and methadone abuse and wants something for his pain but it might interfere with his treatment
• Objective Addressed: 2. Employ pain treatment strategies to prevent relapse and treat pain in patients who are in drug-free (abstinence) addiction treatment programs
• Clinical Skills:

1. Choose less addicting pain medications
2. Consider complementry and alternative medicine treatments
3. Consider intensive counseling treatment

• Objective Addressed: 3. Employ strategies for preventing and recognizing abuse and relapse
• Clinical Skills:

1. Identify behavioral red flags suggestive of abuse and/or relapse to addiction
2. Monitor pain medication use through pill counts
3. Increase frequency of visits and decrease size of prescription

Case 5

Manny Docs Starting Addiction Treatment With Chronic Back Pain: 37 YOBM

• Chief Complaint: Too much back pain when he follows the medication protocol given to him by the addiction specialist.
• Narrative: Manny is wondering whether it is safe to take the prescription his addiction doctor gave him along with the prescription he has been getting from you for a long time. The addiction doctor said to taper off the prescription you gave him in preparation for treatment but he had trouble following the tapering schedule and never went back to the specialist.
• Past Medical History: Lower back pain gradually worsening over past 10 years.
• Objective Addressed: 2. Employ pain treatment strategies to prevent relapse and treat pain in patients who are in drug-free (abstinence) addiction treatment programs
• Clinical Skills:

1. Refer for physical therapy when appropriate

• Objective Addressed: 4: Co-manage patient treatment with addiction and/or pain specialists
• Clinical Skills:

1. Obtain permission to communicate with all parties involved including addiction and pain specialists and friends and family
2. Establish an agreement between primary care and specialist providers that that describes what care each clinician will provide
3. Establish communication protocol to be followed by primary care and specialist providers
4. Establish a schedule for optimal patient management that includes each provider
5. Request consultation when appropriate
6. Inquire about status of addiction recovery at each pain evaluation visit
7. Identify indications for referral back to the specialist