Clinical Cases With Common Pain Conditions

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Contents 1 Course 8: Clinical Cases With Common Pain Conditions 1.1 Practice Gap/Need 1.2 Goal 1.3 Core Competencies & Clinical Skills 1.3.1 A. Screen and Assess for Substance Abuse When Treating Common Pain Conditions 1.3.2 B. When Indicated, Prescribe Opioids Appropriately for Common Pain Conditions 1.3.3 C. Stratification of Risk 1.3.4 D. Monitor Patients with Common Pain Conditions for Substance Abuse 1.4 Case Studies/Standardized Patients 1.5 Back Pain 2 Osteoarthritis 3 Headache 4 Neuropathy 5 Acute Pain 6 New courses:

Course 8: Clinical Cases With Common Pain Conditions

Clinical Cases: Treating Common Pain Conditions While Minimizing Risk of Addiction

Practice Gap/Need

Co-morbid substance abuse affects 20 to 40% of patients on opioid therapy for chronic pain (Katz, et al., 2003; Manchikanti et al., 2001). Non-medical use of opioids is high: an estimated 4.7 million people over age 12 have used opiate pain medication in the past month, according to the 2008 National Survey on Drug Use and Health, which represents a slight increase over the past 5 years (SAMHSA, 2009).

The importance of preventing, identifying and treating substance abuse when managing chronic pain with opioids is well documented (Compton, 2008). However, a 2004 national survey of 979 physicians for a report on diversion by the National Center on Addiction and Substance Abuse at Columbia University (CASA) identified a number of deficiencies in both competency and practice in substance abuse practices that are important in pain management. For instance, nearly half of physicians do not ask about prescription drug abuse when taking an initial health history at a patient's first visit and physicians with more training in pain and addiction are more likely to ask for this information (CASA, July 2005, p. 53). The same survey found that nearly 25% of physicians do not discuss the possibility of addiction when prescribing a controlled substance (CASA, July 2005, p. 54). In CASA's national survey of 648 primary care physicians in 1999, only 30.2% felt "very prepared" to diagnose prescription drug abuse and rates were even lower for alcoholism (19.9%) and illegal drug use (16.9%) (CASA, April 2000, p. ii. The same survey found that very few physician (2.1%) feel that treatment is very effective for illegal drug abuse (CASA, April, 2000, p. iii).

In CASA's report on the problem of diversion, they recommended that physicians should receive more continuing medical education related to prescribing and administering controlled substances and identifying, diagnosing, and treating substance abuse and addiction (CASA, July 2005, p. 100). In addition, the National Institute on Drug Abuse (NIH) has identified a need for increased education and training for physicians in the identification and treatment of comorbid pain and substance abuse (NIDA RFP 093, 2008). However, The majority of 979 physicians surveyed in 2004 by the National Center on Addiction and Substance Abuse at Columbia University (CASA) did not receive training, either in medical school or in CME, in identifying prescription drug abuse and addiction (CASA, JULY 2005, pp. 90-91).

Back pain, acute pain, osteoarthritis, headache, neuropathy, and fibromyalgia are the most common chronic conditions for which opioids are prescribed in primary care (Fleming et al., 2007; Reid et al., 2002). Physicians studied in a teaching hospital did not use a standard approach to common issues in addiction medicine and pain management (Merrill, et al, 2002). More costly, extensive approaches often have no better outcomes than the simpler approaches in the guidelines. For example, despite evidence-based guidelines for back pain, the most common form of chronic pain, approaches to treatment vary widely and have similar outcomes (Chou et al, 2007).

A multidisciplinary panel, after a review of the evidence chronic opioid therapy in chronic non-cancer pain, recommended that physicians follow certain guidelines when prescribing opioids; many of the recommendations were designed to reduce the risk of addiction and other substance abuse (Chou, et al. 2009). According to these guidelines, ideally, physicians should screen every pain patient for substance abuse or risk of substance abuse (Chou, et al. 2009). Physicians should use first line pain therapies first, and only use opioids when they are indicated (Chou, 2009). Physicians should structure treatment so that the risk of developing addiction is minimized and modify treatment structure when risk is identified (Chou et al, 2009). Physicians should follow certain baseline precautions with every chronic pain patient requiring chronic opioic therapy (Gourlay et al, 2005).

Physicians need to be able to follow evidence-based guidelines for treating the pain of common chronic conditions and when opioids are indicated, they need to take the appropriate clinical steps to avoid triggering or contributing to an addiction problem (Chou et al, 2009).

Goal

The learner will be able to apply knowledge of appropriate precautions to minimize risk of addiction when treating common pain conditions.

Core Competencies & Clinical Skills

Each learner should be more proficient in the following core competencies and clinical skills after completing this course:

A. Screen and Assess for Substance Abuse When Treating Common Pain Conditions

Recognize substance misuse in patients who have common pain conditions

1. Screen for risk of substance abuse
2. Assess for current substance abuse
3. Order and interpret baseline urine drug testing
4. Interpret relevant physical exam and other laboratory and findings
5. Use a Prescription Monitoring Program

B. When Indicated, Prescribe Opioids Appropriately for Common Pain Conditions

Prescribe opioids appropriately when needed in treating common pain conditions

1. Use opioids for chronic pain only after first-line and second-line treatments have failed
2. Recognize the infrequent situation in which opioids are indicated for treatment of chronic pain
3. Use non-opioid medications on a schedule rather than as needed before trying opioids
4. When opioids are indicated, use in combination with other pharmacological (adjuvant) and non-pharmacological therapies in order to minimize the dose and increase effectiveness
5. Use non-scheduled and/or extended-release opioids before scheduled, high-potency opioids when appropriate

C. Stratification of Risk

Recognize when pain patients can be treated in primary care and when they require referral to a specialist or consultation

D. Monitor Patients with Common Pain Conditions for Substance Abuse

Monitor patients who have common pain conditions for substance abuse

1. Use an assessment tool to assess for substance abuse during ongoing treatment
2. Conduct pill counts
3. Conduct and interpret urine drug testing
4. Identify behavioral and other "yellow flags" that are indicative of substance misuse
5. Address with the patient findings suggestive of substance abuse problems

Case Studies/Standardized Patients

Back Pain

Case 1: Becky Bad Back - 29YOWF

• Chief Complaint: Gradual onset of daily back pain that intensifies at night
• Narrative: Becky is a dentist who has been experiencing back pain despite attention to posture and doing back exercises. Her pain stopped responding to NSAIDs 2 months ago.
• Opioid Issue: Back pain not responding to NSAIDs
• Relevant Past Medical, Psychosocial, Family History: Practicing dentistry for nearly one year; back pain gradually came on over the last 6 months
• Competencies Covered: A

Case 2: David Back Pain - 44YOBM

• Chief Complaint: Ran out of back pain medication
• Narrative: David went to physical therapy for 6 months after injuring his back in a bicycle accident and also took oxycodone for 1 month. He says that he "just felt better" while taking the oxycodone and he started buying it illegally on the Internet after his prescription ran out. He "isn't sure" how much oxycodone he takes now.
• Opioid Issue: Undiagnosed substance use disorder
• Relevant Past Medical, Psychosocial, Family History: Sustained a back injury and broken arm 6 months ago when a car crashed into his bicycle
• Competencies Covered: B, C

Osteoarthritis

Case 1: Olivia Osteoarthritis - 67YOWF

• Chief Complaint: Cannot take NSAIDs any more due to gastrointestinal problems; wants to try opioids, which work for her husband
• Narrative: Olivia has had arthritis for 17 years but can no longer tolerate NSAIDs. She tried her husband's fentanyl and thought it worked "marvelously."
• Opioid Issue: Can no longer tolerate NSAIDs; has tried fentanyl and requests a prescription
• Relevant Past Medical, Psychosocial, Family History: Husband takes fentanyl for sciatica
• Objectives Covered: A

Case 2: Mary Oxycodone - 56YOWF

• Chief Complaint: Would like her usual pain medication, oxycodone, for joint pain
• Narrative: Mary participated in some breast cancer clinical trials which did send the cancer into remission but also resulted in chronic pain. During this time Mary became addicted to oxycodone, taking as many as 12 tablets a day at times. She admits that her ongoing pain is minimal, but she still takes 1 to 2 oxycodone a day as prescribed by her oncologist.
• Opioid Issue: Addicted to opioids; opioids may not be appropriate for pain diagnosis
• Relevant Past Medical, Psychosocial, Family History: Diagnosed with breast cancer 15 years ago; continues to be cancer free
• Competencies Covered: B, C

Headache

Case 1: Hedda Headache - 28YOWF

• Chief Complaint: Headaches have increased in frequency and severity
• Narrative: Hedda suffers from headaches lasting most of the day nearly every day. They become severe in the afternoon and evening. While visiting her sister she found that Percodan relieved them "better than anything else" and would like it prescribed.
• Opioid Issue: Tried unprescribed opioids, which relieved chronic daily headaches more effectively than prescribed non-opioid medications
• Relevant Past Medical, Psychosocial, Family History: Mother often complained of severe headaches
• Competencies Covered: A, B

Case 2: Mandy Migraine - 47YOWF

• Chief Complaint: Needs someone to prescribe another migraine medication; Oxycodone prescribed by her neurologist has worked in the past
• Narrative: Mandy suffers from frequent migraine headaches and says migraine medications do not work. She asks specifically for oxycodone.
• Opioid Issue: Migraine headaches refractory to standard treatment
• Relevant Past Medical, Psychosocial, Family History: Went to "rehab" over 10 years ago (details unknown)
• Competencies Covered: B, C

Neuropathy

Case 1: Sydney Sciatic - 61 YOWM

• Chief Complaint: Needs new doctor to manage longstanding sciatic neuropathy
• Narrative: Sydney has suffered from sciatic neuropathy for "a long time". He has a new job and so can no longer afford to take off a half day to go to the city to see a neurologist.
• Opioid Issue: Typically has prescriptions for at least three different opioids at the same time
• Relevant Past Medical, Psychosocial, Family History: Injury to sciatic nerve persisted after healing from multiple fractures from a fall on a construction job at age 37.
• Competencies Covered: A, C

Case 2: Nora Neuropathy - 72 YOWF

• Chief Complaint: Diabetic neuropathy is worsening
• Narrative: The neuropathic pain is not responding as well to her usual medications. She has been on controlled-release oxycodone for over a year for moderately severe diabetic neuropathy. She's been self-medicating with additional opioids from multiples sources. She had some left over pain medication from having a kidney stone twice last year and sometimes she takes a few of her busband's "pain pills" or a friend sometimes "helps her out."
• Opioid Issue: Supplements her prescribed medication with opioids from other sources
• Relevant Past Medical, Psychosocial, Family History: Diabetes is moderately well-controlled; has had a number of hospitalizations for various diabetes-related complications
• Competencies Covered: B, C

Acute Pain

Case 1: Anna Ankle - 34YOAF

• Chief Complaint: Pain from acute ankle injury not responding to medication for chronic pain
• Narrative: Anna takes about 6 Percocet a day to control chronic back pain from a car accident injury - she gets some of the Percocet from her orthopedist (3 tablets/day) and "dips into" her husband's supply of "pain meds" from prior dental surgeries. Anna fell down the porch steps and fractured her foot and needs something additional for the acute pain.
• Opioid Issue: Acute pain from trauma in a patient already on opioids for chronic pain (Opioid-induced hyperalgesia)
• Relevant Past Medical, Psychosocial, Family History: Hurt back in a car accident 8 months ago; goes to physical therapy twice a week
• Competencies Covered: B, C