Headache

From Clinicaltools.com

Contents 1 Course 7: Headache and Opioids: Patients at Various Stages of Addiction/Recovery 1.1 Need 1.2 Goal 1.3 Objectives 1.3.1 Objective A. Limit Opioid Use 1.3.2 Objective B. Recognize Misuse 1.3.3 Objective C. Consult or Refer 1.4 Case Study/Simulated Patients

Course 7: Headache and Opioids: Patients at Various Stages of Addiction/Recovery

Need

Many clinicians overprescribe opioids for headache. Headache is one of the most common condition for which opioids are prescribed in primary care (Fleming et al., 2007; Reid et al., 2002). Furthermore, they often do not take the appropriate clinical steps to avoid triggering or contributing to an addiction problem when managing pain from headache. 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).

Goal

The learner will manage the headache in primary care, in a way that avoids triggering or contributing to addiction problems.

Objectives

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

Objective A. Limit Opioid Use

Limit use of opioids and prescribe appropriately when treating headache

1. Use opioids for headache only after first-line and second-line treatments have failed
2. Recognize the uncommon situation in which opioids are indicated for treatment of headache
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 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

Objective B. Recognize Misuse

Recognize substance misuse in headache patients

1. Monitor total use of opioids for headache pain and compare to expected use for the diagnosis
2. Identify "yellow flags" that are indicative of substance misuse

Objective C. Consult or Refer

Recognize when patients with headache require referral to a specialist or consultation

1. Determine which type of pain or addiction specialist is appropriate
2. Consider referring to patients who develop a chronic pain syndrome to a pain specialist
3. Refer headache patients who require opioid therapy and have "yellow flags" for addiction to a pain specialist or orthopedist
4. Refer patients who have an addiction disorder for addiction treatment
5. Refer patients to other medical and mental health specialists when appropriate
6. Include all key patient information (history and current status) in referral report

Case Study/Simulated Patients

Case 1: Hedda Headache - 28YOWF

• Chief Complaint: Headaches have increased in frequency and severity.
• Narrative: 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: Her mother often complained of severe headaches.
• Objectives Covered: A, B

Case 2: Mandy Migraine - 47YOWF

• Chief Complaint: Needs someone to prescribe another migraine medication. Oxycodone has worked for her in the past, prescribed by her neurologist.
• Narrative: 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).
• Objectives Covered: B, C