Neuropathy

From Clinicaltools.com

Contents 1 Course 8: Neuropathy 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 Studies/Simulated Patients

Course 8: Neuropathy and Opioids: Patients at Various Stages of Addiction/Recovery

Need

Many clinicians overprescribe opioids for neuropathy and do not take the appropriate clinical steps to avoid triggering or contributing to an addiction problem when managing pain from neuropathy. Neuropathy is one of the most common 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).

Goal

The learner will manage the neuropathy 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 neuropathy

1. Use opioids for neuropathy only after first-line treatments have failed
2. Use non-opioid medications on a schedule rather than as needed before trying opioids
3. Identify the small subgroup of neuropathy patients for whom opioids are indicated
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 neuropathy patients

1. Monitor total use of opioids for neuropathy 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 neuropathy require referral to a specialist of consultation

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

Case Studies/Simulated Patients

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 his sciatic nerve persisted after healing from multiple fractures after a fall on a construction job at age 37.
• Objectives 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: Her diabetes is moderately well-controlled and she has had a number of hospitalizations for various diabetes-related complications.
• Objectives Covered: B, C