Osteoarthritis

From Clinicaltools.com

Contents 1 Course 6: Osteoarthritis 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 6: Osteoarthritis and Opioids: Patients at Various Stages of Addiction/Recovery

Need

Osteoarthritis 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 osteoarthritis. 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 osteoarthritis 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 osteoarthritis

1. Use opioids for osteoarthritis only after first-line treatments have failed (NSAIDs, PT, other?)
2. Use non-opioid medications on a schedule rather than as needed before trying opioids
3. When opioids are indicated, use in combination with other pharmacological and non-pharmacological therapies in order to minimize the dose and increase effectiveness
4. Use non-scheduled and/or extended-release opioids before scheduled, high-potency opioids

Objective B. Recognize Misuse

Recognize substance misuse in osteoarthritis patients

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

1. Determine which type of pain or addiction specialist is appropriate
2. Refer osteoarthritis patients who require opioid therapy and have "yellow flags" for addiction to a pain specialist or rheumatologist
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: 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: Mary was diagnosed with breast cancer 15 years ago and continues to be cancer free.
• Objectives Covered: B, C