Preventing SubAb -- PainMeds

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focus on working   with that patient to avoid trouble

Contents 1 Course 2: Preventing Substance Use Disorders When Prescribing Opioids to Pain Patients 1.1 Need 1.2 Goal 1.3 Objectives 1.3.1 A. Use a prescribing strategy that minimizes risk of pain medication abuse/addiction 1.3.2 B. Use patient education and other clinical strategies and to prevent improper use of opioid pain medication 1.3.3 C. Develop signed treatment agreements describing expectations and obligations for the patient and the provider 1.4 Case Study/Simulated Patients - IN DEVELOPMENT 1.4.1 Fibromyalgia Janet 37YOWF 1.4.2 Wendy Whiplash 34YOWF

Course 2: Preventing Substance Use Disorders When Prescribing Opioids to Pain Patients

Need

Many clinicians do not prescribe opioid pain medications with the caution needed to prevent pain patients from developing substance use disorders.

The majority of physicians either did not receive any training or a maximum of a few hours on prescribing controlled drugs (CASA, 2005). Only a minority of physicians use medication contracts with patients suspected of abusing prescription drugs (CASA, 2005), so it seems unlikely that the contracts are being used with all pain patients to much extent. Nearly a third of 132 physicians surveyed in another study hesitated to prescribe opioids because of concerns about causing addiction and uncertainty about the correct dose (Lin et al, 2007).

Goal

The learner will be able to minimize the risk of pain patients developing substance use disorders through best practice approaches to prescribing opioids.

Objectives

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

A. Use a prescribing strategy that minimizes risk of pain medication abuse/addiction

1. Use first-line medications for treating pain condition before prescribing opioids
2. Choose the least-addictive drug that will adequately manage the pain
3. Prescribe the lowest dose that will adequately manage the pain
4. Prescribe opioids in combination with other effective medications and treatments
5. Prescribe opioids in short time intervals and refill pain medication only with verification of continued pain diagnosis and/or impaired function
6. Prescribe extended release formulations of opioids for patients with constant pain in order to minimize the reward effect and provide more stable blood levels
7. Re-evaluate effectiveness of pain treatment periodically and change medication if needed

B. Use patient education and other clinical strategies and to prevent improper use of opioid pain medication

1. Inform pain patients of the risk of substance use disorders with use of prescription opioids
2. Explain that the risk of substance use disorders is present even when there is legitimate pain
3. Discuss proper use of opioid pain medications and the dangers of self-medication
4. Advise patients of opioid toxicity and potentially harmful interactions
5. Advise patients of harm from changing form of opioid drug delivery (e.g. insuflation or injecting)
6. Provide patient education materials about correct use of opioids, including side effects and risks
7. Ask about proper use of opioid medication at each appointment and adjust treatment plan if pain is under-treated

C. Develop signed treatment agreements describing expectations and obligations for the patient and the provider

1. Discuss with the patient the necessity of establishing a treatment agreement
2. Develop the core components of a written treatment agreement
3. Describe expectations of the patients that best minimize risk
4. Discuss consequences with the patient of breaking a treatment contract
5. Include exit strategies that describe in advance the criteria for stopping opioids

Case Study/Simulated Patients - IN DEVELOPMENT

Fibromyalgia Janet 37YOWF

• Chief Complaint: Increasingly severe pain from fibromyalgia and needs a new physician.
• Narrative: Janet was recently diagnosed with fibromyalgia and it is not responding as well as she would like to NSADs. She needs a new physician because her long-time family doctor recently retired. Janet self-medicates with alcohol and has done so for the two years she has had symptoms. She is concerned that her pain is increasing and quality of life is decreasing (along with co-morbid depression) and that she needs something to treat the chronic pain.
• Objective Addressed: zz
• Skills-Training Goals: zz

Wendy Whiplash 34YOWF

• Chief Complaint: Pain from Whiplash
• Narrative: Pain has persisted for several weeks since being evaluated in an emergency department. She says the pain is severe and interfering with sleep, driving, and her work. She is a new patient.
• Family History: Mother was addicted to Valium for many years
• Objective Addressed: zz
• Skills-Training Goals: zz