Focus on Pain Conditions

From Clinicaltools.com

Contents 1 Course 5: Focus on Common Pain Conditions 1.1 Need 1.2 Goal 1.3 Objectives 1.3.1 Objective A. Prescribe Opioids Appropriately 1.3.2 Objective B. Recognize Misuse 1.3.3 Objective C. Consult or Refer 1.4 Case Studies/Standardized Patients 1.5 Back Pain 2 Osteoarthritis 3 Headache 4 Neuropathy 5 Acute Pain

Course 5: Focus on Common Pain Conditions

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

Need

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). However, some clinicians prescribe opioids incorrectly for common and problematic pain conditions. Furthermore, clinicians who prescribe opioids often do not take the appropriate clinical steps to avoid triggering or contributing to an addiction problem when managing chronic pain. 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 be able to minimize risk of addiction when prescribing opioids and other controlled substances for treatment of common pain conditions.

Objectives

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

Objective A. Prescribe Opioids Appropriately

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

Objective B. Recognize Misuse

Recognize substance misuse in patients who have common pain conditions

1. Monitor total use of opioids for chronic 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 pain patients require referral to a specialist or consultation

1. Determine which type of pain or addiction specialist is appropriate
2. Consider referring patients who develop a chronic pain syndrome to a pain specialist
3. Refer chronic pain patients who require opioid therapy and have "yellow flags" for addiction to a pain specialist or other appropriate specialist
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 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
• Objectives 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
• Objectives 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
• Objectives 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
• Objectives 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)
• Objectives 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.
• 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: Diabetes is moderately well-controlled; has had a number of hospitalizations for various diabetes-related complications
• Objectives 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
• Objectives Covered: B, C