Ongoing Management

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Contents 1 Course 3: Ongoing Management 1.1 Practice Gap/Need 1.2 Goal 1.3 Core Competencies & Clinical Skills 1.3.1 A. Update Pain Information Regularly 1.3.2 B. Monitor for Substance Abuse 1.3.3 C. Address Substance Abuse 1.3.4 D. Co-manage Patients 1.4 Case Studies/Standardized Patients

Course 3: Ongoing Management

Managing Substance Misuse and Addiction in Ongoing Treatment of Chronic Pain Patients

Practice Gap/Need

Co-morbid substance abuse affects 20 to 40% of patients on opioid therapy for chronic pain (Katz, et al., 2003; Manchikanti et al., 2001). Non-medical use of opioids is high: an estimated 4.7 million people over age 12 have used opiate pain medication in the past month, according to the 2008 National Survey on Drug Use and Health, which represents a slight increase over the past 5 years (SAMHSA, 2009).

The importance of preventing, identifying and treating substance abuse when managing chronic pain with opioids is well documented (Compton, 2008). However, a 2004 national survey of 979 physicians for a report on diversion by the National Center on Addiction and Substance Abuse at Columbia University (CASA) identified a number of deficiencies in both competency and practice in substance abuse practices that are important in pain management. For instance, nearly half of physicians do not ask about prescription drug abuse when taking an initial health history at a patient's first visit and physicians with more training in pain and addiction are more likely to ask for this information (CASA, July 2005, p. 53). The same survey found that nearly 25% of physicians do not discuss the possibility of addiction when prescribing a controlled substance (CASA, July 2005, p. 54). In CASA's national survey of 648 primary care physicians in 1999, only 30.2% felt "very prepared" to diagnose prescription drug abuse and rates were even lower for alcoholism (19.9%) and illegal drug use (16.9%) (CASA, April 2000, p. ii. The same survey found that very few physician (2.1%) feel that treatment is very effective for illegal drug abuse (CASA, April, 2000, p. iii).

In CASA's report on the problem of diversion, they recommended that physicians should receive more continuing medical education related to prescribing and administering controlled substances and identifying, diagnosing, and treating substance abuse and addiction (CASA, July 2005, p. 100). In addition, the National Institute on Drug Abuse (NIH) has identified a need for increased education and training for physicians in the identification and treatment of comorbid pain and substance abuse (NIDA RFP 093, 2008). However, The majority of 979 physicians surveyed in 2004 by the National Center on Addiction and Substance Abuse at Columbia University (CASA) did not receive training, either in medical school or in CME, in identifying prescription drug abuse and addiction (CASA, JULY 2005, pp. 90-91).

A multidisciplinary panel, after a review of the evidence chronic opioid therapy in chronic non-cancer pain, recommended that physicians follow certain guidelines when prescribing opioids; many of the recommendations were designed to reduce the risk of addiction and other substance abuse (Chou, et al. 2009). According to these guidelines, ideally, physicians should screen every pain patient for substance abuse or risk of substance abuse (Chou, et al. 2009). Physicians should use first line pain therapies first, and only use opioids when they are indicated (Chou, 2009). Physicians should structure treatment so that the risk of developing addiction is minimized and modify treatment structure when risk is identified (Chou et al, 2009). Physicians should follow certain baseline precautions with every chronic pain patient requiring chronic opioic therapy (Gourlay et al, 2005).

Physicians should continue to monitor patients on chronic opioid therapy using assessment/tracking tools, urine drug tests, prescription drug monitoring, and pill counts (Chou et al, 2009, Gourlay et al, 2005). Physicians need to intensify treatment structure when there is the possibility of substance abuse (Compton, 2008).

Goal

The learner will be able to take steps to minimize the development of substance use disorders throughout treatment of chronic pain patients and will be able to monitor chronic pain patients in order to detect substance use disorders when they do occur.

Core Competencies & Clinical Skills

Each learner should be more proficient in the following core competencies and clinical skills after completing this course:

A. Update Pain Information Regularly

Continue to prescribe opioids in accordance with the patient's current pain situation and functioning

1. Re-evaluate pain and function (assess analgesia and activity) periodically using standardized pain scales (e.g., verbal or numeric rating or visual analogue scales) to determine the need for continued pain medication
2. Assess current mood
3. Monitor patients for adverse effects and adherence
4. Consider incorrect pain diagnosis as a possible reason for non-response to medication
5. Follow strategies for exiting treatment when appropriate

B. Monitor for Substance Abuse

Continue to monitor pain patients for substance abuse and inappropriate use throughout treatment

1. Stratify risk by using a risk assessment tool to determine level of monitoring needed (assign the patient to a low, medium, or high risk group for substance abuse disorders or noncompliant opioid use)
2. Monitor pain patients over time for other possible signs of medication abuse including non-compliance with medication regimens or drug-seeking or other aberrent behaviors using an assessment tool such as the PDUQ, COMM or similar.
3. Differentiate drug-seeking behaviors due to substance dependence or addiction from drug-seeking behaviors or misuse (overuse) due to under-treated pain
4. Recognize behaviors due to psychiatric problems or drug misuse for "chemical coping"
5. Regularly continue to screen for addiction, abuse, and chemical coping using a tool appropriate for chronic pain patients
6. Talk with significant others and obtain other collateral information
7. Ask about proper use of medication at each appointment and adjust medication if pain is under-treated
8. Consider implementing random urine drug testing in your pain practice
9. Select appropriate drugs for which to screen in urine drug tests
10. Recognize pseudoaddiction and opioid induced hyperalgesia as well as anxiety from therapeutic dependence and discern from addictive drug seeking

C. Address Substance Abuse

Address abuse of prescribed pain medications if it develops by tightening treatment structure and making appropriate referrals

1. Communicate effectively with patient about problematic medication use
2. Document abuse in the patient's medical record, including type, quantity, and duration of substances used
3. Prescribe pain medications in shorter time intervals and require more follow-up appointments
4. Require regular pill counts and limit medication refills
5. Increase other monitoring
6. Revise treatment agreements in accordance with tightened structure
7. If opioids must be discontinued, taper or detox humanely or refer for this purpose
8. Refer to a specialist if addiction is detected

D. Co-manage Patients

Co-manage patients with specialists and other healthcare providers when appropriate

1. Identify patients requiring co-management with a specialist
2. Determine which type of specialist is appropriate, considering both addiction, pain, and other specialists
3. Distinguish between cases requiring a simple initial consultation versus ongoing co-management
4. Obtain legal permission to share patient information with all parties involved including addiction and pain specialists, other healthcare providers, family members, and friends
5. Establish an agreement between primary care, specialist healthcare providers, and other members of the treatment team that describes the care that each clinician will provide and includes a communication protocol and schedule of visits
6. Become familiar with any addiction treatment plans
7. Continually share information as appropriate with other healthcare providers throughout the patient's treatment

Case Studies/Standardized Patients

Case 1: Chris Chronic Pain - 29 YOBM

• Chief Complaint: Chronic pelvic pain from past crushing injury
• Narrative: Chris has been in treatment with you for 2 years and reports increased pain recently. It has been over a year since his last appointment.
• Opioid Issue: Increasing pain possibly from opioid induced hyperalgesia; time lag since last appointment
• Relevant Past Medical, Psychosocial, Family History: History of crushed pelvis in car accident at age 18
• Competencies Covered: A

Case 2: Bob Backache - 52YOWM

• Chief Complaint: Flare up of chronic back problem
• Narrative: Bob is a long-term back pain patient (20+ years) who calls sporadically and asks for a refill. He reports that 4 back injuries have exacerbated the problem and thus he has called for refills more frequently as of late.
• Opioid Issue: Increasingly frequent requests for refills
• Relevant Past Medical, Psychosocial, Family History: Longstanding back pain started with injury while moving furniture over 20 years ago
• Competencies Covered: B

Case 3: Tina TMJ - 27 YOBF

• Chief Complaint: Lost her prescription for a refill on pain medication for chronic TMJ pain
• Narrative: Tina says that a surgical procedure to relieve temporomandibular joint (TMJ) pain instead left her with constant jaw pain. She uses a fentanyl patch. During the interview she admitted that she started using 2 patches simultaneously, when the one patch you prescribed was not working. Then she found that she liked the euphoric effect and started wearing 2 patches all the time. Now she has pain if she does not use 2 patches. She obtained the second patch by seeing a second doctor.
• Opioid Issue: Misuse/possible substance abuse
• Relevant Past Medical, Psychosocial, Family History: TMJ problems since college; surgical treatment for TMJ problems 5 years ago was not effective
• Competencies Covered: C, D