Chronic Pain 101 Evidence Based Medicine
Chronic Pain 101 was the next topic at the conference.
Dr. Nemeth ([email protected]) with RestoreFx was the prior Medical Director for the TDI – State of Texas. He is from Austin, TX. He is going to talk about medication misuse.
Definitions
- Abuse – Addiction is a brain disease with loss of control, compulsive use, craving, and consequences.
- Tolerance – the state of physical adaption in which exposure to a drug induces changes that result in decreases of drug effect over time
- Hyperalgesia- a state of hypersensitivity following the withdrawal or of opioids or in chronic addiction
- Pseudoaddiction – drug seeking due to the undertreatment of chronic pain
Pain
- Acute
- Chronic
- Nocieceptive
- Neuropathic
Chronic Pain Syndrome
- Copers – tolerate the pain
- Chronic pain syndrome
Screening
- Up to 56% of Pain Clinic patients
- Alcohol/Drug/Use
- Family History of Addiction
- Behavioral indicators
- Urine Drug Screening
- Smoking
- Medical Indicators
TAKEAWAY – CHRONIC PAIN – ADDICTION IS A BRAIN DISEASE
Dr. Suzanne Novak – Board Certified Anesthesiologist, PhD Outcomes research and pharmacoeconomics, Professor in pharmacotherapy, at University of Texas, lead author ODG Treatment Guidelines
She is the wife of the prior speaker – Dr. Nemeth
ODG- National Guidelines- prescribing guidelines that are now accepted in the 13 states.
Evidence Based Medicine (EBM) is here to stay
There are obviously limitations to the use of EBM
Handling a Complex Case Main Focus
- Evidence based
- Effective
- Safe
- Cost-effective in most cases
Paying for something that is not work-related
- Diabetes
- Hepatitis
- Autoimmune disease
- Numerous other conditions
Part of the problem missed
- Injections
- Other care – e.g. urine drug screens
- Compounded drugs
- Causality
- Underlying comorbidity
Why to do the review and uses of info
- Treatment plan issues
- Settlement//MSA
- Have a plan
- Get a team
- Who will first contact provider?
- Type of info
- Options to offer
State of Washington – Labor and Industry has a daily morphine equivalency calculator – used to see the amount of morphine can be equated to a daily amount of narcotics. There is also a Benzodiazepine equivalency calculator.
Injections
- Interventional techniques increased by 228% – 2000 to 2011
- Medicare expenditures increased by 240% – 2000 to 2008
- Office of Inspector General (DHHS) significant proportion of facet joint and ESI’s were not medically necessary.
- A single facet joint injection is recommended
- If 50% or more pain relief for 6 weeks from the single facet injection, proceed to other blocks
- Series of three injections is antiquated
Urine Drug Testing
- A Point of Care screen is recommended before initiating chronic opioid therapy
- Risk assessment should be made on a schedule determined by patient abuse risk factor
- Random collection is encouraged
- Quantitative testing is not recommended
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