medications for pain: what you need to know for treatment in workers’ compensation suzanne novak,...

Medications for Pain:What You Need to Know for Treatment in

Workers’ Compensation

Suzanne Novak, MD, PhD

5/17/07

Outline

Opioids in general Adderall Actiq NSAIDS Benzodiazepines Barbiturates Soma Anti-depressants Prialt

Opioids: How did they get so popular?

These drugs were noted to treat both acute pain and cancer pain effectively

This was extended to treatment of chronic pain

Addiction was thought to arise only rarely during legitimate treatment of pain

Tolerance could be overcome by dose escalation

Opioids: What we learned

50% of patients abandon treatment in trials because they don’t work or they have side effects

Patients become refractory to treatment These drugs have significant neuroendocrine

effects Behavioral problems, and often, frank

addiction interfere with treatment

Opioids: Failed Treatment

Is there evidence of failed treatment?- Opioid hyperalgesia- Frank tolerance

What did we do in the past?

- Increase the dose until tolerance is overcome

Opioids: How to avoid failed treatmentStart to address the use of opioids early in treatment

Rule Out Risk Factors for Possible Misuse Cage Questionnaire Screener and Opioid Assessment for

Patients with PainHistory of substance abuse

Legal problems Heavy Smoking

Cravings Mood Swings

Opioids: How to avoid failed treatmentStart to address the use of opioids early in treatment

Consider a Psychological Evaluation

Diagnoses that have a poor outcome with opioid therapy:

Conversion disorder Somatization disorder Pain disorders associated with depression

and/or anxiety

Additional Steps Before a Trial

Set treatment goals Document baseline pain and functional

assessments Function assessments (social, physical,

psychological, daily and work activities) Could the claimant be weaned? Treatment agreement

Once started: What to look for

Prescriptions from a single practitioner and single pharmacy

Ongoing review:

Current pain Least/most pain

Average pain How long before relief

How long it lasts

Once started: What to look for

The 4 A’s for Ongoing Monitoring Pain Relief Side Effects Physical and Psychosocial Function Occurrence of Aberrant/non-adherent

Behavior

Opioids: Side Effects

Constipation Nausea Dizziness Somnolence or Drowsiness Vomiting Dry Skin Itching/Pruritis

Opioids: When to continue and when to discontinue

Continue: Don’t stop if it’s working Improved pain and function Return to work

Discontinue No overall improvement in function Continuing pain with intolerable adverse

effects

Opioids: When to continue and when to discontinue

Illegal activities: diversion; forgery; arrest related to drugs

Suicide attempts Threatening behavior in the office

Repeated slips from the drug agreement:

Suggest a consult with a physician trained in addiction

Treatment of Opioid-Related Sedation:Most Common Initially and With Dose Increases

Eliminate unnecessary medications Rest Exercise Timing Opioid rotation Reducing the dose

Psychostimulants for Management of Sedation: Adderall

Not recommended

Data supporting the use of this treatment is lacking in clinical trials.

Actiq

Ongoing review: Current pain, Least/most pain, Average pain, How long before relief, How long it lasts

Not recommended for musculoskeletal pain

Recommended for breakthrough cancer pain

NSAIDs

There is no current evidence for long-term effectiveness for pain or function

There is a risk of gastrointestinal and cardiovascular side effects

GI/no CV: Non-selective +PPI or Cox-2 CV: Naproxyn if required

Benzodiazapenes

Not recommended for long-term use

(No more than 4 weeks)

Tolerance develops rapidly

Barbituates

Not recommended

The potential for drug dependence is high

No evidence of clinically important analgesic effect

Soma

Metabolized to meprobamate: anxiolytic Main effect may be due to sedation Withdrawal symptoms may occur with abrupt

withdrawal Soma-Coma: Street-drug name when used

with opioids

Anti-depressants

First-line treatment for neuropathic pain Possible for non-neuropathic pain Analgesia occurs within a few days

Tricyclic anti-depressants

SNRIs: Effexor (venlafaxine) and Cymbalta (duloxetine)

Wellbutrin (bupropion)

Prialt

Not recommended until all other intrathecal medication options have been exhausted

Advantage: Considered non-addictiveDisadvantage: Possible side effects including

severe psychiatric symptoms and neurological impairment

Use with caution in patients with history of depression and psychosis

Questions