Amyotrophic lateral sclerosis (ALS), commonly called Lou Gehrig's disease, is a progressive neuromuscular condition characterized by weakness, muscle wasting, fasciculations and increased reflexes.Management of Chronic Non- Cancer Pain. MANAGEMENT OF CHRONIC NON- CANCER PAIN: A GUIDE TO APPROPRIATE USE OF OPIOIDS. Jennifer P. Schneider, M. D., Ph. D. Wilmot Rd., Suite 2. Tucson,AZ 8. 57. 12(5. Fax (5. 20) 2. 90- 0. Miniabstract: Myths and fears about addiction often prevent the use of opioids in treatment of chronic non- cancer pain. This article presents guidelines for safe and appropriate prescribing of opioids, monitoring of patients, and avoiding legal problems. This article will describe the relationship between addiction and ongoing use of opioid drugs, and will describe how to assess patients who have chronic pain, determine the appropriateness of treating them with opioids, and follow them on a regular basis. Fear of getting the patient . Experience with patients who have abused opioids and have lied to them about their drug use. The health care provider is not comfortable trying to differentiate between . Belief that using opioids on a chronic basis is intrinsically bad. Fear of incurring problems with their state licensing board. Studies indicate that the de novo development of addiction when opioids are used for the relief of pain is low. The American Pain Society stated . The patient exhibits drug- seeking behavior and becomes overwhelmingly involved with using and procuring the drug. The addiction becomes the addict's number one priority, and relationships with family and friends suffer. The addict's mental interior becomes filled with preoccupation about the drug. Other activities are given up. Life revolves around obtaining and using the drug. The alcoholic finds himself/herself gradually consuming more and more alcohol in order to . Most of the focus on transdermal systems has been on the patch dosage form, but a variation in the patch system of the transdermal era is a metered spray, for example Evamist Clonidine reference guide for safe and effective use from the American Society of Health-System Pharmacists (AHFS DI). Safety and Effectiveness of Transdermal Nicotine Patch in Smokers Admitted With Acute Coronary Syndromes Trip J. Washam, PharmD, Paul A. Pappas, MS, and James G. Practical Considerations for Optimal Transdermal Drug Delivery. Cheryl Durand; Abdullah Alhammad; Kristine C. Am J Health Syst Pharm. Varenicline (Chantix) Varenicline (Chantix) Nicotine polacrilex lozenge (Commit) PHARMACOTHERAPY PHARMACOTHERAPY Bupropion SR (Zyban) Dose: 150 mg q AM for 3 days, then 150 mg bid 7-12 weeks. Begin 1-2 Weeks before quit date. He or she takes the drug on a different schedule, may combine it with other, unprescribed, drugs, and, despite admonitions to discuss any changes with the physician in advance, repeatedly reports them after the fact. Loss of control over drug use: The patient repeatedly uses up the drug before time for next refill. In the context of chronic pain, this does not refer to simply wanting the drug. Rather, the patient frequently requests early refills with a host of creative reasons, such as that the medication was stolen by the neighbor, left on the bus, fell down the sink, was forgotten at the out- of- town hotel, or was eaten by the dog. The patient gets prescriptions from different doctors and has them filled at multiple pharmacies. He may visit different emergency rooms to obtain opioid drugs rather than consulting his physician. Abuse of drugs other than the prescription drugs. The patient may be using marijuana, cocaine, and other illegal drugs, or may have excessive use of alcohol. Contact with street drug culture. The patients sells his or her prescription drug, or buys and uses street drugs. Negative consequences resulting from drug use. This type of patient is often stigmatized with the label of . Once a sufficient dose of opioid is prescribed, this phenomenon, termed . Some of these drugs have intrinsic properties which result in physical dependence if the drug is repeatedly taken into the body. Months of heavy use are required to produce physical dependence on alcohol or nicotine, whereas only weeks of using opioids can induce physical dependence. Some drugs of abuse - - for example marijuana, cocaine, and hallucinogens - -do not produce physical dependence. It simply means that a habituated user will experience certain symptoms if the drug is stopped abruptly. Withdrawal symptoms can be avoided simply by tapering the drug over days. Physical dependency on opioids is an expected ocurrence in all individuals in the presence of continuous use of opioids for therapeutic or for non- therapeutic purposes. It does not, in and of itself, imply addiction. For example, a person who regularly drinks can remain awake and alert at a blood alcohol level that would put an alcohol- naive person to sleep. It is important to recognize, however, that not all the physical effects of a drug are subject to tolerance. With opioids, for example, tolerance develops to the respiratory depression, sedation, and nausea that opioids induce, but not to constipation. In practice, this means that if the dose of opioid is gradually increased, respiratory depression can be avoided and sedation and nausea will abate, whereas constipation will remain a problem to be dealt with. Does prescribing opioids for pain lead to addiction? Portenoy. 4 reviewed this and other studies, as well as his own experience, and concluded that addiction to opioids in patients without an addiction history rarely results from long- term opioid treatment for pain. According to the AAPM/APS position paper. Patients with prior drug abuse histories in whom opioid prescription is being considered should be strongly encouraged to strengthen their chemical dependency recovery programs by increasing attendance at 1. Alcoholics Anonymous or other 1. My experience and that of other clinicians is that recovering alcoholics are less likely to relapse than are patients who formerly were addicted to opioids; prescribing opioids to the latter group should be considered only as a last resort if every other approach has failed. Types of chronic non- cancer pain which can be alleviated by opioids. Pain has been classified into three types: Somatic pain - - arising in skin, bone, and muscle. Examples are bone and joint pain resulting from injury, rheumatoid arthritis, osteoarthritis, sickle cell anemia, or chronic osteomyelitis; chronic headache; and chronic back pain related to injury or multiple surgeries. Visceral pain - -involves the visceral organs. Examples are chronic pelvic pain and chronic interstitial cystitis. Neuropathic pain - - results from injury to nerves. Examples are peripheral diabetic neuropathy, reflex sympathetic dystrophy, and post- herpetic neuralgia. In addition to the primary physician, other possible team members are: a physiatrist, physical therapist, anesthesiologist (for administering local injections), biofeedback specialist, hypnotist, acupuncturist, orthopedic surgeon, neurologist, neurosurgeon, addictionist, and psychologist. The first step is to assess the goal of treatment - - is it to diagnose and eliminate the pain by removing the source? Has the patient had a workup to determine the cause of the pain and the treatment options? For example, a patient with severe hip pain due to osteoarthritis might best be served by undergoing a hip replacement, which might result in no pain and improved function. These changes are not usually observed in chronic pain patients. It is not possible to assess chronic pain objectively. Direct questioning is therefore indicated: ? How severe is it usually? What kinds of medications, and how much, does it take to relieve your pain? For example, a patient may have fallen down several stories in an elevator, with resultant back pain, or may have had multiple failed back surgeries, or had osteomyelitis. It is crucial to learn how the pain has impacted the patient's life, and what his or her life was like before the pain began. The constriction of the patient's life helps assess the severity of the pain. It is important to be able to compare what happens to the patient's life once opioid use begins. Opioids are generally a last resort. Has the patient been tried on: non- opioid analgesics, e. NSAIDstricyclic antidepressants - - good in low doses especially for neuropathic pain. Full- dose antidepressants - for associated depression. TENS unit. Physical therapy. Steroid/local anesthetic injections. Muscle relaxants, including benzodiazepines. Psychotherapy. Biofeedback. Anticonvulsants, especially for neuropathic pain Hypnosis. Surgical procedures to relieve pain (sometimes an option). Both specialists can evaluate the role of local injections, physical therapy, TENS units, and other physical modalities. The physiatrist can recommend improved assistive devices such as wheelchairs or braces. The anesthesiologist might consider placement of a spinal cord stimulator for some types of pain. Only two criteria are physical: development of tolerance and presence of withdrawal symptoms. The other five are all behavioral: Three involve loss of control, two continuation despite negative consequences, for example, . In addition, the patient may be very concerned with obtaining the medication, so he may be labeled a . Since we can't use these criteria, we must rely on the patient's level of functioning. If they are using the drug for other than pain relief, their loss of control will become apparent soon enough. Was there evidence of loss of control (prescriptions lost, getting medications from several doctors, demanding refills early)? Some patients state that they drink alcohol in order to dull their pain. If the patient is using mood- altering substances, ask about his or her willingness to forego using these drugs in exchange for adequate pain relief with opioids. In such cases, the decision to dispense opioids must be made reluctantly and with great caution. Records of prior surgeries, accident reports, physical therapy and other assessments and treatments will not only assist in the current evaluation, but will also protect the clinician in case of questions by licensing bodies. Deformities, surgical scars, and other relevant features should be documented in the chart. In particular I look for physical signs that support the history provided by the patient. In addition, if the patient has not had an evaluation by a physiatrist, rheumatologist, or other specialist knowledgeable in the area of the patient's problems, I refer the patient for such consultation. The contract. Once a decision has been made to proceed with opioid treatment, the first step is to discuss a contract with the patient and obtain his or her signature. It is understood that if the patient breaks the contract, prescription of opioids will cease. Occasionally, even the most knowledgeable clinician will be fooled by a drug- seeker who is experienced in deception.
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October 2016
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