1. STOP! Safe Treatment of Pain
Corey Black, MD FACP

2. Opioid Epidemic 120 Deaths per day in the US 7000 ED visits per year
245 Mil prescriptions
US prescribes 80% world opioids

3. Centegra’s Data CHM 2,853,000 ml IV Opioids 2013
CHM 3,320,000 ml IV Opioids 2015 (877 G)
CHM 72,ooo ml IV Naloxone 2013
CHM 78,000 ml IV Naloxone 2015

4. Patients Presenting On Opioids
Assess Risk
Bedside Opioid Overdose Calculator
Talk to patients about their overdose risk
Document conversation in discharge note

5. Bedside Opioid-Overdose Calculator
Pain Med 2017 April 13. doi /pm/pnx038
18 Mil patients from IMS PharMetrics Plus health plan claims database prescribed opioids
Substance Use Disorders (OR=10.2); Depression (OR=3.12);
Impaired liver, renal, pulmonary function; mental health disorders

7. Practice Plan Guidelines
CDC Opioid Prescribing Guidelines
Look at non pharmacologic pain management options (ie. Heat/cold, message, stress management)
Long term treatment starts with acute pain management
Need to provide informed consent
Prescribing naloxone to high risk patients
Avoid prescribing benzodiazepines with opioids

9. Acute Pain Start with nonopioid medication
Informed consent when starting opioids
Treat with lowest effective dose
Opioid limited to 3 to 7 days

12. Mild Pain(1-5/10 patient reported) (1-2 Functional Scale)
Non-opiods (NSAIDS, Acetaminophen, Hot/ Cold packs, Lidoderm patch
Moderate Pain(6-8/10) patient reported (3/5 Functional Scale)
Low Dose Opioids (Codeine, Norco, Percocet)
Adjuvant Analgesics
Antidepressants
Gabapentin
Anticonvulsants
Severe Pain (9-10/10) patient reported) (4-5/5 Functional Scale)
High Dose Opiods (IV Opiods, PO Morphine, Oxycodone)

13. Chronic Pain Patient Selection Failed Non-opioid Analgesics
Other Analgesics Contraindicated
Not on Unresponsive Dx List
Initial Patient Assessment
Exam to confirm diagnosis
Quick Screen
ABCDPQRS
Query PMP
Comprehensive Pain Management Plan
Non pharmacologic measures
Non opioid Pain Medications
Trial of Opioid Therapy
Informed Consent
Review Side Effects
Exit Strategy
Follow up in 3-5 days
Patient Reassessment
Continue Opioid

14. Patient Selection Failed non-opioid analgesics NSAIDS
Topical Anesthetics
Other analgesics contraindicated
Not on unresponsive diagnosis list

15. Diagnoses Not Responsive to Opioids
Fibromyalgia
Migraine
Irritable Bowel Syndrome
Cyclic Vomiting
Uncomplicated Back and Neck pain

16. Initial Patient Assessment
Exam to confirm diagnosis
Assess functional pain scale
Quick Screen questions
ABCDPQRS
Query Patient Monitoring Program

17. Functional Pain Scale Rating Description No Pain 1
No Pain 1
Tolerable: Doesn’t prevent activity 2
Tolerable but does affect some activity 3
Intolerable but can use phone, watch TV, Read 4
Intolerable and unable to use phone, watch TV, Read 5
Intolerable and unable to verbally communicate because of pain

18. Quick Screen Questions:
In the past year, how often have you used the following?
Alcohol
For men, 5 or more drinks a day
For women, 4 or more drinks a day
Tobacco Products
Prescription Drugs for Non-Medical Reasons
Illegal Drugs

19. ABCDPQRS Alcohol Benzodiazepines Clearance and metabolism of the drug
Delirium, dementia and falls risk
Psychiatric comorbidities
Query the prescription monitoring program
Respiratory insufficiency and OSA
Safe driving, work, storage and disposal

20. Comprehensive Pain Management
Non pharmacologic measures
Non opioid pain medications
Opioid pain medications when indicated

21. Trial of Opioid Therapy
Informed Consent
Review Side Effects
Exit Strategy if Opioids Ineffective
Follow up in 3-5 days

22. Informed Consent Explain addiction potential of opioids
Take with other drugs or alcohol “you may not wake up”
Explain Illinois prescription monitoring program
Explain use of urine drug screening per CDC guidelines

23. Patient Reassessment The Four “A’s” Analgesia Activity of Daily Living
Adverse Effects
Aberrant Drug-Taking Behaviors

24. Continue Opioids Establish Pain Contract Urine Drug Screening
Prescription Monitoring Program
Reassess Pain Management

25. Exit Strategy
Document the lack of improvement in functional status/pain
Emphasize that the patient is not being abandoned
Taper off opioid therapy

26. Remember Proper Patient Selection Key
Proper Patient Assessment is Mandatory
Opioids Are Only One Component of a Comprehensive Pain Treatment Plan
Prescribing Opioids on a Trial Basis MUST be Monitored
Patient Reassessment is KEY
Any Medical Therapy can be Continued, Discontinued, or Modified

27. Kevin MD video