Chronic Non-Cancerous PainChronic Non-Cancerous Pain& Problematic Opiate Use & Problematic Opiate Use

Diagnostic and Therapeutic Principles with Diagnostic and Therapeutic Principles with some Guidelinessome Guidelines

James K. Rotchford MD MPHJames K. Rotchford MD MPH

Olympic Pain & Addiction Services Olympic Pain & Addiction Services (OPAS)(OPAS)

Port Townsend, WAPort Townsend, WA

Disclosure:Disclosure:

OPAS is a private medical practice.OPAS is a private medical practice.New patients are seen primarily New patients are seen primarily because of consultation request.because of consultation request.

Medicare ProviderMedicare ProviderLabor & Industry ProviderLabor & Industry ProviderKitsap Physician Service Kitsap Physician Service

ProviderProvider

ObjectivesObjectives• Be familiar with issues pertinent to caring Be familiar with issues pertinent to caring

for patients who are candidates for opiate for patients who are candidates for opiate therapies and are at risk for problematic therapies and are at risk for problematic opiate use.opiate use.

• Be familiar with the clinical and theoretical Be familiar with the clinical and theoretical overlap in helping patients with chronic overlap in helping patients with chronic pain and chemical dependency. pain and chemical dependency.

• Be familiar with some guidelines for Be familiar with some guidelines for prescribing opioids to patients at risk for prescribing opioids to patients at risk for problematic opioid use.problematic opioid use.

Clinically Pertinent Clinically Pertinent QuestionsQuestions• Is prescribing opioids to this patient part of the Is prescribing opioids to this patient part of the

solution or part of the problem?solution or part of the problem?– How does one answer this question?How does one answer this question?

• Are improved pain and activity scores enough?Are improved pain and activity scores enough?

• Are presence of aberrant behavior the tip off?Are presence of aberrant behavior the tip off?

• Is formal screening for past or present addictive problems the Is formal screening for past or present addictive problems the way to go?way to go?

• Can I in the context I’m prescribing safely Can I in the context I’m prescribing safely prescribe opioids to this patient? And for how prescribe opioids to this patient? And for how long? Which opioids are best and which ones are long? Which opioids are best and which ones are available & legal to use?available & legal to use?

• How do I safely prescribe opioids to a patient with How do I safely prescribe opioids to a patient with known addiction problems or who already is on known addiction problems or who already is on methadone or buprenorphinemethadone or buprenorphine??

Basic Principles:Basic Principles:

• If risk factors are prominent treat the patient as If risk factors are prominent treat the patient as though they are opiate dependent.though they are opiate dependent.

• Limit self-medicating in patients at risk.Limit self-medicating in patients at risk.

• With high risk patients consider only methadone and With high risk patients consider only methadone and buprenorphine ; the only proven effective agonists in buprenorphine ; the only proven effective agonists in opiate dependency.opiate dependency.

• Limit amounts and increase frequency of visits if in Limit amounts and increase frequency of visits if in doubt about safety.doubt about safety.

• Don’t argue, show respect, and treat withdrawal Don’t argue, show respect, and treat withdrawal aggressively. Encourage behavioral and “active” aggressively. Encourage behavioral and “active” treatment modalities.treatment modalities.

Further Lecture OverviewFurther Lecture Overview• Contextual Issues Contextual Issues

• Some pertinent issues related to chronic non-Some pertinent issues related to chronic non-cancerous paincancerous pain

• Some pertinent issues related to chemical Some pertinent issues related to chemical dependency.dependency.

• Overlap between addictive disorders and Chronic Overlap between addictive disorders and Chronic Pain Pain

• Discussion of Pseudo-Addiction vs problematic opioid Discussion of Pseudo-Addiction vs problematic opioid use . Seeing Problematic Opioid Use as a continuum use . Seeing Problematic Opioid Use as a continuum in terms of severity and clinical relevance.in terms of severity and clinical relevance.

• Some suggested solutionsSome suggested solutions

• Some guidelines for prescribing opiates to patients Some guidelines for prescribing opiates to patients with problematic opioid use concerns.with problematic opioid use concerns.

Contextual Issues are Contextual Issues are Important!Important!• PopulationPopulation

– Risk FactorsRisk Factors• Pain Etiology, Psychiatric and CD co-morbidity, Social Pain Etiology, Psychiatric and CD co-morbidity, Social

Support, Activity Engagement, third party coverage?Support, Activity Engagement, third party coverage?

– Hospital/Surgical vs. OutpatientHospital/Surgical vs. Outpatient– Co-morbid conditions/treatmentCo-morbid conditions/treatment

• LocaleLocale– Rural vs. Cosmopolitan vs. IncarcerationRural vs. Cosmopolitan vs. Incarceration– Methadone Clinic vs. traditional medical, behavioral, or Methadone Clinic vs. traditional medical, behavioral, or

chemical dependency servicechemical dependency service

• Acute nocioceptive vs. chronic painful conditionsAcute nocioceptive vs. chronic painful conditions

• Financial and other access issuesFinancial and other access issues

• Legal ConcernsLegal Concerns

• Other!Other!

Contextual Issues are Contextual Issues are Important!Important!

• Too numerous to elaborate upon fully.Too numerous to elaborate upon fully.

• Well trained and experienced clinicians Well trained and experienced clinicians essential for optimal outcomes in patients with essential for optimal outcomes in patients with complex chronic pain and problematic opioid complex chronic pain and problematic opioid use, addictive disorders, and other psychiatric use, addictive disorders, and other psychiatric diagnoses.diagnoses.

• Guiding principles, evidence based medicine, Guiding principles, evidence based medicine, and objective findings are very important but and objective findings are very important but flexibility based on contextual considerations flexibility based on contextual considerations and solutions are essential for optimal and solutions are essential for optimal outcomes.outcomes.

OPAS’s Population:OPAS’s Population:– On longstanding opioids or being considered for On longstanding opioids or being considered for

chronic opioid treatment for pain or agonist chronic opioid treatment for pain or agonist therapy.therapy.

– Co-morbid psychiatric problems are common and Co-morbid psychiatric problems are common and include active or in remission chemical include active or in remission chemical dependency (ies).dependency (ies).

– Significant disability (GAF scores commonly in Significant disability (GAF scores commonly in 50-60 range)50-60 range)

– Financially challenged/Rural settingFinancially challenged/Rural setting– At “End” of procedural roadAt “End” of procedural road– Frequently discharged from previous medical Frequently discharged from previous medical

practicespractices– Multiple past traumas (Includes surgeries)Multiple past traumas (Includes surgeries)

Other Medical Settings with Other Medical Settings with unique contextual issues:unique contextual issues:• Primary Care SettingPrimary Care Setting

• Outpatient Orthopedic ClinicOutpatient Orthopedic Clinic

• Outpatient procedurally based pain Outpatient procedurally based pain management service.management service.

• Emergency Room/Urgent Care SettingsEmergency Room/Urgent Care Settings

• Mental Health/Behavioral Mental Health/Behavioral settings/Methadone Clinicssettings/Methadone Clinics

• Jail SettingsJail Settings

• Inpatient SettingsInpatient Settings

• Hospice CareHospice Care

Chronic Non-Cancerous PainChronic Non-Cancerous PainBasic Pertinent IssuesBasic Pertinent Issues• A chronic relapsing disease involving A chronic relapsing disease involving

primarily the Central Nervous System.primarily the Central Nervous System.– Patho-physiology more complex than acute Patho-physiology more complex than acute

painpain• Less about nocioceptionLess about nocioception• More about lack of proper inhibitionMore about lack of proper inhibition• More about improper responses to “memories” or More about improper responses to “memories” or

“triggers”“triggers”• More about improper “operant conditioning” and More about improper “operant conditioning” and

reward system dysfunction.reward system dysfunction.

– Neuro-adaptation/sensitization at spinal & Neuro-adaptation/sensitization at spinal & brain levels.brain levels.

– The analogy of refrigerator coming onThe analogy of refrigerator coming on

Various Models used to Various Models used to Explain & Treat Chronic PainExplain & Treat Chronic Pain• Neuro-Anatomical-PhysiologicalNeuro-Anatomical-Physiological

– Structural and Chemical/PharmaceuticalStructural and Chemical/Pharmaceutical• Spiritual/MoralSpiritual/Moral

– Thorn in the FleshThorn in the Flesh– Punishment/Consequence to poor choices in self or Punishment/Consequence to poor choices in self or

othersothers• PsychologicalPsychological

– BehavioralBehavioral– SomatizationSomatization

• Energetic DisturbanceEnergetic Disturbance• NutritionalNutritional• SocialSocial• Addictive ModelAddictive Model

Addictive Model for Addictive Model for explaining Chronic Painexplaining Chronic Pain

• It is important to understand basic It is important to understand basic neurophysiology that pain and addictions neurophysiology that pain and addictions have in common: have in common: – Dopamine levels in Nucleus AccumbensDopamine levels in Nucleus Accumbens

• Would some patients with chronic pain Would some patients with chronic pain have better outcomes if there condition have better outcomes if there condition was considered to be primarily an was considered to be primarily an “addictive” disorder, possibly aggravated “addictive” disorder, possibly aggravated by opiate dependency or other chemical by opiate dependency or other chemical dependencies? This approach doesn’t dependencies? This approach doesn’t deny nocioceptive pathology and other deny nocioceptive pathology and other medical & psychiatric conditions!!medical & psychiatric conditions!!

Copyright ©2001 CMA Media Inc. or its licensors

Tomkins, D. M. et al. CMAJ 2001;164:817-821

Fig. 1: Schematic diagram of the human brain that highlights some of the main brain areas and neurotransmitter pathways implicated in reward processes

Amygdala

FRONTALCORTEX

NUCLEUSACCUMBENS

ST

RIATUM

IS IT IMPORTANT?

IF I ACT ON ITWILL I BE REWARDED?

HOW DO IACT ON IT?

SHOULD I ACT ON IT?

ME

MO

RY

First Exposure to natural reward

Timeof Reward

First Exposure to drug reward

Timeof Reward

Repeated exposure to same natural reward & predictor:

DopamineSpike

DopamineSpike

DopamineSpike

Time ofReward

First time a better than predicted reward is had:

Cue

Cue DopamineSpikes

Time ofReward

Dopamine is the “currency” which determines the response of Nucleus Accumbens: dopamine spikes within the NA occur as below to “cues” and promotes behavior accordingly

Cue

T ime ofRew ardSpike DropsBelow Baseline

Cue

T ime ofRew ard Spike Continues

Cue

T ime ofRew ard Spike Continues

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AddictionAddiction• A primary, chronic, neurobiological A primary, chronic, neurobiological

diseasedisease, with genetic, psychosocial, , with genetic, psychosocial, and environmental factors and environmental factors influencing its development and influencing its development and manifestations.manifestations.

• It is characterized by behaviors that It is characterized by behaviors that include one or more of the following: include one or more of the following: impaired control over drug use, impaired control over drug use, compulsive use, continued use compulsive use, continued use despite harm, and craving.despite harm, and craving.

A consensus document from the American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Definitions Related to the Use of Opioids for the Treatment of Pain. 2001.

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Addiction: 5CsAddiction: 5Cs

• CChronichronic

• CCompulsive useompulsive use

• CControl—impairedontrol—impaired

• CCravingraving

• CContinued use despite harmontinued use despite harm

2020

Addiction ≠ Physical Addiction ≠ Physical Dependency Dependency Physical dependency is a strong predictor of chemical Physical dependency is a strong predictor of chemical dependency when substances that increase dopamine levels in dependency when substances that increase dopamine levels in NA are being used chronically.NA are being used chronically.

• Physical Dependency as manifested by Physical Dependency as manifested by tolerance and withdrawal are often tolerance and withdrawal are often associated with addiction associated with addiction

• 2 of necessary three out of seven DSM 4 2 of necessary three out of seven DSM 4 criteria for chemical dependency include criteria for chemical dependency include tolerance and withdrawal (signs of tolerance and withdrawal (signs of physical dependence)physical dependence)

• The vast majority of patients who are on The vast majority of patients who are on chronic opiates for painful conditions can chronic opiates for painful conditions can be considered to be opiate dependent be considered to be opiate dependent based on DSM IV criteria.based on DSM IV criteria.

Hypothesis regarding Hypothesis regarding pseudoaddiction:pseudoaddiction:

Our ideas about pseudoaddiction in pain Our ideas about pseudoaddiction in pain management stem from “neurotic” patterns management stem from “neurotic” patterns particularly prominent in American culture:particularly prominent in American culture:

““In 1919 , a Federal ruling held that In 1919 , a Federal ruling held that treatment of addiction was “outside the treatment of addiction was “outside the

realm of legitimate medical interest”. This realm of legitimate medical interest”. This created the conundrum that allowed created the conundrum that allowed

physicians to treat pain but not addiction physicians to treat pain but not addiction that sometimes occurs in the context of that sometimes occurs in the context of

medical use. medical use.

(Principles of Addiction Medicine, 2009 p. 1329, (Principles of Addiction Medicine, 2009 p. 1329, Chapter on Opioid Therapy of Pain by Savage SR et Chapter on Opioid Therapy of Pain by Savage SR et

al.)al.)

Is the behavior observed Is the behavior observed from patient on opioids from patient on opioids “pseudoaddiction” or not?“pseudoaddiction” or not?

• Let’s explore the dilemmaLet’s explore the dilemma– Elements of dilemma?Elements of dilemma?– Reason for dilemmaReason for dilemma– How to extricate oneself from it?How to extricate oneself from it?

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PseudoaddictionPseudoaddiction

• An iatrogenic misinterpretation An iatrogenic misinterpretation caused caused by under treatment of pain that is by under treatment of pain that is misidentified by the clinician as misidentified by the clinician as inappropriate drug-seeking behaviorinappropriate drug-seeking behavior

• Behavior ceases when adequate Behavior ceases when adequate pain relief is provided pain relief is provided

• Not a diagnosisNot a diagnosis, rather a , rather a description of a clinical interactiondescription of a clinical interaction

Weissman DE, Haddox JD. Pain. 1989;36:363-6.

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Difference Between a Difference Between a Chronic Pain Patient & an Chronic Pain Patient & an AddictAddict

Adapted from: Schnoll SH, Finch J. J Law Med Ethics. 1994;22:252-6.

YesNoDenial about any problems

YesNoUse continues in spite of problem

NoYesMedications improve quality of life

YesNoOut of control with medications

AddictionPhysical

dependence

Addiction is a disease; medication compliance is not addiction

DSM 4 Criteria for Chemical DependenceDSM 4 Criteria for Chemical Dependence& Typical Justifications for lack of Validity in Chronic Pain & Typical Justifications for lack of Validity in Chronic Pain patientspatients

• ToleranceTolerance• Expected with prolonged analgesic useExpected with prolonged analgesic use

• WithdrawalWithdrawal• Expected with prolonged regular analgesic use.Expected with prolonged regular analgesic use.

• Used in greater amounts or longer than Used in greater amounts or longer than intendedintended

• Emergence of pain may demand increase dose Emergence of pain may demand increase dose or prolonged use.or prolonged use.

• Unsuccessful attempts to cut down or Unsuccessful attempts to cut down or discontinuediscontinue

• Emergence of pain may deter dose taper or Emergence of pain may deter dose taper or cessationcessation

• Much time spent pursuing or recovering from Much time spent pursuing or recovering from useuse

• Difficulty in finding proper pain managementDifficulty in finding proper pain management

• Important activities reduced or given upImportant activities reduced or given up• Valid Criteria – activity engagement expected Valid Criteria – activity engagement expected

to increase not decline with pain treatment.to increase not decline with pain treatment.

• Continued use despite knowledge of Continued use despite knowledge of persistent physical or psychological harm.persistent physical or psychological harm.

• Valid Criteria – limited harm anticipated from Valid Criteria – limited harm anticipated from analgesic opioid use for pain.analgesic opioid use for pain.

Differential Dx. Of Misuse of Differential Dx. Of Misuse of Analgesic Opioids by Savage et Analgesic Opioids by Savage et al.al.• Misunderstanding of instructionsMisunderstanding of instructions

• Self-medicating of:Self-medicating of:– Mood/stressMood/stress– SleepSleep– Disturbing MemoriesDisturbing Memories– Undertreated PainUndertreated Pain– OtherOther

• Effective use for reward or euphoriaEffective use for reward or euphoria

• Compulsive use due to addictionCompulsive use due to addiction

Addictive Model for Chronic Addictive Model for Chronic PainPain• Pain effects the reward system in ways Pain effects the reward system in ways

similar to drugs of abuse including similar to drugs of abuse including opioids.opioids.

• In patients with a chronic pain disorder In patients with a chronic pain disorder there is often a strong personal or family there is often a strong personal or family history of an addictive disorder.history of an addictive disorder.

• The same areas of the brain involved in The same areas of the brain involved in “suffering” modulation strongly correlate “suffering” modulation strongly correlate with those involved in modulating with those involved in modulating addictive disorders.addictive disorders.

• Pain has all through history been treated Pain has all through history been treated by substances that have addictive by substances that have addictive properties; opiates, alcohol, and properties; opiates, alcohol, and marihuana.  Indeed, in some patients marihuana.  Indeed, in some patients stimulants such as amphetamines help stimulants such as amphetamines help modulate pain.modulate pain.

Addictive Model of Pain Addictive Model of Pain (Cont.)(Cont.)• Complex bio-psycho-social factors are involved in Complex bio-psycho-social factors are involved in

etiology and maintenance of both addictions and etiology and maintenance of both addictions and chronic pain.chronic pain.

• The same psychiatric conditions which The same psychiatric conditions which predispose one to chronic pain are very similar to predispose one to chronic pain are very similar to those associated with a predisposition for those associated with a predisposition for addictive disorders. That is: affective disorders, addictive disorders. That is: affective disorders, personality disorders, anxiety disorders, PTSD, personality disorders, anxiety disorders, PTSD, ADHD, and sleep disorders.ADHD, and sleep disorders.

• Effective treatment approaches have much in Effective treatment approaches have much in common between the two disorders; counseling, common between the two disorders; counseling, education, motivation, support, along with education, motivation, support, along with appropriate pharmacological and nutritional appropriate pharmacological and nutritional support .  Family support/dynamics need to be support .  Family support/dynamics need to be addressed in both addiction and chronic pain.addressed in both addiction and chronic pain.

Addiction Model (Cont. #3)Addiction Model (Cont. #3)• Both conditions are often considered shameful Both conditions are often considered shameful

with people with chronic pain often being accused with people with chronic pain often being accused of malingering or of having weak natures. of malingering or of having weak natures. Patients with addictions clearly are looked down Patients with addictions clearly are looked down on and often face criminal proceedings.on and often face criminal proceedings.

• Relapses are quite common with both conditions Relapses are quite common with both conditions and preparation for relapse is a prerequisite for and preparation for relapse is a prerequisite for good outcomes. good outcomes. 

• Standard imaging or biological markers are often Standard imaging or biological markers are often unable to confirm the diagnoses.  Observation, unable to confirm the diagnoses.  Observation, interviews, history, and contextual issues are interviews, history, and contextual issues are prominent in establishing the diagnoses. Both prominent in establishing the diagnoses. Both clearly involve “subjective” experience.clearly involve “subjective” experience.

Addiction Model for Chronic Addiction Model for Chronic PainPain(Cont. #4)(Cont. #4)• Both appear to benefit from similar Both appear to benefit from similar

behavioral approaches, including behavioral approaches, including spiritual growth and stress reduction.spiritual growth and stress reduction.

• Addiction has been broadly defined as Addiction has been broadly defined as maintaining a relationship with maintaining a relationship with someone or something that interferes someone or something that interferes with proper self care. Using this broad with proper self care. Using this broad definition of addiction, a relationship definition of addiction, a relationship with chronic pain could also be with chronic pain could also be considered an addiction.considered an addiction.

• Other!?Other!?

Problematic Analgesic Problematic Analgesic Opioid Use - a disorder Opioid Use - a disorder with a clinical continuum?with a clinical continuum?Less than effective Use/Prescribing? Less than effective Use/Prescribing? Poor Pain Management/educationPoor Pain Management/educationChemical Coping/Self Medicating Chemical Coping/Self Medicating Occasional Abuse Occasional Abuse Regular Abuse Regular Abuse 5 C’s of Addiction 5 C’s of Addiction Complications alone define Complications alone define problematic analgesic opioid problematic analgesic opioid use use

Response to Problematic Response to Problematic Analgesic Opioid Response:Analgesic Opioid Response:• Attempt to determine where on the Attempt to determine where on the

continuum of problematic use the patient is continuum of problematic use the patient is and respond accordingly.and respond accordingly.

• Often clinically impossible to know for sureOften clinically impossible to know for sure– Even in an established Heroin Dependent Even in an established Heroin Dependent

individual.individual.• They can have untreated painThey can have untreated pain

• Agonist therapy generally stabilizing and helpful.Agonist therapy generally stabilizing and helpful.

• Respond based on risk factors and Respond based on risk factors and contextual issues??!!contextual issues??!!

Practical ConsiderationsPractical Considerations& Guidelines for responding & Guidelines for responding to problematic opioid use.to problematic opioid use.

• Contextual IssuesContextual Issues• Universal PrecautionsUniversal Precautions• Attempt to maintain relationshipAttempt to maintain relationship

• Coordination of CareCoordination of Care• Policies/ProceduresPolicies/Procedures

Practical ConsiderationsPractical Considerations& Guidelines& Guidelines• Contextual Issues Very ImportantContextual Issues Very Important

– Results of formal risk assessmentResults of formal risk assessment– Acute Nocioceptive Pain/Pain EtiologyAcute Nocioceptive Pain/Pain Etiology– Type and severity of chemical dependencyType and severity of chemical dependency– Hospitalized Patient/Surgical PatientHospitalized Patient/Surgical Patient– Time in “recovery” and time without any Time in “recovery” and time without any

aberrant behavioraberrant behavior– Age of patientAge of patient– Co-morbid medical & psychiatric Co-morbid medical & psychiatric

conditions/longevity etc.conditions/longevity etc.

Practical ConsiderationsPractical Considerations& Guidelines& Guidelines

•Universal PrecautionsUniversal Precautions– Basics: required workups & follow ups, Basics: required workups & follow ups,

documentation, screening UA’s, consents documentation, screening UA’s, consents & agreements.& agreements.

– Treat patients similarly who or at Treat patients similarly who or at significant risk for chemical dependency significant risk for chemical dependency as those with documented chemical as those with documented chemical dependency. dependency.

– At risk chronic pain patients & CD At risk chronic pain patients & CD patients with pain problems receive patients with pain problems receive similar treatment similar treatment

Practical ConsiderationsPractical Considerations& Guidelines& Guidelines

• Attempt to maintain therapeutic Attempt to maintain therapeutic relationship relationship – time in treatment is primary – time in treatment is primary predictor of outcome in chemical dependenciespredictor of outcome in chemical dependencies– Progress not PerfectionProgress not Perfection

•Tighten Reins in the context of aberrant behaviorTighten Reins in the context of aberrant behavior

•Therapeutic Plan & Adjunctive CareTherapeutic Plan & Adjunctive Care

– Some reasons for discharge or limiting Some reasons for discharge or limiting controlled substance prescribing:controlled substance prescribing:•Patient is a danger/threat to othersPatient is a danger/threat to others

•Patient behavior interferes with helping othersPatient behavior interferes with helping others

•Established diversion or illegal behaviorEstablished diversion or illegal behavior

•Unwillingness to get further help.Unwillingness to get further help.

Practical ConsiderationsPractical Considerations& Guidelines& Guidelines

• Coordination of Care - Coordination of Care - Integration & continuity of care Integration & continuity of care essential. Ideally pcps, diagnosticians, proceduralists, mental essential. Ideally pcps, diagnosticians, proceduralists, mental health providers, addiction specialists, pharmacists, family, health providers, addiction specialists, pharmacists, family, social workers, case managers, etc. are all part of an informed social workers, case managers, etc. are all part of an informed team.team.– Fragmentation of care is the rule!Fragmentation of care is the rule!– Send out frequent progress notes to pertinent members of Send out frequent progress notes to pertinent members of

team! team! – Assume that other providers/third parties are not informed Assume that other providers/third parties are not informed

about or are highly prejudiced against the medical about or are highly prejudiced against the medical management of addictive disorders and the importance of management of addictive disorders and the importance of managing co-morbid psychiatric issues.managing co-morbid psychiatric issues.

Practical ConsiderationsPractical Considerations& Guidelines& Guidelines• Policies & ProceduresPolicies & Procedures

– Opiate AgreementOpiate Agreement– Missed/late appointmentsMissed/late appointments– Payment issuesPayment issues– Scheduling & Frequency of AppointmentsScheduling & Frequency of Appointments– Acute pain managementAcute pain management– Group Consent FormGroup Consent Form– Staff follows procedures and know when to Staff follows procedures and know when to

ask for help.ask for help.

OPAS ExperienceOPAS Experience• Group/Class visits 6-10 patientsGroup/Class visits 6-10 patients– Counseling/Educational 30-40 minutesCounseling/Educational 30-40 minutes

• Individual visitsIndividual visits– 10-15 minutes . Medical management10-15 minutes . Medical management– Limit to chronic pain/addictionLimit to chronic pain/addiction

• 99215 E&M code 45 mins. with more 99215 E&M code 45 mins. with more than 50% in counseling now has than 50% in counseling now has become 99214 with 90853 group time.become 99214 with 90853 group time.

• Occasional need for office pick upsOccasional need for office pick ups• Opiate Rx’s contingent upon adherence Opiate Rx’s contingent upon adherence

to other medical recommendations.to other medical recommendations.

Clinically Pertinent Clinically Pertinent QuestionsQuestions• Is prescribing opioids to this patient part of the Is prescribing opioids to this patient part of the

solution or part of the problem?solution or part of the problem?– How does one answer this question?How does one answer this question?

• Are improved pain and activity scores enough?Are improved pain and activity scores enough?

• Are presence of aberrant behavior the tip off?Are presence of aberrant behavior the tip off?

• Is formal screening for past or present addictive problems Is formal screening for past or present addictive problems the way to go?the way to go?

• Can I in the context I’m prescribing safely prescribe Can I in the context I’m prescribing safely prescribe opioids to this patient? And for how long? Which opioids to this patient? And for how long? Which opioids are best and which ones are available & legal opioids are best and which ones are available & legal to use?to use?

• How do I safely prescribe opioids to a patient with How do I safely prescribe opioids to a patient with known addiction problems or who already is on known addiction problems or who already is on methadone or buprenorphinemethadone or buprenorphine??

Questions:Questions:

• J. Kimber Rotchford, MD MPH DBAMJ. Kimber Rotchford, MD MPH DBAM– JKRotchford@gmail.com

•Transferring to Methadone from another opiateTransferring to Methadone from another opiate

•Treating acute nocioceptive pain in the context of Treating acute nocioceptive pain in the context of chronic methadone or opioid prescribingchronic methadone or opioid prescribing

• Policy guidelines for an orthopedic clinicPolicy guidelines for an orthopedic clinic

– www.opas.us– Principles of Addiction Medicine 4Principles of Addiction Medicine 4thth Edition, Ries et Edition, Ries et

al., 2009 by Lippincott Williams & Williams, pp al., 2009 by Lippincott Williams & Williams, pp 1275-1353 cover Pain & Addiction.1275-1353 cover Pain & Addiction.