Professional Documents
Culture Documents
Pain Management:
Patient Evaluation, Addiction, Physical
Dependence, and Federal Regulations
— IASP, 1994
Pain is the most common complaint for which
individuals seek medical attention!
SAMHSA. (2007). Results from the 2006 National Survey on Drug Use and Health: National Findings
(Office of Applied Studies, NSDUH Series: H-32, DHHS Publication No. SMA 07-4293). Rockville, MD.`
Sources of Diverted Rx Drugs
♦ Thefts & losses
− Armed robberies
− Night break-ins
− Employee & customer pilferage
♦ Growing number of “rogue” Internet pharmacies
♦ International smuggling
♦ Study within Eastern 22 states from 2000-2003
− Almost 28 million CS dosage units diverted
• Approximately 7 million (25%) were opioids
♦ Media focus on diversion stemming only from prescribers
can hinder patient access to care
Joranson DE, Gilson AM. J Pain Symptom Manage. 2005;30:299-301. Brushwood DB, Kimberlin CA.
J Am
Pharm Assoc. 2004;44:439-44. Inciardi JA, et al. Pain Med. 2007;8:171-83. National Center on
Addiction & Drug Abuse at Columbia University. “You’ve Got Drugs!” Prescription Drug Pushers on
N a t i o n a l S u r v e y o n D r u g Use
a n d H e a l t h (NSDUH)
NSDUH Report: How Young Adults Obtain Prescription Pain Relievers for Nonmedical Use
Issue 39, 2006
Barriers to Pain Management
♦ Addiction/Misuse/Diversion
of Controlled Substances
Addiction
Consensus Document. The American Academy of Pain Medicine. The American Pain Society. The
American Society of Addiction Medicine. 2001.
Physical Dependence
Consensus Document. The American Academy of Pain Medicine. The American Pain Society. The
American Society of Addiction Medicine. 2001.
♦ Physical dependence and addiction
can coincide, but physical dependence does
not equal addiction in all cases. Physical
dependence is a neuro-pharmacological
phenomenon while addiction is both a
neuropharmacological and behavior
phenomenon
Triangle of the Disease of Addiction
Genetics
Social
Neurochemical
Environment
Tolerance
Consensus Document. The American Academy of Pain Medicine. The American Pain Society. The
American Society of Addiction Medicine. 2001.
History of AA
Portenoy, R.K., Savage, S.R. Journal of Pain and Symptom Management. Vol. 14 No. 3 (Suppl.) Sept. 1997
Fishbain DA, Cole B et al. Pain Medicine 9(4): 2008; 444-459
Iatrogenic Addiction
Heit HA, Gourlay DL. Treatment of Pain in Substance Abuse Disordered Population.
Ballantyne JC, Rathmell JP, Fishman SM (eds). Bonica’s Management of Pain. 4th ed.
Lippincott Williams & Wilkins. In Press.
Treatment of Pain with Opioids
♦ Decrease pain
♦ Increase function
♦ Use medications that do not have
unacceptable side effects
Patient Evaluation
♦ Initial evaluation
♦ Each appointment
Universal Precautions in Pain Medicine
*Model Policy for the Use of Controlled Substances for the Treatment of Pain.
Policy Statement: Federation of State Medical Boards of the United States, Inc; 2004
Federal Regulations
Consultation with
Appropriate Specialist:
Example:
Addiction Medicine,
Mental Health
Basic Boundary
Setting
Enhanced Boundary
Setting
Gourlay D, Heit HA et al. Pain Med. 2005;6(2):107-112.
Inform, Set and Enforce Boundaries with Your
Patient Based on Mutual Trust and Honesty
Discharge Patient