Objectives. A Standardized Approach for the Chronic Pain Patient. Visit Overview. Case. Four serial chronic pain visits

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1 A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO Family Medicine Spring Symposium April 10, 2015 Objectives A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO, PGY 3 University of Kansas School of Medicine Wichita Family Medicine Residency Program at Wesley April 10th, 2015 Four serial chronic pain visits Stepwise standardized approach Monitoring and follow up Pros and cons Tips for adapting to your practice 2 Visit 1 Visit Overview Visit 2 Information Physical exam gathering Pain Screen for Inventory patient appropriateness Visit 3 Recap Treatment plan Case L.M., 61 year old white female Medical History: Chronic pain Fibromyalgia Diffuse neuropathy Asthma Depression Osteoarthritis 3 4 1

2 A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO Family Medicine Spring Symposium April 10, 2015 Chronic Pain Visit 1 of 3 Information Gathering and Goal Setting Review plan of care and expectations Thorough review of patient s history History of abuse, legal problems and substance use Review of previous testing, imaging, work up, etc. Collection of outside records Chronic Pain Visit 1 of 3 cont d Screening PHQ 9 (Depression Screen) Opioid Risk Tool CAGE/CAGE AID (Adapted to Include Drugs) Mania Self Reporting Tool Patient Appropriateness DIRE (Diagnosis, Intractability, Risk, Efficacy Score) SOAPP (Screener and Opioid Assessment for Patients with Pain) 5 6 Case Long history of fibromyalgia Diffuse neuropathy/weakness Work up negative for: MS, autoimmune, B12 deficiency, and thyroid disease MRI brain, C and L spine, EMG/NCT and LP non diagnostic Previous Prescriptions: Pregabalin Gabapentin Tramadol Oxycodone Citalopram Lidocaine patch Morphine Screening Case PHQ 9: 17/37 (mod severe depression) On Citalopram Opioid Risk Tool: 5/14 (Moderate) CAGE/CAGE AID: Negative Mania Self Reporting: Negative DIRE score 18/21 (may be a candidate for long term opioid analgesia) 7 8 2

3 A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO Family Medicine Spring Symposium April 10, 2015 Chronic Pain Visit 1 of 3, cont d Patient Education Comparative Pain Scale Set expectations Frequency monthly to bi annually Rx only for 28 day supply until established Random UDS Brief Pain Inventory Used to follow patient throughout care plan Chronic Pain Visit 2 of 3 Physical exam Review of information gathered since CPV #1 Kansas Tracking and Reporting of Controlled Substances(KTRACS) Urine Drug Screen (UDS) Brief Pain Inventory 9 10 Case Exam noted foot drop Patient referred for bracing UDS obtained Positive for oxycodone and tramadol Agreeable with current treatment regimen Behavioral Group Visit Led by psychologist Group visit Mind body education Emphasis placed on relationship between pain and well being Lifestyle considerations

4 A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO Family Medicine Spring Symposium April 10, 2015 Chronic Pain Visit 3 of 3 KTRACS and UDS as indicated Brief Pain Inventory Physical Functional Ability Questionnaire (FAQ5) Score followed throughout care plan Evaluate need for/efficacy of current pain regimen Case Reviewed KTRACs no aberrant behavior Current pain meds: Tramadol and Oxycodone Prescribed prn but taking regularly Pregabalin Transitioned to long term Fentanyl patch Low dose oxycodone for breakthrough Switched to Fluoxetine for depression Follow up Pros and Cons Use screening tools to guide follow up Prescriptions kept in lock box Random UDS Patient fairness and equality Ensure safety for physicians and patients Monitor compliance Avoid abuse Time consuming Uncomfortable for established patients Limited resources (psychology) Plan for patients that are not appropriate

5 A Standardized Approach for the Chronic Pain Patient Traci Dieckmann, DO Family Medicine Spring Symposium April 10, 2015 Practice Tips Divide appointment time Half with RN, half with doctor Contact community resources More time for new patients Establish cut off for appropriate patients DIRE Morphine Equivalent Doses SOAPP 17 References Blackman K., Odom A., Identifying and Initiating Treatment for Bipolar Disorder in the Family Medicine Office. STFM Preconference Workshop Hooten WM, et al. Assessment and Management of Chronic Pain. Institute for Clinical Systems Improvement. Updated November Kroenke, K, et al. The PHQ 9: validity of a brief depression severity measure. J Gen Intern Med Sept. 16(9): Moeller, K. et al. Urine Drug Screening: Practical Guide for Clinicians. Mayo Clinic Proceedings; Jan 2008; 83 (1): PainEDU.org Scanlan, T. Drug Testing: Overview. Clinical Topic. Scanlan, T. Drug Testing: Interpreting Results. Clinical Topic. Webster, LR and Webster, RM, Pain Med: 2005; 6:

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