Organizing your Practice for Efficient Pain Assessment. Session #4 Roman D. Jovey, MD

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2 Organizing your Practice for Efficient Pain Assessment Session #4 Roman D. Jovey, MD 2

3 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

4 Introduction Using a progressive case scenario, participants will practice pain assessment using a standardized checklist and tools, create a biopsychosocial pain diagnosis. Participants will re-assess the patient again one year later to determine progress.

5 Objectives: 1. Describe an efficient office-based approach to the assessment of patients with pain 2. Incorporate the use of pain tools completed by the patient to make assessment thorough but efficient 3. Develop checklists and templates to facilitate followup documentation

6 Mr. Anthony Delaney Mr. James Delany is a 43 year old transport truck driver with an 8-yr history of chronic low back pain. He is married with three children and must work to support his family. He is a full-time truck driver and works mostly long days (>10 hours). He is often on the road out of town but sees his family about every three weekends. He is new to your office over the past 5 months (due to a change in address).

7 Current Meds: Mr. Anthony Delaney CR-Oxycodone 60 mg PO BID for the past one year. Acetaminophen 325mg-Oxycodone 5mg 1-2 tabs q3-4h PRN Previous Treatments: Naproxyn and Ibuprofen caused GI upset. Celecoxib was ineffective. Muscle relaxants caused drowsiness; Amitriptyline caused drowsiness and severe dry mouth Previous series of physiotherapy x 2 (mostly passive) not helpful

8 Mr. Anthony Delaney Continue reading the history (Handout 4a) Analyze and score the tools in your handout Make a biopsychosocial Dx

9 CHRONIC PAIN EVALUATION SUMMARY Patient Name: Anthoney Delaney Age: 43y.o. male Date: today 1. Brief pain history onset, changes over time, response to treatments: Chronic LBP for 8 yrs began with a lifting / loading incident at work. Intermittent recurrences 2-3 times per year lasting 2-4 weeks usually with long (>10hr) trips as truck driver. Overall his episodes are becoming more severe and lasting longer. Previously tried physio x 2 (mostly passive modalities) 4 B NSAIDs caused GI upset, Celebrex not effective, muscle relaxants caused drowsiness, amitriptyline caused dry mouth and morning drowsiness. Xrays mild-moderate degenerative changes CT lumbar spine: degenerative disk disease at multiple levels, worst in lower lumbar spine Current Tx: Started Oxycontin 20mg bid 4 yrs ago and increased to 60mg bid ~ 1 yr ago + Percocet prn 2-8 per day. Pain meds do not work as well as 1 year ago. Chiropractic helps for a short ime HPH: hypertension on HCT 2. Brief Pain Inventory (BPI): (see body pain map for detailed locations and characteristics of pain) Pain Description(s) (in order of severity): PQRST Deep ache R lumbar area, worse with movement, heavy lifting and repetitive bending and better with rest and medication. Sometimes radiates to the R leg as far as his R foot with occasional pins and needles over his lateral R foot.

10 Pain scores 4-10 up to 10/10 after a long drive. Average is ~ 6/10. Pain worst 1 st thing in am. He estimates about 20% pain relief with current threatment. 3. Current Functioning and BPI Interference score : 38 /70 Can do all ADLs although wife has to help with socks sometimes. Works hours per week driving truck across Canada. Sometimes has to pull over to lie down due to pain. Misses ~ 6-8 weeks per year due to back pain flares. Can do some light housework but cannot vacuum or shovel snow. Teen son helps out. Family complains of his moodiness recently. He is reluctant to socialize as much as previously. Intimacy affected by pain. Worried re: keeping his job due to all missed time. Financial stressors. Eldest son (19) in some trouble recently due to alcohol and drugs Sleep is usually disrupted by pain. 4 B The higher the Interference score, the more that the patient s pain interferes with function and contributes to his/her disability. Some patients may require an assessment by a PT / OT to assess their limitations and recommend aids to living. All patients can benefit from recommendations for graded exercise, beginning at whatever level they are currently functioning at and gradually increasing the duration and intensity. Warm pool low impact aerobics or walking are each examples of activity most people can participate in at their own pace. By repeating the BPI Interference Scale in the future, you will have a more objective assessment of functional improvement with treatment. 4. s-lanss score: 12 a score 12 or above means a probable neuropathic element For treatment of neuropathic pain, please see the algorithm in the handout for specific recommendations as well as the description of adjuvant medications. 5. Hospital Anxiety and Depression Scale (HADS) a. Anxiety Score: is borderline, 11+ = significant anxiety b. Depression Score: ) is borderline, 11+ = significant depression A patient s suffering and QOL will be adversely affected by significant anxiety and/or depression. Patients with high scores on the HADs may benefit from a psychiatric consultation. Meanwhile, if you choose to treat depression in a patient with pain, start with the use of medications that also have evidence in pain management ( TCAs, SNRIs, bupropion) rather than SSRIs that have much less utility for pain. For concurrent anxiety

11 disorders, start with evidence-based treatments that also may be helpful for pain (SNRIs, GPN/PGN) and try to avoid the use of long-term benzodiazepines, if possible. 6. Pain Catastrophizing Scale (PCS) score: 26 A score less than 15 is normal, is intermediate, >24 is high A patient with a high PCS score likely has a significant element of pain-related anxiety and pain avoidance behaviour contributing to his/her disability and may benefit from a referral for cognitive-behavioural treatment. These patients may confuse the difference between hurt and harm and need education and encouragement to participate in activities to improve fitness. 7. Addiction Risk: Smoker? Y #cigs/day:30 Duration(yrs): 20 yrs 1 st cigarette of the day: 10 min 4 B Quantity/Frequency: 6-8 beers 2 x weekly Opioid Risk Tool Score : 5 Risk level : low moderate high If long-term opioid therapy is part of the treatment plan, remember to use Universal Precautions for prescribing and monitoring. The higher the risk level, the more careful the prescribing and monitoring precautions required. See the 10 Pearls for Prescribing Opioids in the handout. Other significant drug history: Wild youth with cocaine, LSD and THC. Has occ. joint THC after a long day in truck helps relax him. Never uses before driving. Last use 1weekago. FHx: father and 2 paternal uncles had ETOH problems 8. Patient goals: Pain Scores: would like 0 but could live with 3-4 / 10 Function: Drive truck without severe pain at end of day, do more around the house, socialize more, improve sexual function Other: Not miss so much work, go hunting with buddies again 9. Other significant information: Good drug plan at work with 80% coverage

12 Mr. Anthony Delaney 1 year later Read the updated history (Handout 4c) Analyze and score the tools Look at the Progress Note (Handout 4d) Decide whether or not he has made progress in a year Any issues to manage?

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14 Essential Follow-up Documentation The 6 A s 1. Analgesia (pain relief) 2. Activities (physical and psychosocial functioning) 3. Adverse Effects (and your advice) 4. Ambiguous Drug Taking Behaviours (and your response) 5. Accurate medication record 6. Affect Passik & Weinreb HJ. Adv Ther 2000; 17:70-80 Gourlay DL, Heit HA, Almahrezi A. Pain Medicine 2005;6: Jovey R. Managing Pain. 2008

15 Pain Management Goals Decrease pain Improve function Physical Psychological Social Minimize risk Patient Physician Society

16 Questions?