Njm8/30/05

**Appropriate use of narcotics for chronic non-malignant (non-cancer)
pain**

Health care providers have been criticized for under treating patients
with acute pain and cancer pain.  Now there is widespread abuse of
prescription drugs and American youth are more likely to abuse
prescription drugs than illicit drugs.  The evidence base for the value
of using narcotics in chronic pain conditions is small and clinical
practice guidelines do not provide clear direction.  Chronic pain
patients often have co-morbid psychiatric and substance abuse issues
which complicate treatment further.  Indian Health physicians across the
country have expressed concern about the appropriateness of narcotic use
in the treatment of chronic pain.  Chronic pain conditions include
headaches, back pain, fibromyalgia, abdominal pain, pelvic pain and
arthralgias, especially osteoarthritis of the knees and hips.  Some
patients have several pain conditions and others have serial complaints
of pain in different sites. To start a national discussion on this topic
we ask the following questions.

DISCUSSION POINTS:

-   Are you comfortable using narcotics to treat chronic pain?  Describe
    your level of comfort based and your experience.

-   Is there abuse of prescription controlled medications in your
    community?  What are the most popular drugs?  Are narcotics,
    benzodiazepines or stimulants most popular?  Are particular brand
    names valued more than others?  Do you know the local \"street
    value\" of prescription pills?

-   What controls should health professionals have in place to regulate
    the use of controlled substances?  Do you use pain contracts?  Are
    they useful?

-   What services are available to serve your chronic pain patients in
    addition to primary care? 

-   Are you successful in obtaining mental health services for your
    patients? Would you like to consult with a psychiatrist yourself
    about some of your patients?

Let us hear your thoughts on the above or any other issues that apply to
the appropriate use of narcotics for chronic non-malignant (non-cancer)
pain

Just reply to the address above. It goes to all of us.

If you have a personal response, just address your message to that
person individually

This month's discussion will be moderated by Charles Q. North, MD, MS

**Creelman, Thomas (Warm Springs) \[Thomas.Creelman@IHS.GOV\]**

**Sun 7/31/2005 1:13 PM**

At the Warm Springs Health and Wellness Center in Warm Springs, Oregon,
we are presently using narcotics in some of the pain management we
encounter. We have spent over a year accumulating and bring together a
chronic pain management protocol and contract. If narcotics are being
used or requested for more than 2 to 3 weeks, we require the patient to
be on a pain contract.

We do in fact encounter a fair amount of substance abuse both with
prescription drugs and recreational drugs and alcohol.

We have a community counseling program on the reservation. This is owned
and operated by the Warm Springs Confederated Tribes. This also includes
a visiting psychiatrist approximately once a month. This is felt never
to be quite enough.

The clinic has been authorized to have a social worker. For the last 12
years we have had this position filled several times, but most of time
it has gone vacant. It is difficult to attract social workers to our
area and to secure them for a long period of time. When not available,
we find the primary care practitioner is often faced with spending
additional time dealing with psycho-social and mental health problems.

In dealing with chronic pain, our focus is on returning the patient to a
good functional status. . We include physical therapy, mental health,
vocational rehabilitation,victims assistance, the local police
department, the local fire and safety department, as well as traditional
and spiritual leaders in dealing with chronic pain issues. Thanks Tom
Creelman

[**Anthony.Dekker@ihs.gov**](mailto:Anthony.Dekker@ihs.gov)

**Sun 7/31/2005 9:39 AM**

Here is a PPT that will be given by Sid Schnoll, MD PhD at the Tacoma
IHS Primary Care Practicum on August 10.

XXXXurl

**Steele, Lois F (TUC) \[Lois.Steele@IHS.GOV\]**

**Mon 8/1/2005 7:12 AM**

Thank you for bringing up such a timely and important topic. We are
fortunate at Tucson to have Dr. Angie Wall to help with such chronic
pain patients. She reviewed many charts and pain contracts and is trying
to get more of it under control. She works with the other services such
as PT. The problem is hard and recently the pain clinic at the
University closed for the same type of problems we all face in this.
This was a good resource but is gone for the moment. We do have pain
contracts and they help.

I wanted to bring up another concern we discovered about two years ago.
A patient came in with his own "back" x-rays in hand demanding
oxycodone, and several other drugs. He had a primary physician here, but
was "upset" for various reasons. To make a long story short, I checked
on his story, would not prescribe the drugs and found that he was
getting similar amounts of the same drugs from PIMC and a clinic in OK.
I contacted both and we coordinated to be sure he was not "triple
dipping" as he was filling prescriptions at all three places each month.
He seemed to be flying back and forth to OK. He filed a grievance
against me for questioning him and faded away, when confronted with the
"triple dipping". The other clinics agreed that he would only be able to
get narcotics from his home clinic in OK. The pharmacists coordinated
this. I have been out of the loop the past year, but has this
coordination by pharmacy been tightened, and if not could it be? Could
we be sure that the Indian Health Service network is as tight as some of
the commercial drugstores that track such narcotic sales?

**Gutierrez, Lonna (PIMC) \[Lonna.Gutierrez@IHS.GOV\]**

**Mon 8/1/2005 8:31 AM**

FYI, there are two words that certified pain specialists avoid when
discussing patients with pain. They are ***contract*** and
***narcotic***. Instead, we use the words, ***agreement*** and
***opioid***. The former words are avoided for good reason. I suggest
that we start from the beginning with the accepted, professional,
nomenclature. Here is the rational\...

If we use the word ***contract*** on our documents or in our speech, we
can be held accountable, under state contract laws, should we fail any
of **our** contract responsibilities. Providers who have used
***contracts*** have been sued, by patients, who have won such contract
suits. Provider failure might include such things as not being available
24/7 to write for new opioid fills or to evaluate for new pain onsets.
Thus, the American Academy of Pain Management recommends using the term,
*agreement*, and not *contract*.

The word *narcotic* is a Latin word that means *sleep--inducing*.
Correct pharmacological nomenclature for this class of drugs is
*opioids*. When used correctly, opioids are not sleep-inducing. In its
expert testimony against providers who violated the law, the DEA has
noted that providers who have used the word *narcotic* imply a different
intention for the use of the drug (illegal). They point out that the
accepted nomenclature for opioid drugs is *opioid drugs* and that
professional providers intending to use the drug for the treatment of
pain would use the nomenclture *opioid drugs*. Thus, how we use language
has legal implications for how we are perceived by regulatory agencies.

A final note is that most patients associate the word *narcotic* with
disparaging street slang. Such a word often scares the person who needs
legitimate pain treatment out of accepting it.

I hope this has been of help. It is important to remember that language
does structure the way we think and the way we are perceived. Thanks for
the opportunity to share this important information.

**Long, Bernard (FT) \[blong@ABRMAIL.IHS.GOV\]**

**Mon 8/1/2005 8:47 AM**

[Are you comfortable using narcotics to treat chronic pain?]{.underline}
[Do you use pain contracts? Are they useful?]{.underline}

I think the Ft Thompson Service Unit [is]{.underline} comfortable in
prescribing narcotics for chronic pain. It has taken some time to
develop/modify, but we have pain contracts in place where we need them.
WE are all quite concerned with the number of people on narcotics, some
with high volume, and especially those who are not compliant with
prescribed medical therapy. We are aware of intrinsic and extrinsic
concerns of use and misuse of narcotics. (The street value is \$5
minimum and \$10.00 max.) We find the contract very useful.

We began to meet as a team to address chronic pain as a
multi-disciplinary approach to care.

For our facility, multi-disciplinary is limited to the levels of care
available. This approach assists the collaboration of professionals to
address the multi-factorial issue the usually accompany the symptomatic
diagnosis of 'Chronic Pain". Many drug seeking patient are experts in
manipulating professional against each other. By coming together as a
team, we collaborate better than just referring patient to each other.

The challenge before us is to sort out those who require a narcotic
prescription versus those who don't, and determine when intermittent
increase in medications is of merit versus other therapies.

The team suggests diagnostic referral such as Neurology, Orthopedics,
MRI, Behav Heath, Special Pain Clinics, etc.

[Is there abuse of prescription controlled medications in your
community?]{.underline}

YES. We hear it from the community.

[What controls should health professionals have in place to regulate the
use of controlled substances?]{.underline}

1.  Establish it by policy that the misuse of your prescription medicine
    in neither in your best interest, nor the facilities and may be
    reported to the law enforcement. This should also be written in your
    Patients Right policy.

```{=html}
<!-- -->
```
1.  Certainly, you can limit the number of dose prescribed to the
    patient.

2.  You can go as far a requiring daily visits.

3.  Lab testing for compliance is being reviewed to determine if it will
    track medication compliance.

[What services are available to serve your chronic pain patients in
addition to primary care?]{.underline}

Behavioral Health, Physical Medicine/ PT, Nutrition, Health Education.

[Are you successful in obtaining mental health services for your
patients?]{.underline}

For the most part...yes. There are more non-compliant patients than
complaint patients.

Bernie Long, PT

Director of Community Service

Ft Thompson Health Center

PO Box 200

Ft Thompson, SD 57339

605-245-1529 (O)

605-245-2150 (F)

<blong@abrmail.ihs.gov>

**North, Charles \[Charles.North@IHS.GOV\]**

**Wed 8/3/2005 9:05 AM**

Thanks to you who have taken time out of your busy schedules to
contribute to the ongoing discussion.  Please note that the following
list of references will be added to the web site for this discussion.

-   Evidence-Base Recommendations for Medical Management of Chronic
    Non-Malignant Pain: Reference Guide for Clinicians, Facilitated by
    the College of Physicians and Surgeons of Ontario, November 2000

-   Universal Precautions in Pain Medicine: A Rational Approach to the
    Treatment of Chronic Pain. Gourlay D, Heit HA, Almahrezi A. Pain Med
    2005;6:107-112

-   Opioid Therapy for Chronic Pain.  Ballantyne J, Mao J.  N Engl J Med
    2003;349:1943-53

-   VA Guidelines

To summarize the discussion:

-   Dr. Creelman points out the need for a multidisciplinary approach
    with adequate behavioral health resources especially social services
    integrated into the clinical care team.  Has anyone been successful
    in increasing BH resources lately?

-   Dr. Steele points out the need to have our pharmacies network to
    prevent inappropriate dispensing.  Liz Perea, PharmD, from
    Albuquerque will comment on this important point.  Does anyone have
    a network of pharmacists that communicate about pain
    agreement/contract violations, diversion or abuse?

-   Lonna Gutierrez points out that we should use the terms \"opioid\"
    and \"agreement\" rather than \"narcotic\" and \"contract\" to avoid
    stigmatizing patients and legal problems.  Samples of pain
    management agreements are available on the American Academy of Pain
    Management web site
    [www.aapainmanage.org](../../../../../../../../%5C%5Cwww.aapainmanage.org). 
    They have an excellent discussion entitled \"Prescribing Issue:
    Opioid Agreements & Contracts: The American Academy of Pain
    Management\'s Take on the Subject.

-   Bernie Long comments on his local situation and street prices for
    diverted drugs.  He points out the value of specialty referrals and
    the need to communicate within our health care team.  He also raises
    the issue of mental health referrals being unacceptable to some
    patients with chronic pain problems.  Should we be in a position to
    provide mental health and substance abuse care in primary care
    settings to patients who we feel need these specialty services?

-   Tony Dekker attached an excellent Power Point from our colleague in
    Tacoma with some helpful Guidelines to Prescribing Drugs with Abuse
    Liability.

How do you handle patients with family histories and personal histories
of drug and/or alcohol abuse with chronic non-malignant pain? 

How have you dealt with patients who violate pain agreement/contracts?\
How have you dealt with health professionals who divert drugs and/or
have abuse problems themselves?\
How have you dealt with employees who forge prescriptions or divert
drugs?\
How prevalent is underutilization of opioid therapy due to the fear of
addiction, \"opioid phobia\"? Charles Q. North, MD, MS\
Medical Director\
Albuquerque Service Unit\
Chief Clinical Consultant for Family Practice\
Indian Health Service\
cnorth@abq.ihs.gov\
FAX 505-248-4093\
Office 505-248-4065

**Murphy, Neil**

**Fri 8/5/2005 4:55 PM**

Here are the links to the web based resources Dr. North referred to:

[Treatment of Pain Patients with Substance
Abuse](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/TreatPainPatWsubAbuse.ppt)
(PPT 132k)

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/TreatPainPatWsubAbuse.ppt>

Gourlay DL, et al. [Universal precautions in pain medicine: a rational
approach to the treatment of chronic
pain.](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15773874&query_hl=1)
Pain Med. 2005 Mar-Apr;6(2):107-12.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15773874&query_hl=1>

 

Ballantyne JC, Mao J. [Opioid therapy for chronic
pain.](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14614170&query_hl=4)
N Engl J Med. 2003 Nov 13;349(20):1943-53.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14614170&query_hl=4>

VA / DoD Clinical Practice Guidelines for [Management of Opioid Therapy
for Chronic
Pain](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ChronicpainguidelinesVA2003.pdf),
3/03 (PDF 1.8mb)

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ChronicpainguidelinesVA2003.pdf>

[Evidence Based Recommendations for Medical Management of Chronic
Non-Malignant
Pain](http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/EBMchronicpainguidelines2000.pdf),
College of Physicians, 11/00 (PDF 2.7mb)

<http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/EBMchronicpainguidelines2000.pdf>

[Discussion,
8/4/05](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Opioid8405.doc)
(WORD 103k)

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Opioid8405.doc>

or

If you want all of these you could just go here and scroll down to the
word Narcotic.....

(Topic list is in alpha order)

<http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForumMod.asp>

Let me know if you directly have questions or issues with the links at
<nmurphy@scf.cc>

Neil

**Judith Kitzes \[JKitzes@SALUD.UNM.EDU\]**

**Wed 8/3/2005 11:18 AM**

Great comments. I am wondering how these concerns affect the dispensing
of opioids for persistent pain management in progressive, non malignant
illness in the, pediatric,  geriatric and end of life cohorts. (
osteoarthritis, spinal stenosis, diabetes, shortness of breath for COPD,
etc.).  A primary health care practitioner may not need a behavioral
health  practitioner to evaluate  for depression, and could  choose to
begin treatment with an adjuvant anti depressant. Our colleages are not
always available for consultation.  The team approach is the best;
unfortunately the resources might not be available to create one.

Judith A. Kitzes, MD MPH\
UNM Palliative Care Office\
MSC 11 6020\
1 University of New Mexico\
Albuquerque, New Mexico  87131-0001\
p: 505 272-4868\
f: 505 272-8572\
cell: 505 220-1373\
email: <jkitzes@salud.unm.edu>

**Applegate, Roger MD \[Roger.Applegate@IHS.GOV\]**

**Wed 8/3/2005 12:13 PM**

RE:  patients who violate pain contracts, I've dealt with a few; one
patient who was "double dipping" by receiving meds from a nearby Urban
clinic.  In our pain agreement we state that the patient gives
permission to share medical information with other outside providers and
pharmacies.  Another patient was using marijuana pretty heavily in
addition to her pain meds & even went so far as to request medical
marijuana.  This in spite of the fact that she was an obese asthmatic
who had signed our agreement not to use illegal substaces.  Most
recently I had to D/C methadone on a patient with multiple episodes of
lost medicines, overuse, and ER visits for withdrawal.  This person was
homeless and had inconsistent transportation, we had tried to deal with
him by using the "short leash" method, giving 1 or 2 week supplies of
meds in hopes of improved compliance but he just seemed incapable of
using the medicine as prescribed.  During his last withdrawal episode he
actually agreed to being tapered off the meds.  We should probably have
considered this person's social history a little more carefully before
starting the chronic meds.

Roger Applegate, M.D.

Clinical Director

Chemawa Health Center

3750 Chemawa Rd. NE

Salem, OR  97305

Voice: 503.304.7600

Fax:  503.304.7677

roger.applegate@ihs.gov

**Elizabeth Perea <eperea@abq.ihs.gov>**

**Wed 8/3/2005 1:08 PM**

I am a pharmacist here in Albuquerque, I am the \"narcotics officer\",
and I maintain organization of the patients on pain contracts. We have
had several issues arise and have had great success in containing the
abuse of the controlled substances and muscle relaxers, both with
patients on pain contracts, and those that have chronic non-malignant
pain.  I work closely with the community pharmacies, the state board of
pharmacy, and Department of HHS special agents, to keep an open line of
communication to protect both the patient and the providers and
pharmacists.  We recently have started a pain management team to include
pharmacy, behavioral health, primary care provider, and social
services. 

Although this group is in the planning/development stages, it looks
quite promising. I am also in the works of developing a pharmacy based
narcotic/controlled substance listserve that will be IHS wide, and this
help temendously in containing the IHS \"shoppers\".   It is vital to
everyone involved that a multidisciplinary approach is taken, and that
the providers and pharmacy work together toward the same goal. 
Albuquerque IHS pharmacy is fortunate to have a great line of
communication and professional relationship with our providers. 

Elizabeth Perea

**From Alfredo Vigil <alfredo.vigil@hcnnm.org>**

**Wed 8/3/2005 1:19 PM**

Thanks for the opportunity to participate.

COMFORT:  The comfort level varies with the clinical situation: the
greater the certainty that there is clear pathology as the etiology for
the pain, the greater the comfort.

ABUSE:  There is wide spread abuse varying all the way from a sweet
grandma who is not even aware that her narcotic misuse is helping her
cope with daily stress all the way to malingerers who merely resell the
drug on the streets.  All types of abusers are seriously
underestimated.  Popular drugs are Percocet, Oxycontin and Xanax.

CONTROLS:  The most important control is giving providers the clinical
skills and intestinal fortitude to know when to say "no".  The problem
is that pretty much all educational efforts surrounding the topic of
"chronic pain" fail to address this specific need.  Pain contracts are
very helpful and useful.  They probably motivate the provider, as much
as the patient, to make correct decisions.

OTHER SERVICES:  Pretty much [none]{.underline} in this difficult area. 
Most so-called pain clinics merely increase the dose of narcotic and
then send the patient back to the referring provider so that they can
shoulder the burden of the increased narcotic usage.

PSYCHIATRIC SERVICES:  Overall fair availability IF the patient has a
clear diagnosis OTHER than DSM-IV 307.89 Pain Syndrome.  For that
diagnosis, which is the crux of the problem, there is essentially NO
available support for providers or patients.

I believe this summarizes the experience of the providers in our
clinics.  Thanks.

Alfredo Vigil

**Domer, Tim (FDIH) \[Tim.Domer@ihs.gov\]**

**Wed 8/3/2005 2:32 PM**

I am happy to see this discussion taking place on this Listserv. The
subject of adequate pain management - or lack of it - has received a
great deal of needed attention in recent years - especially since JCAHO
made evaluation of pain the \"5th vital sign\".

 

I find it interesting that nearly every discussion or formal talk on the
subject of use of opioids for pain and symptom management in the IHS has
quickly focused on the MIS-use of opioids.

 

I think it would be most helpful to divide the discussion into the
clinical aspects of appropriate prescribing and use of opioids and into
the social/legal and behavioral issues that arise because of the
abuse-potential of these medications. Mixing the two tends to perpetuate
the connotations, suppositions and judgmentalism that have resulted in
the marked under use of opioids in pain and symptom management.

 

One participant commented on how most pain management experts avoid the
use of the terms \"narcotic\" and \"contract\". This may seem like a
small point but I think it is important because it points out how words
and attitudes make a difference in providing optimal management for
patients with chronic pain. Providers seem to remember the cases of
abuse more than they remember patients who suffered unnecessarily
because their pain was not properly managed. Patients who ask for
opioids are all too frequently labeled \"drug-seeking\" when in fact
what they are seeking is proper management of their pain. Because we
frequently under-prescribe opioids, as well as non-opioids used in pain
management, we set up a situation where patients are forced to seek
additional relief.

 

As a rule I do not use contracts or agreements. There may be times when
one is needed but those are in the minority. What I would rather see is
a better system for our pharmacies to communication between hospitals
and providers so that \"opioid shopping\", and doctor shopping in
general, can be identified quickly and addressed. Having blanket
policies that \"contracts\" be in place is not the answer in my opinion.
It puts the patient on the defensive from the start. In addition there
are many times that the medical system does not live up to its\' end of
the bargain - doctors on leave, not enough medication for breakthrough
pain, inadequate dosing to begin with, judgmental ER and pharmacy staff
etc.

 

What is needed, in my opinion, is better education of physicians, other
providers, nurses and pharmacists on optimal pain and symptom
management. I have found that in many cases medications other than
opioids are more effective. I have been able to lower the dose of
opioids in quite a number of patients who were in fact being mismanaged
because of lack of knowledge and inexperience. A multi-disciplinary
approach, as Dr. Kitzes mentioned, is also critical to overall success
in the monument of chronic pain.

 

One suggestion is for each Service Unit, or certainly each Area, to have
a physician, or team, who has received special training in pain and
symptom management. This individual or team would be a local resource
for specific cases, but also serve as an expert who could teach pain and
symptom management to larger groups. As we raise the level of expertise
in treating pain, many of the social/legal/behavioral issues could be
addressed in the same multidisciplinary context that we address
social/behavioral issues in other areas of medicine - such as diabetes,
obesity etc.

Timothy Domer M.D. ABHPM

Clinical Director

Fort Defiance

**Locker, Rachel (Warm Springs) \[Rachel.Locker@IHS.GOV\]**

**Thu 8/4/2005 9:55 AM**

Here in Warm Springs we have adopted our policy to the benefit of both
the patient and the provider.  When we first adopted our policy we went
through tremendous growing pains with many arguments between the
treating team) and administrative persons who were handling the
complaints  from those who were not receiving medications they felt due
mostly due to an inability or refusal to comply with the requirements).
  Finally these seem to be over after almost 2 years. Currently we are
working to update the policy procedures and agreement to reflect
problems we have found with our system and problems faced with a change
to the Electronic Record

 

This policy has greatly increased  the comfort level of the providers in
prescribing narcotics chronically.  Intermittent and urgent care
providers have tools now to refer a patient to the primary provider more
easily if there seems to be a need for long term opiod pain management.

 

Word travels fast in a small community and now that patients know the
rules regarding long term narcotics are much stricter,  those who were
drug seeking have been weeded out and only show up for such when there a
new doc in town or there is a true need.  .

 

Those who have had  previously under treated pain.  Have for the most
part noted improvement in control of pain, there ability to communicate
with the provider regarding issue pain control issues and life is more
pleasant for all.

 

The policy has also aided providers in the ability to say no when they
feel such is not indicated but felt pressure to do other wise.  The
program has also aided to identify  some persons who have previously 
unidentified addiction issues and refer them for assistance.

 

I would applaud anyone who is the  "narcotics officer\" " or any group
of  persons who has the strength to deal with all of such patients alone
-- even with contract s these are typical very time consuming and needy
patients and  the majority have complex social life histories that make
for very draining visit. Different patients communicate and find comfort
in talking to different providers.  Due to the complexity of these
patient sand the effect other health, social, emotional factors play on
the management I belief it is best kept with the primary care physician.

 

The majority of patients here in Warm Springs that have had there
contract made null and void have occurred due to urine screen positive
for methamphetamine.

 

I have for those tired to work with them with weekly urine screens,
weekly pickup and required counseling attendance with alcohol and drug
program .  Thus far none have been able to comply with the needs and
have had repeated urine screen positive for meth.   These are very
difficult as I'm sure of the pain they are experiencing.

 

 

One tool we have found tremendously helpful in assess in pain is the
Mankoski Pain Scale . We have adopted this throughout the facility.
(<http://www.valis.com/andi/painscale.html>) 

We have modified it to remove the right and column regarding what pain
medications are needed.

 

This scale associates a description along with the number level of
pain.  The number 1-10 is so subjective and I frequently find with this
alone  a patient may come in laughing and reading with a 10/10 migraine
and other patient with an open fracture reports pain is a "2 or 3"

 

I give this scale to all my contracted patients to have at home so when
they call regarding changes in pain and to assess improvement we can
better understand each other. This also gives some assessment of
functional improvement that is partial purpose of the pain management
.  

Rachel E .Locker MD

Warm Springs Health and Wellness Center

Warm Springs OR

**Willinghurst, Lori \[Lori.Willinghurst@IHS.GOV\]**

**Thu 8/4/2005 10:58 AM**

As a psychiatrist at Albuquerque Indian Health Center and ACL Hospital,
I agree with the concern that patients with chronic pain often have very
complex lives and social histories, often have a history of trauma as
well. What has surprised me is how few of these patients are referred to
my department or if they are referred the chronic pain is not part of
the reason for referral. I had a patient this week use most of his
session talking about his pain and the impact on his life but then say,
"I shouldn't be burdening you with my pain problems." I educated him
about the appropriateness of the discussion and encouraged him to
continue in further sessions. My concern is that this patient's attitude
about pain and mental health may be that of many providers yet the
mental health issues are often paramount to the patient's overall
health. I would encourage a greater involvement of mental health
providers in the treatment of pain. I work with Liz Perea and two of the
PCPs in Albuquerque to address chronic pain in a multidisciplinary way.
Although our pain team is just getting started, it has great potential.
And, although I cannot speak for other providers in my field, I would
hope that they agree that we want to help with the treatment of these
often difficult and draining patients. To treat them alone can be
discouraging.

**Domer, Tim (FDIH) \[Tim.Domer@IHS.GOV\]**

**Thu 8/4/2005 10:51 AM**

I like the narrative description of what the 0-10 scale actually means.
A scales is only as good as the instruction given for it\'s use.

 

I generally use an *analogue scale* in which a symptom is identified,
followed by a straight line. One end of the line is marked \"best\" or
\"none\", the other is marked \"worst\" or \"extreme\". The patient then
marks the line according to where they feel that symptom is on that
particular day. The scale is then compared to the previous scale(s). One
can more easily get a broader picture of how things are going - pain,
nausea, constipation, sleep, appetite, activity level etc. I ask all my
patients what aspect of their life has been most affected by their
chronic pain syndrome and add this to the analogue scale. For one it
might be that they can\'t travel, for another that they can\'t go
shopping, for a third that they can\'t lift their child. I target
therapy to improve that aspect of their life. If a patient\'s mark moves
from \"worst\" toward \"best\" next to \"Shopping\" or \"activity
level\", for example, I know they have improved even though the patient
may initially say \"nothing has changed\".

 

The analogue scale is also helpful because it reminds one to ask about a
variety of symptoms - especially constipation.

 

What kind of training in the management of chronic pain is provided to
the medical, nursing and pharmacy staff at Warm Springs - and other SU
as well?

Timothy Domer M.D.

**Pond, Diane (PIMC) \[Diane.Pond@IHS.GOV\]**

**Fri 8/5/2005 9:08 AM**

I completely agree with Dr. Domer's points.  Appropriate pain management
is a responsibility we all have to our patients. Lack of training in
pain for physicians has led to many problems including both under and
over prescribing pain medications. Many medical schools in California
are now requiring rotations in pain management. The most important thing
we can do for our patients who suffer from chronic pain is educate our
patients about why they are experiencing chronic pain (clarifying their
diagnosis), and letting them know what the risks, benefits, and
alternatives to various treatment options are available to them for
symptom management and improved function.  As an anesthesiologist who
works with patients in a team approach at Phoenix Indian Medical Center,
I find that the majority of patients demonstrate improvement in
function, mood, and an ability to use various tools for pain management
in a responsible appropriate manner. We do run into a few patients who
abuse the medications, and or demonstrate addiction problems, these
patients are by far in the minority.  Although I feel comfortable
providing opioids in certain situations to patients who have not
demonstrated addictive behaviors, I do not start with these agents. They
are reserved as a last resort, once everything else has been tried, and
optimized.  Other tools that can be offered to patients include physical
therapy, Tens units, acupuncture, nerve blocks, epidural steroid
injections, trigger point injections, and most importantly coping
strategies including psychological techniques for pain management. 
Because there is no cure for most chronic pain conditions the focus has
to be on improving function and learning to live with a manageable level
of pain.  As far as escalating doses of opioids, in my experience most
patients do not have improvement in function at higher doses; they
simply get more side effects. The doses should remain fairly
consistently stable, with additions of adjuvant agents to treat flares,
and escalating pain.  We use a multidisciplinary **outpatient** approach
that includes pharmacy, behavioral health, physical therapy,
acupuncture, and procedural techniques.

Other controls used at our facility:

-Treatment agreements are utilized in our facility as both an
educational tool for patients to outline the goals, risks, benefits and
alternatives to opioid therapy, but to also to outline the possibility
that the opioids may not be found to improve function or for reasons of
medical risk may need to be discontinued.

-random urine drug screening is used to ensure the use of illegal
substances is not being combined with opioid therapy.

-We have two providers with specialized training in addiction medicine
including Tony Dekker M.D., and Lonna Gutierrez FNP to provide
assessments and recommendations if addiction is suspected.  It is very
helpful to have someone on staff who has this type of training to assist
as part of a chronic pain management team.

Diane Pond M.D.

Chief, Dept.of Anesthesiology

Phoenix Indian Medical Center

602-263-1768

fax 602-263-1593

**John Sears, <jsears01@citlink.net>**

**Sun 8/7/2005 6:20 PM**

Has anyone read John Sarno, MD? His radical new theory concerning
chronic pain is quite interesting. After reading a couple of his
interviews on Medscape (free). I bought one of his books (less than \$10
over the internet) and found it fascinating. According to him, more of
our pain management budget should go to psychologists and psychiatrists.

John Sears, MD

Family Medicine

Tuba City

**Pena, Dennis (PIMC) \[Dennis.Pena@IHS.GOV\]**

**Thu 8/11/2005 2:53 PM**

I have read Dr. Sarno\'s books, and i have benefited from them
personally

I believe that a very large component of chronic pain is psychological

not to say that it is all imagined by the pt., rather generated and
maintained by their mind (mainly subconscious)

Dennis Pena, DPM

PIMC

Phoenix

**Two Hawk, Sophie \[Sophie.TwoHawk@IHS.GOV\]**

**Mon 8/8/2005 7:45 AM**

I am currently at a facility that is quite remote and like many others
has no contract health funds for appointments other than those that are
linked to Priority I cases. 

We have a chronic pain clinic and have had some very good results with
patients who are in pain receiving more thorough evaluations for
conditions that had been overlooked in the past.  Often patients are
labeled especially if there are a lot of temporary providers and no
investigation has been done to fully evaluate the cause of the patient's
pain.

We have contracts in place, it is amazing that there were so many
patients getting large numbers of narcotics without anyone trying
adjuvant therapy or non-narcotic additions to manage pain.

We had a pain management team which is great when it works but
unfortunately due to the large turnover in staff, especially without any
permanent pharmacists we are unable to meet regularly.  We were
concerned about the lack of workups for pain so we did put it into our
policy that we would consider allowing patients to see a pain management
specialist esp. if there were procedures such as epidurals that might be
able to be done if needed that could benefit the patient. 

We have had issues with only a handful of patients who have broken
contracts.  Unfortunately, in our facility there is a big push to call
the OIG for any consideration or perception of providers prescribing
narcotics inappropriately.  Many don't understand the difference between
chronic pain vs. acute or the need to change doses especially if trying
new agents.  It gets difficult if the pharmacists and techs are telling
the providers that they won't fill for certain patients and they have to
report you to the OIG for writing for the narcotic.   Are there other
facilities out there with this problem?

**Wall, Angela D (TUC) \[Angela.Wall@IHS.GOV\]**

**Mon 8/8/2005 3:10 PM**

That\'s absurd - preposterous - ridiculous. It irritates me just to read
that. The OIG must be loving this. Are they getting a lot of calls? 

 

I\'ve inherited a lot of chronic pain patients with little or no work up
or documentation, on copious amounts of opiates and little or nothing
else.  It\'s very difficult to try then to re-invent their wheel,
implement adjuvant therapies, and God forbid, taper the opiates.  My
sympathy and encouragement go out to you.  I do what I can, and if I\'m
still not comfortable with the amount of controlled medication required,
I will send for pain management consultation.  If I\'m still
uncomfortable with the plan (i.e. I needed more than just a specialist
to back me up) I\'ll require the patient to obtain all rxs from the pain
consultant.  Are there any pain clinics within a reasonable distance?

 

Do your patients qualify for state/federal assistance?  Medicaid?  These
particular \"third party payers\" are supposed to be considered payment
in full, so pain consultation/intervention should be little or no actual
burden on your CHS.  I entered the referrals as \"medical referral only,
pt on \<Medicare\>.\"

 

As for the OIG - if your documentation is complete, then bring them on! 
No one can tarnish appropriate imaging studies, adjuvant therapy (pharm
and non-pharm), HEP (home exercise program - free), monitoring for side
effects, depression, and substance abuse, random drug screening,
documentation of symptom control on current medication plan, referrals,
and even documentation such as \"referral for orthopedic surgery would
be optimal, but patient is unemployed, has no third party payer, and was
denied for Medicaid benefits.\"  We have a \"Pain\" section in
appropriate charts, where we keep everything you need to know about the
patient\'s disease and treatment.

**Bunt, Clayton \[Clayton.Bunt@IHS.GOV\]**

**Mon 8/8/2005 4:12 PM**

We clearly practice in a system that is sub-optimal in many ways.  One
is the ability to pay for outside evaluation of pain.  The  threat of
the OIG is real, however.  If you haven\'t experienced them, be
grateful.  If they can\'t find something they\'ll just make it up so
they can nail someone.  I sympathize with the situation described by
Sophie Two Hawk. 

As I\'ve read the postings on this topic, I am struck by the difficulty
of finding the right balance.  Several have declared that we need to be
more aggressive about treating patient\'s pain, others discuss their
frustrations.  Several have mentioned a small number of patients who
divert meds or have abused them. 

 

I\'ve got to confess my utter frustration with this area of my
practice.  The attitude among the providers at our facility varies
greatly from those who rarely prescribe, to those who make a real effort
to treat pain aggressively, and even several in the past who were
clearly over-prescribing. Both extremes create problems for the rest of
the staff.  Our multidisciplinary team collapsed about a year ago due to
the interpersonal problems within the team.  We haven\'t been successful
in getting it going again.  

As one of the physicians who has been more willing to treat pain, at
least among our staff, I have over the last 8 or 9 years dealt with
quite a number of pain patients, and at least in this population, there
are problems which haven\'t been discussed.

Pain Scales - the standard pain scales seem to have very little
reliability among the patients I see.  Somehow, I don\'t think that a
patient who is smiling and joking with the staff really has 10/10 pain. 
(They do, however). 

DIVERSION - We have uncovered significant problems with diversion. 
There is an active black market in which opiates are traded for
Meth. Some are also sold for cash.

We have had at least 8 hospital staff - all in clinical areas- who have
been busted for diversion.  Most faced criminal charges.  

As a result, I actively screen urines for compliance.  By the way, this
should always include specific testing for the opiate the patient is
on.  It\'s a send out, but well worth it to settle any questions.

I have also pretty much lost tolerance for patients who violate their
contracts.  I may give one replacement for lost or stolen meds, even
though the agreement says we won\'t, but I have begun requiring a police
report before filling them.  Any more incidents and I terminate the
agreement.  Testing positive for Meth is automatic termination, although
at least one of our providers is not as rigid on the issue.  A negative
compliance screen for the drug prescribed is also, unless there is a
very good reason, automatic termination.  A second, regardless of the
reason, is grounds for termination.  By the way, **none** of the people
I terminated have come back in opiate withdrawal !!! 

Pain Clinics - I have found these useful in house as they gave me a
larger block of time to get into the background of the patient\'s pain.

We haven\'t had as much luck with the outside pain clinics.  One nearby
is basically a prescription mill run by a physician with a problem
himself.  One is legitimate, but somehow, after the expensive procedures
are done, our patients always seem to run afoul of the nurse who
administers prescriptions, and they wind up cut off and back at our
door.

Regulatory Issues - You haven\'t lived until you have discussed a
patient\'s history with a physician from a substance abuse treatment
program, while he decides whether he thinks he should report you to the
State Board of Medicine.

 

Treating pain patients can be one of the biggest hassles we face. It is
also one of the most rewarding when a patient has a legitimate need and
is willing to stay within the rules.

 Clayton Bunt MD\
Clinical Director\
Crow/Northern Cheyenne Hospital

**Wall, Angela D (TUC) \[Angela.Wall@IHS.GOV\]**

**Mon 8/8/2005 6:47 PM**

I\'m surprised to hear about the OIG.  My only experience with them was
once when a co-worker reported or threatened to report me to the OIG for
my \$1 NFL pool.  The OIG office said \"Please ask your colleague NOT to
call us for a \$1 football pool.\"  Perhaps the OIG needs some pain
management classes.  Lets send them that horribly dry JCAHO document on
pain management\....

 

Pain Management Does Not Equal Opiate Medication.

 

Many times it includes opiate use, but it is not a requirement.  That
being said, pain is under-treated, both by not implementing other
treatment options, and by prescribing an inadequate dose of controlled
medication.

 

When my patient reports 10/10 pain to the nurse, we talk about it. 
10/10 means it can\'t possibly get any worse.  You can\'t walk.  Not
\'you can barely walk,\' but \'you can\'t walk.\'  If they walked in on
their own accord, it\'s not 10/10. 

 

It can be maddening when all of your providers are not on the same
page.  You facility uses an institutional DEA?  If a provider is
inappropriately prescribing controlled medications, that DEA can be in
danger of being revoked.  That\'s everybody\'s DEA.  Plus, the pharmacy
can\'t so much as order penicillin without the DEA.  Get your pharmacist
on board.  Usually, the provider will come around.  If not, require
him/her to obtain their own DEA.  Talk to the PIMC pharmacist - I think
they had a similar coo sometime back\....

 

We do random drugs screen here, and I do mean random.  As a general
rule, I screen at the initiation of the \"Pain Management Medical Plan\"
(aka pain contract), roughly every year or so, and anytime things seem
hinky.  Here, we have more pts that test positive for both the Rx'd meds
and cocaine, rarely Meth.  To be honest, THC is such a huge problem that
we off the record decided not to tackle it.  I remind my patients that
possession in Arizona IS a felony.  Generally, I have a 3 strikes and
you\'re out rule, with some exceptions at less than 3 strikes.  It was
too much shell shock to have a no tolerance policy - they all tested the
boundaries.  About half clean up once they figure out that we\'re
serious.  The rest don\'t get narcotics anymore.  I replace stolen
medicine with a police report only.  I figure if they\'re up to know
good, they won\'t want the cops around, and it looks good on paper.  I
document the violation on the back of the Pain Management Medical Plan
(which will from here out be referred to as the contract), and if it
becomes a trend, then they are a \"poor candidate for chronic opiate
treatment.\"  If they drop their meds in the toilet (why do they
always count the pills over the toilet?)

(please see <http://www.placebojournal.com/narcotic_mystery.htm>),

they better fish them out and bring them in a Ziploc.  If the dog ate
them (it happened once) they better bring in a dead dog.  If the
grandkids got into them, they must keep them more secure - usually by
purchasing a lock box. 

 

I have also never had a patient return in opiate withdrawal from
contract termination.  I always document that the patient was offered
inpatient Detox.  They always decline.  Keep in mind that opiate
withdrawal is painful, but not life-threatening.

 

I don\'t know of any staff diversion, but then again, I\'m always the
last to know. 

 

The pain clinics we have used have been strong allies.  When I refer a
patient, I usually send my own \"Pain Management Evaluation,\" which
documents the direction I\'m leaning in.  Maybe I just need someone with
more credentials to officially agree with the current plan.  That\'s
usually what I tell the patient they have to see the specialist for. 
Sometimes I\'ll send information such as \"frequently self-escalates
doses, multiple early refill requests, lost Rx 6 times in one year,\"
etc.  Then they\'ll usually recommend to taper the meds.  When the
patient comes back, well, my hands are tied\....the specialist has
spoken.  Hopefully the specialist offers another plan - epidurals,
physical therapy, trigger point injections, Lidoderm patches, Psych
Eval.  It\'s up to the patient to use these suggestions.  

 

Ah yes, the dual diagnosis:  chronic pain and substance abuse.  There
are painfully few treatment programs prepared to address both, and
Medicaid sure isn\'t paying for any of them.  We can Detox here, but if
they\'re not strong enough to rehab as an outpatient, then they\'ll
likely chose the addiction over the pain management, and they can\'t
have both.

**Wall, Angela D (TUC) \[Angela.Wall@IHS.GOV\]**

**Mon 8/8/2005 4:02 PM**

OK, thanks for the complement, but that\'s laying it on a little thick. 
All I do is thrive on the patients that would cause a sane physician to
hide under the desk and not answer the phone.

 

There was a number you could call with Medicaid - they would tell you
what controlled substances (or any Rx) the patient had gotten and by
whom.  I called it a couple of times, then all of the sudden, they
clammed up and wouldn\'t release any info.  When I was in Parker, there
was only one pharmacy in town, and only a couple in nearby Havasu.  The
pharmacists there were only too happy to give me information regarding
questionable narcotic use by my patients.  Every now and then, I\'ll
still come across a pharmacy that cowers behind the HIPPAA shield.  Any
comments on the legal logistics of my detective work?

**Wall, Angela D (TUC) \[Angela.Wall@IHS.GOV\]**

**Mon 8/8/2005 7:08 PM**

On substance abuse and pain management, I should have mentioned
Suboxone.  Tony Dekker is the expert on this - he taught me everything I
know.  It is being used off-label in chronic pain management.  Here\'s
an excerpt from my first encounter

 

\"**CC/HPI:** Mrs. C is a x y/o female treated for chronic pain
attributed to a long history of SLE. She was diagnosed with lupus 30
years ago. She was on prednisone for 15 years, has been off it for about
5 years. She was treated with IV Cytoxan for a total of 8 years. She
describes her pain as all over, all the time, like a body flu ache, and
like a bad toothache all over. She was recently on 200 mcg Duragesic
patch every 3 days, but saw a doctor in Alaska who successfully weaned
her off the opiates and onto Suboxone, 2-3 tablets sublingual every
morning with alternating Tylenol and ibuprofen PRN. She says that her
pain is acceptable at a level of 4-5/10 with these medicines. She is
able to go shopping, do housework, self-care, and hobbies she enjoys,
such as painting and woodcarving. She feels much better since switching
to Suboxone, and her husband describes it as "getting his wife back."

 

Since then I successfully switched one patient to Suboxone - she takes
12 mg per day for DJD/DDD L-spine, very foul-looking plain film,
relatively high dose of Oxy, don\'t recall exactly what, she kept
testing positive for amphetamines and benzos.  She says she feels much
better on the Suboxone.

 

One 400 pound 37 y/o woman with RA kept testing positive for cocaine.  I
tried to start her on Suboxone.  She didn\'t like the suboxone -
dizzyness, headache, I can\'t remember exactly what.  She is off
narcotics.

 

My third patient was a 33 y/o female with LBP, probably true
Fibromyalgia (yes, it is very rare), cocaine habit, she felt great on
Suboxone, but I had to stop it because it caused her to itch all over.

**Domer, Tim (FDIH) \[Tim.Domer@IHS.GOV\]**

**Tue 8/9/2005 9:35 AM**

The issues and points brought up in this discussion underscore the
critical need for education and training of a wide variety of
disciplines of IHS staff in the management of chronic pain and in the
appropriate use of opioids. Dr. Wall is correct in saying that \"Pain
Management Does Not Equal Opiate Medication\" - yet that is all to often
where these discussions migrate.

 

When the focus of the management of chronic pain is primarily on the use
and abuse of opioids, we have a problem. Opioids play a significant role
in pain management as a part of the overall discipline but may or may
not be a major part of optimal pain management in a particular patient.
Other medications and \"adjuvant\" therapy is often far more effective
depending on the underlying cause of the chronic pain. What I have found
most commonly is a failure by providers to recognize *neuropathic pain*
or the emotional/social factors as the major cause of ongoing pain.
Opioids often play either a small role, or essentially no role in the
optimal management of many chronic pain patients.

 

When we have IHS staff eager to report other IHS staff to the OIG for
potential prescription abuse, we have a real problem. What is the
motivation of such reporting? If there is a suspected problem it should
start with an internal review and the involvement of Administration. In
all likelihood it is a lack of knowledge and understanding of the
appropriate use of opioids that lies behind the perception
of prescription abuse.

 

Dr. Willinghurst brought up the need for Behavioral Health involvement
in most of these patients - a very important point. Even there, though,
I have found MH staff that need education and training in chronic pain
management. Social services may play a role just as significant as MH.

 

Unless there is better training in both acute and chronic pain
management we will continue to spin our wheels. Inappropriately treated
acute pain, such as post-op or post-injury pain will often become
chronic pain. Inappropriately treated chronic pain leads to all kinds of
problems - many quite avoidable.

 

In the overall scheme of things I would place the effectiveness of
opioids *behind* anticonvulsants (valproate, gabapenin and many others),
SSRIs and SNRIs (paroxetine and venlafaxine for example) and muscle
relaxants such as lioresal - with the addition of physical therapy and
behavioral health interventions. Long-acting opioids often serve as good
background pain modifying agents, with short acting opioids for
breakthrough, but the control of the underlying cause and mechanism of
chronic pain will generally come from interventions other than opioids.

 

Bigger and better \"contracts\" and OIG involvement are not the answer.
In my opinion education and training of staff and patients, however,
are. 

 Timothy Domer M.D.

Clinical Director

Fort Defiance AZ

**Willinghurst, Lori \[Lori.Willinghurst@IHS.GOV\]**

**Thu 8/11/2005 6:40 AM**

In Albuquerque we are starting an in house pain management team.

Are there suggestions for what approach, services work or have worked
for others with similar teams?

**Anthony Dekker \[dekkerclan@AOL.COM\]**

**Thu 8/11/2005 8:26 PM**

Sidney Schnoll MD PHD was our presenter for the IHS Primary\
Care Practicum in Tacoma over the past two days.  His topics on
evaluation and treatment of Chronic pain have been excellent.  I have
included another of his presentations in PPT. 

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/2005prescropoidsgoodbadugly.ppt>

The OBOT program starts Friday at 0800 at the La Quinta Inn in Tacoma
(tomorrow)

There is room for more to attend.

Tony

Anthony Dekker, DO

CCC Addiction Medicine

<anthony.dekker@ihs.gov>

6027621908

**Perea, Elizabeth \[Elizabeth.Perea@IHS.GOV\]**

**Mon 8/15/2005 6:14 AM**

I have a great working relationship with the inspectors at the New
Mexico Board of Pharmacy.  I my discussions with them, I better
understand HIPPAA.  If a health care provider is seeking information to
\"catch\" someone doing wrong, that is a violation of HIPPAA.  If one is
making inquiries in terms of patient safety and patient care, and to
protect the patient, prescriber, and pharmacist from a potential lawsuit
in these sue-happy times we live in\...\.....then this is not a
violation of HIPPAA and information may be shared among pharmacists and
providers, including private doctors offices and emergency rooms.  The
patients that have legitimate pain and are concerned about managing
their pain usually do not doctor/pharmacy shop.  These patients are
concerned with their own well being and quality of life and are a
pleasure to help.  However, there are the ones that we do question, and
these are the ones that we are concerned with in both managing
legitimate pain and abuse and misuse.  This is not just within the IHS
communities\...\....New Mexico Board of Pharmacy requires by law (as of
July 1, 2005) that any pharmacy (non-Federal) report electronically, all
controlled substance prescription information on the patient and
prescriber for the previous month.  This information is sent to a
clearinghouse, where data is analyzed and questionable patterns of use
and prescribing are identified.  As a Federal facility, we do not have
to participate, however, we have registered with them and will
participate.  There is an acceptable means to obtain the necessary
information.  Hopefully we all agree that it is better to do the
detective work if you have any questions about a situation, than find
yourself in a legal battle if a patient is harmed by large amounts of
medication, be it opioids, acetaminophen or whatever.

**Wall, Angela D (TUC) \[Angela.Wall@IHS.GOV\]**

**Mon 8/15/2005 9:25 AM**

Very helpful information, thank you.

 

I\'m wondering, what if that document formerly known as the pain
contract contained a line such as:

\"I give my permission for Sells Indian Hospital to obtain medical
information from other providers/facilities/pharmacies.\"

**Perea, Elizabeth \[Elizabeth.Perea@IHS.GOV\]**

**Mon 8/15/2005 12:18 PM**

That is a line on our \"pain contract\"

**Bunt, Clayton \[Clayton.Bunt@IHS.GOV\]**

**Mon 8/15/2005 8:08 PM**

We have it in ours as well.

**Masis, Kathleen (Billings) \[Kathleen.Masis@IHS.GOV\]**

**Mon 8/15/2005 9:47 AM**

The Billings Area took the Albuquerque and Aberdeen Pain and Palliative
Care Circulars as the model for ours. A team from nursing, medicine,
administration, behavioral health, tribal leaders, traditional/cultural
healing, pharmacy conferred for about a year on a regular basis.(prior
to Sep 01 when our attention turned to Emergency Preparedness.)

See link Pain Management Circular --Sample Policy

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/PainMngmntCircular0304.doc>

I take the Federation of State Medical Boards Standards as the "bottom
line" as far as documentation of work up and follow up is concerned.

**North, Charles \[Charles.North@IHS.GOV\]**

**Wed 8/24/2005 9:03 AM**

Thank you all who participated in this lively and interesting
discussion.

       

Resources pertinent to the discussion including formal presentations,
guidelines, links and references may be found at the portal:

[http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForumMod.asp#narcNonCanc](http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForumMod.asp)

A synopsis of some of the recent points:

1.      Dr. Locker in Warm Springs mentioned methamphetamine positive
urine drug screens

leading to "contract" issues and suggested the Mankoski Pain Scale as an
alternative to our current method of recording pain symptoms.

2.      Dr. Domer from Fort Defiance made several good points including
the relatively infrequent need for pain agreements, the need for better
pharmacy communication, education of physicians, special training in
pain management and multidisciplinary teams.

3.      Dr. Wall from Tucson related her experience with Suboxone
(Buprenorphine and Naloxone) by documenting some instructive cases

4.      Dr. Bunt from Crow expressed concern about finding the right
balance when clinicians on the same medical staff have very different
styles.  He documented the very real problem of diversion in our
facilities and the use of methamphetamine in his community.  He asks why
don't patients who are discontinued from opiates ever come back in
withdrawal?

5.      Dr. Wall mentions that if she is uncomfortable with a pain
treatment plan from a consultant that she will require patients to get
all of their prescriptions written by the consultant.

6.      Dr. Pond from Phoenix mentions the crucial issue of "clarifying
their diagnosis" and the use of physical therapy, Tens units,
acupuncture, nerve blocks, epidural steroid injections, trigger point
injections and the need to teach coping strategies including
psychological techniques for pain management to improve function and
learn to live with a manageable level of pain.  She also adds the need
for a multidisciplinary outpatient team, treatment agreements, random
urine drug screens and specialized training in addiction medicine.

I would like to add some questions for discussion and hear the comments
of our Chief Medical Officers, Chief Clinical Consultants and Pharmacy
Director.

1.      What is the role of Adverse Childhood Experiences, trauma and
abuse in the development of chronic non-malignant pain syndromes?

2.      How important is a family history of alcohol and substance abuse
in assessing appropriateness of opioids for chronic non-malignant pain?

3.      What is the role of exercise, aerobic fitness, resistance
training and physical therapy in the treatment of chronic pain?

4.      Are there any particularly good books, pamphlets and educational
resources for patients with chronic pain?\
5.      What is the evidence base for the use of cognitive behavioral
therapy with pain patients?  How useful are support groups?

6.      The State of Oregon recently made pseudoephedrine a prescription
drug.  Should the Indian Health system consider limiting the dispensing
of pseudoephedrine to prescription only?  Are there other measures we
should take to address the methamphetamine epidemic?

7.      Should the Indian Health Pharmacy programs improve communication
to address the drug shopping issue?  Would this save money like the
National Formulary or be too costly and risk privacy violations?

8.      What resources should Indian Health put into continuing
education and training on the management of chronic pain, substance
abuse and regulation of controlled substances?

9.      Should Buprenorphine therapy be offered more widely?

Thanks again to all of you who took the time to share your experiences,
thoughts and advice on this important national issue.

Charles Q. North MD, MS

**Dekker, Anthony (PIMC) \[Anthony.Dekker@IHS.GOV\]**

**Wed 8/24/2005 2:57 PM**

I would like to reply to #1 & 9 from the list

 

1.  Adverse Childhood Experiences (Trauma) seem to be a common
denominator for patients with substance abuse.  Rates for women in
residential substance abuse treatment approaches 70%.  Patients with
chronic pain have a 50% chance of having a depressive disorder using
DSM-IV-TR definitions.  As chronic pain may decompensate the behavioral
status of many patients, old issues of anger, depression, compulsivity
and other behavioral disorders may emerge.

 

9.  We have had over 100 patients on Suboxone at PIMC.  Half of them
have been patients who became opioid dependent from prescription
opioids.  The other half are patients with heroin addiction and are a
challenge and need comprehensive BH and medical services.  The
prescription opioid dependent population seems to fall into two
categories.  The first are those with addictions (multiple providers,
lost meds, prescription forgeries, etc) and need the comprehensive
services.  The second are motivated opioid dependent patients who have
no or minimal maladaptive behaviors and do very well on the Suboxone to
be detoxified.

 

The IHS provides at least two 8 hour DATA 2000 Waiver qualifying courses
per year.  This year we had three (Phoenix, Bemidji and Tacoma)  We are
planning the 2006 programs next week and if anyone has suggestions, let
me know.  We tentatively are looking at St Regis or another NE site and
Phoenix.

Tony