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A little funny, follow up about DF (long) okay when are they not?
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<blockquote data-quote="judi" data-source="post: 344872" data-attributes="member: 148"><p>As a prescriber, you do have to be careful with chronic narcotic use. Here is one article from the Institute on Safe Medicine Practices:</p><p></p><p><a href="http://www.ismp.org/Newsletters/acutecare/articles/20080214.asp" target="_blank">http://www.ismp.org/Newsletters/acutecare/articles/20080214.asp</a></p><p></p><p>From Medscape:</p><p></p><p>10 Steps of Universal Precautions in Pain Medicine</p><p>1.Diagnosis. Identify causes of chronic pain through appropriate imaging, electromyography, and other testing. Identifying the pathophysiology for the pain supports the use of opiate therapy.</p><p></p><p></p><p>2.Psychological assessment, including risk of addictive disorders. Assess for depression, as some patients tend to cope with depression or anxiety by using opiates. Nontreatment of depression makes it very difficult to obtain adequate pain relief. Screen for patient/family history of any substance abuse. This does not rule out chronic opiate therapy, but does raise the level of risk and may indicate need for referral to a pain/addiction specialist.</p><p></p><p></p><p>3.Informed consent. Discuss the risks and benefits of chronic opiate therapy, including side effects and risk of addiction. There is also a risk that the pain may not respond to the opiates, and they may need to be discontinued if pain and function does not improve. Patient and provider should sign an agreement that specifically addresses these points prior to starting opiate therapy.</p><p></p><p></p><p>4.Treatment agreement. Also called a narcotic contract, this specifies the conditions under which opiate therapy will be continued or discontinued. Typically, the patient agrees to obtain prescriptions for opiates through one provider, take only the prescribed amount, undergo random urine drug testing, and abstain from use of illicit substances or alcohol with the prescribed drug. Both the patient and the provider should retain a copy of the agreement.</p><p></p><p></p><p>5.Pre and post intervention assessment of pain level and function. Document pain scores and level of function at baseline before opiates are started. A set of simple questions such as "Are you able to complete your job duties/household chores/self care activities?" can be rated on a 1 to 10 scale and reassessed during treatment, along with a pain score, to support continuation of therapy with improved function.</p><p></p><p></p><p>6.Appropriate trial of opioid therapy with or without adjunctive medication. Antidepressants, muscle relaxants, neuropathic medications, and anti-inflammatory medications can improve the response to opioids. Titrate the opiate dose to obtain pain relief and minimize side effects. If there is no improvement in pain and function, the medication should be titrated back down and discontinued.</p><p></p><p></p><p>7.Reassessment of pain score and level of function. This should be completed at each visit and used as the basis for continuation or adjustment of therapy.</p><p></p><p></p><p>8.Regularly assess the "4 As" of pain medicine. Routine assessment of Analgesia, Activity, Adverse effects, and Aberrant behaviors will support the current therapy and alert the provider to problems with medication use. Aberrant behaviors range from low risk (associated with inadequate pain relief) to high risk (more associated with substance abuse) ( Table 1 ).[7]</p><p></p><p>I can't cite the URL unless you join but if you are a member of Medscape - its easy to find.</p><p></p><p>Chronic use of methadone can also cause prolonged Q-T which can lead to sudden death:</p><p></p><p>QTc prolongation: [U.S. Boxed Warning]: May prolong the QTc interval and increase risk for torsade de pointes. Patients should be informed of the potential arrhythmia risk, evaluated for any history of structural heart disease, arrhythmia, syncope, and for existence of potential drug interactions including drugs that possess QTc interval-prolonging properties, promote hypokalemia, hypomagnesemia, or hypocalcemia, or reduce elimination of methadone (eg, CYP3A4 inhibitors). Obtain baseline ECG for all patients and risk stratify according to QTc interval (see Monitoring Parameters). Use with caution in patients at risk for QTc prolongation, with medications known to prolong the QTc interval, promote electrolyte depletion, or inhibit CYP3A4, or history of conduction abnormalities. QTc interval prolongation and torsade de pointes may be associated with doses >100 mg/day, but have also been observed with lower doses.</p><p></p><p>These are all from reputable websites. </p><p></p><p>And...I'll be honest, I am tasked by the DEA to document, document, document and cont to document attempts to wean, change to a different medication, offer PT/Occupational Therapist (OT), etc..</p></blockquote><p></p>
[QUOTE="judi, post: 344872, member: 148"] As a prescriber, you do have to be careful with chronic narcotic use. Here is one article from the Institute on Safe Medicine Practices: [url]http://www.ismp.org/Newsletters/acutecare/articles/20080214.asp[/url] From Medscape: 10 Steps of Universal Precautions in Pain Medicine 1.Diagnosis. Identify causes of chronic pain through appropriate imaging, electromyography, and other testing. Identifying the pathophysiology for the pain supports the use of opiate therapy. 2.Psychological assessment, including risk of addictive disorders. Assess for depression, as some patients tend to cope with depression or anxiety by using opiates. Nontreatment of depression makes it very difficult to obtain adequate pain relief. Screen for patient/family history of any substance abuse. This does not rule out chronic opiate therapy, but does raise the level of risk and may indicate need for referral to a pain/addiction specialist. 3.Informed consent. Discuss the risks and benefits of chronic opiate therapy, including side effects and risk of addiction. There is also a risk that the pain may not respond to the opiates, and they may need to be discontinued if pain and function does not improve. Patient and provider should sign an agreement that specifically addresses these points prior to starting opiate therapy. 4.Treatment agreement. Also called a narcotic contract, this specifies the conditions under which opiate therapy will be continued or discontinued. Typically, the patient agrees to obtain prescriptions for opiates through one provider, take only the prescribed amount, undergo random urine drug testing, and abstain from use of illicit substances or alcohol with the prescribed drug. Both the patient and the provider should retain a copy of the agreement. 5.Pre and post intervention assessment of pain level and function. Document pain scores and level of function at baseline before opiates are started. A set of simple questions such as "Are you able to complete your job duties/household chores/self care activities?" can be rated on a 1 to 10 scale and reassessed during treatment, along with a pain score, to support continuation of therapy with improved function. 6.Appropriate trial of opioid therapy with or without adjunctive medication. Antidepressants, muscle relaxants, neuropathic medications, and anti-inflammatory medications can improve the response to opioids. Titrate the opiate dose to obtain pain relief and minimize side effects. If there is no improvement in pain and function, the medication should be titrated back down and discontinued. 7.Reassessment of pain score and level of function. This should be completed at each visit and used as the basis for continuation or adjustment of therapy. 8.Regularly assess the "4 As" of pain medicine. Routine assessment of Analgesia, Activity, Adverse effects, and Aberrant behaviors will support the current therapy and alert the provider to problems with medication use. Aberrant behaviors range from low risk (associated with inadequate pain relief) to high risk (more associated with substance abuse) ( Table 1 ).[7] I can't cite the URL unless you join but if you are a member of Medscape - its easy to find. Chronic use of methadone can also cause prolonged Q-T which can lead to sudden death: QTc prolongation: [U.S. Boxed Warning]: May prolong the QTc interval and increase risk for torsade de pointes. Patients should be informed of the potential arrhythmia risk, evaluated for any history of structural heart disease, arrhythmia, syncope, and for existence of potential drug interactions including drugs that possess QTc interval-prolonging properties, promote hypokalemia, hypomagnesemia, or hypocalcemia, or reduce elimination of methadone (eg, CYP3A4 inhibitors). Obtain baseline ECG for all patients and risk stratify according to QTc interval (see Monitoring Parameters). Use with caution in patients at risk for QTc prolongation, with medications known to prolong the QTc interval, promote electrolyte depletion, or inhibit CYP3A4, or history of conduction abnormalities. QTc interval prolongation and torsade de pointes may be associated with doses >100 mg/day, but have also been observed with lower doses. These are all from reputable websites. And...I'll be honest, I am tasked by the DEA to document, document, document and cont to document attempts to wean, change to a different medication, offer PT/Occupational Therapist (OT), etc.. [/QUOTE]
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