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Recorded March 14, 2009. Watch this prerecorded webinar on your computer now in Windows Media Format (.wmv). Playing time is 1 hour.
Differentiating between people in pain seeking relief and addicts seeking drugs worries physicians and can be a barrier to good pain control.
This presentation will help you to:
Understand screening instruments and their application in primary care;
Distinguish dependence from addiction;
Identify the predictors of patients at risk for substance abuse.
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Featured speaker:
Renowned opioid expert Jane Ballantyne, MD, FRCA, professor of Anesthesiology and Critical Care at the University of Pennsylvania
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This program is part of a larger initiative by the PA Department of Health Violence and Injury Prevention Program to target unintentional poisonings. According to the CDC, drug overdose deaths are largely unintentional and growing steadily. Opioid analgesics account for most unintentional drug overdose deaths from narcotics.
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Credit Statement
This activity has been reviewed and is acceptable for up to 2 Prescribed credits by the American Academy of Family Physicians. Of these credits, 1 conform to the AAFP criteria for evidence-based CME clinical content. CME credit has been increased to reflect 2 for 1 credit for only the EB CME portion. AAFP accreditation begins July 1, 2009. The term of approval is for one year from this date, with option for yearly renewal. When reporting AAFP credit, report total Prescribed credit for this activity. It is not necessary to label credit as evidence-based CME for reporting purposes.
The EB CME credit awarded for this activity was based on practice recommendations that were the most current with the strongest level of evidence available at the time this activity was approved. Since clinical research is ongoing, AAFP recommends that learners verify sources and review these and other recommendations prior to implementation into practice.
Evidence-Based Findings and Literature:
Identifying Drug Seekers Versus Relief Seekers
Pain is a subjective sensation that can only be experienced by the sufferer. Since there is no objective marker of pain, physicians are taught not to judge pain, but that pain is whatever the person suffering says it is.
Opioids are not first line treatment for pain, but are the only intervention that can help when other interventions have failed. Physicians may thus be faced with a patient's claim of severe pain, and demand to be treated with opioids.
Since opioids can easily be misused, for example, to satisfy an addiction, or for diversion, physicians are faced with a dilemma. How can they distinguish genuine pain from opioid seeking for some purpose other than pain relief?
Presently, mental health clinicians have been found to be more effective at assessing substance abuse with up to 70% accuracy Graham et al (2001). Physicians need to be better informed on the screening questionnaires available, such as the Pain Assessment and Documentation Tool (PADT) which assesses 4 domains and is completed by physicians; Scoring system to predict outcome (DIRE) which assesses 4 domains (diagnosis, intractability, risk, efficacy) and is completed by physicians; and Current Opioid Misuse Measure (COMM) which is a 17-item questionnaire and is completed by patients.
Clinically, dependence will occur but “dependence” is not defined as substance abuse or addiction or coping. Research shows that appropriate screening for patients being treated with opioids exists to monitor their risk for problematic opioid seeking behavior. Some of these screening methods are more practical for use in primary care. Updated guidelines urge more caution and more screening to balance the need for humane pain control with the risk of addiction and death.
The strongest predictor of addiction in pain patients is personal or family history of prior addiction. Opioid induced hyperalgesia is a sensitization process that occasionally arises with high dose or continued use. The most reliable way to identify aberrant opioid use is expert evaluation, use of screening instruments and urine toxicology screening combined. CAGE, ORT (Opioid Risk Tool) and the 4 As are simple, practical screening instruments for primary care.
SOURCES
Author: Angst & Clark
Source or Journal: Anesthesiology Volume 104 - Issue 3, March 2006
For source article, click here
Author: Ballantyne JC, LaForge KS.
Source or Journal: Pain Journal
Volume/Issue: 131(3) , June 2007
Page Number: 235-255
Author: Katz NP, S. S, Beach M, et al.
Source or Journal: Anesth Analg
Volume 104 - Issue 3 , March 2006
For source article, click here
Author: Brown et al
Source or Journal: Journal of Family Practice
August, 1996
For source article, click here