Pain Management in Today’s Legal Environment

1. Pain Management in Today’s Legal Environment J.K. Lilly M.D. M.S. Appalachian Pain Therapy 4407 MacCorkle Ave. S.E. Charleston, WV 25304 Bulldogdoc@msn.com 304-925-2922

2. Pain Management in Today’s Legal Environment Objectives Enjoy the “Signs of the Time” images Recognize capability, competency and currency in therapy Recognize “Best Practices” for Compliance and Compassion Recognize the “5 Ps”

3. Pain Management in Today’s Legal Environment Preparation Capability Residency – ACGME approved Licensure – Practice and Dispensing Certification – Specialty, Subspecialty Board Competency – Critical Skill Maintenance Currency – CME, Literature, Mentoring

4. Pain Management in Today’s Legal Environment Professionalism Collegiality – Networking, Organizations, Instruction Conduct – Polite, Attentive, Timely, Communication – Reasonable, Rational, Responsible, Available, Affable, Assertive Validation- Never claim to be something you’re not!

5. Pain Management in Today’s Legal Environment Privacy Documentation (HIPPA compliant) Telephone (Logs, Notes, Response Sheets) Office Policy & Procedure(On Hire & Recurrent) Computers (Memos, HDs, VPNs, Tech Reps, Security, Encryption) Personnel (Skill Sets, Recruitment & Training, Chaperones)

6. Pain Management in Today’s Legal Environment Proof Nationally Published Guidelines (i.e. Dx-based, VA-SCI, COEs ) Professional Society Standards of Care and Ethical Behavior State Regulatory Agencies Peer-reviewed Efficacy/ Outcome-validated Literature Personal Practice Data

7. Pain Management in Today’s Legal Environment Permission General Consent to Examine and Treat Procedural Informed Consent (~10%) Opioid Access Agreements Off-Label Treatment Statements “Second Chance” Non-compliance Form Communication Qualifiers on Fax & E-mail

8. Pain Management in Today’s Legal EnvironmentChronic Pain Control Plan • Pain lasts longer than six months • Persists disproportionately beyond the initial cause • May not respond in the same way as acute pain to techniques and medications • Cause may not be resolvable! • May require combined treatment modalities • Long Term Opioid Therapy (LTOT) may be the final therapeutic (last/ best) alternative • Chronic Pain Syndrome and its attendant behavior ARE NOT equivalent to Addiction Disorder or Drug Diversion

9. Pain Management in Today’s Legal EnvironmentPain Taxonomy • Acute Pain- tissue injury, distention or inflammation • Episodic Pain- related to activity recurrent, breakthrough, incident • Chronic Pain- constant and unremitting waxes & wanes but seldom subsides

10. Pain Management in Today’s Legal EnvironmentAnalgesic Selection 1st & 2nd line Mu (m) Opioid Receptor Activators – most familiar to clinicians as to effects and side-effects; best for initiating opioid therapy for moderate to severe pain (VAPS 5-10/10). Morphine, Hydromorphone, Oxycodone, Hydrocodone, Fentanyl, Codeine, Hydrocodeine, Levorphanol, Methadone, Meperidine.

11. Pain Management in Today’s Legal Environment- Analgesic Selection3rd & 4th line • Limited Proven Analgesic Efficacy • Adverse Effects • Drug-to-Drug Interaction • Toxic Metabolites • Organ-limited Elimination

12. Pain Management in Today’s Legal Environment-3rd & 4th line analgesics • Propoxyphene equianalgesic to Extra Strength Tylenol in blind studies (VAPS 1-3/10 = mild) norpropoxyphene- cardio & neurotoxic • Tramadol weak m agonist but primarily active on spinal adrenergic receptors similar to tricyclics (VAPS 4-5/10 = moderate) • Meperidine short acting (45-90 mins), metabolites accumulate within 48 hrs, side-effects common normeperidine- cardio & neurotoxic • Codiene effective pain relief (equianalgesic o Meperidine) but many side-effects at analgesic doses • Hydrocodiene isn’t routinely monitored on UDS • NSAIDs, APAP and AEDs, TCAD are “co-analgesics”

13. Pain Management in Today’s Legal Environment Summary • Pain relief is defined as a primary care (PCP) function • Remain reasonable, rational, responsible and available • Examine thoroughly and review regularly • Utilize LTOT Informed Consent to TreatandOpiate AccessAgreement • Document & define providers & pharmacy • Require patient to notify all providers of Opiate AccessAgreement participation • Monitorcompliance (pill counts, UDS, etc.) andresponse to therapy (functional assessments, charts, diaries, surveys, etc.), • Review OAA violation consequences regularly • Match the tool to the problem- SR opioid for continual pain, IR for recurrent pain; pick analgesics sensibly

14. Pain Management in Today’s Legal EnvironmentSummary (continued)Plan if Addiction is Recognized Be Humane -Intervene and Wean to withdrawal -Evaluation, treatment and extended recovery care by addiction professionals is optimal -Know community and regional resources for treatment & extended recovery care when initiating LTOT -Prescribing opioids to treat addiction (Methadone Clinics) is advisable only for specially certified addiction medicine and psychiatry physicians, -Buprenorphine Addiction Treatment (Subtex) requires additional training and additional DEA certification…too new to assess.

15. Pain Management in Today’s Legal EnvironmentSummary (continued) • Consult and co-manage appropriately • Require formal behavioral assessment periodically • Stipulate that verified non-clinical information may be considered when deciding whether to continue LTOT • Beware of 90 day prescription “Prescription Drug Benefit Plan Requirements” -cost saving scheme that may be technically illegal for opioids; i.e.. unmonitored and unlicensed warehousing of Schedule II & III medications in homes not supported by law or regulation • Recognize that LTOT may be the therapy oflast resort

16. Pain Management in Today’s Legal EnvironmentTake Home Thoughts The Main Thing is to keep the Main Thing the Main Thing. (Stephen Covey) What we don’t need is another way to do things poorly. (Balfour Mount)

17. Pain Management in Today’s Legal Environment “Signs of the Time” Thanks for your attention!! Hope to see you again soon.