Traumatic Brain Injury and Use of Narcotic Pain Agents: Treatment Considerations in Post Acute Rehabilitation Scott Peters MS, OTR/L - Clinical Director, ReMed Brain Injury Association of Maryland 2017 Annual Conference Headlines Overdose Deaths Rise By More Than 100% in Some States, CDC Says. (12/16/16) Drug Overdoses Now Kill More Americans Than Guns. (12/9/16) Overdoses Skyrocket as Kids Eat Opioids Like Candy. (10/31/16) West Virginia Distributing 8000 Overdose
Antidote Kits. (2/6/17) Opioid Overdose Crisis Plagues Cleveland. (2/7/17) Prescription Opioid Addiction and Overdose Centers for Disease Control and Prevention 2016 More people died from drug overdose in 2014 than in any other previous year Drug overdose now the leading cause of accidental death in the US Of all the deaths from overdose, 6 out of 10 involve opioids From 1999 to 2014 overdose deaths from prescription opioid pain agents and heroin have increased fourfold From 2000 to 2014 nearly half a million people died
from drug overdoses. This translates into 78 Americans dying each day from an opioid overdose. Narcotic Pain Agents Codeine (only available in generic form)
Fentanyl (Actiq, Duragesic, Fentora) Hydrocodone (Hysingla ER, Zohydro ER) Hydrocodone /acetaminophen (Lorcet, Lortab, Norco, Vicodin) Hydromorphone (Dilaudid, Exalgo) Meperidine (Demerol) Methadone (Dolophine, Methadose) Morphine (Astramorph, Avinza, Kadian, MS Contin, Ora-Morph SR) Oxycodone (OxyContin, Oxecta, Roxicodone) Oxycodone and Acetaminophen (Percocet, Endocet, Roxicet) Oxycodone and Naloxone (Targiniq ER) (Web MD) Comprehensive Drug Abuse Prevention and Control Act of 1970 Schedule I Schedule II
Schedule III Schedule IV Schedule V 1. Highly addictive; high potential for abuse; no acceptable medicinal use 2. Highly addictive; high potential for abuse; have an acceptable medicinal use 3. Moderate to low risk for dependence; less risk for abuse
4. Lower potential for abuse relative to Schedule III 5. Low potential for abuse; preparations containing limited quantities of certain narcotics Center for Disease Control Guidelines 2016 Recommendations 1. Non opioid or non pharmacologic therapy preferred for chronic pain. 2. Before starting opioid therapy, establish treatment goals for pain and function. 3. Prior to and during opioid therapy discuss risks and realistic benefits of use. 4. When starting opioid therapy, prescribe immediate release vs. extended release
5. When starting opioid therapy, prescribe lowest effective dosage. 6. When starting opioid therapy for acute pain, lowest dose and immediate release (3 days or less; more than 7 rare). Center for Disease Control Guidelines 2016 Recommendations 7. Evaluate benefits and harms with patients within 1 to 4 weeks of starting for chronic pain. 8. Before starting and periodically during opioid therapy, evaluate risk factors for opioid related harms. 9. Review patients history of controlled substance prescriptions using state prescription drug monitoring program (PDMP). 10.When prescribing opiods for chronic pain, use urine drug testing before and throughout the course of treatment.
11.Avoid prescribing opioid pain medication and benzodiazepines. 12.Should offer evidence based treatment (medication assisted with behavioral therapies). #Turn the Tide Campaign The United States Surgeon General (www.turnthetiderx.org) Calls on health care professionals: 1. Educate themselves on treating pain safely and effectively 2. Screen patients for opioid use disorder and help provide them with evidence based treatment 3. Discuss and treat addiction as a chronic illness rather than a moral failing
(OT Practice October 24, 2016) Opioid Abuse Disorder Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013) American Psychiatric Association 1. 2. 3. 4. 5. Opiods taken in larger amounts over a longer period than was intended. Persistent desire or unsuccessful efforts to cut down or control abuse. Great deal of time spent to obtain, use or recover from opiods. Craving or strong desire to use opiods. Recurrent opioid use resulting in failure to fulfill major role obligations
(work, school, home). 6. Continued opioid use despite having persistent problems caused or exacerbated by the effects of opiods. 7. Important social, work or recreational activities reduced because of use. 8. Recurrent opioid use in situations in which it is physically dangerous. 9. Continued use despite knowledge of having a persistent problem that has been caused or exacerbated by opiods. 10. Tolerance 11. Withdrawal Definition of Chronic Pain (National Institutes of Health 2016) Occurs on at least half of the days over a 6 month period or longer Chronic pain lasts after injuries heal, is poorly localized and may not have a
identifiable physical cause. Acute pain is a physiologic experience to noxious stimuli, normally sudden in onset, time limited and focused which motivates behaviors to avoid actual or potential injuries TBI and Polytrauma Polytrauma Definition: Concurrent injury to two or more body parts or systems resulting in cognitive, physical, psychological or other psychosocial impairments 2005 Veterans Health Administration defined polytrauma as injury to the brain in addition to other body parts or systems resulting in cognitive, physical, psychological or other
psychosocial impairments and functional disability TBI and Pain (Nampiaparampil, 2008) Among civilians perception that mild TBI had a higher prevalence of pain syndromes (75.3%) than those with moderate to severe TBI (32.1%) In general with civilian populations, chronic pain is at 51.5% versus 43.1% for veterans TBI and Pain (Brain Neurotrauma: Chronic Pain in Neurotrauma 2015)
Post traumatic headache pain 59% (Nampiaparampil, 2008) Muscle Spasticity (Sherman, et al 2006) Low Back Pain 46% Extremity Pains 39% Complex Regional Pain Syndrome12% Heterotrophic Ossification 11% Peripheral Neuropathies 10%
Center for Disease Control Guidelines 2016 Non Pharmacologic Treatments Cognitive Behavioral Therapy Exercise Therapy Multimodal and Multidisciplinary Therapies Exercise Psychologically based therapies Center for Disease Control Guidelines 2016 Non Opioid Pharmacologic Treatments Analgesics Acetaminophen, NSAIDS, COX-2 inhibitors
Anticonvulsants Neurontion (Gabapentin), Lyrica Antidepressants Tricyclic Antidepressants SSRI SNRI Rehabilitation Modalities (OT Practice January 23, 2017, p 13 16)
Setting goals Addressing ergonomic issues in the workplace Conserving energy and managing fatigue Exercising Learning self management of pain flare ups Receiving education on body mechanics and good posture Using heat modalities and / or electrical stimulation Establishing effective sleep habits Managing stress Getting help from a peer support network Making use of psychologically based management
strategies including cognitive behavioral therapy and psychotherapeutic approaches Opioid Addiction Features Opiods reduce perception of pain by binding with opioid receptors Opiods also produce a sense of well being and pleasure Tolerance and Dependency issues Opioid medication effects are immediate and highly rewarding Addiction hypothesis that it is an endpoint of transition from initial voluntary use to habitual and, ultimately compulsive drug use The Basis of Addiction: The Neural Circuits of Pleasure
When the reward pathway is destroyed, we lose interest in pleasurable things such as food, sex and exploring its environment Drugs are pleasurable and tap into the reward pathway (they are reinforcing) Specific drugs are potent reinforcers (cocaine, amphetamine, heroin, nicotine and alcohol) These drugs are highly addictive to humans Maintaining Factors for Addiction
Continued exposure/access Rigid belief system (identity) Supportive environment (peer group) Pain/Discomfort Inadequate coping skills Inadequate sources of pleasure/esteem Limited understanding Ambivalence to change Inadequate support to change Behavior Change is Difficult
Long standing pattern of behavior habits High frequency pattern of behavior Brain becomes predisposed to substance use Stress in your life Support may be lacking Rewards are not immediate Resistance to Change: Denial Denial is the inability to recognize a problem despite the evidence of its existence Rationalization: providing excuses for problems caused by substance use Externalization: blaming drug use on forces or circumstances outside yourself
Minimizing: making problems seem less important than they are, and therefore not a subject of concern Projection: projecting your thoughts, beliefs and feelings onto those around you Behavior Change Can Occur Best in the Presence of Two Essential Elements: Motivation to change Have I made the decision to make the necessary changes in my life? Skills to change
Do I have the skills to implement these changes? Motivational Interviewing Motivation to Change People who resolve to change their behavior actually change their behavior more often than those who believe that there may be a problem but do not resolve to change their behavior (Norcross et al., 2002). Generally speaking, the more action that is taken directed at behavior change, the greater are the chances that successful behavioral change will occur (Norcross et
al., 1989; Prochaska et al., 1992) Treatment: Stages of Change Motivational Interviewing Client Stage Precontemplatio n Contemplation Preparation Action Maintenance Therapist Motivational Tasks Raise doubt / Tip Best course of
action Take steps toward change Prevent Relapse Behavioral Approaches Functional analysis of pain behavior, substance use Coping skills for managing the antecedents of pain behavior, substance use Contingency management Antecedent Management Approaches Social Antecedents: Lifestyle changes, enhancing social support, refusal skills
Environmental Antecedents: Cue exposure, decision making skills Emotional Antecedents: Change strategies (daily thought records), distraction, self soothing, relaxation Cognitive Antecedents: Modifying automatic thoughts and drug related beliefs Physical Antecedents: Distraction, urge surfing, focus on consequences Contingency Management Approaches Using principles of operant conditioning, implement reinforcement to strengthen the incentive to become abstinent and weaken the incentive to continue using drugs Money based incentives: vouchers, access to jobs, etc.
Community Reinforcement Community Access Substituting Alternative Behaviors Punishment: inducing nausea (Disulfiram/Antibuse) ReMeds Pain / Wellness Program Proposal Task Force Members: Sandra McCool Physical Therapist Mick Sittig - Psychologist Susan Martin White, PT Physical Therapist Christina Peters, MS, BCBA Behavior Analyst Ann Marie McLaughlin, PhD - Neuropsychologist Jim Jaep, MA Psychologist Keith Robinson, MD - Physiatrist Scott Peters, MS, OTR/L Occupational Therapist
Pain Clients New admit residential Known unstable pain History of narcotic pain use and / or misuse Prior failures at pain programming New admit or existing outpatient with emergent or chronic pain Existing clients with emergent or chronic pain Treatment Philosophy Pain can be real following brain injury Pain experience is subjective Pain will not be eliminated or completely
resolved Treatment must be comprehensive, not just medications Acceptance of residual pain must be pursued Positive coping with residual pain must be pursued Improved functional abilities and pursuit of productive activity versus inactivity is critical Treatment Goal Areas Improve client functioning toward wellness activity Teach client to positively cope with residual pain Help to stabilize clients pain generators Minimize use of narcotic pain agents Teach client to self direct comprehensive pain
plan elements Set up discharge services that support wellness efforts Treatment Phases Phase 1 Preadmission Phase 2 Admission Phase 3 Evaluation Key Words: Evaluate, validate, educate Phase 4 Stabilization Key Words: Wellness, healthy, productive skill acquisition lifestyle, Phase 5 Generalization
Key Words: Wellness strategy application, increased independence Treatment Phase Preadmission Admissions Department Referral Call Preadmission Pain Questionnaire (To be completed by Admissions) Intake: specific assessment tools Chronic Pain Acceptance Questionnaire Pain Outcomes Questionnaire Tampa Scale for Kinesiophobia Specific Narrative Questionnaire Orientation to ReMed Pain Wellness Program One Page Pain - Wellness Program Philosophy Statement
Client Specific Guideline review and signature Revised Pain Client Specific Guidelines Additional Medical Record Request / Review Preadmission discussion with Physiatrist Admissions Committee Review preliminary impressions with team to prepare for admit Treatment Phase Day of Admission Day of admission review of Client Specific Guidelines
Current medication review (what they come in with) Possession search / inventory UDS if indicated PT and Nursing assessment Physiatry assessment Treatment Phase Evaluation: evaluate, validate, educate Comprehensive Evaluation Elements pending funding authorizations (see next slide) 30 day duration Residential campus restriction to be considered (phone / computer access / visitor
access) Medication Trials Treatment team meeting at 2 weeks; meeting with family / funder / client at end of 4 weeks Treatment Phase Evaluation: evaluate, validate, educate Comprehensive Evaluation Elements Additional diagnostics Pain medication history Labs / UDS findings Current ReMed therapy assessments with specific additional components Nursing Assessment Addendum to Initial Physical Therapy Evaluation Function Based Pain Scale
Treatment Phase Evaluation: evaluate, validate, educate Current ReMed therapy assessments with specific additional components continued: Psychology Assessment to include Neuropsychological Evaluation MMPI 2; BDI; BAI Pain Catastrophizing Scale Pain Stages of Change Family Interview ReMeds Observational Pain Scale (Non verbal Pain Indicators) Treatment Phase Stabilization:
Wellness, healthy, productive lifestyle, skill acquisition Medication trials with efforts to minimize use of narcotic pain agents Continue manual therapy with introduction of home exercise / use of modality and pacing program Facilitate acceptance of residual pain and shift to improved functional activity Facilitate stabilization of sleep, mood, diet, etc Incorporate all features into a comprehensive wellness plan (written individualized manual) Individualized Wellness Resource Book (Table of Contents) Treatment Phase Generalization: Wellness strategy application, increased independence Shift of program from physician / therapist directed to a
self - directed approach Shift from intensive therapy to stable activity pattern elements (home exercise, relaxation / coping plan, pacing, sleep schedule, residential skills, leisure plan elements) Additional Wellness Group modalities routinely available Active involvement in all program elements is encouraged and expected Consider medication self administration efforts Discharge planning is further refined and resources are established (home visits) Client Resistance Ambivalence / resistance to change may be displayed ReMed will employ best efforts to support client commitment Education
Family Intervention Big Picture Meeting Emergent discharge from program Medication Plan Brief Written Summary assembled Transportation Plan Physician appointment Medical 1. Pain: 2. 3. 4.
Anxiety: Mood: Sleep: a. Mobic 15mg qam; Acetaminophen 1000mg twice a day; Flexeril 10mg as needed; Tramadol 50mg as needed b. Manual Therapy with PT c. Home Exercise Program a. Klonopin 1mg twice a day (Reduction to .5mg twice a day then discontinued) a. Viibryd 40mg daily; Doxepin 50mg once a day a. Melatonin 3mg at bedtime J.B. Treatment Plan Skills Development
Coherence Breathing eM Wave Distraction Escalation Chain Stretching / Strengthening Home Program Sleep Hygiene Pacing with Work Out Plan Life Skills Preparation
Healthy Activity Plan AA / NA Sponsor Relationship Work Out Home Exercise Program Work at Law Office Return to School
Counseling Effective Pacing of Schedule Free Time Plan Cover this
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