Gallardo Power Point

Grace Gallardo, MD
Board Certified Family Practice
Private practice , Oklahoma Pain
Center Oklahoma City
• Speaker, Endo Pharmaceuticals
Risk Assessment
Forms, tools, “Gut Feeling”
Questionnaire with Score System:
– Family and Personal history of:
• Alcohol abuse
• Illegal drug use
• Prescription drug abuse
– Mental Health diagnosis
• ADD, bipolar, depression, schizophrenia
– Age
• Between 16-45
– History of preadolescent sexual abuse
Adapted from Webster, LR and Webster, RM, Pain Med
Impact of Pain, Stratification Tools
Lifestyle decline
Social withdrawal
Cognitive decline
Quit working
Deterioration of family relationships
• Focus on function from the beginning
• Set realistic expectations
• Do not start if you are not comfortable
• Avoid polarizing
“I believe or do not believe in opiate treatment”, or
“I am pro-con opiate treatment”, should be neither
a metaphysical nor a political vision or position.
• Opiates do not work for all pain conditions
• They may not work for every patient
• Not every patient is a candidate
• Monitor closely for side effects
– response may involve discontinuation or opiate rotation
What Do I Need
• Understand Federal and State Laws
• Good history & physical, previous treatments,
specialist visits, imaging/diagnostic tests
• Look at medication list carefully
– Special focus on sedatives and hypnotics
• Patient education
– Discuss risks and benefits
– Side effects and realistic goals to therapy
– Informed narcotic consent.
…and more
• Periodic reassessment
• Monitoring tools
– Prescription Monitoring Program (PMP)
– Urine Drug Screens
– Pill counts (scheduled and random)
• Across the board, no exceptions!
Opiates, the Good
• Improved function
– Back to work or longer hours
– Improved productivity
– Better care of family
– Improved relationships
– Better sleep
• Decrease in complaints
– more hopeful attitude
– Minimal or controllable side effects
Opiates, the feared
Abuse, misuse, diversion, addiction
Tolerance and dependency
Impaired sleep patterns
Negative impact on mood, personality, behavior
Immune system suppression
Delay in functional improvement
...and more
• No precise data exists on rates of
addiction and misuse in patients with
Longitudinal Opiate Therapy who are
legitimately prescribed opiates.
• As prescribers, we need to take
responsibility in understanding the impact
of Opiate Abuse in the community .
Miscellaneous and Pearls
• Consequences of pain and excessive opiate doses
can be difficult to discern.
• Sometimes there is a fine blurry line between use
and misuse, listen to what patient says:
– “I can do more when I take my pain pill, it keeps me
going”. This should raise a concern for stimulant effect
and/or euphoric effect of medication which may lead to
– “It helps me sleep”
– “I hurt more because of family or other stressors so I
need more medication”
…and more
• “One more pill and I will be fine” - likely this
patient is relying on opiates for their entire pain
treatment, not coping with pain, and probably
has declining function despite opiate use.
• Lots of denial, rationalization and fear found in
these patients, anxiety arouses or worsens.
• Keep in mind the high variability in patient
response to different opiate treatments, in
effectiveness, and to side effects.
Almost There
• Keep in mind that curves of development of tolerance of pain
control and to side effects do not run parallel, the first one
grows faster.
• Remember that there is an incomplete cross- tolerance
between opiates, always decrease the total daily dose by 2550% when bridging from one opiate to another. Go Slowly.
• Age consideration
– Young - higher risk of abuse, misuse, diversion and addiction
– Elderly- higher incidence of organ failure and frailty.
• Involve the family. Ask the patient to bring them to the visit.
• Up is not always the way to go!!!! May be the fastest though;
stop and think.
Why Are They Abused
• Opiates target the reward system, especially the
dopamine system.
• Results in uncontrollable, unconscious,
impulsive behavior.
• Be vigilant: a large subset of the population is
vulnerable to potential abuse.
•, great
• Fishman Scott, 2012, Responsible Opiate
Prescribing, 07-83.
• Waldman Steven,2009, Pain Review, 667-675.
And sometimes things can go wrong,
but it’s worth the challenge.

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