Torment Management Updates and Issues

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´╗┐Torment Management Updates and Issues Robert Twillman, PhD The University of Kansas Medical Center

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Pain is a noteworthy general wellbeing issue 80% of patients present for medicinal services in view of torment Chronic agony influences 30-40% of the populace Over 40% of doctor's facility patients report poor torment control Unrelieved torment costs our economy over $100 billion every year

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Prescription Opioid Abuse is a Public Health Issue 2007 National Survey on Drug Use and Health (NSDUH): 33.5 million Americans had utilized a torment reliever non-therapeutically at any rate once in their lifetimes (13% expansion from 2002)

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Sources of Abused Drugs, NSDUH 2007 "Other" incorporates "Composed Fake Prescription", "Stole from Doctor's Office/Clinic/Hospital/Pharmacy", and "Some Other Way"

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Sources of Abused Drugs, NSDUH 2007 "Other" incorporates "Composed Fake Prescription", "Stole from Doctor's Office/Clinic/Hospital/Pharmacy", and "Some Other Way"

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NSDUH Data Are Unreliable Definition of "nonmedical utilize" is dangerous Asking about wellspring of medication is tricky High social attractive quality element Asking your exploration subject where he got his medication is influenced by this Asking your examination subject where his source got the medication is colossally untrustworthy

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Prescription Opioid Abuse is a Public Health Issue 2002 Drug Abuse Warning Network information (DAWN; ED visits) : 108,320 for opioid analgesics (153% expansion from 1995) 2006 Treatment Episode Data Set (TEDS): Non-heroin opioids were essential medication of manhandle for 74,750 patients entering substance mishandle treatment across the country (550% increment from 1996)

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Drug Treatment Admissions, Non-Heroin Opioids as Primary Drug 450% Increase more than 10 years

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Recent Survey Teen-agers now say it is less demanding to get physician endorsed drugs than it is to get brew

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Sources of Diverted Prescription Opioids Supply chain burglaries Internet drug stores Thefts from patients "Buys" from patients Prescription imitation Illegal recommending works on Prescribing to people who betray prescribers

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Measuring and Controlling Drug Diversion Due to the way of the issue, measuring the degree of medication preoccupation is to a great degree troublesome Pharmacy robberies can be followed, as can remedies Most different sources are for all intents and purposes difficult to inspect Can tranquilize manhandle insights be utilized as a surrogate? Are all mishandled drugs occupied?

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HCP-Related Reasons for Inadequate Pain Management Survey of 1177 Oncologists: Inadequate Pain Assessment (79%) Patient Reluctance to Report Pain (62%) Patient Reluctance to Take Opioids (62%) MD Reluctance to Prescribe Opioids (61%)

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Why are doctors on edge about overseeing unending agony with opioids? Vulnerability identified with appraisal Concern about hindering symptoms Unfamiliarity with opioids, adjuvants Fear of habit Fear of claims Fear of administrative examination

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Means of Improving Pain Management Changes to approaches and gauges Education of suppliers and patients Development of practice rules Monitoring and ceaseless quality change

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Patient-Related Reasons for Inadequate Pain Management Fear of fixation Fear of reactions Expectations are low MD may need to pick which to treat- - infection or agony Fear of diverting the specialist Complaining about torment may bother the specialist

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What We Hear From Patients Many experience issues discovering doctors who will treat their torment enough A couple report issues with drug stores filling medicines for torment solutions Some experience issues getting insurance agencies and Medicaid to pay for torment treatment Many have (erroneously) been told they either are dependent or at high hazard for enslavement

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National Pain Policy Issues

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Current Issues Federal enactment National Pain Care Policy Act Methadone Treatment and Protection Act FDA exercises Propoxyphene Acetaminophen proposals REMS for long-acting opioids

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Current Issues DEA exercises ePrescribing Disposal of Controlled Substances American Geriatric Society torment treatment rules

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National Pain Care Policy Act Originally presented in mid 2000s In last session of Congress Passed House close end of session Stalled in Senate HELP Committee Current session Passed House immediately Stalled in Senate HELP Committee Now revised to human services change charges in both houses

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National Pain Care Policy Act Background Pain influences around 80% of individuals displaying for medicinal services Pain look into subsidizing at NIH speaks to 0.1% of all NIH give financing There are 23 audit gatherings to assess torment related stipends, which must go up against extremely not at all like concede applications Ongoing noteworthy shortages in health awareness supplier instruction identified with torment administration

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National Pain Care Policy Act Provisions IOM to assemble a Conference on Pain ($500K appropriated) Director of NIH urged to extend, through Pain Consortium, a forceful program of fundamental and clinical research Pain Consortium to issue yearly proposals on research activities NIH to build up Interagency Pain Research Coordinating Committee

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National Pain Care Policy Act Secretary of HHS is to set up give program for instruction and preparing in torment mind ($5M every year appropriated) Secretary might set up and execute a national torment mind training effort and mindfulness crusade (concentrated on customers; $2M appropriated for FY 2010, $4M for FY 2011 and FY2012)

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Methadone Treatment and Protection Act Introduced by Senator Rockefeller (D-WV) on 3/31/09 Referred to Senate HELP Committee

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Methadone Treatment and Protection Act Background Methadone is an exceptionally viable, extremely modest long-acting opioid pain relieving It is hard to utilize as a result of its pharmacological properties It has a long half-life (up to 100 hours for some of its metabolites) Does not create huge happiness Effects of dosage change not totally observed for around 4 days

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Methadone Treatment and Protection Act Methadone utilizes Methadone upkeep for opioid addicts Intended to counteract withdrawal, check yearnings Administered day by day at centers Typically a deep rooted treatment Management of torment Very low measurements might be extremely successful Administered 2-4 times each day May be halted if torment is do not present anymore

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Methadone Treatment and Protection Act 1998-2006: Prescriptions expanded 700% In 2005, there were 4462 methadone-related passings, up by 468% since 1999 Other harming passings expanded by 66% over same period Rate of methadone passings in 15 to 24-year-olds expanded 11-crease, and might be underreported

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Methadone Treatment and Protection Act Bill calls for: Consumer training effort ($15M every year FY2010-2014) Practitioner instruction (supported through segment of DEA enlistment restoration expenses) No utilization of 40 mg diskette measurements outside of support projects Secretary of HHS to set up Controlled Substances Clinical Standards Commission

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Methadone Treatment and Protection Act Bill calls for: Funding of 1995 National All-Schedules Prescription Electronic Reporting (NASPER) program at $25M every year for FY2010-2014 Improved reporting benchmarks for methadone-related passings

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Food and Drug Administration Activities

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Propoxyphene is an opioid pain relieving Research proposes it is might be just barely powerful, if by any stretch of the imagination, in treating torment It has a seemingly perpetual metabolite that chafes the sensory system and causes heart musicality aggravations Found in Davron, Darvocet; promoted since 1957 Pain rules prescribe not to utilize this medication

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Propoxyphene FDA was requested that survey tranquilize in light of the fact that: Insufficient proof to propose it is a viable pain relieving It was pulled back from the UK advertise in light of the danger of consider and coincidental overdose It is cardiotoxic and has limit remedial list It is generally endorsed, particularly in elderly, and is connected with a substantial number of passings

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Propoxyphene FDA consultative board of trustees voted 14-12 to suggest withdrawal from the market FDA chose to keep sedate available "Advantages exceed dangers" Manufacturer required to do wellbeing ponders FDA to work with different organizations to lead extra studies

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Acetaminophen Active fixing in Tylenol Found in a large number of over-the-counter meds Also found in some professionally prescribed meds, consolidated with opioids High intense dosages can bring about fulminant liver disappointment and demise High interminable measurements can bring about constant liver disappointment

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Acetaminophen Frequently, issues emerge on the grounds that patients are recommended meds containing acetaminophen while additionally taking OTC acetaminophen FDA chose to audit this pharmaceutical to check whether there were approaches to enhance its security Advisory board meeting was held June 29-30 Votes gone up against various inquiries

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Acetaminophen Question: Do you prescribe ebb and flow most extreme measurements be permitted? Solid yes: 11 Yes: 10 No: 16 Question: Should max single measurement be 650 mg? Solid yes: 12 Yes: 12 No: 13

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Acetaminophen Question: If current measurements of OTC items are brought down, ought to current greatest dosage (2 X 500 mg) be changed to solution as it were? Solid yes: 8 Yes: 18 No: 11

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Acetaminophen Question: Do you prescribe pack measure limits for OTC items? Solid yes: 2 Yes: 15 No: 20 Question: Should OTC mix items be dispensed with? Solid yes: 2 Yes: 11 No: 24

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Acetaminophen Question: Should stand out grouping of OTC fluid be accessible? Solid yes: 19 Yes: 17 No: 1 Question: Should medicine mix items be wiped out? Solid yes: 10 Yes: 10 No: 17

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Acetaminophen Question: Should all solution mix items be rankle pressed? Solid yes: 5 Yes:

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