Understanding Pain Management

Understanding Pain Management Requirements

We have noticed severe situations with our patients not understanding the laws, restrictions and guidelines which we are REQUIRED to follow when prescribing pain medications. To ensure everyone is on the same page the below information and algorithm will assist in explaining the steps to the pain management progression within this practice. If any patient is not able to understand or comply with these requirements then we will gladly forward your records to the pain management of your choosing.

Please understand that these steps are required to ensure the health and safety of our patients as well as to comply with all local and federal regulations, guidelines, and laws.

Thank You for your understanding and cooperation

Understanding the Pain Scale

For the purposes of this scale the Activities of Daily Living specifically pertain to the activities requires to leave the house, examples include but are not limited to cooking, cleaning, bathing, dressing, shopping, going to work etc.

0 - No pain at all

1 - mild discomfort which is intermittent (comes and goes) - does not impact daily activities

2 - mild discomfort which is frequently intermittent (comes and goes multiple times a day)- does not impact daily activities

3 - Moderate discomfort which is frequently intermittent (comes and goes multiple times a day) - does not impact daily activities

4 - Moderate discomfort which does not go away but does not impact daily activities

5 - Moderate discomfort which does not go away and sometimes (less than 2 times per day) interferes with daily activities

6 - Moderate discomfort which does not go away and frequently (2-4 times a day) interferes with daily activities

7 - Moderate discomfort which does not go away and interferes with daily activities at least 5-7 times per day

8 - Moderate-Severe Discomfort which does not go away and prevents person from doing more then basic tasks and leaving the house

9 - Severe discomfort which prevents the person from leaving their bed, thinking straight, or being able to focus

10 - Severe Discomfort which is severe enough to cause loss of consciousness.

We understand that all patients have their own tolerance level to pain; however if you are able to walk, talk, think coherently, and drive you are not higher than a 7-8/10 on the pain scale

We are not trying to eradicate pain, we are trying to control it to levels which will allow a person to function and perform their daily activities, this means our goal is to get all patients to between 4-6/10 pain level with the use of therapy, treatment, and medication management.

Your copay covers the cost of investigation, evaluation and appropriate treatment from the provider along with the staffing overhead costs. These costs are expensive and insurance typically does not reimburse enough to cover all costs, so please understand that when mentioning copay or finances to the staff or providers. You (or your insurance) are paying for the services of trained licensed professionals. This means we have rules to follow and you may not always “get it your way” . This is not fast food, this is medicine and if we fail to follow the proper steps it will cause harm.

UNDERSTANDING MORPHINE EQUIVALENCY

Most pain medications are measured in Morphine Equivalents this is the amount of morphine required to replace your medication on a daily basis

Examples:

5 mg of Hydrocodone = 5 mg Morphine 50 mg Nucynta = 20 mg of Morphine

5 mg of Oxycodone = 7.5 mg of Morphine 2 mg Hydromorphone = 10 mg of Morphine

12.5 Fentanyl Patch = 30 mg of Morphine for 3 days (total 90 mg per patch)

5 mg Methadone Oral Tablet = 23.5 mg Morphine 5 mg Oxymorphone = 15 mg Morphine

50 mg Tramadol = 10 mg of Morphine 30 mg Codeine = 4.5 mg of Morphine

There are some medications which treat pain however do not have a Morphine Equivalent per the governing bodies - however studies indicate they produce pain alleviating effects at the following levels. These medications are also used for addiction and opiate craving control. The base medication is called Buprenorphine.

Examples:

75mcg of Belbuca = 15 mg of Morphine 2 mg Buprenorphine Tablet = 30 mg of

Morphine - several factors contribute to the relief felt

Understanding the rules pertaining to Pain Medication:

IF IMAGING HAS NOT BEEN COMPLETED WITHIN THE PAST TWO YEARS NO NEW MEDICATION/INCREASE IN PREVIOUS DOSING WILL BE PROVIDED

IF IMAGING IS NOT UP TO DATE PREVIOUSLY PRESCRIBED MEDICATION (WITHIN THE PAST 3 MONTHS) WILL BE CONTINUED; HOWEVER ONLY A 7 DAY SUPPLY WILL BE PROVIDED AND IMAGING BE COMPLETED PRIOR TO ANY ADDITIONAL MEDICATION IS PRESCRIBED

IF IT HAS BEEN MORE THAN 3 MONTHS, BUT LESS THAN 12 MONTHS SINCE THE LAST LEGAL PRESCRIPTION FOR PAIN MEDICATION - THE PREVIOUS MEDICATION AT A LOWER DOSING MAY BE INITIATED - FOR A 7 DAY SUPPLY WITH REQUIRED FOLLOW-UP.

ANY PATIENT WHO IS NEW TO PAIN MANAGEMENT, OR HAS NOT BEEN ON PAIN MANAGEMENT WITHIN THE PAST 12 MONTHS WILL FOLLOW THE BELOW ALGORITHM

NEW PATIENT PAIN MANAGEMENT ALGORITHM

STEP 1 - 7 day supply - Will not exceed a total of 15 Morphine Equivalents per 24 hour period

STEP 2 - either 7 day supply or 30 day supply - will NOT exceed a total of 22.5 Morphine Equivalent per 24 hour period

STEP 3 - 30 day supply - will NOT exceed a total of 22.5 Morphine Equivalent per 24 hour period

ALL REMAINING STEPS WILL ADHERE TO THE FOLLOWING:

60 days/2 months are required on current medication before any dosing increases will be considered.
NO MORE than a Maximum increase of 7.5 Morphine Equivalents per 24 hours is allowed without the consultation and permission of the Owner Carol Cherry
Seeking behavior such as aggressive demanding statements, demanding specific medications, failure to follow the testing requirements may result in reduction of medication, transition to anti-addictive medication, or discharge from the practice.
Prior to exceeding a total of 45 Morphine Equivalent per 24 hour period; Extended Release Medications will be required to be utilized.
The following combinations of medications will NOT be initiated at this practice
- Pain Medicine+Benzodiazepine (xanax)+Soma+Ambien
- Pain Medicine+Benzodiazepine+Soma
- Pain Medicine+Benzodiazepine+Ambien
The Combination of Pain Medicine and Soma will NO LONGER be initiated at this practice
The Combination of Pain Medicine and Benzodiazepine will only be considered of the below are met
- failure on ALL of the following anti anxiety medications
  - Hydroxyzine
  - Buspirone
- Required to be on a maintenance medication examples include but are not limited to
  - sertraline (zoloft)
  - fluoxetine (prozac)
  - Wellbutrin
- Genesite testing to be completed if insurance allows
- consideration of the addition of benzodiazepines will be completed with trials of medication in the following order
  - diazepam (valium)
  - clonazepam (klonopin)
  - lorazepam (ativan)
  - alprazolam (xanax)
- Pain medicine + Ambien - will NEVER be initiated at this practice - you will be required to see a specialist, and the specialist will be required to evaluate and provide the ambien if deemed medically necessary.

Understanding the rules pertaining to Pain Medication and Attempted Dosing Reduction Requirements:

- 45-89 morphine equivalents - required dosing reduction attempt of 5 morphine equivalents per day

- 90-119 morphine equivalents - required dosing reduction attempt of 10 morphine equivalents per day

- 120-200 morphine equivalents - required dosing reduction attempt of 15 morphine equivalents per day

- 200 or more morphine equivalents - required dosing reduction attempt of 20 morphine equivalents per day

ESTABLISHED PATIENT PAIN MANAGEMENT ALGORITHM

Dosage Increase and High Risk Medication Combination Restrictions

60 days/2 months are required on current medication before any dosing increases will be considered.
NO MORE than a Maximum increase of 7.5 Morphine Equivalents per 24 hours is allowed without the consultation and permission of the Owner Carol Cherry
Seeking behavior such as aggressive demanding statements, demanding specific medications, failure to follow the testing requirements may result in reduction of medication, transition to anti-addictive medication, or discharge from the practice.
Prior to exceeding a total of 45 Morphine Equivalent per 24 hour period; Extended Release Medications will be required to be utilized.
The following combinations of medications will NOT be initiated at this practice
- Pain Medicine+Benzodiazepine (xanax)+Soma+Ambien
- Pain Medicine+Benzodiazepine+Soma
- Pain Medicine+Benzodiazepine+Ambien
The Combination of Pain Medicine and Soma will NO LONGER be initiated at this practice
The Combination of Pain Medicine and Benzodiazepine will only be considered of the below are met
- failure on ALL of the following anti anxiety medications
  - Hydroxyzine
  - Buspirone
- Required to be on a maintenance medication examples include but are not limited to
  - sertraline (zoloft)
  - fluoxetine (prozac)
  - Wellbutrin
- Genesite testing to be completed if insurance allows
- consideration of the addition of benzodiazepines will be completed with trials of medication in the following order
  - diazepam (valium)
  - clonazepam (klonopin)
  - lorazepam (ativan)
  - alprazolam (xanax)
- Pain medicine + Ambien - will NEVER be initiated at this practice - you will be required to see a specialist, and the specialist will be required to evaluate and provide the ambien if deemed medically necessary.

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