New York Non-Acute Pain Medical Treatment Guidelines

New York

Non-Acute Pain

Medical Treatment Guidelines

First Edition, September 15, 2014

New York State Workers' Compensation Board

New York Non-Acute Pain Medical Treatment Guidelines

Table of Contents

GENERAL GUIDELINE PRINCIPLES ............................................. 1

MEDICAL CARE ............................................................................................... 1

RENDERING OF MEDICAL SERVICES ........................................................... 1

POSITIVE PATIENT RESPONSE ..................................................................... 1

RE-EVALUATE TREATMENT ........................................................................... 1

EDUCATION ..................................................................................................... 2

DIAGNOSTIC TIME FRAMES ........................................................................... 2

TREATMENT TIME FRAMES ........................................................................... 2

DELAYED RECOVERY ..................................................................................... 2

ACTIVE INTERVENTIONS ............................................................................... 3

ACTIVE THERAPEUTIC EXERCISE PROGRAM ............................................. 3

DIAGNOSTIC IMAGING AND TESTING PROCEDURES ................................. 3

SURGICAL INTERVENTIONS .......................................................................... 4

PRE-AUTHORIZATION .................................................................................... 4

PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL EVALUATIONS .......... 4

PERSONALITY/PSYCHOLOGICAL/PSYCHOSOCIAL INTERVENTION ......... 5

FUNCTIONAL CAPACITY EVALUATION (FCE) .............................................. 5

RETURN TO WORK ......................................................................................... 6

JOB SITE EVALUATION ................................................................................... 6

GUIDELINE RECOMMENDATIONS AND MEDICAL EVIDENCE .................... 7

EXPERIMENTAL/INVESTIGATIONAL TREATMENT ....................................... 7

INJURED WORKERS AS PATIENTS ............................................................... 7

SCOPE OF PRACTICE ..................................................................................... 7

DEFINITION OF NON-ACUTE PAIN ............................................... 7

INTRODUCTION ............................................................................. 8

KEY CONCEPTS .............................................................................................. 8

Biomedical vs. Biopsychosocial Approaches to the Diagnosis, Treatment and

Management of Pain ............................................................................................... 8

Medical vs. Self-Management Model .............................................................. 10

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New York State Workers' Compensation Board

New York Non-Acute Pain Medical Treatment Guidelines

Delayed Recovery ............................................................................................. 11

Importance of Early Identification .................................................................. 11

Functional Restoration Approach to Non-Acute Pain Management ..............12

Pain Outcomes and Endpoints.........................................................................12

Summary ..........................................................................................................13

EVALUATION AND DIAGNOSTIC PROCEDURES ....................... 13

HISTORY TAKING AND PHYSICAL EXAMINATION (HX & PE) .................... 13

Pain History, History of Present Illness ..........................................................13

Past Medical History ........................................................................................ 15

Physical Examination ....................................................................................... 17

Red Flags ......................................................................................................... 18

PERSONALITY/ PSYCHOLOGICAL/PSYCHOSOCIAL CLINICAL

EVALUATION FOR PAIN MANAGEMENT ..................................................... 18

Clinical Evaluation .......................................................................................... 19

Tests of Psychological Functioning ................................................................. 20

DIAGNOSTIC STUDIES (Imaging, Electrodiagnostic Studies (EDX), Special

Testing, Laboratory Testing) ........................................................................... 21

NON-PHARMACOLOGICAL APPROACHES ................................ 21

DELAYED RECOVERY .................................................................................. 21

PSYCHOLOGICAL EVALUATION AND INTERVENTION .............................. 22

Evaluation........................................................................................................ 22

Intervention ..................................................................................................... 23

NON-PHARMACOLOGIC TREATMENT OPTIONS ....................................... 24

NON-ACUTE PAIN MANAGEMENT PROGRAMS (INTERDISCIPLINARY OR

FUNCTIONAL RESTORATION PAIN MANAGEMENT PROGRAM) .............. 24

Interdisciplinary or functional restoration program ...................................... 24

Core components of an interdisciplinary pain program ................................ 24

MULTIDISCIPLINARY PROGAMS ................................................................. 25

GOALS OF PAIN MANAGEMENT PROGRAMS ............................................ 25

TYPES OF PROGRAMS ................................................................................. 26

DURATION OF PROGRAMS/INTERVENTIONS ............................................ 26

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New York State Workers' Compensation Board

New York Non-Acute Pain Medical Treatment Guidelines

Inpatient or Outpatient Pain Management Programs ................................... 26

Cognitive Behavioral Therapy ......................................................................... 26

Psychological Evaluations ............................................................................... 27

Psychological Intervention .............................................................................. 27

Biofeedback ..................................................................................................... 27

PHARMACOLOGICAL APPROACHES ......................................... 28

NON-OPIOID MEDICATIONS AND MEDICAL MANAGEMENT ..................... 28

Introduction .................................................................................................... 28

Goals ................................................................................................................ 28

Pharmacological Principles ............................................................................. 28

Neuropathic Pain............................................................................................. 29

Medications ..................................................................................................... 30

OPIOIDS: INITIATING, TRANSITIONING AND MANAGING LONG-TERM

ORAL OPIOIDS............................................................................................... 39

Long-Term Use of Opioids in the Opioid-Na?ve Patient: Opioid Therapeutic

Trial ....................................................................................................................... 39

Long-Term Use of Opioids: Transitioning/Managing Patients ON Existing

Opioid Therapy ..................................................................................................... 43

Ongoing, Long-Term Opioid Management .................................................... 45

Guidelines for Optimizing Opioid Treatment .................................................... 48

Introduction .................................................................................................... 48

Assessing Effects of Long-Term Opioid Therapy ........................................... 48

Patient Informed Consent for Opioid Treatment Form and Patient

Understanding for Opioid Treatment Form ......................................................... 51

Urine Drug Testing (UDT) for Monitoring Opioid Therapy........................... 53

Optimizing Opioid Doses ................................................................................ 58

OPIOID-RELATED MEDICATIONS: Tramadol, Methadone, Buprenorphine,

Tapentadol ...................................................................................................... 69

Tramadol ......................................................................................................... 69

Methadone ....................................................................................................... 70

Buprenorphine ................................................................................................ 70

Tapentadol ........................................................................................................ 71

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New York State Workers' Compensation Board

New York Non-Acute Pain Medical Treatment Guidelines

SPINAL CORD STIMULATOR AND INTRATHECAL DRUG

DELIVERY ..................................................................................... 72

IMPLANTABLE SPINAL CORD STIMULATOR (SCS) .................................... 72

Indications ....................................................................................................... 72

SCS Neurostimulation Screening Trial ........................................................... 73

Permanent SCS Implantation ......................................................................... 74

Special Circumstances ..................................................................................... 74

INTRATHECAL DRUG DELIVERY (Pain Pumps)........................................... 74

Indications ....................................................................................................... 75

Pain Pump Screening Trial ............................................................................. 75

Pain Pump Implantation ................................................................................. 76

FUNCTIONAL MAINTENANCE CARE .......................................... 76

General Recommendations for Functional Maintenance Care ........................ 76

Ongoing, Independent, Self-Management Plan ............................................. 76

Self-Directed Pain Management Plan ............................................................. 77

Review of Self-Management and Self-Directed Treatment Programs ........... 77

Ongoing Care ................................................................................................... 77

Ongoing Maintenance Care ............................................................................. 78

APPENDIX A: Fear-Avoidance Beliefs Questionnaire (FABQ) ................ 80

APPENDIX B: Frequently Used Tests of Psychological Functioning ....... 82

1.

Comprehensive Inventories for Medical Patients ............................................ 82

A. Battery for Health Improvement, 2nd Edition (BHI-2?) ................................... 82

B. Millon? Behavioral Medical Diagnostic (MBMD?)........................................... 82

2.

Comprehensive Psychological Inventories ...................................................... 82

A. Millon? Clinical Multiaxial Inventory?, 3rd Edition (MCMI- III?) ................ 83

B. Minnesota Multiphasic Personality Inventory?, 2nd Edition (MMPI-2?) ....... 83

C. Minnesota Multiphasic Personality Inventory?, 2nd Edition Revised Form

(MMPI-2?)........................................................................................................... 83

D. Personality Assessment Inventory? (PAI) .......................................................... 83

3.

Brief Multidimensional Screens for Medical Patients ....................................... 84

A. Brief Battery for Health Improvement, 2nd Edition (BBHI-2?) ....................... 84

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