Navigating Pain Management Prescriptions In Wound Care

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Author(s): 
Clinical Editor: Kazu Suzuki, DPM, CWS

   Dr. Jacobs has found several opioid and opioid-like agents very helpful for the management of symptomatic diabetic neuropathy. Tapentadol (Nucynta, Janssen Pharmaceuticals) has recently received approval for the treatment of diabetic neuropathy. He notes that tramadol, with mu-2 receptor activity and some tricyclic activity, is also helpful to manage symptomatic neuropathy. He cites studies indicating that oxycodone is helpful for the management of neuropathic pain.3

   As is the case with adjuvant analgesics, Dr. Jacobs will personally insist on good control of diabetes and evaluate the patient for entrapment neuropathy. He utilizes agents such as Metanx to reverse the actual disease process before considering opioid analgesics for the management of symptomatic neuropathy. Dr. Jacobs advises that patients must understand that concurrent treatment of the oxidative and nitrosative stress causing the neuropathy is essential in addition to the use of opioids for the management of symptoms.

   “The chronic use of opioids for pain management is an arena in which not all podiatric physicians are comfortable. This is understandable,” says Dr. Jacobs. “However, there are patients who require these medications and should not be made to suffer from pain, lack of restorative or restful sleep, or decreased quality of life because of our fears associated with such medications.”

   Dr. Jacobs adds that one may consider alternatives such as spinal cord modulation, sequential peripheral nerve blockades, peripheral nerve release or the referral of the patient to a pain management specialist.

   Dr. Brill does not use oxycodone but does use hydrocodone and tramadol. He has no problem prescribing opioids and other analgesics but says if those medications fail to alleviate patients’ pain to an acceptable level, he will refer them to a pain management specialist for more aggressive treatment.

   Dr. Suzuki has not had many problems with patients who may or may not abuse opioids, such as those who ask for too many tablets. Instead, he has had more problems with pharmacies refusing to dispense these medications because they are either “out of stock” or they suspect drug abuse, rightfully or not.

   “Since more and more pharmacies are connected electronically for e-prescribing capability, I think it is easier to spot potential ‘drug seekers’ who may do doctor shopping for pain medications,” says Dr. Suzuki. “We always instruct our residents to believe the patient’s report of pain, and it is against our institution’s policy to prescribe ‘placebo’ pills to see if the pain is ‘real’ or not.”

   When patients require chronic opioid use, Dr. Jacobs will document clearly that he has discussed with the patient the potential for addiction, tolerance and adverse systemic sequelae to the medications. He documents the pain requiring such medication in detail and documents that he instructed the patient to carefully read all of the printed materials that typically will accompany the prescription at the pharmacy. Finally, his patients must enter into a “pain management contract,” a consent form in which they agree not to abuse the medications, not to receive opioid analgesics elsewhere and limit the quantity per month.

Q:

Do you worry about pain medication “seekers”?

A:

Having an open wound is an inherently painful condition and Dr. Suzuki has not had too many “pain medication” seekers who caused a lot of problems. Occasionally, he does require a “contract” if a single patient asks for multiple refills of narcotic medications or his practice will sometimes require patients to get a consultation and receive supervision with pain management specialists before his office provides prescriptions.

   As Dr. Brill notes, pain medication seekers are a potential problem in any medical practice. He acknowledges that it sometimes can be very challenging to identify a potential abuser versus someone who is truly in need and not responding to the medical regimen.

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