Provider Update
Volume 21, Issue 3
May/June 2004
CommunityCARE Referrals
As of December 2003, CommunityCARE is a statewide program, and 75% to 80% of all Medicaid recipients are enrolled in CommunityCARE. Therefore, it is important that all providers to remember that referral/authorization must be obtained prior to providing non-emergency services to a CommunityCARE enrollee. Any provider who renders non-emergency services prior to obtaining the appropriate referral/authorization puts themselves at risk for non-payment by Medicaid.
When a patient is being discharged from the hospital, it is the responsibility of the discharging physician/discharge planner to coordinate with the patient�s PCP and obtain the appropriate referral/authorization for any additional services such as Durable Medical Equipment (DME) or home health. The home health or DME provider, cannot receive payment from Medicaid without the appropriate PCP referral/authorization. The Home Health or DME provider must have that referral/authorization in-hand prior to rendering the services.
There seems to be some confusion among PCPs and hospitals regarding the approval or denial of
emergency room post referral/authorization requests for low level emergency room visits. CommunityCARE policy states that the decision whether to approve or deny a post-authorization request for emergency room service, must be based solely on whether the patient�s presenting symptoms met the prudent layperson�s standard, and the PCP must respond within 10 days from the date of the request (CommunityCARE Handbook Supplement, page 6). Factors such as the time of day the patient went to the emergency room, the patient�s ultimate diagnosis, or whether the PCP�s office was open at the time are inappropriate reasons for denial. It is the hospital�s/ER physician�s responsibility to provide the PCP with enough information, regarding the patient�s presenting symptoms, to allow the PCP to make an informed decision. Listing presenting symptoms such as �fever�, �stomach pain�, or �headache� is not sufficient. However, the patient�s age and severity/duration of pain are relevant factors, and this information should be included on the request. If the PCP is unable to determine whether the post-authorization request should be approved or denied due to insufficient information provided by the hospital, the PCP should request that the hospital send additional information. Although the referral authorization forms (both the paper form as well as eRA) list �during/after office hours,� in conjunction with �Doesn�t meet prudent layperson standards� is simply additional information for DHH tracking purposes and can not be used as the reason for denial. The overriding factor, and the only one which should be considered for approval or denial, is whether the patient�s presenting symptoms met the prudent layperson standard.
Birth Control Patch Billing
Johnson and Johnson currently produces and markets the Ortho Evra patch for the following
NDC's:
| NDC |
Strength |
Package Quantity |
Marketed as |
| 00062-1920-01 |
20-150/24H |
1 patch per box |
Replacement Patch Only |
| 00062-1920-15 |
20-150/24H |
3 patches per box |
1 month supply |
Pharmacy claim reviews have revealed many instances of NDC 00062-1920-01 being billed for greater than a quantity of one (1) which indicates the use of this patch not as a replacement patch, but as a 1 month supply. Specifically, as provided in the package insert, Ortho Evra, NDC 00062-1920-01 is intended for use as a replacement patch in the event that a patch is inadvertently lost or destroyed.
The manufacturer of Ortho Evra is disputing rebate payments on claims for more than a quantity of one (1) for NDC 00062-1920-01, and for quantities not divisible by three for NDC 00062-1920-15.
The manufacturer offers rebate coupons to the general public for up to three (3) single replacement patches per year (NDC 00062-1920-01), and is also offering that additional rebate to the state. However, they will only provide the additional rebate on NDC 00062-1920-01 that is being used as intended, as a replacement patch. Therefore accurate provider billing of these NDCs is vital in order to maximize revenue collected for the state.
Please ensure that billings for these NDCs accurately reflect the NDC being dispensed.
XENICAL
In accordance with FDA indications, Louisiana Medicaid will lower the age restriction for Xenical prescriptions to age twelve, effective July 1, 2004. All other existing Xenical criteria for Medicaid reimbursement remains in effect. Please refer to the 2004 Pharmacy Provider Training Packet for Xenical policy.
DIASTAT UNIT BILLING ERRORS
Approximately 50% of LA Medicaid providers are billing Diastat claims incorrectly. The correct billing unit for Diastat is a kit. Each kit is packaged with 2 syringes. Please do not bill per syringe. Reimbursement is based on each kit dispensed. LA Medicaid is reviewing claims for DIASTAT and will recoup money from claims billed per syringe.
Billing example:
QTY of Diastat kits
dispensed |
Qty of SYRINGES
dispensed |
Correct QTY to bill
LA Medicaid |
| 1 |
2 |
1 |
| 2 |
4 |
2 |
Currently the Diastat NDCs are as follows:
| 66490-0650-20 |
59075-0650-20 |
| 66490-0651-20 |
59075-0651-20 |
| 66490-0652-20 |
59075-0652-20 |
| 66490-0654-20 |
59075-0654-20 |
| 66490-0655-20 |
59075-0655-20 |
Notice to PCPs
The CommunityCARE Program has recently learned that some PCPs are refusing to accept hard copy (faxed or mailed) emergency room post authorization requests when the hospital has not completed the recipient information on the standard CommunityCARE authorization form and forwarded it to the PCP.
The CommunityCARE Handbook (section 4.3) states �The PCP will carefully review the emergency room face sheet and pertinent copies of the emergency room record forwarded by the emergency department for visits with CPT codes 99281, 99282 and 99283 for post authorization and provide timely (within 10 days) written referrals/authorizations when indicated.�
It is the PCP�s responsibility to provide written referrals/authorizations, and he/she cannot unreasonably withhold them or require the requesting provider to complete them. The purpose of the CommunityCARE management fee is to provide compensation for the additional case management/administrative requirements placed on providers who choose to enroll as CommunityCARE PCPs.
Hospital Program � Outpatient Surgery Services
Effective for dates of service on or after October 1, 2004, Current Standard Healthcare Common Procedure Coding System (HCPCS) codes and modifiers must be used to bill for all Medicaid outpatient surgery services. Medicaid payment rates shall be established and assigned to each code based on the Medicare payment rates for outpatient surgery services. Additional instructions for billing these services will be provided in the near future.
PCP Referral
Program Integrity has been conducting field audits on durable medical equipment (DME) providers and has found in some cases, that the provider is not maintaining a copy of the primary care physician�s referral. This is a requirement under the DME Program. Failure to maintain a copy of a referral is grounds for recoupment of payment for services, equipment and supplies as well as for imposition of other sanctions for non compliance with Medicaid Policy.
It is not necessary to have a referral from the primary care physician prior to submitting a request for authorization of payment to the Prior Authorization Unit (PAU). However, a referral must be obtained and maintained on file prior to billing since all conditions required for payment must be met prior to billing.
Prior Authorization of Durable Medical Equipment Rental
Effective immediately, all durable medical equipment (DME) approved as rental equipment will be approved by the Prior Authorization Unit (PAU) and must be billed, using the appropriate procedure code and the RR modifier which designates it as rental equipment.
Because of this change, the PAU will no longer require an anticipated delivery date and will instead give a span date to providers. The provider must deliver the equipment prior to the end of this span date or the authorization will no longer be valid. The actual date of delivery must be indicated on the claim as the date of service.
If the equipment has already been delivered by the provider prior to the request, the actual date of delivery should be indicated on the prior authorization request form.
Providers must never delay delivery of equipment or supplies until after payment is received, but should make delivery as soon as possible after receiving notification of approval for payment from PAU. Providers may deliver the equipment or supplies prior to receiving authorization from PAU, at their own risk.
Cost Report Deadlines
ICF/MR providers are required to submit their 2004 cost reports by September 30, 2004. Cost reports are required for central offices, facilities, related habilitation program, extraordinary costs, etc. One 30 day extension may be granted upon written request. The cost report software (LA ICF/MR Cost Reporting Solutions version 9.0 and Extraordinary Costs version 6.0) is available free of charge on the internet at
http://www.medimax.com.
ICAP Reimbursement Methodology
The Department of Health and Hospitals, Bureau of Health Services Financing is proposing to revise the reimbursement methodology for private intermediate care facilities for the mentally retarded (ICF-MR). The new reimbursement methodology was developed by the Inventory for Client and Agency Planning (ICAP) Project Team and committee members which include member of the provider community, Arnett & Foster, LC, DHH consultants and DHH staff. The Inventory for Client and Agency Planning tool will be used to determine the level of need of individual recipients. Rates will be client specific rather than based on the level of care (LOC) of the facility.
The transition to the ICAP reimbursement methodology will be cost neutral to the Department and revenue neutral to the industry as a whole based on payments for the quarter beginning January 1, 2004 through March 31, 2004. However, individual provider revenue will be impacted contingent upon the acuity of their residence based on the ICAP levels. A Notice of Intent if being published in the July 20, 2004 issue of the Louisiana Register.
Prior to actual implementation effective for date of service on or after January 1, 2005, there will be a �shadow rate period� of six months beginning July 1, 2004. Providers will be reimbursed under the current LOC reimbursement methodology will simultaneously being notified of what the facility revenue stream would be based on the ICAP reimbursement methodology.
One feature of the ICAP reimbursement methodology is a direct care floor requiring that providers expend a set percentage of the direct care component of the rate on direct care costs or refund the difference to the Medicaid Program. Because the new reimbursement methodology will be implemented in the middle of a fiscal year, the direct care floor will not be in effect until the year beginning July 1, 2005.
Providers were recently asked to resubmit their ICAP data in electronic data files by facility name. In addition, providers were asked to review the ICAP information and correct information in the files. This updated information will be used to disseminate the �shadow rate� for individuals in July. Providers should no longer submit any paper copies of the ICAP to the Rate and Audit Section. Once this last data set is submitted by computer disk, provider must maintain ICAP records in the recipient�s record.
If you have any questions, you may call Mary Norris at 225-342-2768 or MNORRIS@dhh.la.gov.
New Claims Status Inquiry (CSI) Web Application Activated
The LA Medicaid Claims Status Inquiry Application (e - CSI) is now in production. This new application is HIPAA compliant; allows providers to obtain the status of claims submitted to LA Medicaid; and can be found in the secure area of the LA Medicaid web site, LAMedicaid.com. To ensure appropriate security of recipient/provider information and in order to use the application, providers who do not currently have a login and password for this area of the web site must obtain one by using the link, Provider Web Account Registration Instructions. Effective immediately, providers wishing to check the status of claims submitted to LA Medicaid should use this application. Should you need assistance with obtaining a login and password or have questions about the technical use of the application, please contact the Unisys Technical Support Desk at 877-598-8753. An RA stuffer and the next edition of the Provider Update will outline the complete details of this application.
BCSS Provider Enrollment and Training Material
Beginning with the provider enrollment set for July 15, 2004, BCSS will establish an internet based enrollment process. BCSS will also make provider enrollment training material available through the internet at
http://www.dhh.state.la.us/bcss.
BCSS Provider Enrollment Orientation Training for New Providers of EDA and NOW Waiver Services
The Department of Health and Hospitals (DHH), Bureau of Community Supports and Services (BCSS) will be conducting a Provider Enrollment Orientation Workshop for new providers of Elderly and Disabled Adult (EDA) Waiver and New Opportunities Waiver (NOW) Services on July 15, 2004. Participation in this workshop is a mandatory requirement for enrollment as a provider of Medicaid home and
community-based waiver services. Workshop details are as follows:
| Date: |
Thursday, July 15, 2004 |
| Time: |
9:00 a.m. to 4:30 p.m. (Registration 8:30 a.m. to 9:00 a.m.) |
| Place: |
Claiborne Building, Louisiana Purchase Board Room
1201 North 3rd Street, Baton Rouge |
| Registration: |
Please contact Janice Laborde at (225) 219-0235, or
Loida Kellgren at (225) 219-0214 for registration information |
You must contact the Department of Social Services (DSS) for licensing information. They may be reached at (225) 922-0015.
BCSS Provider Enrollment Orientation Training for New Providers of Children�s Choice Waiver Services
The Department of Health and Hospitals , Bureau of Community Supports and Services (BCSS) will be conducting a Provider Enrollment Orientation Workshop for new Children�s Choice Waiver service providers on July 16, 2004. Participation in this workshop is a mandatory requirement for enrollment as a provider of Medicaid home and community-based waiver services. Workshop details are as follows:
| Date: |
Friday, July 16, 2004 |
| Time: |
9:00 a.m. to 4:30 p.m. (Registration 8:30 a.m. to 9:00 a.m.) |
| Place: |
Louisiana Association Municipal Building
700 N. 10th Street, Baton Rouge, LA |
| Registration: |
Please contact Janice Laborde at (225) 219-0235, or
Loida Kellgren at (225) 219-0214 for registration information. |
You must contact the Department of Social Services (DSS) for licensing information. They may be reached at (225) 922-0015.
BCSS Provider Re-Enrollment Orientation Training for
Currently Enrolled Providers of Home and Community Based Waiver Services
Pursuant to the Provider Standards for Participation published in September 20, 2003 LA Registry Volume 29 Number 9, currently enrolled Medicaid providers of home and community-based waiver services are required to attend an annual Provider Re-Enrollment Orientation training conducted by the Bureau of Community Supports and Services 9BCSS) in order to continue enrollment.
At this time, only currently enrolled providers for provider types (82) PCA, (89) SIL, (14) Day Habilitation, (13) Pre Vocational Habilitation., and (98) Supported Employment will be required to attend a regional, annual Provider Re-Enrollment Orientation training workshop in each DHH administrative region where they are licensed and enrolled as providers of home and community-based waiver services.
BCSS will be contacting the above noted enrolled provider via the mail with specific information regarding provider workshop dates, times and locations in their area.
*The Provider Standards of Participation may be accessed via the internet at the Office of the State Register website:
http://www.doa.state.la.us/osr/reg/register.htm.
Ultrasound Policy Change
Effective with date of service July 1, 2003, the following CPT codes were added to the list of codes payable to audiologists.
| 92541 |
92543 |
92544 |
92545 |
92547 |
2003 Professional Training Packet Correction
The policy written on page 36 of the 2003 Professional Training Packet, regarding "urinalysis" policy, is incorrect. The correct policy is written on page 54 of the 2003 Professional Training Packet. Please make note of this correction in your training material. If you obtained the 2003 Professional Training Packet from the internet, please refer to the pages on the document and not the pages on the scroll bar.
LADUR Education Article
Issues in Pain Management
By
Gina C. Biglane, Pharm.D.
Assistant Professor
School of Pharmacy
University of Louisiana at Monroe
Issues...
� Pain is...�an unpleasant sensory and emotional experience associated with actual or potential tissue damage...�
� Pain has multiple types and roles.
� This article focuses on the management of pain associated with some common chronic conditions.
Pain is a part of the human experience; everyone will experience pain at some point in his or her life. Pain has been defined by the International Association for the Study of Pain as �an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.� [1]
Pain has multiple types and roles:
Protective or acute pain is a sharp, intense pain resulting from injury. It can serve as a warning of potential danger; for example, the heat from a flame warns of potential danger. Reparative pain is a dull, spreading pain that is produced in an attempt to avoid stimuli and immobilize an injured area.
Chronic pain is pain that continues a month or more beyond the usual recovery period for an illness or injury or pain that goes on over months or years as a result of a chronic condition. It may be continuous or may fluctuate.
Neuropathic pain occurs as a result of damage to the nervous system itself. It doesn�t protect or repair the body.
Somatic pain arises from somatic structures such as bone and joints. It is usually well localized and is worsened by palpation or movement.
Visceral pain arises from the visceral organs and is usually poorly located.
This article focuses on the management of pain associated with some common chronic conditions.
Cancer Pain
Pain is the most feared symptom for patients diagnosed with cancer,[2] affecting 9 million people worldwide.[3] As many as 1/5 of all cancer patients have pain that is inadequately relieved, despite the availability of many analgesic agents and published guidelines such as the analgesic ladder established by the World Health Organization (WHO).[2] When used appropriately, up to 90% of patients will experience pain relief.[3, 4]
Pain associated with a diagnosis of cancer can have many possible origins. It can result from tumor infiltration or pressure on pain sensitive structures, or it can result from attempts to treat the cancer, such as surgery or chemotherapy.
In 1986, the WHO published guidelines for the treatment of cancer pain. These guidelines are comprised of three steps to the management of cancer pain.
Step 1- For patients experiencing mild pain, a non-opioid analgesic should be initiated. This would include NSAIDS, acetaminophen, and aspirin.[4]
Step 2- For patients experiencing pain despite the non-opioid analgesics, or for patients experiencing moderate to severe pain, opioids such as codeine, dihyrocodeine, hydrocodone, or oxycodone should be added to the maximum dose of the non-opioid analgesic.[4]
Step 3- Patients who continue to experience pain despite adequate doses of the step 2 products, or those who are experiencing moderate to severe pain, should be started on morphine, hydromorphone, oxycodone, fentanyl, or methadone.[4]
The level of pain a patient is experiencing is assessed by written or verbal numerical rating scales. Ratings of 1-4 are usually considered to be mild, 5-6 are considered moderate, and 7-10 are considered severe.[4]
Non-opioid analgesics
Care should be used to ensure that the maximum dose of acetaminophen or the NSAIDS is not exceeded. This should also be considered when using combination products such as Lorcet�, Lortab�, Vicodin�, etc.
| Product |
Usual Dosage Range |
Maximum daily dose |
| Acetaminophen |
325-1000mg q4-6h |
4000mg |
| ASA |
325-650mg q4h |
4000mg |
| Ibuprofen |
200-400mg q4-6h |
3200mg |
| Ketoprofen |
25-50mg q6-8h |
300mg |
| Naproxen |
220-440mg q8-12h |
660mg |
| Rofecoxib |
50mg q24h |
50mg |
| Celecoxib |
200mg q12h |
400mg |
Possible side effects with NSAIDS
| Gastric ulceration |
Patients at greatest risk include:
- Pts>65 years of age with a history of GI bleed or
PUD
- Pts on long term corticosteriods
- Pts on anticoagulation therapy
|
| Inhibition of platlet aggregation |
Patients at greatest risk include:
- Pts with cancer who have thrombocytopenia or
symptomatic bleeding
|
| Renal dysfunction |
Patients at greatest risk include:
|
Opioid analgesics
The opioids used in the second step of the WHO analgesic ladder are limited to use in moderate pain due to either their fixed combination with non-opioid analgesics or dose limiting side effects. Propoxyphene is not recommended for use due to its long half-life and toxic metabolite, norpropoxyphene.[4]
The opioids used in step three of the WHO analgesic ladder should be used one agent at a time, and the dosages should be titrated to relieve the patient�s complaints of pain. Morphine is the opioid of choice, and is the standard of comparison in the management of cancer pain. Oxycodone that is not part of a fixed combination with non-opioid analgesics is a good alternative agent.[4] Meperidine is not used due to its short half-life and toxic metabolite, normeperidine. Fentanyl patches are especially useful for patients with stable pain who cannot take oral medications.
Equianalgesic dosages for opioids
| Step 2 Opioids |
Oral/Rectal dose (mg) |
Parenteral dose (mg) |
|
Codeine |
200 |
120 |
| Dihydrocodeine |
100-150 |
N/A |
| Hydrocodone |
45 |
N/A |
| Oxycodone |
20 |
N/A |
| |
|
|
|
Step 3 Opioids |
|
|
| Morphine |
30 |
10 |
| Hydromorphone |
8 |
4 |
| Oxycodone |
20 |
N/A |
| Methadone |
20 |
10 |
| Fentanyl |
* |
* |
*see package insert for dosing table
It is important to remember that there is no ceiling dose with Step 3 opioids.[4] The regimen should be started with a dose that is appropriate for the patient�s current level of pain and previous response to analgesic therapy. The dosage should be titrated upwards to a level that will alleviate the pain while minimizing side effects. A good approach is to start the patient on a regimen of a short acting opioid and titrate until the patient is comfortable. The patient can then be changed to a long acting opioid, with rescue doses of the short acting product allowed for breakthrough pain. As the patient�s use of rescue doses increases, the long-acting product should be increased. The goal would be for the patient to be as comfortable as possible with a minimum of side effects and only infrequent use of rescue doses.
Points to remember:
The simplest regimen and least invasive methods should be used first.[5] Many patients can be adequately managed on oral therapy, which is not only the simplest and least invasive, but also less expensive than parenteral or transdermal therapy.[4]
Doses of long acting opioids should be scheduled around the clock, with additional rescue doses allowed for breakthrough pain.[4, 5] The same amount of medication given as the regularly scheduled dose should be allowed in rescue doses. For example, a patient taking 60mg of morphine every 12 hours should be allowed 20mg of short acting morphine every 4 hours for breakthrough pain.
For patients who cannot take oral medication, the rectal, transdermal, subcutaneous, or intravenous routes may be used.[4, 6]
Adverse Effects of Opiods
|
Effect
|
Treatment
|
| Somnolence |
Tolerance may reduce effect; persistent somnolence may
require caffeine or methylphenidate. |
|
Nausea/vomiting
|
Centrally acting anti-emetics such as prochlorperazine,
haloperidol, or metoclopramide may be useful. |
| Respiratory depression |
Appropriate titration will usually prevent. |
| Decreased GI motility resulting in constipation |
Regular laxative therapy should be initiated when opioid is
started. |
| Histamine release resulting in urticaria and pruritis |
Usually diminishes over time. |
| Confusion or delirium |
Haloperidol 0.5-1mg 2-3 times daily may be useful.
|
| Myoclonic jerks |
Clonazepam 0.25-5mg 3 times daily may be useful. |
Adjuvant medications
Adjuvant medications are used to enhance the analgesia of opioids or treat certain types of pain. The drug classes most commonly used include: NSAIDS, tricyclic antidepressants, anticonvulsants, and corticosteroids.
� NSAIDS. NSAIDS are used in treating pain due to bone metastasis as well as other
inflammation based pains.
� Corticosteroids. Corticosteroids are used in nerve compression, elevated intracranial pressure,
and visceral distension.
� Tricyclic antidepressants. Tricyclic antidepressants are useful in the treatment of neuropathic
pain. They provide additional advantages of improving depression and insomnia.
� Anticonvulsants. Anticonvulsants are used for neuropathic pain, either alone or in combination
with antidepressant therapy.
Neuropathic Pain
Neuropathic pain is the result of damage to the nervous system, which causes hypersensitivity of the neurons in the spinal cord. It can be associated with a variety of conditions, and can be grouped according to the location of the damage to the nervous system.[7]
| Peripheral |
Central |
| � Diabetic neuropathy |
� HIV sensory neuropathy |
| � Phantom limb pain |
� Multiple Sclerosis |
| � Post herpetic neuralgia |
� Parkinson�s disease |
| � Trigeminal neuralgia |
� Post-traumatic spinal cord injury
pain |
| � HIV sensory neuropathy |
� Post-stroke pain |
| � Chemotherapy induced polyneuropathy |
Medications commonly used to treat neuropathic pain include anticonvulsants and antidepressants.
1st Line Therapy
Have been shown to be effective in more than one randomized, controlled trial.[7]
� Gabapentin
� 5% Lidocaine patch
� Opioid analgesics
� Tricyclic antidepressants
2nd Line Therapy
Reserved for use in patients who don�t respond to first line therapy.[7]
� Lamotrigine
� Carbamazepine
� SSRIs � citolapram, paroxetine
� Venlafaxine
� Buproprion
Rheumatoid Arthritis
Pain in rheumatoid arthritis results from the chronic inflammation affecting diarthrodial or hingelike joints.[8] Analgesic therapy usually focuses on agents possessing both analgesic and anti-inflammatory properties, such as the NSAIDS.[9] Topical analgesics, such as capsaicin, may also be of benefit.
Osteoarthritis
Osteoarthritis is not due to inflammatory processes, but is due to the breakdown of cartilage in the joints. Pain management focuses on the analgesic properties of medications rather than anti-inflammatory properties.[9]
� Acetaminophen, in doses up to 4gm/day, is the drug of choice.[10]
� Tramadol may be used for acute exacerbations or in patients not responding to acetaminophen.[10]
� NSAIDS should be used in patients not responding to acetaminophen.
� Opioid analgesics should be used for short term management of acute exacerbations.
� Topical agents may also be of benefit.[10]
Sickle Cell Anemia
Sickle cell anemia is a disease in which the red blood cells become crescent shaped instead of the normal disc shape. As a result, they function abnormally and cause small blood clots, which give rise to recurrent painful episodes called �sickle cell pain crises�. Crisis management usually consists of hydration and analgesia. The American Pain Society has developed guidelines for the management of sickle cell crisis.[9]
� Mild to moderate pain. The patient should be started on a non-opioid analgesic, such as NSAIDS or acetaminophen. If the patient doesn�t respond, an opioid should be added.
� Moderate to severe pain. The characteristics and duration of pain should guide the choice of
opioids. For pain expected to occur for several days, a sustained release product should be used, along with a short acting product for breakthrough pain.
� Severe pain. The management of severe pain should include intravenous administration, if possible. The use of patient-controlled analgesia (PCA) should be considered. Doses should be scheduled around the clock, with rescue doses available.
Common Misconceptions
In order to appropriately manage pain, healthcare professionals must be able to separate facts from commonly held myths regarding opioid use and pain management, especially in terms of addiction and dependence. It is generally understood that patients treated with opioids for chronic pain may experience physical dependence and tolerance, but rarely do they experience addiction. The American Society of Addiction Medicine (ASAM), the American Academy of Pain Medicine (AAPM), and the American Pain Society (APS) have recommended the use of the following definitions:[11]
Addiction: a primary chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.
Pseudoaddiction: a term used to describe patient behaviors that may occur when pain is undertreated. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.
Physical Dependence: a state of adaptation that often includes tolerance and is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.
Tolerance: a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug�s effects over time.
Conclusion
The recognition and treatment of pain is becoming increasingly important within the health-care industry in the United States. This is evident by the variety of agencies that have produced clinical guidelines for the treatment of various types of pain, ranging from acute pain during operative procedures to pain resulting from sickle cell disease.[12] In addition, the Joint Commission on Accreditation of Healthcare Organizations included pain management standards in its 2000-2001 standards manual.[13]
Management of pain associated with a variety of conditions must be addressed in order for the patient to be able to function in any sort of normal capacity. Drug therapy, including opioids, is often an integral part of the management of pain. Hopefully, increasing the knowledge and awareness of the members of the healthcare team will prevent anyone from suffering needlessly.
References
1. International Association for the Study of Pain. 2003.
2. Ahmedzai, S., Current strategies for pain control. Ann Oncol, 1997. 8 Suppl 3: p. S21-4.
3. Ripamonti, C. and E.D. Dickerson, Strategies for the treatment of cancer pain in the new
millennium. Drugs, 2001. 61(7): p. 955-77.
4. Levy, M.H., Pharmacologic treatment of cancer pain. N Engl J Med, 1996. 335(15): p. 1124-32.
5. Lucas, L.K. and A.G. Lipman, Recent advances in pharmacotherapy for cancer pain
management. Cancer Pract, 2002. 10 Suppl 1: p. S14-20.
6. Management of cancer pain: adults. Agency for Health Care Policy and
Research. Am J Hosp Pharm, 1994. 51(13): p. 1643-56.
7. Dworkin, R.H., et al., Advances in neuropathic pain: diagnosis, mechanisms, and treatment
recommendations. Arch Neurol, 2003. 60(11): p. 1524-34.
8. Herfindal, E.T. and D.R. Gourley, eds. Textbook of Therapeutics: drug and disease
management. Seventh ed. 2000, Lippincott Williams & Wilkins.
9. Dipiro, J.T., et al., eds. Pharmacotherapy: A Pathophysiologic
Approach. Fifth ed. 2002, Appleton & Lange: Stamford.
10. Schnitzer, T.J., Non-NSAID pharmacologic treatment options for the management of chronic
pain. Am J Med, 1998. 105(1B): p. 45S-52S.
11. Public policy statement on definitions related to the use of opioids in pain treatment. American Society of Addiction Medicine. J Addict Dis, 1998. 17(2): p. 129-33.
12. Pain: Current Understanding of Assessment, Management, and
Treatments. 2001, National Pharmaceutical Council, Inc and Joint Commission on Accreditation of Healthcare Organizations.
13. Hill, C.D., Joint Commission Focuses on Pain Management. 1999.