What is Kentucky KASPER and Controlled Substance Prescribing?
Opioid usage and mishandling for treating short-term and long-term pain has become a major issue in the United States and Kentucky. The number of overdoses linked to misused opioids has dramatically risen both nationally and in Kentucky. Chronic pain, which lasts longer than three months as defined by the International Association for the Study of Pain, affects more than a quarter of the U.S. population. This makes it one of the most common problems experienced by patients in clinics and emergency departments.
Clinics report about one in five patient complaints being about pain, with the majority of people visiting their primary care doctor due to some sort of pain. However, not effectively managing short-term and long-term pain can cause additional optional health issues. Moreover, it brings the risk of the patient becoming dependent on opioids, which can lead to serious health complications or even death. Helping doctors understand how to manage chronic pain effectively can significantly improve a patient’s quality of life. It can also have long-term benefits, as chronic pain can negatively impact many areas of a person’s life.
Despite the significant consequences, many medical schools and training programs have not provided enough education about pain management. This has led to problems with prescribing opioids, a type of pain medication. Some doctors may not prescribe enough to effectively control the pain, while others may prescribe too much or continue prescribing them even when they’re no longer needed. As a result, patients are at an increased risk of addiction and misuse, which can lead to overdose, illegal sharing of drugs, and other harmful behaviors. Recognizing this, the Association of American Medical Colleges has encouraged schools to include instruction on how to properly prescribe opioids according to the Centers for Disease Control and Prevention’s guidelines in their curricula.
Addiction, a chronic disease that can be treated, is characterized by overwhelming urges to take drugs, dysfunctional emotional responses, behavior and relationship problems, inability to stop consistently, and lack of control over behavior. There is a lot of misunderstanding about addiction among health providers, those creating laws, and law enforcement. This misunderstanding affects how patients with addiction are treated and how laws are written and enforced.
Finally, managing chronic pain, specifically with opioids, poses many challenges to health providers. For example, not giving enough medication can result in inadequate pain relief, while giving too much can result in tolerance and potential addiction. These issues often lead to significant emotional and psychological problems, such as anxiety and depression. Education and training are crucial for health providers to improve their understanding of opioid addiction and improve patient outcomes.
What Causes Kentucky KASPER and Controlled Substance Prescribing?
People with chronic pain often experience more than one type of discomfort. For instance, someone with long-lasting back pain might also have fibromyalgia, a condition causing widespread muscle pain. Interestingly, over two-thirds of individuals with chronic pain also suffer from psychiatric issues such as major depression or generalized anxiety disorder.
Pain can take many forms and can be grouped into different types, including neuropathic pain (nerve pain), nociceptive pain (caused by tissue damage), musculoskeletal pain (related to muscles and skeleton), inflammatory pain (related to inflammation), psychogenic pain (related to psychological factors), and mechanical pain (caused by physical forces).
- Peripheral neuropathic pain might be due to problems like post-herpetic neuralgia (nerve pain following shingles) or diabetic neuropathy (nerve damage due to diabetes).
- Central neuropathic pain could be due to outcomes of a stroke.
- Nociceptive pain might be caused by tissue damage from burns, bruises, sprains, fractures, etc.
- Musculoskeletal pain could include issues like back pain and myofascial pain (pain in the tissue surrounding muscles).
- Inflammatory pain might be associated with autoimmune disorders like rheumatoid arthritis or infections.
- Psychogenic pain could occur due to emotional, psychological or behavioral factors causing headaches or abdominal pain.
- Mechanical pain might be due to expanding cancer.
Sadly, the treatment for pain, often using opioid therapy, can lead to serious problems, including increased illness, death, and abuse of opioids. Opioid abuse can stem from healthcare issues, social aspects, and economic problems.
About two decades ago, healthcare professionals in the US were encouraged to treat pain more intensively, considering pain as the 5th vital sign that needed to be monitored. There were potential legal and professional problems for clinicians under-treating pain. As a result, prescription opioid use increased rapidly over more than ten years.
Economic factors also facilitated increased opioid use, which included marketing directly to consumers and promotion from sales forces to doctors and pharmacists. The opportunity for huge profits led to the rise of “pill mills” where doctors gave out opioid prescriptions for little or no evaluation. Heroin use has increased as these sources have decreased.
Opioid manufacturers, particularly Purdue Pharma, have faced successful lawsuits from individuals and governments at various levels for promoting opioid use. There has also been concern about prescribers who prescribe high doses or large volumes of opioids without proper follow-up, which has led to increasing opioid abuse and related health problems.
In conclusion, pharmacists can play a role in controlling the opioid crisis by checking patient prescription databases and interacting with the prescribing doctors about any concerns. This type of collaboration, often mandated by different states, fosters safer patient care.
Risk Factors and Frequency for Kentucky KASPER and Controlled Substance Prescribing
In the United States, over 100 million people meet the description for chronic pain syndrome, with more than 50 million struggling with disabling chronic pain. It affects their daily life and activities. Chronic regional pain, back pain, arm, hand, leg, and foot pain, as well as headaches, are all common forms of chronic pain. Chronic pain is even high amongst elderly patients, who tend to receive fewer pain medications compared to the general population. This medical issue costs over $600 billion each year due to lost productivity and medical treatment. Over half of adults will face chronic pain at some point in their lives, with more than 40% of those affected indicating that their pain is not right under control. More than 10% suffer from chronic pain resulting in long-term disability. Recent research has shown that patients suffering from chronic pain are at risk of suicidality, with a considerable proportion attempting suicide, and many who commit suicide doing so through firearm-related injuries or opioid overdose.
Interestingly, the number of people suffering from chronic pain is on the rise. This rise can be attributed to obesity-related pain, increased survival rates for trauma and surgery patients, an aging population, and increased recognition of pain as a condition that can be treated.
Opioids are often the most commonly used treatment for chronic pain. They are synthetic substances derived from unrelated compounds, while opiates come from opium poppy extracts. Both opioids and opiates act on various opioid receptors, which combined, serve different functions such as providing pain relief, suppressing respiration, slowing the heartbeat, and even causing hallucinations, among others.
Notably, in the past, the use of opioids was limited mainly to chronic cancer pain cases. However, since the 1990s, the use of opioids for various chronic pain conditions has increased significantly, leading to an increase in opioid abuse cases.
The state of Kentucky, for example, has seen a severe impact from the misuse of prescription drugs, notably hydrocodone and oxycodone. With efforts to educate providers on suitable opioid prescribing practices and control diversion, individuals dependent on opioids have, unfortunately, shifted their consumption to heroin and fentanyl. As such, death rates due to prescription drugs have decreased, while deaths due to non-prescription opioids have increased significantly.
- Every year, about 2,000 people there die due to an overdose.
- Kentucky features in the top 10 states grappling with opioid-related overdose deaths and a high rate of opioid misuse.
- Opioids are prescribed at an alarmingly high rate.
- There’s been a recent surge in the use of street opioids like methamphetamine and heroin.
- The abuse of fentanyl and carfentanil, in particular, has risen substantially, with fentanyl accounting for almost half of all overdose deaths.
- Despite legislative changes leading to a decrease in the prescribed use of opiates, the use of drugs of abuse has increased.
Signs and Symptoms of Kentucky KASPER and Controlled Substance Prescribing
In evaluation of chronic pain, the doctor usually inquires about the onset of discomfort, cause, location, intensity, and frequency. Factors that increase or reduce pain will also be investigated. Measures like a verbal numeric rating scale are often used to gauge the severity of discomfort. This scale ranges from 0 to 10, with 0 being no pain and 10 being the most intense. Beyond this, related symptoms such as muscle spasms, temperature changes, and changes in muscle strength might also be explored.
Another key aspect of evaluation is considering how pain affects the patient’s daily life. Doctors may ask questions related to how pain affects relationships, hobbies, sleep quality, ability to exercise, and regular activities like dressing, eating, and walking. For older adults, it’s common to encounter challenges in self-reporting of pain, which may hinder effective treatment. As such, their comments about discomfort or soreness are taken into account.
There are a few standard abbreviations used during these examinations, such as “COLDERAS” and “OLDCARTS”, which cover aspects like character, onset, location, and severity of the pain. Another one is “PQRST”, standing for provocation or palliation, quality, radiation or region, severity, and timing.
Multidimensional assessment tools such as the Pain, Enjoyment, General Activity (PEG) tool can help monitor a patient’s pain and its effect on their quality of life. Scores range from 0 to 10, with higher scores indicating worse pain and function.
The Four-item Patient Health Questionnaire or PHQ-4 is another common tool used to screen for depression and anxiety in chronic pain cases. The Defense and Veterans Pain Rating Scale (DVRPS) provides an assessment of the impact of pain on various aspects like sleep, mood, and activity levels.
For children, pain is typically assessed through age-based rating scales and visual analogs with facial expressions. Tools like the Pediatric Pain Questionnaire and the Adolescent and Pediatric Pain Tool are used to identify the location of discomfort. Other methods include observational pain assessments, used for those unable to report their pain, and specialized tools for nonverbal children with neurologic impairment (NI).
Lastly, evaluations like the Brief Pain Inventory (BPI) are used to understand a patient’s beliefs about their pain. The McGill Pain Questionnaire (SF-MPQ-2) is used to draw the location of pain on the human body, while the Neuropathic Pain Scale can help track responses to therapy for nerve pain.
A physical exam focused on the painful area, alongside musculoskeletal, neurologic, and psychiatric assessments, is also performed.
Testing for Kentucky KASPER and Controlled Substance Prescribing
Medical professionals generally don’t use standard lab tests or imaging for assessing chronic pain, unless they suspect a specific cause of the pain. Depending on the situation, a urine test might be used to check that a patient is taking their prescription medications and not using any non-prescribed drugs.
Mental health matters significantly when it comes to chronic pain. Conditions like depression and anxiety can make the pain feel worse and delay diagnosis. Also, these conditions often go hand in hand with chronic pain. So if a patient feels more pain than usual, it might be due to a mental health condition worsening their experience. Therefore, it’s essential to also check for depression when treating patients with chronic pain. Common tools for this purpose include the Minnesota Multiphasic Personality Inventory-II or Beck’s Depression Scale.
Patients receiving opioid medications need careful monitoring to prevent misuse and addiction. A patient’s risk of such adverse behaviors can be rated low, moderate, or high based on their medical history, family background, and other factors.
Before prescribing opioids, their risks should be weighed against their benefits. The patient’s medical and personal history, any other conditions they have, and even their home and work environments should be taken into consideration. If the patient has a history of substance abuse, consult with a specialist before prescribing opioids.
Various tools are available for assessing a patient’s risk level and helping create a suitable treatment plan. These include questionnaires and urine tests, with certain measures recommended based on the patient’s risk level. The opioid prescription should be in line with medical guidelines and monitored throughout.
Finally, data on prescriptions is an invaluable resource for medical professionals. It allows them to monitor prescriptions, gather data on how well interventions are working, and helps in detecting misuse. Going forward, this system is expected to become more robust and updated in real-time.
Treatment Options for Kentucky KASPER and Controlled Substance Prescribing
Healthcare professionals managing chronic pain should be well-versed in pain assessment, managing pain, and administering pain-relieving opioids safely and effectively. A range of treatments, both drug and non-drug approaches, should be considered. For those suffering from moderate to severe chronic pain that can’t be relieved by non-opioid therapy, opioids could be a suitable treatment. However, this should be started as a trial before becoming a permanent part of the treatment plan. Updated guidelines from the CDC provide advice on prescribing opioids for chronic pain.
When a patient’s pain is extreme and unresponsive to initial treatment, a referral to a specialist in pain management may be necessary. The treatment of both pain and any psychiatric disorders can lead to a significant reduction in symptoms for both conditions. Various options, both drug and non-drug treatments, can address chronic, severe, and ongoing pain.
There are many drug options for chronic pain. These include non-opioid painkillers such as NSAIDs, acetaminophen, and aspirin, as well as medications like tramadol, opioids, and antiepileptic drugs like gabapentin or pregabalin. Antidepressants, topical painkillers, muscle relaxers, and others could also be effective. The treatment plan is often tailored to the individual’s needs and may use a step-by-step approach to limit the use and dosage of opioid painkillers, as there is no one-size-fits-all treatment for pain management.
Chronic musculoskeletal pain should be treated using a combination of non-opioid painkillers, opioids, and non-drug therapies. Acetaminophen or NSAIDs are often the first choice of treatment, but if these are not effective, opioid painkillers might be considered.
Directly addressing pain can also impact the patient’s quality of life significantly. Before starting opioid treatment, it is crucial to weigh up the benefits against the potential side effects and long-term consequences. This should include a conversation with the patient about the risks, benefits, and alternatives to opioids.
Patients’ reactions to opioids vary widely, but common issues can include increased sensitivity to pain, constipation, dependence, and sedation. For chronic musculoskeletal pain, opioids are not necessarily superior to non-opioid painkillers.
Certain types of pain might require specific treatments. For example, chronic musculoskeletal back pain might be treated differently from severe diabetic neuropathy. Neuropathic pain often requires multiple drug treatments as a part of the management strategy, and less than half of patients with neuropathic pain find a single medication to be enough. Alternatives like topical painkillers and non-drug treatments can also be part of the treatment strategy.
There’s a myriad of non-drug therapies for chronic pain. These include heat and cold therapy, cognitive-behavioral therapy, relaxation therapy, counseling, ultrasound stimulation, acupuncture, aerobic exercise, chiropractic care, physical therapy, and other techniques.
Specialists can also utilize interventional techniques in treating chronic pain. These include spinal cord stimulation, injections into the epidural space of the spine, radiofrequency nerve ablations, nerve blocks, and specialized pumps delivering pain medication directly to the space around the spinal cord.
Non-drug options like spinal cord stimulators can be considered if other treatments aren’t effective. They’re often used when back surgeries have not been successful but can also be used to manage conditions like complex regional pain syndrome, severe and uncontrollable chest pain, painful peripheral vascular disease, painful diabetic neuropathy, and certain types of abdominal and perineal pain. A 50% reduction in pain has been demonstrated when comparing spinal cord stimulators to continued medical therapy.
What else can Kentucky KASPER and Controlled Substance Prescribing be?
Pain is often a sign of something being wrong within the body, rather than a condition in and of itself. When a patient experiences ongoing pain, doctors need to figure out what underlying issues could be causing this discomfort. By pinpointing the root cause, they can then treat the pain effectively. For example, if someone has a type of pain known as neuropathic pain, it’s important to find out if it originates from the peripheral nerves or from the central nervous system.
Take knee pain as another instance. If it’s due to severe osteoarthritis, treatments might include injections or even a knee replacement. However, if the knee pain comes from other conditions like rheumatoid arthritis, infection, gout, pseudogout or meniscal injury, the required treatment would be different.
There’s a long list of health issues that could lead to general, chronic pain. These include allodynia (an overly sensitive reaction to pain) due to long-term opioid use, major depressive disorder, sleep disorders like insomnia, autoimmune diseases such as lupus or psoriatic arthritis, fibromyalgia, and central pain syndromes. Pain can generally be categorized into four types: neuropathic, musculoskeletal, mechanical, and inflammatory.
A persistent painful condition that isn’t properly treated can turn into chronic pain. In other words, long-term pain isn’t just a symptom. If it persists and changes the body’s chemistry, it can also become a diagnosis in its own right. Therefore, it’s crucial to treat acute and subacute pain early on to prevent the development of chronic pain.
What to expect with Kentucky KASPER and Controlled Substance Prescribing
While current treatments for chronic pain could potentially reduce a patient’s discomfort by an estimated 30%, the long-term outlook for such individuals generally exhibits a decrease in life quality and functionality. Notably, dealing with other mental health conditions, which often accompany chronic pain, could enhance the results. Chronic pain has been associated with increased rates of chronic disease and obesity, alongside a rise in the risk of suicide when compared to the average population.
In the case of spinal cord stimulation, a treatment for chronic pain, about half of the patients might not find enough relief. Additionally, over time patients might develop a tolerance, reducing the effectiveness of this treatment. A similar situation arises with chronic pain patients reliant on opioids – their tolerance to the medication increases over time, which in turn elevates the amount required for pain relief, thus escalating health risks.
In conclusion, the best way to manage chronic pain is prevention. If acute and short-term pain is efficiently handled, the transition to chronic pain could potentially be avoided, thereby minimizing negative impact on the patient’s quality of life.
Possible Complications When Diagnosed with Kentucky KASPER and Controlled Substance Prescribing
Chronic pain can decrease the quality of life, productivity and worsen existing health conditions. It can also lead to psychiatric problems like depression, anxiety, and even suicidal thoughts. Along with these challenges, people suffering chronic pain are often subjected to potential side effects and risks from medicines used to manage their pain.
Common painkiller, acetaminophen, often used either alone or in combination with an opioid, can be harmful if more than four grams are taken per day. It can lead to liver damage and is a leading cause for acute liver failure in the United States. This liver toxicity can also happen at lower doses if the patient already has a chronic liver disease.
Popular medication like gabapentin or pregabalin can trigger side effects like sedation, swelling, mood changes, confusion, and breathing problems in older patients. So they should be used with caution. Additionally, when these medications are combined with opioid painkillers, they can increase the risk of patient mortality.
Duloxetine, another medication for chronic pain, can cause mood changes, headaches, nausea and is not suitable for patients with a history of kidney or liver disease.
When it comes to the use of opioid therapy, deep concerns remain, including addiction, overdose leading to respiratory problems and heightened pain sensitivity. Long-term use of opioids can cause side effects like constipation, tolerance, dependence, nausea, arrhythmia and hormonal imbalances, resulting in symptoms like missed periods, sexual issues, breast swelling in men, and reduced energy and libido. There is also an increased risk of opioid overdose linked to the amount of daily dosage.
Spinal cord stimulators, which are used to manage chronic pain, can have complications ranging from minor issues to serious concerns such as spinal cord trauma. Common complications include lead migration, inadequate pain relief, spinal cord stimulator lead fracture, and seromas. There is also a risk of infection after a spinal cord stimulator is placed, and in some cases, serious complications like a spinal cord abscess can occur. This can lead to severe headaches in about 70% of patients. The most worrying adverse effect would be a spinal epidural hematoma, which would require immediate surgical attention.
With opioid medications, there is unfortunately the risk of misuse. People might seek out these drugs for addictive or financial motives. Illicit means of obtaining these opioids could include demanding more opioids, forging prescriptions, or obtaining medicines from non-medical sources or multiple providers.
Prescription misuse signs:
- Aggressive demands for more opioids
- Asking for opioids by name
- Behaviors suggesting misuse
- Forged prescriptions
- Inappropriate alcohol use
- Increasing dosage without doctor’s permission
- Injecting oral medications
- Obtaining medications from nonmedical sources
- Obtaining opioids from multiple providers
- Prescription loss or theft
- Reluctance to decrease opioid dosage
- Resistance to changing medications
- Requesting early refills
- Selling prescription drugs
- Sharing or borrowing similar medications
- Stockpiling medications
- Inappropriate dose escalation
- Using illegal drugs
- Using pain medications to treat other symptoms
To prevent the misuse of opioid medication, doctors and pharmacists can adopt a range of strategies. These can include communicating with multiple providers and pharmacies, educating patients about the dangers of sharing opioids, and prescribing smaller quantities of opioids. If misuse is detected, actions like drug screening, pill counting, thorough examinations could be taken, and the provider-patient relationship can be legally terminated if the patient violates treatment agreement. It is also important that patients suffering from substance abuse issues be referred to a pain specialist further help. If opioids are stolen or lost, it should be reported to the authorities.
Preventing Kentucky KASPER and Controlled Substance Prescribing
Patients and their families have an important role in deciding whether to continue or stop taking opioid painkillers. It’s crucial to involve family members in this process since they often notice signs of depression and decreased functionality in the patient. A few important questions for the family to consider include whether their loved one spends their day focused on taking their medication, how frequently the pain medication is needed, if the patient has any substance abuse problems, if the patient is avoiding activity, how the patient’s mental health is holding up, and whether or not the patient can function as needed.
Patients taking opioids need to be aware of safety measures and take their medications responsibly. This includes not driving or handling heavy machinery while on these drugs, never abruptly stopping the use of opioids, not mixing the medication with substances like alcohol or sedatives that slow down the respiratory system, and reaching out to the prescribing doctor if the current pain medication isn’t providing enough relief. It’s also necessary to destroy leftover opioids according to specific guidelines; for example, by flushing them down the toilet or mixing with cat litter or coffee grounds. Chewing tablets is discouraged, as is sharing your prescription with friends or family. Always make sure to follow the prescribed dosage and take the medication only as directed by your healthcare professional.
A team of healthcare professionals, including doctors and pharmacists, needs to work together to ensure that opioids are used safely and appropriately. The roles of this team involve careful evaluation of the patient’s needs and the legitimacy of opioid prescriptions. The pharmacist’s task is particularly crucial in assessing which prescribed drugs should ultimately be dispensed to the patient. A balanced approach is essential: a lack of proper assessment could contribute to harmful outcomes including substance abuse and societal issues, while an overly cautious approach could deprive patients of needed pain relief. By working as a team, doctors and pharmacists will increase the chance of best outcomes for patients.
