Development of a pain management policy in and indigent clinic in Galveston, TX

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Title: Development of a pain management policy in and indigent clinic in Galveston, TX
Author: Ashley Maltz
Abstract: Millions of Americans suffer from nonmalignant chronic pain (NMCP ) , often with life altering consequences , such as loss of job function and expensive medical bills . Opioid prescription therapy has gained acceptance among medical professionals for the treatment of this pain and a substantial increase in the number of opiates prescribed has occurred over the last two decades6 . Along with this increase in opioid prescribing have come increases in the number of unintentional overdoses and /or deaths secondary to opioids7 . Physicians may feel reluctant to prescribe opioids on a continued basis due to the increased number of deaths due to unintentional opioid overdose as well as out of fear of causing a patient to become addicted to the medication (termed “opiophobia” in the literature3 ,8 ,9 ) . Former or active drug use by patients and psychiatric co -morbidities further compound this complex topic . \r \n \r \nAt St . Vincent’s clinic , a student and nurse practitioner -run indigent primary care clinic in Galveston , Texas , practitioners have historically avoided prescribing opioids for pain management . It was at their request that a MPH student investigate the possible efficacy of a doctor -patient opioid contract in similar clinical settings and create a pain management protocol based on its effectiveness . Thus , this Capstone aims to 1 ) review the current literature on the effectiveness of opioid pain contracts in primary care clinics for patients on long -term opioid therapy for non -malignant chronic pain ; 2 ) to review pain management guidelines at indigent clinics in the Houston -Galveston area , and 3 ) to create a pain management guideline for St . Vincent’s clinic . To do this , a PubMed search was conducted using terms related to opioid use in indigent primary care clinics . Studies that a ) used an opioid contract as or in conjunction with an educational intervention for non -malignant chronic pain ; b ) that took place in primary care or pain management clinics in conjunction with primary care physicians ; c ) that analyzed characteristics of opioid contracts ; and d ) were commentaries and expert opinion on the use of pain contracts for non -malignant chronic pain for patients with and without a psychiatric history or a history of substance abuse were identified . Studies that did not use pain contracts and or discuss the use of opioid contracts for managing non -malignant chronic pain were excluded . Of the 103 papers screened , 13 were selected according to inclusion /exclusion criteria , including 8 observational studies using a doctor -patient opioid contract and 5 expert literature reviews from major peer -reviewed journals . Three of the 8 observational studies did not use an opioid contract for an intervention , but rather analyzed characteristics of the contracts . \r \n \r \nTheir recommendations were analyzed . Additionally , 30 indigent primary care clinics in the Houston -Galveston area were screened for their pain management practices . Seven informal interviews with the medical directors of these clinics were conducted (including one pain medicine specialist and one psychiatrist specialized in addiction medicine ) . Recommendations from both the literature review and interviews with practicing primary care practitioners were synthesized and a pain contract was created . The contract and recommendations were then presented to St . Vincent’s clinic directors for review and /or use . \r \n
URI: http : / /hdl .handle .net /2152 .3 /144
Date: 2009-05-18


Development of a pain management policy in and indigent clinic in Galveston, TX. The University of Texas Medical Branch. Available electronically from http : / /hdl .handle .net /2152 .3 /144 .

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