Contents part 1: Introduction




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NONSELECTIVE NSAIDS: (Inhibits COX-1 and COX-2) Mechanism of action: Inhibits prostaglandin synthesis by decreasing the activity of the enzymes COX-1 and COX-2, which results in decreased formation of prostaglandins involved in the physiologic response of pain and inflammation. Side Effects: See Disease-state warnings above. Other common side effects include the following. CNS: headache, dizziness, insomnia; Skin: rash including life-threatening skin reactions (Stevens-Johnson syndrome) **Discontinue if rash develops**; GI: abdominal cramps, nausea/vomiting, diarrhea, constipation, flatulence; Otic: Tinnitus; Hematologic: Anemia. Specific NSAIDS are listed below:


Diclofenac Sodium (Voltaren®, Voltaren-XR®) generic available: (Voltaren®, diclofenac sodium enteric-coated tablet Package Insert), (Voltaren®-XR, diclofenac sodium extended-release tablets Package Insert) See also Zorvolex (diclofenac).

Diclofenac Potassium (Cataflam®, generic available): (Cataflam®, diclofenac potassium immediate-release tablets Package Insert) Different formulations of diclofenac are not necessarily bioequivalent. Dosing: Cataflam®: Osteoarthritis: Adults: 50 mg PO 2—3 times daily. Dosages > 150 mg/day PO are not recommended. Pain: 50mg PO 3 times per day (max dose is 150mg/day). An initial dose of 100 mg PO followed by 50-mg doses may provide better relief. Voltaren®: Osteoarthritis: 50 mg PO 2—3 times daily or 75 mg PO twice daily. Dosages > 150 mg/day PO are not recommended. Ankylosing spondylitis: 25 mg PO 4 times a day with an extra 25-mg dose at bedtime if necessary. Voltaren®-XR: 100 mg PO once daily for chronic therapy. Voltaren®-XR is not indicated for the management of acute pain and should only be used as chronic maintenance therapy.

Diflunisal (Dolobid®, generic available): Dosing: Mild to moderate pain (arthralgia, bone pain, myalgia); 1 gm initially, followed by 500mg every 12 hours; some patients may require 500mg PO every 8 hours (Max 1500mg/day). Osteoarthritis: 250-500mg PO twice daily (Max 1500mg/day). (Dolubid® Package Insert)

Etodolac (Lodine®, Lodine XL®, generic available): Dosing: Lodine®: Mild to moderate pain (acute); 200-400mg PO every 6 to 8 hours (max 1000mg daily). Osteoarthritis: 300mg PO 2-3 times daily or 400 – 500mg twice daily (doses > 1000mg/day have not been evaluated). Lodine®-XL: Osteoarthritis: 400 to 1000 mg once daily. A therapeutic response may not be seen for 1-2 weeks.

Fenoprofen (Nalfon®, generic available): 200, 600 mg. Dosing: osteoarthritis; (off-label use for ankylosing spondylitis); 300 – 600mg PO 3 to 4 times per day (Max daily dose is 3200mg). Improvement may take as long as 2 to 3 weeks. Mild to moderate pain (off-label use for bone pain): 200mg PO every 4 to 6 hours as needed.

Flurbiprofen (Ansaid®, generic available): 50, 100 mg. Dosing: Osteoarthritis and mild to moderate pain: 200-300mg per day at intervals of 2 to 4 divided doses. The maximum daily dose is 300 mg/day and the maximum divided dose is 100 mg (for instance, 100 mg twice a day).

Ibuprofen (Motrin®, Advil® [otc], generic available): 300, 400, 600, 800 mg. Dosing: Osteoarthritis and off-label for ankylosing spondylitis: 1200 mg to 3200 mg daily. Individual patients may show no better response to 3200 mg as 2400 mg, and sufficient clinical improvement should be observed to offset potential risk of treatment with the increased dose. Higher doses are generally recommended for rheumatoid arthritis: 400-800 mg PO 3-4 times a day, use the lowest effective dose. Higher doses are usually necessary for osteoarthritis. Doses should not exceed 3200 mg/day. Mild pain to moderate pain: 400 mg PO every 4-6 hours as needed. Doses greater than 400 mg have not provided greater relief of pain.

Indomethacin (Indocin®, Indocin SR®, generic available): This medication is generally not recommended in the elderly due to increased risk of adverse effects. Indocin is not commonly used any more, now that its risks are known, so it is not recommended as a first-line NSAID. Dosing: Osteoarthritis, or ankylosing spondylitis: NOTE: If minor adverse effects develop as the dosage is increased, rapidly reduce the dose to a tolerated dose and closely observe the patient. If severe adverse reactions occur, discontinue. Regular-release capsules, suspension (25 mg and 50 mg): 25 mg PO 2—3 times a day with food or antacids; may increase dose by 25 mg/day PO every 7 days up to 150—200 mg/day. In patients who have persistent night pain and/or morning stiffness, administer a large portion of the total daily dose, up to 100 mg/dose, at bedtime. Sustained-release capsules (75 mg): Initially, 75 mg PO daily. Use the regular-release capsules to provide a higher dose, if needed. If 150 mg daily is tolerated and is needed, a 75 mg sustained-release capsule PO bid may be used. After the acute phase is under control, attempt to decrease the dosage to the lowest effective dosage or discontinue the drug. Moderate pain to severe pain including painful shoulder (bursitis and tendinitis) as well as off-label for bone pain: Regular-release capsules, suspension (25 mg and 50 mg): 75-150 mg/day PO in 3-4 divided doses. Discontinue the drug once the signs and symptoms of the inflammation have been controlled for several days. The usual length of therapy is 7-14 days. Sustained-release capsules (75 mg): 75 mg PO 1-2 times per day. See also Tivorbex (indomethacin).


Ketoprofen 50, 75 mg, Ketoprofen ER 200 mg: Dosing: Osteoarthritis: Regular release capsule 50mg four times per day or 75mg three times per day (max 300mg/day). XR capsule 200mg once daily. Mild to moderate pain: Regular release capsule 50mg every 6 to 8 hours (Max 300mg/day); Extended-release capsules are not recommended for acute pain.

Ketorolac (Toradol®, generic available): 10 mg. [Boxed Warning]: The oral form is only recommended for short-term (up to 5 days) in management of moderately severe acute pain that requires analgesia at the opioid level and only as continuation following IV or IM dosing, if necessary. This medication is not indicated for minor or chronic painful conditions. Increasing doses beyond a daily maximum dose of 40 mg will not provide better efficacy, and will increase the risk of serious side effects. The FDA boxed warning would relegate this drug to second-line use unless there were no safer alternatives. Dosing: Acute pain (transition from IV or IM) for adults < 65 years of age: 20mg PO followed by 10mg PO every 4 to 6 hours (max 40 mg/day). An oral formulation should not be given as an initial dose. (Toradol® Package Insert) The FDA has approved a nasal formulation of ketorolac (Sprix) for short-term pain management. (FDA, 2010)

Mefenamic Acid (Ponstel®, generic available): 250 mg. Mild and moderate pain: Initially, 500 mg PO followed by 250 mg every 6 hours as needed for no longer than 7 days. (Ponstel® Package Insert)

Meloxicam (Mobic®, generic available): 7.5, 15 mg. Dosing: Osteoarthritis: The usual initial dose is 7.5 mg/day, although some patients may receive additional benefit with an increase to 15 mg a day. The maximum dose is 15 mg/day. Use for mild to moderate pain is off-label. (Mobic® Package Insert)

Nabumetone (Relafen®, generic available): 500, 750 mg. Dosing: Osteoarthritis: The recommended starting dose is 1000 mg PO. The dose can be divided into 500 mg PO twice a day. Additional relief may be obtained with a dose of 1500 mg to 2000 mg per day. The maximum dose is 2000 mg/day. Patients weighing less than 50 kg may be less likely to require doses greater than 1000 mg/day. The lowest effective dose of nabumetone should be sought for each patient. Use for moderate pain is off-label. (Relafen® Package Insert)

Naproxen (Naprosyn®): delayed release (EC-Naprosyn®), as Sodium salt (Anaprox®, Anaprox DS®, Aleve® [otc]) Generic available; extended-release (Naprelan®): 375 mg. Different dose strengths and formulations of the drug are not necessarily bioequivalent. Dosing Information: Osteoarthritis or ankylosing spondylitis: Dividing the daily dose into 3 doses versus 2 doses for immediate-release and delayed-release formulations generally does not affect response. Morning and evening doses do not have to be equal in size. The dose may be increased to 1500 mg/day of naproxyn for limited periods when a higher level of analgesic/anti-inflammatory activity is required (for up to 6 months). Naprosyn® or naproxyn: 250-500 mg PO twice daily. Anaprox: 275-550 mg PO twice daily. (total dose may be increased to 1650 mg a day for limited periods). EC-Naprosyn: 375 mg or 500 mg twice daily. The tablet should not be broken, crushed or chewed to maintain integrity of the enteric coating. Naprelan®: Two 375 mg tablets (750 mg) PO once daily or two 500 mg tablets (1000 mg) once daily. If required (and a lower dose was tolerated) Naprelan® can be increased to 1500 mg once daily for limited periods (when higher analgesia is required). Pain: Naprosyn® or naproxyn: 250-500 mg PO twice daily. The maximum dose on day one should not exceed 1250 mg and 1000 mg on subsequent days. Anaprox: 275-550 mg PO twice daily. The maximum dose on day one should not exceed 1375 mg and 1100 mg on subsequent days. Anaprox is recommended for the management of acute painful conditions because the sodium salt is more rapidly absorbed. EC-Naprosyn: 375 mg or 500 mg twice daily. Extended-release Naprelan®: Not recommended due to delay in absorption (Naprelan® Package Insert) and risk of upper GI bleeding/perforation. (Massó, 2010)

Oxaprozin (Daypro®, generic available): 600 mg. Dosing: Osteoarthritis: Two 600 mg caplets (1200 mg total) given PO once daily. The maximum dose is 1800 mg/day (26 mg/kg, whichever is lower). For patients with low body weight (i.e., < 50 kg or 110 pounds), an initial dosage of 600 mg PO once daily is recommended. Patients with severe renal impairment should initiate therapy at 600 mg/day. An increase to 1200 mg can be cautiously increased, but only with close monitoring. For quick onset of action, a one-time loading dose of 1200 to 1800 mg can be given (do not exceed 26 mg/kg). Mild to moderate pain: Used off-label. (Daypro® Package Insert)

Piroxicam (Feldene®, generic available): 10, 20 mg. Dosing: Osteoarthritis: 20 mg PO once daily. Adjust dose, as needed. The daily dose may be divided in two doses, if desired. This drug has a long half-life and steady state is not reached for 7-12 days. There is a progressive response over several weeks and therapy effect should not be assessed for two weeks after initiating therapy. Elderly: Initially, 10 mg PO once daily. Adjust dose, as needed, up to 20 mg/day. Pain: Not recommended. (Feldene Package Insert)

Sulindac (Clinoril®, generic available): 150, 200 mg. Dosing Information: Osteoarthritis, ankylosing spondylitis: Initially, 150 mg PO twice daily. Adjust dosage as needed. May increase up to 200 mg PO twice daily depending on patient response. The maximum dose is 400 mg a day. Acute Painful Shoulder (bursitis/tendinitis): 200 mg PO twice a day. Therapy for 7-14 days is usually adequate. Mild to moderate pain: Off label. (Clinoril® Package Insert)

Tolmetin (Tolectin®, Tolectin DS, Tolectin 600mg, generic available): Dosing Information: Osteoarthritis (acute and chronic): Initially, 400 mg PO three times a day. If needed, adjust dose upward or downward after 1-2 weeks. Maintenance dosage is usually 600-1800 mg/day PO in 3-4 divided doses. (Max dose is 1800mg/day). Symptomatic improvement may occur within 7 days, with progressive improvement during successive weeks of therapy. (Clinical Pharmacology, 2008) (Lexi-Comp, 2008)



Nucleoplasty

Not recommended. Given the extremely low level of evidence available for Nucleoplasty (Coblation Nucleoplasty), and the lack of clinical trials, it is recommended that this procedure be regarded as experimental at this time. (Manchikanti, 2003) (Boswell, 2007) See DWC MTUS chapter on Low Back Complaints.

Nucynta™ (tapentadol)

See Tapentadol.

Nuedexta

Not recommended.

Number needed to treat (NNT)

Recommended as a measure of absolute risk in evaluating drug therapies. This is the average number of patients that need to be treated in order to have improvement in one patient. As an example, for every 4 patients treated with neuropathic pain, pain relief described as good is found in 1 patient. The NNT is a useful and relatively simple tool for practicing evidence-based medicine. This calculation can be applied to intervention studies and reflects the number of additional patients who need to receive an intervention to prevent 1 additional outcome. In this recent study, using NNT was superior to achieve participant consent versus other explanations. (Halvorsen, 2007)

Nuvigil

See Armodafinil (Nuvigil).

Occupational therapy (OT)

See Physical therapy.

Office visits

Recommended as determined to be medically necessary. Evaluation and management (E&M) outpatient visits to the offices of medical doctor(s) play a critical role in the proper diagnosis and return to function of an injured worker, and they should be encouraged. The need for a clinical office visit with a health care provider is individualized based upon a review of the patient concerns, signs and symptoms, clinical stability, and reasonable physician judgment. The determination is also based on what medications the patient is taking, since some medicines such as opioids, or medicines such as certain antibiotics, require close monitoring. As patient conditions are extremely varied, a set number of office visits per condition cannot be reasonably established. The determination of necessity for an office visit requires individualized case review and assessment, being ever mindful that the best patient outcomes are achieved with eventual patient independence from the health care system through self care as soon as clinically feasible. The ODG Codes for Automated Approval (CAA), designed to automate claims management decision-making, indicates the number of E&M office visits (codes 99201-99285) reflecting the typical number of E&M encounters for a diagnosis, but this is not intended to limit or cap the number of E&M encounters that are medically necessary for a particular patient. Office visits that exceed the number of office visits listed in the CAA may serve as a “flag” to payors for possible evaluation, however, payors should not automatically deny payment for these if preauthorization has not been obtained. Note: The high-quality medical studies required for treatment guidelines such as ODG provides guidance about specific treatments and diagnostic procedures, but not about the recommended number of E&M office visits. Studies have and are being conducted as to the value of “virtual visits” compared with inpatient visits, however the value of patient/doctor interventions has not been questioned. (Dixon, 2008) (Wallace, 2004) Further, ODG does provide guidance for therapeutic office visits not included among the E&M codes, for example Chiropractic manipulation and Physical/Occupational therapy.

Omega-3 EFAs

See Cod liver oil.

Ondansetron (Zofran®)

Not recommended for nausea and vomiting secondary to chronic opioid use. See Antiemetics (for opioid nausea).

Onsolis™ (fentanyl buccal film)

Not recommended for treatment of chronic musculoskeletal pain.

Opana®

See Oxymorphone.

Opioid hyperalgesia



Opioid-induced hyperalgesia remains a controversial subject. The only well-controlled human study of reasonable size to date failed to show its existence. (Chu, 2011)


Opioid-induced constipation treatment



Recommended as indicated below. If prescribing opioids has been determined to be appropriate, then prophylactic treatment of constipation should be initiated. Opioid-induced constipation is a common adverse effect of long-term opioid use because the binding of opioids to peripheral opioid receptors in the gastrointestinal (GI) tract results in absorption of electrolytes, such as chloride, with a subsequent reduction in small intestinal fluid. Activation of enteric opioid receptors also results in abnormal GI motility. Constipation occurs commonly in patients receiving opioids and can be severe enough to cause discontinuation of therapy.

First-line: When prescribing an opioid, and especially if it will be needed for more than a few days, there should be an open discussion with the patient that this medication may be constipating, and the first steps should be identified to correct this. Simple treatments include increasing physical activity, maintaining appropriate hydration by drinking enough water, and advising the patient to follow a proper diet, rich in fiber. These can reduce the chance and severity of opioid-induced constipation and constipation in general. In addition, some laxatives may help to stimulate gastric motility. Other over-the-counter medications can help loosen otherwise hard stools, add bulk, and increase water content of the stool.

Second-line: If the first-line treatments do not work, there are other second-line options. About 20% of patients on opioids develop constipation, and some of the traditional constipation medications don't work as well with these patients, because the problem is not from the gastrointestinal tract but from the central nervous system, so treating these patients is different from treating a traditional patient with constipation. An oral formulation of methylnaltrexone (Relistor®) met the primary and key secondary end points in a study that examined its effectiveness in relieving constipation related to opioid use for noncancer-related pain. The effectiveness of oral methylnaltrexone in this study was comparable to that reported in clinical studies of subcutaneous methylnaltrexone in subjects with chronic noncancer-related pain. There was an 80% improvement in response with the 450 mg dose and a 55% improvement with 300 mg. Constipation drug lubiprostone (Amitiza®) shows efficacy and tolerability in treating opioid-induced constipation without affecting patients' analgesic response to the pain medications. Lubiprostone is a locally acting chloride channel activator that has a distinctive mechanism that counteracts the constipation associated with opioids without interfering with the opioids binding to their target receptors. (Bader, 2013) (Gras-Miralles, 2013) See also Tapentadol (Nucynta™), which has improved gastrointestinal tolerability for patients complaining of constipation, nausea, and/or vomiting.

Opioid pumps

See Implantable drug-delivery systems / Intrathecal drug-delivery systems (IDDSs).

Opioids



Refer to the DWC “Guideline for the Use of Opioids to Treat Work-Related Injuries” for information and recommendations.

Opioids, criteria for use



Refer to the DWC “Guideline for the Use of Opioids to Treat Work-Related Injuries” for information and recommendations.

Opioids, dealing with misuse & addiction (plus aberrant behaviors & abuse)



Refer to the DWC “Guideline for the Use of Opioids to Treat Work-Related Injuries” for information and recommendations.

Opioids, long-acting


Refer to the DWC “Guideline for the Use of Opioids to Treat Work-Related Injuries” for additional information and recommendations. In September 2013 the FDA announced labeling changes to reflect that extended-release and long-acting opioids are no longer indicated for merely moderate pain. Previously, the labels for ER/LA opioid analgesics stated that they were indicated for moderate to severe pain in patients requiring continuous, around-the-clock opioid treatment for an extended period of time. The labels now will state that the drugs are indicated for the management of pain severe enough to require daily, around-the-clock opioid treatment and for which alternative treatments are inadequate, and the FDA will require manufacturers to perform more studies and clinical trials to further assess the known risks of misuse, abuse, addiction, overdose, and death. However, the FDA did not take action on dose and duration limits, as had been suggested by stakeholders. (FDA, 2013).


Opioids, psychological intervention



Refer to the DWC “Guideline for the Use of Opioids to Treat Work-Related Injuries” for additional information and recommendations. The following steps have been suggested to improve opioid treatment: (a) Provide ongoing education on both the benefits and limitations of opioid treatment. In particular, this should be based on the patient’s experience with medication treatment and behavior regarding controlled substances in general. (b) Emphasize non-opioid care including self-management techniques. These may include relaxation, mindfulness meditation, acceptance, and distraction. (c) Emphasize realistic goals. (d) Avoid increasing dosages of medications to “chase pain.” The result may ultimately be development of tolerance. (e) Encourage development of strategies for self-regulation of medication misuse. This may also include incorporation of a support group such as friends, family, an identified group (such as a 12-step group or group counseling), and/or individual counseling. (Naliboff, 2006)

Opioids, risk evaluation & mitigation strategy (REMS)



Refer to the DWC “Guideline for the Use of Opioids to Treat Work-Related Injuries” for additional information and recommendations. The FDA announced a new Risk Evaluation and Mitigation Strategy (REMS) program and reports that it has already contacted the manufacturers of the extended-release and long-acting opioid medications hydromorphone, oxycodone, morphine, oxymorphine, morphone, methadone, and transdermal fentanyl, to require these manufacturers to develop and pay for programs to educate doctors on proper pain management, patient selection, and ensuring that their patients understand how to use these drugs safely. (FDA, 2011) On July 9, 2012, FDA approved a risk evaluation and mitigation strategy (REMS) for extended-release and long-acting opioid medications. (FDA, 2012) However, requiring drug companies to provide educational material to doctors on opioids, and making physician education under REMS voluntary are possible flaws in the plan. The propriety of having the pharmaceutical industry develop unbiased education for prescribers and patients is a concern. Another alternative would be to revise existing labeling to reflect the current clinical science and risk-benefit profile, and a black box warning might have more impact. In addition, a REMS for short-acting opioids has not been proposed despite data showing problems with these. (Nelson, 2012)

Opioids, specific drug list



Information on selected drugs are listed here. Refer to the DWC “Guideline for the Use of Opioids to Treat Work-Related Injuries” for additional information and recommendations.

Hydrocodone/Ibuprofen (Vicoprofen®; generic available): 7.5mg/200mg. Side Effects: See opioid adverse effects and NSAIDS. Note: Analgesic dose: 1 tablet every 4-6 hours as needed for pain; maximum: 5 tablets/day (Product information, Abbott Laboratories).

Oxycodone/acetaminophen (Percocet®; generic available): Side Effects: See opioid side effects and acetaminophen. Analgesic dose: Dosage based on oxycodone content and should be administered every 4 to 6 hours as needed for pain. Initially 2.5 to 5 mg PO every 4 to 6 hours prn. Note: Maximum daily dose is based on acetaminophen content (Maximum 3000mg/day). For more severe pain the dose (based on oxycodone) is 10-30mg every 4 to 6 hours prn pain. Dose should be reduced in patients with severe liver disease.

Oxycodone/ibuprofen (Combunox®; generic available): Side Effects: See opioid adverse effects and NSAIDS. Note: Recommended for short-term use only (generally less than 7 days). 1 tablet (ibuprofen 400mg; oxycodone 5mg) every 6 hours as needed. Do not exceed 4 tablets/24 hours. Duration of therapy should not exceed 7 days. The elderly may be more sensitive to the usual adult dosage. (Clinical Pharmacology, 2008)

Levorphanol (Levo-Dromoran®; generic available): 2mg tablets. Used for moderate to severe pain, when an opioid is appropriate for therapy. Levophornal has been shown to be effective for neuropathic pain. (Prommer 2007) Levorphanol is 4 to 8 times as potent as morphine and it has a much longer half-life. Side Effects: See opioid adverse effects. Analgesic dose: The usual starting dose is 2mg PO, which may be repeated in 6 to 8 hours. Note: Assess patient for signs of hypoventilation and excessive sedation before continuing subsequent doses. Patients who tolerate dosing and need further pain management may take 3mg PO every 6 to 8 hours. Note: Levorphanol is not recommended for breakthrough pain. (Prommer 2007)

Morphine sulfate, Morphine sulfate ER, CR (Avinza®; Kadian®; MS Contin®; Oramorph SR®; generic available, except extended release capsules): Side Effects: See opioid adverse effects. Analgesic dose: Immediate release tablets for acute pain (moderate to severe); Opiate naive patients should begin with 10mg PO every 4 hours as needed. Opioid tolerant patients may need higher starting doses to achieve pain relief (10-30mg every 4 hours as needed). See specific product for full prescribing information. Controlled, extended and sustained release preparations should be reserved for patients with chronic pain, who are in need of continuous treatment. Avinza® - morphine sulfate extended release for once daily dosing. The 60mg, 90mg and 120mg capsules are for opioid tolerant patients only. Kadian® - (extended release capsules) May be dosed once or twice daily. The 100mg and 200mg capsules are intended for opioid tolerant patients only. MS Contin® - (controlled release tablets) Doses should be individually tailored for each patient.

Tramadol/Acetaminophen (Ultracet®; generic available): 37.5mg/325mg. Side Effects: See tramadol and acetaminophen. Analgesic dose: For short-term use ≤ 5 days in acute pain management. 2 tablets PO every 4 to 6 hours as needed (max 8 tablets/day). Not recommended in patients with hepatic impairment. (Product information, Ortho-McNeil 2004)

Propoxyphene [Off market in U.S.] hydrochloride (Darvon®; generic available), Propoxyphene napsylate (Darvon-N®), Propoxyphene/Apap (Darvocet-N; generic available): Side Effects: See propoxyphene and acetaminophen. As of 2010, propoxyphene is being withdrawn from US market. Note: On 1/30/09 an FDA advisory panel narrowly voted to recommend that propoxyphene should be pulled from the market. The committee stated that the evidence of efficacy for propoxyphene was marginally better than placebo and never greater than acetaminophen. The agency had collected reports of more than 1,400 deaths in people who had taken the drug since 1957, though experts stressed the figure does not prove the drug was the cause of death in all cases, but they concluded that the drug showed little benefit and lots of risk. (FDA, 2009

Opioids, state medical boards guidelines



The Federation of State Medical Boards Model Guidelines for the Use of Controlled Substances for the Treatment of Pain say State medical boards recognize undertreatment of pain as a public health priority. Underprescribing pain medications is considered as much a breach of the appropriate standard of care as overprescribing. (Federation, 2004 )

Oral corticosteroids

Not recommended for chronic pain. There is no data on the efficacy and safety of systemic corticosteroids in chronic pain, so given their serious adverse effects, they should be avoided. (Tarner, 2012) Multiple severe adverse effects have been associated with systemic steroid use, and this is more likely to occur after long-term use. And Medrol (methylprednisolone) tablets are not approved for pain. (FDA, 2013)

Oramorph® (morphine)

See DWC “Guideline for the Use of Opioids to Treat Work-Related Injuries” for additional information and recommendations.

Oxaprozin (Daypro®)

See NSAIDs (non-steroidal anti-inflammatory drugs); NSAIDs, GI symptoms & cardiovascular risk; NSAIDs, hypertension and renal function; & NSAIDs, specific drug list & adverse effects for general guidelines, as well as specific Oxaprozin (Daypro®) listing for more information and references.

Oxazepam

Not recommended. See Benzodiazepines.

Oxcarbazepine (Trileptal®)

See Anti-epilepsy drugs (AEDs) for general guidelines, as well as specific Oxcarbazepine listing.

Oxecta (oxycodone)

Recommended only for selected patients with risk of abuse that has been documented, but not recommended as a first-line medication for other patients. Oxecta is a tamper resistant dosage form of oxycodone approved by the FDA in June 2011 for the management of acute and chronic moderate to severe pain when the use of an opioid analgesic is appropriate. Drug abuse and diversion are serious concerns with the use of oxycodone products. When considering Oxecta, it is important to assess the likelihood of patient abuse, and based on that assessment chose Oxecta. If no risk of abuse is present, a generic form of oxycodone would be preferred. Oxecta is an immediate-release oxycodone medication that applies Aversion Technology, which uses commonly available pharmaceutical ingredients that, for example, cause the active ingredient to gel to prevent injection or to irritate nasal passages to discourage inhalation. Pfizer is licensing the technology in this product from Acura Pharmaceuticals. However, there is no quality evidence that this formulation has a reduced abuse liability compared with immediate-release oxycodone. (FDA, 2011) See DWC “Guideline for the Use of Opioids to Treat Work-Related Injuries” for additional information and recommendations.

Oxycodone

See DWC “Guideline for the Use of Opioids to Treat Work-Related Injuries,” Appendix F1, for dosing recommendations. .

OxyContin® (oxycodone)

On April 2, 2010, the FDA approved a new formulation of Oxyontin designed to discourage abuse, but according to the manufacturer, there is no evidence that the reformulation is less subject to misuse, abuse, diversion, overdose or addiction. (FDA, 2010) See DWC “Guideline for the Use of Opioids to Treat Work-Related Injuries” for additional information and recommendations.

Oxymorphone (Opana®)

Refer to the DWC “Guideline for the Use of Opioids to Treat Work-Related Injuries,” Appendix F1, for additional information and recommendations.

Pain management programs

See Chronic pain programs.

Paracetamol

See Acetaminophen (APAP).

Paroxetine

See SSRIs (selective serotonin reuptake inhibitors).

Pennsaid® (diclofenac sodium topical solution)

Not recommended as a first-line treatment. See the Diclofenac Sodium listing, where topical diclofenac is recommended for osteoarthritis after failure of an oral NSAID or contraindications to oral NSAIDs, and after considering the increased risk profile with diclofenac, including topical formulations. In studies Pennsaid was as effective as oral diclofenac, but was much better tolerated. Compared to a vehicle control topical placebo, outcomes were all statistically significant in favor of Pennsaid, with the standardized mean differences ranging from 0.30 to 0.39. (Towheed, 2006) FDA approved Pennsaid Topical Solution in 2009 for the treatment of the signs and symptoms of osteoarthritis of the knee, and the FDA requires a Risk Evaluation and Mitigation Strategy (REMS) from the manufacturer to ensure that the benefits of this drug outweigh its risks. (FDA, 2010) For more details see Topical analgesics, Non-steroidal antinflammatory agents (NSAIDs), and the diclofenac topical listing.

Pentazocine (Talwin/Talwin NX)

Not recommended for the treatment of chronic pain.

Percocet® (oxycodone & acetaminophen)

Percocet® is the brand name of an oxycodone and acetaminophen combination drug, produced by Endo Pharmaceuticals.

Percura®

Not recommended. Percura® is a medical food that is a proprietary blend of gamma-aminobutyric acid, choline bitartrate, L-arginine, L-serine, and other ingredients. See Medical foods.

Percutaneous electrical nerve stimulation (PENS)

Not recommended as a primary treatment modality, but a trial may be considered, if used as an adjunct to a program of evidence-based functional restoration, after other non-surgical treatments, including therapeutic exercise and TENS, have been tried and failed or are judged to be unsuitable or contraindicated. There is a lack of high-quality evidence to prove long-term efficacy. (Ghoname-JAMA, 1999) (Yokoyama, 2004) Percutaneous electrical nerve stimulation (PENS) is similar in concept to transcutaneous electrical nerve stimulation (TENS) but differs in that needles are inserted to a depth of 1 to 4 cm either around or immediately adjacent to the nerve serving the painful area and then stimulated. PENS is generally reserved for patients who fail to get pain relief from TENS, apparently due to obvious physical barriers to the conduction of the electrical stimulation (e.g., scar tissue, obesity). PENS must be distinguished from acupuncture with electrical stimulation. In PENS the location of stimulation is determined by proximity to the pain. (BlueCross BlueShield, 2004) (Aetna, 2005) See also TENS and the DWC MTUS chapter on Low Back Complaints.

Percutaneous neuromodulation therapy (PNT)

Not recommended. Percutaneous neuromodulation therapy (PNT) is considered investigational. Percutaneous neuromodulation therapy is a variant of PENS in which up to 10 fine filament electrodes are temporarily placed at specific anatomical landmarks in the back. Treatment regimens consist of 30-minute sessions, once or twice a week for eight to ten sessions. Percutaneous Neuromodulation Therapy™ (Vertis Neurosciences) received approval to market by the U.S. Food and Drug Administration (FDA) through the 510(k) process in 2002. The labeled indications reads as follows: "Percutaneous neuromodulation therapy (PNT) is indicated for the symptomatic relief and management of chronic or intractable pain and/or as an adjunct treatment in the management of post-surgical pain and post-trauma pain." (Condon, 2002) (BlueCross BlueShield, 2004)

PGAP™

See Progressive goal attainment program (PGAP™).

Pharmaceuticals

See Medications.

Phentolamine infusion test

Recommended as indicated below. An intravenous infusion of phentolamine, an alpha 2 blocker, results in generalized systemic sympatholysis. The infusion begins with intravenous saline for placebo control. For a positive response, pain relief should be 50 percent or greater and associated with functional improvement. This test aids in the diagnosis of SMP (Sympathetically maintained pain). (Colorado, 2002) See also Sympathetically maintained pain (SMP).

Phenytoin (Dilantin®)

See Anti-epilepsy drugs (AEDs) for general guidelines, as well as specific Phenytoin listing.

Phototherapy

See Low level laser therapy (LLLT).

Physical medicine treatment

Recommended as indicated below. Physical medicine encompasses interventions that are within the scope of various practitioners (including Physical Therapy, Occupational Therapy, Chiropractic, and MD/DO). Passive therapy (those treatment modalities that do not require energy expenditure on the part of the patient) is not indicated for addressing chronic pain in most instances; refer to the specific modality within these guidelines (e.g., massage, ultrasound)  Active therapy is based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, range of motion, and can alleviate discomfort. Active therapy requires an internal effort by the individual to complete a specific exercise or task. Refer to the specific intervention within these guidelines (e.g., exercise.) This form of therapy may require supervision from a therapist or medical provider such as verbal, visual and/or tactile instruction(s). Patients are instructed and expected to continue active therapies at home as an extension of the treatment process in order to maintain improvement levels. Home exercise can include exercise with or without mechanical assistance or resistance and functional activities with assistive devices. (Colorado, 2002) (Airaksinen, 2006). Patient-specific hand therapy is very important in reducing swelling, decreasing pain, and improving range of motion in CRPS. (Li, 2005) The use of active treatment modalities (e.g., exercise, education, activity modification) instead of passive treatments is associated with substantially better clinical outcomes. In a large case series of patients with low back pain treated by physical therapists, those adhering to guidelines for active rather than passive treatments incurred fewer treatment visits, cost less, and had less pain and less disability. The overall success rates were 64.7% among those adhering to the active treatment recommendations versus 36.5% for passive treatment. (Fritz, 2007)

ODG Physical Therapy Guidelines –

Allow for fading of treatment frequency (from up to 3 visits per week to 1 or less), plus active self-directed home PT. Also see other general guidelines that apply to all conditions under Physical Therapy in the ODG Preface.

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