Transcript Opioid use, misuse and abuse in patients labelled as

2012 Canadian Fibromyalgia
Guidelines
Executive committee: Dr. Mary-Ann Fitzcharles, Peter A. Ste-Marie,
Dr. Don L. Goldenberg, Dr. John X. Pereira, Dr. Susan Abbey,
Dr. Manon Choinière, Dr. Gordon Ko, Dr. Dwight Moulin,
Dr. Pantelis Panopalis, Johanne Proulx, Dr. Yoram Shir
Why develop Guidelines?
• Recent guidelines ±10 years old
• Advances in understanding FM
– Neurophysiologic
– Treatments
• New diagnostic criteria (ACR 2010)
• Call for guidance & direction
– Requested by Canadian Pain Society
Objectives
• To provide Canadian healthcare professionals
clinically applicable guidelines for use in daily
practice
– Diagnosis
– Management
– Patient trajectory
Makeup of guideline group
• Executive committee:
– 11 persons
– Health care professionals, international expert, project coordinator,
patient representative
• National Fibromyalgia Guideline Advisory Panel (NFGAP)
– 139 healthcare professionals invited
– 35 agreed to participate and completed voting process
All healthcare professionals active in the care of FM and chronic pain
patients.
Methods
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Step 1: Needs assessment
Step 2: Literature search
Step 3: Grading of evidence
Step 4: Writing
Step 5: Advisory Panel votes on recommendations
Step 6: External Revision
Step 7: Publication & Dissemination
Financial support &
conflicts of interest
• Guideline development requested by CPS
• Louise and Alan Edwards Foundation
– Research assistant: salary support
• All participants stated conflicts of interest
• Needs assessment
– Unrestricted educational grant by Valeant
without any input to content
• No additional industry support
The literature search
• 18 key questions
• McGill Librarians did formal lit search
– Embase, MEDLINE, PsychInfo, Pubmed,
Cochrane, grey literature, hand search
• >5000 articles
– Titles, abstracts reviewed, duplicates removed
– 360 retained
How we did the job
• 18 questions & 360 articles
• Each article
– read
– graded (JADAD)
– level of evidence (Oxford)
• Literature is summarized in three sections
• Recommendations are formulated by the
Executive committee, assigned a level of
evidence and a grade.
Methods: Assessing
individual studies
Grading of individual articles was by JADAD
method (out of 5):
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Was the study described as randomized?
Was the study described as double blind?
Was there a description of withdrawals and dropouts?
The method of randomization was described in the paper, and that method was appropriate.
The method of blinding was described, and it was appropriate.
Points deducted if:
• The method of randomization was described, but was inappropriate.
• The method of blinding was described, but was inappropriate.
Assigning a level of evidence
for each recommendation
Overview of the Oxford Centre for Evidence Based
Medicine (level of evidence table)
Level 1
Systematic
review of
RCTs
Level 2
RCT
(or observational
studies with
dramatic effect)
Level 3
Non-RCT
cohort/follow-up
study
Level 4
Level 5
case-control studies, Opinion
historically controlled
studies
Grading of recommendations
A
consistent level 1 studies
B
consistent level 2 or 3 studies or extrapolations from
level 1 studies
C
level 4 studies or extrapolations from level 2 or 3 studies
D
level 5 evidence or troublingly inconsistent or
inconclusive studies of any level
* Level may be graded down or up by experts
46 recommendations formulated
NFGAP voting process:
• SurveyMonkey used
• Advisors had access to full document
• Voted in three sections:
– Recommendation
– Grading of recommendation
• 80% required for acceptance
Guidelines address three broad
concepts
• Diagnosis and evaluation
• Management
• Patient trajectory and follow-up
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new clinical concepts regarding FM have been
incorporated into these guidelines.
Where we currently stand
• 44 page document (12 000 words)
• 336 references
• Endorsed by Canadian Pain Society and
Canadian Rheumatology Association.
• Publication & dissemination in progress
The diagnosis
• Composite of symptoms (level 5)
– 2/3 pain
– 1/3 other (Sleep disturbance, fatigue, cognitive dysfunction..)
• Diagnosis (level 5)
– Clinical construct
– Simple blood tests only
• Physical exam must be done (level 5)
– Exclude other conditions
– Tender points not required
Diagnosis (cont.)
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As early as possible (level 5)
Primary care is ideal setting (level 1)
Access to team member for support (level 3)
Specialist referral only if (level 5)
– Atypical symptoms
– Difficulties in management
• eg. sleep specialist, psychologist
Diagnosis (cont.)
• Healthcare professionals
– need education (level 5)
– Empathetic, shared decision-making (level 3)
• Contributing factors such as genetics or
triggering events must not hinder care(level 5)
• ACR 2010 criteria (level 3)
– May validate clinical diagnosis
Management
(overview)
• No ideal treatment
• Patient tailored approach (level 5)
– Symptom-based management
– Non-pharmacologic & pharmacologic strategies
• Aim to
–  symptoms
– Maintain / improve function
Management
(overview cont.)
• Self-management strategies are imperative
(level 1)
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Patient active participant!! (level 1)
Multimodal approach (level 1)
Realistic goals (level 5)
Pacing, but continue normal life (level 4)
Management
(psychological interventions)
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Internal locus of control
Recognize psychological distress (level 3)
Patient education – better coping skills (level 5)
Improve self-efficacy (level 1)
Psych counselling helpful for some (level 5)
CBT (level 1)
Management
(non-pharmacologic)
• Exercise (level 1)
– Best available evidence
– Any type
• aerobics, water based, stretching, etc.
• CAM
– Insufficient evidence (level 1)
– Encourage disclosure of use (level 5)
Management
(pharmacologic)
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No perfect drug
Lowest dose, gradual increase (level 5)
Expect only a modest response
Consider combination drugs (level 5)
Be knowledgeable regarding drug mechanisms
(level 5)
• Constant evaluation re risk vs. benefit (level 5)
Management
(pharmacologic cont.)
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WHO step-up analgesic ladder (level 5)
NSAIDS – low dose, short use (level 5)
Tramadol – moderate/severe pain (level 2)
Strong opioids – discouraged (level 5)
Cannabinoid (pharma) – sleep (level 3)
Management
(pharmacologic cont.)
• Antidepressants
– Explain mechanism to patient (level 5)
– TCAs, SSRIs & SNRIs can be used (level 1)
– Choice – MD knowledge, Pt characteristics (level 5)
• Anticonvulsants
– Explain mechanism to patient (level 5)
– Low dose (level 1)
Patient trajectory
• Follow-up time interval depends on MD
judgment (level 5)
• New symptoms
– Evaluate using clinical judgment (level 5)
• FM symptoms persist, wax and wane (level 3)
• No value to dwell on past lifetime events, move
forward (level 5)
Patient trajectory
(continued)
• Poor outcome when (level 5)
– Passive patient
– External locus of control
– Untreated prominent mood disorder
• Outcome tools
– Patient Global Impression of Change (level 3)
– Goal attainment (level 5)
– Do not use tender points for outcome (level 3)
Patient trajectory
(work & costs)
• Retention in workforce encouraged (level 3)
• Rehab program if necessary (level 5)
• Reduce costs by treating depression (level 3)
Key points…
• Clinical construct
– Primary setting is recommended
– Do not over medicalize patient
• Non-pharma strategies VIP
– Patient ownership
• Symptom-based management
– No ideal drug
– Drugs show modest effects only
• Encourage retention in workforce
Thank you!!
Any questions?