Transcript Narcotics Safety - Coleman Palliative Medicine

Narcotics Safety
Sean O’Mahony MB BCh BAO
Stacie Levine MD
Coleman Foundation Winter Conference
February 28, 2014
Learning objectives
1. Incorporate recent regulatory changes in regard
to the prescription of opioid medications into
practice
2. Appropriately use opioid medications in patients
with chronic pain “Universal Precautions”
3. Incorporate strategies for identifying and
mitigating opioid misuse
4. Incorporate non-pharmaceutical modalities into
the treatment of chronic pain
Additional resource
• SCOPE (Safe and Competent Opiate Prescribing
Education)
• Boston University School of Medicine
http://www.extendmed.com/scopeofpain/home.html
Case #1
• 40 year old female visits a primary care doctor after
discharge from medical center following
laminectomy and fusion. It’s her first appointment at
this location. She brings a box of transdermal
Fentanyl 100mcg patches and requests that you refill
her script as her pain is a “20 out of 10”.
• The physician prescribes the patches assuming that
her reports of having received a script for this is
true.
• 2 days later the provider receives a call from the ER
that she was placed on a narcan (naloxone) infusion
because of obtundation
CDC Drug Mortality Data
• 425,000 visits to ER in 2009
-non medical or inappropriate use of opioid
medications
-15,600 deaths attributed to opioid medications
->70% of prescription medication overdose related
deaths
-more than deaths from cocaine and heroin
combined
• This number has increased more than fivefold in
the last 10 years.
Prescriptions Sold
by State 2010
Drug Overdose
Deaths 2008
Universal Precautions and Opioid Risk
Assessment
Questions:
How often do you screen your patients for risk
of misuse when prescribing opioids?
Does your current health system have policies
and procedures in place for safe prescribing?
Opioid regulations
• The need to balance access for relief of
suffering needs to be balanced by patient
safety education and safeguards
• 2012 FDA and the DEA released its final Risk
Evaluation and Mitigation strategy for
extended release opioids (REMS)
• Prescription Drug Monitoring Programs
(PDMPs)
Citizen’s petitions
• Physicians for Responsible Prescribing (PROP)
to the FDA in 2012
-Recommended restricting opioid use in non cancer
pain to “severe pain”
-For only 90 days or less
-Limit of 100mg/day for ambulatory patients
• FDA response
State regulatory requirements
• States with highest rates of adverse events have
enacted strictest legislation (Washington 2013)
• Medicaid and Workers’ compensation program
-Any patient on>120MG oral morphine
equivalent/ day must see a pain specialist
• Subsequent waiver for hospice and palliative
medicine
• Deaths and per capita opioid consumption are
dropping but many chronic pain patients report
being terminated from their PCP’s practices
Prescription Drug Monitoring
Programs
• All states except Missouri have passed
legislation establishing PDMPs
• Have been shown to reduce opioid
prescription rates
• Have not been shown to reduce prescription
opioid abuse or overdoses
https://www.ilpmp.org/
Case #1
Patient visits a primary care doctor after discharge
from medical center following laminectomy with
fusion. It’s her first appointment at this location. She
brings a box of transdermal Fentanyl 100mcg patches
and requests that you refill her script as her pain is a
“20 out of 10”.
-What is the preferred way to assess pain in this patient?
-What measures should the provider take to ensure accuracy of
information?
-What safeguards should be put into place in regards to safe
opioid prescribing?
Pain Assessment
• Pros and cons: Numeric Rating (0-10), Visual
Analog, Faces
• McGill, Brief Pain Inventory
- not practical in primary care
• Assessment that includes function gives
much better information on effectiveness of
treatment
Aligning pain rating to functioning
probably safer way to assess
PEG (Pain, Enjoyment, General
Activity) Scale
Risk of opioid misuse
Opioid misuse risk
• Known risk factors
-Age < 45
-Personal history substance abuse
-Family history substance abuse
-Legal history (i.e. DUI, incarceration)
-Mental health problems
-Sexual abuse
Case #1: Additional history
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No psychiatric history
Denies illicit drugs
Drinks 2-3 beers every other day
Former waitress, on disability for chronic back pain
Medications – norco post-op 5/325 mg but ran out
early
• Was taking her friend’s fentanyl
-How do we assess her risk of misuse?
Opioid Risk Tool
Risk screening tools: how can these
results be used?
• Level of concern
communicated to the
patient
• Level of monitoring should
be implemented
• Need for pain specialist or
addiction consultant?
• Some patient may be too
risky for opioids, use nonopioid modalities as much
as possible
Screen for unhealthy Etoh or drug use
• Alcohol: do you sometimes drink wine or beer
or other alcoholic beverages?
• How many times in the past year have you
had 5 (4 or more for a woman) in a day?
• How many times in the past year have you
used illegal drugs or prescription medications
for non medical reasons?
Screen for mental health problems
• Screen for mental health problems e.g. PHQ2,
PHQ9
• Screen for self harm
• Screening tool for addiction risk (e.g. COMM)
• Screen for PTSD
Universal precautions for opioid
prescribing
• Consistent application takes pressure off
provider
• Reduces stigmatization of patients
• Standardizes office policies
• Concurs with national guidelines
-American Pain Society, American Academy of
Pain Medicine
Common universal precautions
• Ensure there is a single prescriber, regular visits
• Use multidimensional and nonpharm.
approaches to pain management
• Monitor for adherence, misuse, diversion
-random pill counts, patient agreements, random
urine drug testing
• Enroll patient in a recovery program if evidence
of addiction
• Provide supportive counseling
• Manage psychiatric co-morbidities
Patient Prescriber Agreement
• Means of setting
boundaries
• Should not be used
with the intent of
getting rid of
problematic patients
• Should be readable,
reasonable and
flexible
Pill counts
• Confirm adherence,
minimize diversion
• 28 days instead of 30
• Prescribe so patient has
residual medications at
appointments
• Patient brings in
medications at each visit
• If concerned, can do
random pill counts
Urine drug testing
• Window of positivity is 1-3 days
• Specify to lab if you expect to find the presence of
a particular substance
• Take a history including over the counters, herbals
and time of last use
• Initial testing is done with class specific assay
• Gas Chromatography will confirm the presence of
an individual medication or its metabolites
• Different labs different test menus and cut-offs
When using opioids – the Four “A’s”
 Document Analgesia
 Document Aberrant behaviors
 Document Adverse Events
 Document Activities of Daily Living
 Document the name and dose of all pain medications
on admission note and at all clinic visits.
 Document the route of administration.
 Look for patient agreement ‘pain contract’ in EMR
Monitoring strategies during patient visits
• Assess progress towards goals (function)
• Patient engagement in self-care (exercise,
stretching)
• Use of non-pharmaceutical modalities (CAM,
PT)
• Psychiatric, emotional, social issues
• How patient has been taking medications
• Objective information: pill counts, urine test
When to refer to pain
management/consultant?
• Increased risk patient: in recovery/ family
history but no current psychiatric or addictive
disorder
• Referral to a multidisciplinary pain
management clinic for on-going pain
management if uncontrolled pain or active
chemical dependency, psychiatric problem
• Communicate these concerns with the pain
clinician when making the referral
Gourlay 2004
Rational opioid prescribing
Case #2
• 90 yo nursing home patient with dementia
• PAD, s/p bilateral AKA with phantom pain
• Hydrocodone/APAP 5/325 mg q 6 hours, worsening
pain
• Admitted to hospice
• Switched to methadone 10 mg po TID
• Patient found with decreased mental status and
respirations, died within three days
Case #3
• 54 YO man with recurrent oral squamous cell
carcinoma neuropathic neck pain
• Pain is ‘electrical’ in the lateral neck area, severe for
most of the day and interfering with sleep and mood
• Transdermal fentanyl 100MCG/72 + hydromorphone
12MG q 3 hours, minimal relief
• Also on gabapentin 600 mg pGtube TID, and lidoderm
5% patch
• Tried other opioids: oxycodone, morphine
• Should we try methadone?
Multidimensional approach to treatment
•Opioids
•Adjuvants
•Neuralaugmentation
•Ablative
Surgery
Suffering
Pain Perception
Nociception
Loeser JD, Cousins MJ. Med J Aust. 1990;153:208-12, 216.
•Psychotropics
•Anti-depressants/
•Cognitive therapies
•Relaxation
•Spiritual
•NSAIDS
•Radiation
•Chemotherapy
•Local blocks
•Surgery
•Physical modalities
Methadone – a special medication
Methadone
• Long and variable half-life (12 – 120 hours)
• Analgesic duration 6-8 hours
• QTc prolongation, Torsades
• Benefits
-mu agonist, NMDA receptor antagonist
-less tolerance, neuropathic pain
-safe in renal disease
-less street value
-inexpensive
Methadone – many drug interactions
Methadone conversion caution
Daily Morphine
<100 mg
101-300 mg
301-600 mg
601-800 mg
801-1000 mg
>1000 mg
Methadone:Morphine
(1:3)
(1:5)
(1:10)
(1:12)
(1:15)
(1:20)
Gazelle. Methadone for the treatment of pain. J Pall Med. 2003;6(4):620
Case #3 (cont)
• Transdermal fentanyl 100MCG/72 hours
• Hydromorphone 12MG q 3 hours, using ATC
Discuss at your table how you would switch to methadone
What surveillance does this patient need to ensure safety?
When You Suspect Aberrant Behaviors
Case #4
• 51 yo woman with diffuse visceral,
neuropathic pain brain and liver metastases
on 4th line chemotherapy for breast cancer
• Medications:
-Oxycodone IR 40 mg q4 hours prn (using every dose)
-Diphenhydramine 50MG q 8 hrs prn itch (requesting dose
increase)
-Alprazolam 0.5MG BID prn (using every dose)
• Runs out of medications early
• Frequently sleepy when she comes in for
chemotherapy
Case #4 (cont.)
• Depressed, not seeing a mental health
provider
• Condominium recently repossessed
• You request involvement of her husband at
her next visit so that he can help with
monitoring of her prescription opioids
• She is skeptical of this. Her husband ‘doesn’t
understand her’.
-Is she “addicted”? What do you do?
Abuse/addiction
• Published rates in chronic pain population
~10% (3%-50%)
• Risk factors
-personal history of substance abuse
-family history of substance abuse
-co-morbid psychiatric condition
-abuse as child
Opioid pharmacology and addiction
Natural and
Semisynthetics
Synthetic
Why people become addicted to
opioids
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Activate mu receptors in midbrain
Dopaminergic pathways = euphoria
Fast acting opioids most rewarding (IV)
ER/LA are often adulterated for same effect (chewed)
which has lead to overdose
Outpatient management of the
chemically-dependent pain patient
• Maximally structured approach includes:
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Frequent visits
Pain agreement
Limited supply of medications (weekly, monthly)
Rotate from short acting agents to primarily long-acting
opioids with low street value
Ask pharmacy to run a profile of recently filled medications.
Urine Point of Service toxicology and Mass Spectroscopy
(MS)/Gas Chromatography (GC)
Recovery program/psychotherapy
Referral to addiction specialist
Case #5
• 51 YO woman with HIV, triple negative breast cancer
HIV neuropathy, worsening pain
• Use of alcohol, MJ and subsequently cocaine and
heroin consistently from age 14 until age 49
• Incarceration in her 30s for drug trafficking
• Has 2 teenage daughters in the custody of her mother.
• Lives alone, poor relationship with family
• Gabapentin 600 MG TID, Topiramate 25MG BID
• New skeletal metastases – on oral chemo, XRT, NSAIDs
-How would you manage this patient?
Case #5 (cont)
• Meets weekly with a substance abuse counselor that
you work with in the HIV clinic
• Meets monthly with you in the clinic
• UDTs always positive for ‘opiates’ and nothing else
• Participates in recovery groups and abstinence
promotion groups
• Comes to all of her primary care appointments
• Getting acupuncture in the clinic
• Excited to have recently had her 2nd anniversary of
being sober.
Non-Pharmacologic Modalities
Case #6
• 69 yo female with metastatic rectal cancer and chronic
low back pain
• Prior ETOH
• Lives with boyfriend of 15 years, no longer a couple
• Existential distress
• Reluctant to take antidepressant
• Escalating doses of opioids, states they are ineffective
for somatic pain
• Using melatonin and lavender baths for insomnia
• Requesting alternative methods to control pain
What do you do?
CAM – Malignant pain
• 2007 National Health Interview Survey
-65% diagnosed with cancer had used CAM
-53% non-cancer
-Cancer patients rated most likely to use CAM
for general wellness, immune enhancement,
and pain management.
• Many people do not inform their healthcare
providers of CAM use (15-23% of users)
CAM – Non-malignant pain
• 44% with painful neurologic conditions sought
help from CAM practitioners.
IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for
Transforming Prevention
• 60% who used CAM for back pain perceived a
“great deal” of benefit.
Kanodia A 2010 Perceived Benefit of Complementary and Alternative Medicine (CAM) for
Back Pain: A National Survey
• Veterans with chronic non-cancer pain
-80% tried CAM
-all willing to try four CAM modalities being studied
(massage, acupuncture, chiropractic, herbal medicine).
Denneson L J Rehab Res & Dev. 2011; 48(9)1119:1128
Acupuncture and malignant pain
• Surgical oncology (Peri-operative acupuncture and
massage)
-Decrease 1.4 points on a 0-10 pain scale vs 0.6 in the
control group (P=0.038)
-Decrease depressive mood
J Pain Symptom Manage 2007 Mar;33(3):258-66
• Breast Cancer RCT Traditional Acupuncture vs. Sham
Acupuncture
-efficacy for joint pain in patients receiving aromatase
inhibitors
J Clin Oncol 28:7 2010
Acupuncture and malignant pain
• Auricular
acupuncture
->30MM VAS after
analgesic therapy
for>1month
-Treatment: Pain
intensity decreased
by 36% at 2 months
-Placebo (2%).
-(P < .0001).
Journal of Clinical Oncology, Vol 21, Issue 22 (November),
2003: 4120-4126
CAM – other
• Integration of cognitive behavioral therapies into
management of pain targeted to specific symptoms such as
pain and fatigue can significantly reduce pain severity Level of
Evidence I
Given B 2002, Anderson KO 2007
• Art Therapy and Music Therapy have been shown to be
helpful for procedural pain in pediatric cancer patients
• J of Pediatric Oncol Nursing 2010 May-Jun;27(3):146-55
• RCTs have also shown benefits for hypnosis on procedural
and peri operative pain
J of the National Cancer Institute 99:17 2007
Acupuncture and non-malignant pain
• There are promising findings in some conditions,
such as chronic low-back pain and osteoarthritis of
the knee
• Acupuncture appears to be effective for a variety of
pain conditions, including carpal tunnel syndrome,
fibromyalgia, headache/migraine, low-back pain,
menstrual cramps, myofascial pain, neck pain,
osteoarthritis pain and postoperative dental pain.
http://nccam.nih.gov/health/acupuncture/acupuncture-for-pain.html
Biofeedback and non-malignant pain
• Meta-analysis over 100 empirical studies
-50 % reduction in headache symptoms
following biofeedback/relaxation therapy with
stress management training
McGrady, Andrasik, Davies, et al, 1999
Mindfulness based stress reduction
• Systematic review of 3 RCTs with 119 adults
effective for short and long term relief of
chronic low back pain in younger adults
• Negative results in older adults
Cramer H BMC Complement Altern Med. 2012
8 week RCT trial of MBSR vs. a
multidisciplinary pain clinic
-MBSR was as effective at reducing pain
intensity and lessening pain distress at
6months
•
Wong SY Clin J Pain 2011
Yoga
• A systematic review of
10 RCTs for pain
syndrome
• 9 of the 10 reported
significant reduction in
pain
Posadzki Complement Ther Med.
2011 Oct;19(5):281-7
Homeopathy
• No studies have shown effectiveness
specifically for pain: studies of the most
popular homeopathic remedy for tissue
inflammation, arnica, have failed to show its
effectiveness over placebo.
Conclusions
• Opioid prescriptions and misuse are on the
rise
• Universal precautions and safe opioid
prescribing should be integrated into everyday
palliative medicine practices
• Consider additional non-pharmacological
modalities (i.e. CAM) for patients with pain
syndromes