Transcript Slide 1

Opioid Use in Workers’
Compensation
Suzanne Novak, MD, PhD
November 2008
Setting the Stage
What is the Current Data?
• Americans consume 80% of the global
supply of opioids
• This includes 99% of the world’s
hydrocodone and 2/3s of the world’s illegal
drugs
• They constitute 4% of the world’s
population
Manchikanti L. National drug control policy and prescription drug abuse: facts
and fallacies. Pain Physician. 2007;10:399-424.
What is the Current Data?
• The US population increased by 14%
between 1992 and 2003
• The number of people that abused
controlled prescription drugs increased by
81%
Why am I Telling You This?
• Only 19% of surveyed physicians received any
medical school training in identifying prescription
drug diversion
• Only 40% received any training in identifying
prescription drug abuse and addiction
• 43% do not ask about prescription drug abuse
and addiction
• 1/3 do not obtain old records before prescribing
controlled drugs
Manchikanti
Opioids and
Workers’ Compensation
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After controlling for age, gender, job tenure, and
LBP severity, the receipt of higher amounts of
morphine equivalent medications in early
treatment was associated with:
Prolonged disability
Higher medical costs
Higher costs of surgery
Late use of opioids
Webster BS, et al. Relationship between early opioid prescribing for acute
occupational low back pain and disability duration, medical costs, subsequent surgery
and late opioid use. Spine. 2007 Sep 1;32(19):2127-32
140 mg of Morphine
Equivalents/Day vs. None
• There was no significant difference in the proportion of
claimants with more severe injuries among those who
received no early opioids and those who received up to
140 mg of MEA in the first 15 days
• There was a significant increase in risk for those who
received up to 140 mg MEQ to undergo surgery,
continue opioid use, and have a marginal increase in
medical costs.
• These findings suggest that even a limited course of
opioids may have a negative effect on long-term
outcomes.
Opioids and
Workers’ Compensation
These findings suggest that the intensive
use of opioids for the management of
acute LBP may not be effective for
• Long-term pain reduction
• Improving function
• May be counterproductive to recovery
What is Recommended
Before Starting Opioids
Pre-Trial
• Determine the diagnosis
• Include a risk assessment of substance
abuse, misuse, or addiction
• Determine a benefit-to-risk assessment of
the use of opioids
• Obtain informed consent
Therapeutic Trial
• Opioid selection should be individualized
• This depends on factors such as the psych
evaluation, underlying health, risk of
abuse, and risk of adverse events
• Monitor: pain, function, adverse events
and adherence
What about Patients at High Risk
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Closer monitoring
Random urine drug screens
Involvement of family/partner
Consider consultation with a mental health
or addiction specialist
Urine drug screens are also recommended
periodically for all patients to confirm
adherence
What about those frequent
escalations?
WHY?
• Is there evidence of disease progression?
• Is there evidence of another pain
generator?
• Is there evidence of issues such as
secondary gain, exacerbation of
underlying depression or anxiety?
• Is there evidence of development of
addiction?
What about those frequent
escalations?
HISTORY OF RESPONSE TO OPIOIDS
• Has the patient responded to opioids in
the past?
IF SO:
• IS THIS TOLERANCE?
• IS THIS OPIOID HYPERALGESIA?
Opioid Hyperalgesia
Patients who receive opiate therapy sometimes
develop unexpected changes in their response
to opioids.
• Development of abnormal pain (hyperalgesia)
• Change in pain pattern
• Persistence in pain at higher levels than
expected.
Opioids in this case actually increase rather than
decrease sensitivity to noxious stimuli.
Diagnosis of Opioid Hyperalgesia
Opioid trial (assumes there has been previous
improvement)
IMPROVEMENT
• Tolerance
NO IMPROVEMENT
• Possible opioid hyperalgesia
• A pain condition that is non-opioid responsive
Treatment of Opioid Hyperalgesia
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Wean the dose
Rotate opioids
Use of adjuvant pain medications
Further evaluation by a specialist with
additional expertise in psychiatry, pain
medicine, or addiction medicine
What if the diagnosis is
addictive disease?
YOU ARE GOING TO DO THE
EXACT SAME THING
Screening Tools
Have not yet been shown in prospective studies
to accurately predict who will become addicted
Opioid Risk Tool:
1) Family and personal history of alcohol and
substance abuse
2) Age
3) Sexual abuse in females
4) Mental health disease: schizophrenia; bipolar;
OCD; ADD; depression
Kahan M, et al. Misuse of and dependence on opioids: study of chronic pain
patients.Can Fam Physician. 2006;52:1081-7
Screening Tools
• CAGE test
• The Screener and Opioid Assessment for
Patients with Pain (SOAPP)
1) history of substance abuse
2) legal problems
3) craving medication
4) heavy smoking
5) mood swings.
Behavior Suggesting
Opioid Dependence/Misuse
Adverse consequences
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Decreased functioning
Observed intoxication
Negative affective state
Reports of withdrawal
Behavior Suggesting
Opioid Dependence/Misuse
Impaired control over medication use
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Failure to bring in unused medications
Dose escalation without approval
Requests for early refills
Lost or stolen prescriptions
Unscheduled clinic appointments in “distress”
Frequent visits to the ER
Family reports of overuse/intoxication
Behavior Suggesting
Opioid Dependence/Misuse
Craving and preoccupation
• Non-compliance with other treatment
modalities
• Failure to keep appointments
• No interest in rehabilitation
• No relief of pain or improved function with
opioid therapy
• Overwhelming focus on opiate issues
Behavior Suggesting
Opioid Dependence/Misuse
Adverse behavior
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Selling prescriptions
Forging prescriptions
Stealing drugs
Using drugs in ways other than prescribed
Concurrent use of other illicit drugs (UDS)
Obtaining drugs from other sources
Management
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At risk:
Don’t use opioids unless other treatment fails
More frequent visits, pill counts, UDS
Misuse
Avoid oxycodone and hydromorphone
Taper
Evidence of diversion/addiction to other
drugs/illegal activity:
Send to a specialist
Management
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Steps to avoid misuse/addiction
Opioid therapy agreements
Limit prescribing to one pharmacy
Urine toxic screens
Frequent evaluation of clinical history (e.g.
asking if recovered addicts are craving the
former drug of abuse)
Frequent review of medications (pill
counts, electronic medical records)
Management
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Steps to avoid misuse/addiction
Communication with pharmacists
Communication with previous providers,
including obtaining old records
Evidence of participation in a 12-step program
Establish realistic treatment goals
Initiate appropriate adjunct meds and therapy
programs
Document
How do we stop opioids?
IDEAL SITUATION:
• A mutual agreement
WHAT MAY HAPPEN:
• A unilateral decision
How do we stop opioids?
Let’s ask the panel……..