Transcript Prevention and recognition of problems from narcotic

Prevention and recognition of problems
from narcotic prescribing
in your practice
Diversion
Addiction
Failure to relieve pain
Norman Wetterau MD
[email protected]
Detox Admissions and E.D. Visits for
Narcotic Painkillers, 1995-2002
110,000
Emergency
Department
Mentions
100,000
90,000
80,000
70,000
Treatment
Admissions
60,000
50,000
40,000
30,000
1995
1996
1997
1998
1999
2000
2001
2002
Should you treat chronic
nonmalignant pain with opioids?
1. Few studies of long term use. Most show
little or no long term benefit.
• Martell, Bridget et al Annals of Internal Medicine: January
16, 2007
2. AAFP resolution 2004 calling on the
federal government to fund for research into
the benefits and risks of long term opioids
for chronic nonmalignant pain.
Assess effectiveness and need
for medication
• Chart Audit in Tricounty Family Medicine
2005
• Medication: increased 17 some large increases
same 6 decreased 2
• Functional improvement: yes 4, no 4,
questionable 10, not mentioned 8
• Is the medication working: yes 8 no 7
• Questionable 10 detox. 1patient
Problems
• Opioid nonresponsive. In spite of larger and
larger doses and switching opioids, they do not
improve in function and pain control.
• Often the pain becomes less after the opioids are
tapered. Some do well on Suboxone
• Use of short acting with inadequate pain control.
A rollercoaster of pain relief, opioid effect and
withdrawal.
Addiction
• Evidence of dependence (tolerance and
withdrawal) plus
• Impaired control over drug use
• Compulsive use
• Continued use despite harm
• Craving
• WWW .drugabuse.gov
PLEASURE
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Quick onset of action
Smoking tobacco versus a nicotine patch
Snorted oxycotin versus swallowed
Vicodin versus methadone
YOU CAN BECOME DEPENDENT ON LONG
ACTING NARCOITCS, BUT ARE LESS
LIKELY TO BE ADDICTED.
• You are much more likely to become addicted
if you have a history of another addiction
Why do people use non-medically
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To feel good
For various aches and pains
Snorted or given IV for a real high
To prevent withdrawal in those addicted to
IV narcotics
Types of diversion
• Criminal: multiple prescriptions and
physicians
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• One physician and one or two customers
• Taking someone else's drugs, no sale
Case 1
• A 26 yo woman was referred to me for opioid and pain problems.
She had transferred to the referring physician six months before and a
copy of her entire chart was sent with her. The initial visit indicated
she had been seeing another physician for back pain, had been on
vicodin and that the vicodin was not controlling the pain. The record
of the referring physician contained very accurate accounts of each
narcotic prescription including MS contin, Durgisic patches and
regular vicodan prescriptions. It also included notes that various
narcotics were lost or were not working, but when they were not
working they were flushed down the toilet rather than brought in.
Unfortunately there was very little additional history, much of which
might have alerted the physician that this patient might develop
problems with narcotics.
• What initial information might the physician obtained?
Three strikes and you are out
• Did not contact the previous physician
• Did not ask patient about previous alcohol
and drug use, or psychiatric or drug related
hospitalizations.
• Did not obtain a urine drug screen.
For all new patients asking for
narcotics
• Contact previous physicians,
preferably by telephone on
the first visit
The voyage: to the land of
improved function and less pain
The Ship’s name: Opioid
Opioids for Chronic Pain
Navigating a minefield
Preparing for the voyage
Don’t let the patient or the doctor drown!
The minefield
• Some people are trying to obtain opioids for
reasons other than pain - for their addiction,
to sell, to treat their depression or life stresses.
• Some people are at risk for developing addiction.
• In some individuals the narcotics will not really
relieve the pain. If the patients continue on the
opoiods, it will be difficult for them to stop, even
though they are no better.
BUT SOME PEOPLE MAY GET PAIN
RELIEF AND GET THEIR LIFE BACK
Preparing for the voyage
• Who is a good candidate?
– History shows no indication of
substance abuse problems (other
than opioid dependence), past or
current
– No or few risk factors
Preparing for the Voyage
• Who can come, but needs a life jacket and
visits to the ship’s doctor?
- Past SA problems other than opioids
- Risk factors such as FH of SA problems
- Use of tobacco
- Psychiatric problems
- Patients who have had problems in the past
but are honest about them.
Preparing for the Voyage
Who is likely to drown, so they should
stay behind?
- Active SA problems
- -HX of opioid problems in the past
- -Patients who are not being honest with
you
Preparing for the Voyage
• Where are you going?
– To improve functional status, not just lessen
pain
• How will you know if you are off course or lost?
- The pain gets no better
- The dose needs continual increases
- The patient isn’t taking the medication you
prescribe
On the Voyage
• How do you get the information you need to
decide if you are off course or lost?
- Urine drug screens tell you whether the patient
is taking the medication you prescribe
- Urine screens tell you if the patient is taking
other drugs that put him/her in danger of
overdose
- Asking about functional improvement
- Pill counts
Patients who want to go to the
same pain free place, but might
consider a different ship.
• People who were identified as at risk for long term
narcotics
• People who have not already tried other
approaches to their pain relief
• People whose pain is more emotional or related to
life stresses.
• People who understand the risks and benefits and
choose not to be prescribed opioids
Patient assessment
1. The Pain: Subjective pain scale, patient’s
description, how it effects his/her life
2. The Pain: Objective
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What is causing this pain?
What diagnostic tests have been done?
What treatments have been tried and how did they work?
Can it be fixed? Your opinion and patient’s opinion
– You need to obtain this information
3. Is the pain from the medical condition or secondary
to depression or the stress of life?
Screen for conditions that put people
at risk for problems with opioids
1. Past history of SA problems, including drug use
and a lot of binge drinking in HS and college.
2. Current alcohol problems, including binge
drinking and current drug problems including use
of marijuana
3. FH: SA and alcohol problems
4. Depression, especially proceeding the pain
5. Past history of problems with pain medicines
6. Past history of significant legal problems
For all new patients
asking for opioids
• Contact previous physicians,
preferably by telephone on
the first visit
Screening continues:
Ask or use a questionnaire
• Start with alcohol:
How many drinks do you consume in an
average week? (men 14, women 7)
What is the most drinks you have had on
one occasion in the past month (5)
Helping patients who drink too much: A Clinician’s Guide
NIAAA NIH Publication No. 07-3769, Revised 2007
Screening continues:
Ask or use a Questionnaire
• Ask if they have ever had a problem with
alcohol in the past
- If positive screen, give them a CAGE or an
AUDIT
- An AUDIT score over 8 is positive
- The first 3 questions of the AUDIT are
Quantity questions. If questions 4-10 are all
negative, the patient may be able to stop
drinking while taking the medication.
Screening continues
Ask about Smoking: Do you smoke? How much?
• Do you every smoke anything other than tobacco?
• Or Do you every smoke marijuana?
Both tobacco and marijuana smoking is associated
with addictive problems. Tobacco may be
associated with alcohol problems. Marijuana
smoking is associated with use of other illegal
drugs, disrespect for norms and rules, and a desire
to have a mind altered state.
Screening continues
In the past five years:
1. Have you used drugs to get high? Stimulants,
tranquilizers, cocaine, marijuana or narcotics
2. Have you used drugs that were not prescribed for
you?
3. Have you ever been treated for a drug or alcohol
problem?
4. Do you have a family history of alcohol or drug
problems?
“Have you ever” questions are triggers and require
further information: when, how often, do you still
do this?
Urine drug screen
• Obtain one; tell patient that you periodically do
this with patients prescribed controlled substances.
• I have found some positive screens and obtained
help and treatment for the patients.
Reference: Urine Drug Testing in Primary Care
Goukrlay DA; Heit HH; Caplan Y. Booklet CME Activity of
the California Academy of Family Physicians 2004
Other screening questions
Mental health:
• Have you ever been treated for psychiatric problems?
• Do you have frequent mood swings?
• Do you often feel sad or down?
• Have you often been bothered by little interest or
pleasure in doing things?
Reference: Ebell, M, Routine Screening for Depression, Alcohol
Problems, Domestic Violence, from [email protected]
Other screening questions
• Have you ever had an accident after
drinking or taking drugs?
• Ask specifically about the accident that
caused their chronic pain.
• How many times in your life have you
been arrested?
Triage
• Low Risk: (No hx of SA; Few or no risk factors) Primary
care physicians treat these patients
• Medium Risk: (Past history of SA problems but not
opioids or multiple risk factors) Primary care
physician consults or co-manages. Avoid break
through meds or multiple meds. Consider Methadone
or suboxone
• High Risk: Active SA problem or hx of opioid abuse:
Primary care physicians do not prescribe; they refer.
Those for whom primary care physicians
should not prescribe outpatient opioids
1. Current drug or alcohol addiction
– Dangerous: death from alcohol, Valium and
Vicodin and other combinations
– Refer for SA treatment
2. Past history of opioid addiction : if needed
refer. Treat with kappa drug like Talwin,
Suboxone, or very structured use of other
opioids.
Goals of Treatment
• Do functional assessment: use a form or ask
what they cannot do in terms of job,
household work, social activities etc
• Explain that the medication may not get rid
of all their pain
• Explain that if the narcotics are working,
they will be able to do things there are not
currently able to do.
Spending 10 or 20 minutes obtaining a careful
history, including a detailed SA history,
contacting previous physicians and
pharmacists, and another 10 minutes carefully
reviewing old charts might save you future
hours and many future headaches
If you don’t have the time, don’t prescribe the opioids!
Educate the patient
1. The use of medication is to reduce pain and
increase function
2. The medicine does not always work, and so
would be stopped to prevent problems
3. Sharing the medication could result in
criminal charges
4. Do not leave medication where others,
including teenagers, can find it.
Patient Agreement
1. Use to educate the patient
2. Often give it to patient to read at home, share with
SO, and return to the office with SO so as to make
sure everyone understands.
3. Give information about usefulness and potential
problems of opioids, including dependence and
addiction. The problems are presented as medical
issues that, if recognized, can be helped, rather
than bad behavior.
Patient Agreement
4. Include the fact that use of narcotic is a trial, to be
stopped if it is not working or if there are
problems
5. Include information on how the medication is
prescribed -- need to come to office, single
pharmacy
6. Include the side effects of medicine, dangers of
overdose or driving if tired.
7. Get the patient’s agreement to give urine tests, and
unannounced pill counts if asked.
The Voyage
Staying on Course
Follow up 4 or 5 A’s
1. Analgesia
2. Adverse Effects
3. Activities of Daily Living
4. Aberrant behaviors
5. Affect
Also consider urine tests, pill counts, talking with
significant others
Example
• 30 yo woman on Vicodin four a day for 6
months. She wants a refill.
1. Analgesia OK, Later wants to go off of them since
they make her sick and do not get rid of the pain
2. Adverse Effects: constipation, vomits frequently
3. Activities of Daily Living: almost nothing - dusts
4. Aberrant behaviors: none
5. Affect: depressed
Plan: What might you do for her?
Dosage
• Initially increase the dose to provide reasonable
pain control with acceptable side effects. If you
start with short acting, switch to a long acting.
• Ask how she feels when she wakes up, before the
next dose and a hour after the dose. Look for
evidence of withdrawal like sweating, or abd pain.
• You cannot do all of this on the telephone
• See every week or two at first.
Critical General Principles
Prescribing narcotics is a trial,
as with most other medications.
They will be stopped
if they do not work
or if there are problems.
Critical General Principles
2. There is no ethical obligation to prescribe or
continuing prescribing narcotics for chronic pain.
Stop if they are not working or if the patient is
unable to take them as prescribed.
Patients are told they will not be prescribed other
medications if there are contraindications, such as
Ibuprophen and Coumadin.
It is unethical to stop without a taper
or referral
General Principles
1. Look at functional status, not just pain
score. If the patient’s functional status does
not improve, then either increase or change
the opioids, or discontinue them. Try to
make a decision to discontinue before the
person is dependent.
• 2. Do not treat pain with benzos
Use of Opioids in patients with other
addictions but not opioid addiction
1. If Current: Require concurrent treatment for their
addiction, and or possibly require that they stop. Do
not ignore.
2. Treat the pain adequately. Use adequate doses of
opioids
3. Careful follow-up. Pill counts, urine tests, have
someone else keep or administer medication, but
combine this with positive support and the belief that
the patient will be able to take the medication correctly.
“I am your coach and want to make sure you are
successful.”
Patients with other addictions
4. Open Discussion about addiction and
problems.
5. Use long acting. Avoid short acting
for breakthrough pain, or if used, only
prescribe a few.
Getting off a sinking ship
Have an exit strategy
1. Have a member of your group who
has some interest in addiction and can
prescribe buprenorphine.
2. Taper slowly yourself
3. Refer out
Buprenorphine
• Dissolve under tongue
• Neltrexone is part of this, so a person who
takes it IV goes into withdrawal
• Long acting agonist with ceiling effect.
• Little euphoria due to slow onset and long
half life
• Blocks effects of IV heroin
• A physician who takes the 8 hour certifying
course can prescribe this for narcotic
addiction. Go to ASAM.org
Pain in patients
currently addicted to narcotics
1. Detox and rehab. Pain often becomes less.
(Cleveland Clinic Experience)
2. Buprenorphine
3. Careful use of methadone, or duragesic patches if
also having pain. Prescribe for pain since it is
illegal to prescribe for addiction.
4. Treatment of addiction
5. 12 steps for recovery from chronic pain
Case 2
• This patient has had stable chronic back pain
controlled by 50 mcg. Duragesic patch and 8
vicodin a day. The dose has not increased for over
a year. The patient says the medicine helps, but he
has not returned to work. He also says he needs all
of this medication and cannot cut back. He usually
looks comfortable when in the office. Are there
any ways we can check to see if he is actually
taking all this medication and not selling it?
Monitor Medications
• Urine tests for presence of the medication:
– Ask if they took their medication that day
–Ask for the specific medication
–CONSIDER
– Blood acetemetaphine level
– Urine for drugs of abuse (toxic 8) since
they may divert to buy other drugs
Monitor Medications
• Count Pills: Tell patient that you are doing a
quality assurance project and that you are
calling patients and having them bring in
their bottles of all pills to make sure it is
what you have in your records.
Diversion
• 1. Patient said the substance was taken that day
but it is not in the urine.
• 2. Next day, repeat and do pill count.
• 3. Make sure the lab level is low enough to pick
up the medication.
• 4. Make sure that specific medicaton was tested
for.
• 5. See if they go into withdrawal once the
medicine is stopped.
Is the medicine working and still
needed?
• If working: pain is reduced and function
improved
• After a time taper and see if they still need
the drug. Taper slowly and see if the
original reason for needing the medication
is still there
Case 3
• This 26 yo female was begun on Vicodin for back pain.
Because her situation seemed stable, a prescription was
written for 2 qid , 240 with 5 refills. The patient returned a
month later and saw another physician in the group. She
asked for a new prescription and was given one. The new
physician required that she come in monthly. However it was
discovered that she continued to get refills for the first
prescription and went to a second drug store to get the new
prescription fills and paid in cash. When confronted, she said
that the 8 vicodan a day had not been controlling the pain.
• What is the differential diagnosis and what options are
available to the physician?
Case 4
• This 40 yo woman fell on her back in a comp injury. Her husband
worked 18 hours a day and her oldest son got married. Xrays were
normal. She was extremely depressed, but had no insurance coverage
for mental health treatment. The comp carrier initially denied
permission for Physical Therapy or antidepressants. Because the pain
was so bad, the physician began oxycotin 20 mg tid and worked the
dose up to 100 tid. Finally antidepressants were added, and she received
injections and physical therapy, but nothing helped. The pain spread to
include her whole back. Her skin was tender to light touch.
• After a year she asked her physician for something for pain . She said
the pain was worse than ever, worse even than before she began the
medications.
• What is the differential diagnosis? What might be done?
Increasing doses without
improvement
1. Tolerance: usually increase is small
2. Pain was not narcotic responsive:
neuropathic pain, pain due to depression
and psychosocial causes
3. Narcotic hyperalgesia
4. Diversion
5. Addiction
Addiction
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Use to feel good and not for pain relief
Tolerance and withdrawal
Life centers around obtaining the drug
Craving apart from the pain
• Physicians cannot prescribe opioids
except Buprenorphine except for pure
addiction
Tri-County Family Medicine
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6 offices
14 physicians
10 PA’s
120,000 visits per year