Transcript Opioids for Neuropathic Pain

Emerging Pharmacy Issues in the
Texas Workers’ Compensation System
Presented by
Suzanne Novak, MD, PhD
CEO, Austin Outcomes Research, Inc.
June 9, 2009
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Presentation Outline
DO WE HAVE A PROBLEM?
- Current data
- Adverse effects
- Opioids and workers’ compensation
- What is in the guidelines
- Special issues
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Any reproduction of this material is prohibited without the author’s express written permission
Copyright 2008, Austin Outcomes Research
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Current Data
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Opioid Abuse: Current Data
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
•Number
of new opioid users
1990: 573,000
2000: 2.5 million
Manchikanti L. National drug control policy and prescription drug abuse: facts
and fallacies. Pain Physician. 2007;10:399-424.
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Opioid Abuse: Current Data
Current data on Prescription Drug Abuse
•The
reported range of patient’s exhibiting problematic
opioid use ranges from 2.8% to 62.2%
- Seeking prescriptions from multiple providers
- Forging prescriptions
- Preoccupation with obtaining more opioids despite evidence of
pain relief
- Unsanctioned dose escalations
•Abuse
rose 71% between 1997 and 2002
•Opioid misuse reports range from 20% to 40%
Turk DC, et al. Clinical Journal of Pain 2008;24:497-508.
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Opioid Abuse: Current Data
Overdose Deaths: West Virginia
2006 Death Rate from unintentional overdose
16.2/100,000 population (295)
US average: 5.6/100,000
Rate of opioid prescribing from 2000 to 2005
increased at a higher rate in WV
Pharmaceutical diversion: 63.1%
Doctor shopping: 21.4%
Only 44.4% had been prescribed these drugs
Hall AJ et al. JAMA 2008
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Why am I telling you this?
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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 diversion
1/3 do not obtain old records before prescribing
controlled drugs
Manchikanti L. National drug control policy and prescription drug abuse: facts and fallacies.
Pain Physician. 2007;10:399-424.
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Adverse Effects
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Opioid Abuse: Side Effects
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Sedation
Cognitive impairment
Respiratory depression
Nausea
Constipation
Edema
Hypogonadism
Hormonal changes
Immunosuppression
Hyperalgesia
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Opioid Abuse: Side Effects (psychosocial)
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Higher disability
Higher rates of healthcare utilization
Higher rates of tobacco and other substance
abuse
Higher levels of depression
Dersch J et al. Spine 2008: 2219-27
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Opioids and Worker’s
Compensation
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Opioids and Workers’ Compensation
Opioids and Workers’ Compensation
Webster et al study
Controlling for age, gender, job tenure, and LBP severity, the
receipt of higher amounts of morphine equivalent medications in
early treatment was associated with:
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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.
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Opioids and Workers’ Compensation
Opioids and Workers’ Compensation
These findings suggest that the intensive use of opioids for
the management of acute LBP may not be effective for:
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Long-term pain reduction
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Improving function
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May be counterproductive to recovery
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Risk Factors
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Opioids and Workers’ Compensation
Psychosocial factors may be better
predictors of pain and disability than
physical or diagnostic factors
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Chronic pain patients have an increased
prevalence of:
Depression
- Anxiety
Substance abuse/dependence
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Somatization and personality disorders
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Dersch J, et al. Spine 2007;1917-25
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Opioids and Workers’ Compensation
Substance abusers have a higher rate of:
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Psychiatric comorbidity: Depression; Anxiety;
Personality disorders
History of physical and sexual abuse
Use of other substances known for
dependence
Tobacco dependence
Family history of substance abuse
Dersch J, et al. Spine 2007;1917-25
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Evidence for use
of Opioids for
Neuropathic Pain
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Opioids for Neuropathic Pain
Eisenberg et al. Cochrane 2006
 The use of opioids for neuropathic pain remains
controversial
 Opioids have high side effect profiles
 Studies are small and have yielded equivocal
results
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There is no established long-term riskbenefit ratio
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Opioids for Neuropathic Pain
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Short-term studies only provided equivocal
evidence regarding efficacy
Intermediate-term studies demonstrated
significant efficacy of opioids over placebo
Further randomized controlled trials are need to
establish long-term efficacy, safety (including
addiction potential) and effects on quality of life.
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When to use Opioids
When moderate to severe pain is having
an adverse impact on function or quality
of life
Benefits outweigh risk
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What is in the Guidelines?
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APS/AAPM Guidelines
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Prior to initiating treatment:
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Conduct a H&P including assessment of risk of substance
abuse, misuse, or addiction
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Obtain Informed Consent: includes goals, expectations,
potential risks, and alternatives to treatment
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Consider a written management plan to document patient
and clinician responsibilities
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The initial treatment should be considered a trial.
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ODG: Indicators of Poor Outcomes
Little or no relief with acute or subacute treatment
There is evidence of psychiatric pathology such as
conversion disorder, somatization disorder, pain
associated with psych factors (depression, anxiety, or
history of previous substance abuse)
Patient requests opioids and there are inconsistencies
in the history, presentation, and physical findings.
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ODG: Steps Before the Trial
Obtain at least one physical and psychosocial
assessment
“When subjective complaints do not correlate with
imaging studies and/or physical findings and/or
psychosocial concerns exist, a second opinion
with a pain specialist and psychological
assessment should be obtained.”
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Sullivan
2006,
Sullivan 2005, Wilsey 2008, Savage 2008, Ballyantyne 2007
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ODG: On-Going Management
Prescriptions from a single practitioner
 Lowest possible dose to improve pain and
function
 Maintain ongoing review of outcomes
Four A’s: analgesia; activities of daily living;
adverse effects; aberrent drug-taking behavior.
 Urine drug screening for abuse, addiction or
poor pain control (Webster, 2008)
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ODG: On-Going Management
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Document misuse
Consult: multidisciplinary pain clinic
- Doses of opioids are required beyond that
usually required for the condition
- Pain does not improve in 3 months
Consider a psych consult if there is evidence of
depression or anxiety.
Consider an addiction consult if there is
evidence of substance abuse
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ODG: When to Discontinue
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No overall improvement in function
Continued pain with evidence of intolerable
adverse effects and lack of significant benefit
(lack of improved function at high doses with
persistent pain, i.e. > 120 mg MED)
Evidence of serious non-adherence
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ODG: When to Continue
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The patient has returned to work
The patient has improved function and pain
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Special Issues
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What about Patients at High Risk?
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Closer monitoring
Random urine drug screens
Involvement of family/partner
Consider a consultation with a mental Health or
addiction specialist
Urine drug screens are also recommended
periodically for all patients to confirm
adherence.
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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?
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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?
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Opioid Hyperalgesia
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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.
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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
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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
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What if the diagnosis is
addictive disease?
YOU ARE GOING TO DO THE EXACT
SAME THING
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How do we stop opioids?
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Thank You
contact Info: [email protected]
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