Transcript Chronic Opiate Therapy

Chronic Opiate Therapy
Benjamin Meeks, FNP
Agenda
•
•
•
•
•
History of Opiate Therapy
Risks of Opiate Therapy
Benefits of Opiate Therapy
Guidelines for Opiate Therapy
Case Studies
“Give strong drink to those who
are about to perish”
- Solomon
Modern History
• Portenoy and Foley 1986
– Study of 38 chronic pain patients
– 4 – 7 years duration
– 66% maintained on 40mg to 60mg morhpine
Modern History
• 1989 Weissman and Haddox introduce
concept of pseudoaddiction
• 1995 Introduction of time released
oxycodone
• Titrate to effect or side effect
Modern History
• 97% increase in opioid sales from 1997 to 2010
• 2010 Misuse or abuse of pharmaceuticals
overtakes alcohol in reason for ED visits
• Drug overdose deaths increase 250% 2000 – 2010
• 15.1% increase in American population over the
age of 65 from 2000 - 2010
• Estimated 116 million American with chronic pain
Ethical Imperatives
Treat your patients pain.
Do no harm by contributing to abuse
and diversion.
Risks of Opiate Therapy
•
•
•
•
•
•
Constipation/Urinary Retention – 41%
Tolerance
Hypogonadism – 11%
Addiction
Death
Falls/Accidents
Tolerance
• Reversible physiologic response to the
persistent presence of opiate agonists
leading to diminishing therapeutic effect
• Mechanism not fully understood
• Poorly studied
Addiction
• Addiction/Medication Misuse
• Addiction rates vary by study 5% to 41% of
chronic pain patients
• 20% of general population reports “non-medical
use” of opiates
• Aberrant behaviors in 11.5% to 24%
• Aberrant behaviors/Addiction appear greater in
those aged <56 years, smokers and unemployed
Falls/Accidents
• Exposure to opiates increased fall risk by
38%
• Greater than 50mg morphine equivalent
doubled risk of falls
• More common with new opioid prescription
• Greatest in 18 – 29 year old age group
What risks does my patient have?
Benefits of Opiate Therapy
•
•
•
•
Pain Control
Improved Social Function
Improved Mental Health
Improved Physical Function
Benefits of Opiate Therapy
• Meta-analysis of 28 studies with chronic
nonmalignant pain demonstrated improvements in
pain and function studies only up to five weeks
• Very little long term evidence no studies longer
than 2 years, many not controlled
• No long term studies demonstrate strong evidence
for opiate therapy
• No evidence showing benefit of long acting versus
short acting opiates
Guidelines – ASIPP 2012
• Comprehensive Assessment
–
–
–
–
–
–
–
–
–
Pain Condition
Medical History
Physical Exam
Psychosocial History
Functional Status
Sleep
Psychological Evaluation
Prescription Monitoring Program
Urine Drug Screening
Case Study
• 65 year old married white male, 5’10”, 275 lbs,
disabled coal miner, 1 ppd smoker, denies alcohol
usage, reports chronic worsening back pain
without extremity pain, medical history significant
for O2 dependent COPD, HTN, diabetes and mild
kidney disease, lives with wife and teenage
grandchild, no current medications for pain, no
recent radiology
• Do you prescribe opiates for this patient?
Case Study
• 40 year old co-habitating white male, 5’10”, 250
lbs, disabled construction worker, 2 ppd smoker,
denies alcohol usage, reports five year history of
worsening back pain without extremity pain,
medical history significant for COPD, lives with
girlfriend, failing over the counter
NSAIDS/APAP, MRI reveals multilevel disc
degeneration and faect arhtropathy without
foraminal stenosis.
• Do you prescribe opiates for this patient?
Case Study
• 30 year old married female, 5’5”, 140lbs, non-smoker,
employed as elementary school teacher 6 week history of
worsening low back and right leg pain began after lifting a
box of books, numbness right lateral foot, not improving
with physical therapy, missing work due to pain, sleep is
disturbed due to pain, MRI demonstrates right L4-5
herniation, lives with husband and 2 children ages 4 and 6.
Ibuprofen 800 TID not helpful and causing GI upset.
• Do you prescribe opiates for this patient?
Summary
• Long term opiate therapy has medically proven
significant life altering risks
• Long term opiate therapy has not been as yet
proven in the research to improve function, mood
and reduce pain over a period of years
• Consider risks, benefits and potential duration fo
therapy before writing the first prescription for
opiates