Transcript Going Straight Detoxing from Opioids

PA AND NJ IARP 2016
CONFERENCE - 17TH ANNUAL
Detoxing from opioids in
Workman Compensation
patients
Wayne G. Miller, D.O., M.P.H
Medical Director
Valley Forge Medical Center and Hospital
Why consider opioid
detox?
Increases in Drug and Opioid
Overdose Deaths — United
States, 2000–2014
“well when you compare something to
heroin, the other drug will always be
shit in comparison.”
from Visionary_Kpsycho
How did we get here?
ABINGDON, Va., May 10, 2007 — The company that makes the
narcotic painkiller OxyContin and three current and former
executives pleaded guilty today in federal court here to criminal
charges that they misled regulators, doctors and patients about the
drug’s risk of addiction and its potential to be abused
From left, Howard R. Udell, the top lawyer for Purdue Pharma; Dr. Paul D.
Goldenheim, the company’s former medical director; and Michael Friedman,
Purdue’s president. Credit Photographs by Don Petersen for The New York Times
Letter from PROP to TJC
The United States experienced a sharp rise in prescriptions for opioid analgesics
following the introduction of the Pain Management Standards. A recent study found
that physicians prescribed opioids, often in high doses, in more than half of 1.14 million
nonsurgical hospital admissions.
According to the Centers for Disease Control and Prevention,sharp increases in opioid
prescribing have led to parallel increases in opioid addiction and overdose deaths.
Since the Pain Management Standards were introduced 15 years ago, more
than 200,000 Americans have died from accidental overdoses involving prescription
opioids
TJC – rebuttal to being “scapegoated”
The Joint Commission first established standards for
pain assessment and treatment in 2001 in response
to the national outcry about the widespread problem
of undertreatment of pain. The Joint Commission’s
current standards require that organizations establish
policies regarding pain assessment and treatment
and conduct educational efforts to ensure
compliance. The standards DO NOT require the use
of drugs to manage a patient’s pain; and when a drug
is appropriate, the standards do not specify which
drug should be prescribed.
Training in Treatment of NonMalignant Pain
 If it hurts….
 If it hurts a lot….
 If it REALLY hurts…..
 If it still REALLY hurts….
 If it REALLY hurts for a long time….
 If it’s getting worse no matter
what I prescribe….
Give ibuprofen
Give hydrocodone
Give something stronger
Give more
Keep giving more
Discharge patient
Adverse Effects of Opioids
• Nausea/vomiting
•Sedation/lethargy/dizziness/CNS adverse
events (including risk of falls)
• Constipation and urinary retention
• Dermatological adverse events
• Cardiac adverse events
• Endocrinologic adverse events
• Psychiatric adverse events
• Dysimmune effects
• Hyperalgesia
Cost
 The costs for prescription narcotics per claim are
rising in the U.S. In fact, medical costs are now
approximately 59 to 60 percent of workers’
compensation claims costs, according to the
National Council on Compensation Insurance
(NCCI). Of those medical costs, narcotic drugs
account for approximately 25 percent. And the
construction industry has seen the greatest
increase in workers’ compensation claims resulting
from narcotic painkiller addiction.
Difference between opioid and nonopioid costs is with workers’
compensation claims
“The Soaring Cost of the Opioid Economy,”
The New York Times, July 22, 2013
Misconceptions Regarding Opioids
and Addiction.
 Addiction is the same as physical dependence and tolerance
 Addiction is simply a set of bad choices.
 Pain protects patients from addiction to their opioid
medications
 Only long-term use of certain opioids produces addiction
In the face of all this….
FDA approved since 2014
 Targiniq ER (oxycodone and naloxone)- not yet
marketed
 New labeling for Embeda (morphine sulfate and
naltrexone hydrochloride)
 Hysingla ER (hydrocodone bitartrate)
 MorphaBond (morphine sulfate), an extended-release
(ER) opioid analgesic – not yet marketed
 Xtampza ER (oxycodone)
(Zohydro ER (hydrocodone) – reformulated, not yet
approved as an abuse deterrent opioid)
Mitigation Strategies against
Opioid Diversion and Misuse.
 Screening tools to identify patients with a substanceuse disorder (ORT, SOAPP-R)
 Use of data from the Prescription Drug Monitoring
Program
 Use of urine drug screening
 Doctor–patient agreement on adherence
A bit about dosing opioids
Case Study
Oxycontin 480 mg daily
Conversion factor
1.5
MME
720
Oxycodone 240 mg daily
1.5
360
Fentanyl 50 mcg/hr every 48 hr
(1200 mcg/24h = 1.2 mg/24hr)
x100
2.4
120
TOTAL MME
Conversion to methadone
1200 mg
approx. 60 mg
Clinical Guidelines for the Use of
Chronic Opioid Therapy in Chronic
Noncancer Pain
 By panel consensus, a reasonable definition for high dose
opioid therapy is >200 mg daily of oral morphine (or
equivalent), based on maximum opioid doses studied in
randomized trials and average opioid doses observed in
observational studies. Some studies suggest that
hyperalgesia, neuroendocrinologic dysfunction, and possibly
immunosuppression may be more likely at higher opioid
doses, though more evidence is needed to define these
risks, their relationship to dose, and their relationship to
clinical outcomes.
 J Pain. 2009 Feb; 10(2): 113–130.
doi: 10.1016/j.jpain.2008.10.008
The American Pain Society in
Conjunction with The American
Academy of Pain Medicine
Summary of evidence
• There is insufficient evidence (no studies that met inclusion
criteria) to evaluate benefits and harms of high (>200 mg/day)
doses of opioids versus lower doses.
Inpatient detoxification
Usually employs a fairly rapid tapering protocol
in conjunction with behavioral therapy.
This setting is considered for those patients
who:
a) are medically unstable
b) fail outpatient programs
c) are non-compliant
d) have comorbid psychiatric illness
e) require polysubstance detoxification.
Outpatient detoxification
Commonly employs a slower tapering protocol. A
taper using the prescribed short-acting opioid is
frequently employed.
 There is no single protocol that has been proven
more efficacious than another
 Regardless of the strategy used, the provider
needs to be involved in the process and remain
supportive of the patient and his/her family.
VA Suggested Tapering Regimens
for
Short-Acting Opioids [USVA 2003]
● Decrease dose by 10% every 3-7 days, or…
● Decrease dose by 20%-50% per day until lowest
available dosage form is reached (e.g., 5 mg of oxycodone)
then increase the dosing interval, eliminating one dose
every 2-5 days.
VA Suggested Tapering Regimens
for
Long-Acting Agents [USVA 2003]
Methadone
● Decrease dose by 20%-50% per day to 30 mg/day, then…
● Decrease by 5 mg/day every 3-5 days to 10 mg/day, then...
● Decrease by 2.5 mg/day every 3-5 days.
Morphine CR (controlled-release)
● Decrease dose by 20%-50% per day to 45 mg/day, then…
● Decrease by 15 mg/day every 2-5 days.
Oxycodone CR (controlled-release)
● Decrease by 20%-50% per day to 30 mg/day, then…
● Decrease by 10 mg/day every 2-5 days.
Fentanyl – first rotate to another opioid, such as
morphine CR or methadone.
Treatment of Opioid Withdrawal
Symptoms
 Anti-adrenergics, e.g. clonidine
 Benzodiazepines
 NSAIDs
 Anti-spasmodics/anti-cholingerics, e.g.,
dicyclomine
 “Muscle relaxers”
 Anti-emetics
 Anti-diarrheals
Now what?
Opioid are NOT the only way to
manage chronic pain
Physical
Non-addictive medications
Interventional procedures
Physical therapy
Massage therapy
Yoga
Acupuncture
Biofeedback
Opioid are NOT the only way to
manage chronic pain
 Spiritual
 Meditation
 Mindfulness
 Religious practices
 Energetic
 Energy medicine (both physical and spiritual
 Multiple varieties (Reiki, etc)
Opioid are NOT the only way to
manage chronic pain
 Psychological
 Therapy (CBT,DBT, etc.)
 EMDR
 Change beliefs and perceptions
 The problem of catastrophizing
 Emotional
 Grief counseling
 Healthy coping with feelings
Continuing Care is Essential
Structure
 Aftercare Plan
 Group therapy
 Individual therapy
 Spiritual Growth (12 step programs, etc)
 Continued work with Pain Management Physician
 Accountability
 Drug testing
 Prescription Drug Monitoring Program
 Activities
 Resocialization
 Volunteerism
 Anti-craving medications
Challenges for reducing or
eliminate opioids in WC pts.
 Very few health care providers with the experience
and training to care for these patients
 Very few health care providers willing to care for
these patients
 Few resources to care for those who need higher
level of care than outpatient management (i.e.,
hospitals, chem dep treatment centers, dual
diagnosis programs)
 Poor integration with ”normal” health care system
Antagonist Therapy
-naltrexone
 Oral or IM (Vivitrol)
 Antagonizes opioid-containing agents but no other
significant drug-drug interaction
 Side effects are most commonly GI (nausea,
abdominal pain, decreased appetite), daytime
sleepiness, fatigue, insomnia, headache
 Reversible hepatotoxicity
 Need to monitor LFTs
Risks Following
Opioid Detox
Increased Risk of Overdose
Treatment of overdoses
with naloxone (Narcan)
Acute Pain or Need for Surgery
 Have a Plan
 Marshall resources – family, friends, sponsor
 Communicate with surgeon or other practitioners
who may be prescribing medications
 Treat the pain
 Closely monitor
 Patients should NOT control their own medications
 Increase recovery activities
 Consider inpatient detox
Thank-you and enjoy AC!