Transcript Practical Approaches to Opioid Prescribing

MSK Train the Trainer 1
Practical Approaches to
Opioid Prescribing:
Working Within the Guidelines
Brenda Lau MD, FRCPC, FFPMANZCA, MM
www.pspbc.ca
Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name
Relationships with commercial interests:
- Grants/Research Support: PharmaCorp ABC
- Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
- Consulting Fees: MedX Group Inc.
- Other: Employee of XYZ Hospital Group
2
Disclosure of Commercial Support
This program has received financial support from [organization name] in the form
of [describe support here – e.g. educational grant].
This program has received in-kind support from [organization name] in the form
of [describe the support here – e.g. logistical support].
Potential for conflict(s) of interest:
- [Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose product(s) are
being discussed in this program].
- [Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program: [enter generic
and brand name here].
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Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to “Quick Tips” document
4
Certification
 Up to 21 Mainpro+ Certified credits for GPs awarded upon
completion of:
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› At least 1 Action Period
› The Post-Activity Reflective Questionnaire (2 months after LS3)
 Up to 10.5 Section 1 credits for Specialists
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› The Post-Activity Reflective Questionnaire (2 months after LS3)
5
Update/revise
Action Plan
Report of AP1
experiences &
successes
Payment for:
PMV (optional)
LS1
Action Period 1
6
Refine
implementation;
embed & sustain
improvements
attempted in
practice via
Action Plan +
AP2
requirements
Interactive
group learning
Finalize Action
Plan
Report of AP2
experiences &
successes
Payment for:
LS2
Action Period 2
LS3
Reflection
Interactive
group learning
Learning Session 3
Create Action
Plan (using
template)
Planning & initial
implementation
in practice;
review of Action
Plan &
improvements
attempted in
practice + AP1
requirements
Action Period 2
Interactive
group learning
Learning Session 2
Opportunity
for in-practice
visit to
introduce
applicable
EMR-enabled
tools &
templates prior
to LS1
Action Period 1
Learning Session 1
Pre-Module Visit
Learning Session & Action Period Workflow
Reinforce &
validate practice
improvements
GPs & Specialists
complete PostActivity
Reflective
Questionnaire
(PARQ) 2 months
after LS3 &
submit to PSP
Central
Payment Stream 1 (ideal)
Current Rates:
GPs
Specialists
MOAs
Hourly Rate
$125.73
$148.31
$20.00
Action Period 1
$880.10
$1,038.16
N/A
Action Period 2
$660.07
$778.62
N/A
Payment made after attending LS2
Payment made after attending LS3
GPs:
GPs:
PMV
= $125.73
LS2
= $440.05 ($125.73 x 3.5hrs max.)
LS1
= $440.05 ($125.73 x 3.5hrs max.)
AP2
= $660.08
AP1
= $880.10
LS3
= $440.05 ($125.73 x 3.5hrs max.)
TOTAL
$1,445.88
TOTAL
Specialists
Specialists
LS1
= $519.08 ($148.31 x 3.5hrs max.)
LS2
= $519.08 ($148.31 x 3.5hrs max.)
AP1
= $1,038.16
AP2
= $778.62
$1,557.24
LS3
= $519.08 ($148.31 x 3.5hrs max.)
TOTAL
TOTAL
MOAs
$1,816.78
MOAs
PMV
= $20.00
LS1
= $80.00 ($20.00 x 4hrs max.)
LS2
= $80.00 ($20.00 x 4hrs max.)
$100.00
LS3
= $80.00 ($20.00 x 4hrs max.)
TOTAL
TOTAL
7
$1,540.18
$160.00
Learning Objectives
 Incorporate the Canadian Guideline for Safe and Effective Use of
Opioids for Chronic Non-Cancer Pain and apply elements into a
busy practice
 Help you effectively utilize supporting tools such as the
› Brief Pain Inventory (BPI) and the
› Opioid Risk Tool (ORT), and
 Implement improved opioid monitoring practices, including
documenting the
› 6 A’s and using the Opioid Manager*
› Weaning guidelines
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The Canadian Guideline for Safe and Effective Use
of Opioids for Chronic Non-Cancer Pain
 What is it?
› An evidence-based guideline with 24 recommendations outlining
how to use opioids to treat patients with CNCP
 Why was it developed?
› Existing treatment information and guidelines were found to be
outdated
 Why was it necessary?
› To improve the safety and care of CNCP patients being treated
with opioids, and to safely manage potential side effects (including
addiction) and the risk of opioid misuse
http://nationalpaincentre.mcmaster.ca/opioid/,
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The Canadian Guideline for Safe and Effective Use
of Opioids for Chronic Non-Cancer Pain
 Available at: http://nationalpaincentre.mcmaster.ca/opioid/
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The Canadian Guideline for Safe and Effective Use
of Opioids for Chronic Non-Cancer Pain
CNCP = Chronic Non-Cancer Pain
*Courtesy of: “Toronto Rehabilitation Institute” Available at: http://nationalpaincentre.mcmaster.ca/opioid/
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Effects of Chronic Pain on the Patient
Physical Functioning
Mobility
Moods
Impaired Immununity
Depression
Sleep disturbances
Anxiety
Fatigue
Anger
Loss of appetite
Irritability
Societal Consequences
Social Functioning
Diminished social relationships
(family/friends)
Decreased sexual function/intimacy
Decreased recreational and social activities
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Ashburn MA, et al. Lancet. 1999;353:1865-1869. Harden RN. Clin J Pain. 2000;16:S26-S32.
Agency for Health Care Policy and Research. Clinical Practice Guideline No. 9. 1994. Meyer-Rosberg, K et al. Eur J Pain. 2001;5:379-389.
Zelman D, et al. J Pain. 2004;5:114. Manchikanti L, et al. J Ky Med Assoc. 2005;103:55-62. Hoffman NG, et al. Int J Addict. 1995;30:919-927.
Health care utilization
Disability
Loss of work days or
employment
Substance abuse
Deciding to Initiate Opioid Therapy – Cluster 1
 Pain is moderate to severe
 Pain has significant impact on function and QOL
 Non-opioid pharmacotherapy has been tried and failed
 Opioids indicated for specific pain condition
 Opioid risk assessment has been done & documented
 Informed consent (goals, risks, benefits, AEs, complications …)
 Patient agreeable to have opioid use closely monitored (UDS,
treatment agreement, freedom of information …)
 Responsible prescribing of opioids
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Opioid Risk Tool & Checklist
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Universal Precautions in Pain Medicine
1. Diagnosis with appropriate differential
2. Psychological assessment
› Including risk of addictive disorders
3. Informed consent
› Verbal v. written/signed
4. Treatment agreement
› Verbal v. written/signed
5. Pre trial assessment of pain/function and goals
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Content of a Treatment Agreement
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One prescriber (include name)
One dispensing pharmacy (include name)
Will comply with safe/secured storage of opioid; Will comply with no driving while titrating
No sharing/selling of opioid; No accepting of any opioid medications from anyone else
Will not change the dose or frequency of taking the medication without consulting the doctor
Strict rules with respect to medication loss, early refills, possible abuse or diversion
(e.g. Dr._________ will not prescribe extra medication for me. I will have to wait until the next
prescription is due.)
Strict rules with respect to concomitant usage of other sedating medications, OTC/prescription
opioids, recreational drugs (e.g. 222’s, Tylenol® #1 …)
Will comply with scheduled office visits and consultations
Will comply with pill/patch counts and random UDS when requested, and with limited quantity of
opioid dispensed per prescription
Adverse effects, medical complications and risks (including addiction) of opioids understood
Freedom of information permitted
Understanding and agreement that if there is no demonstrable improvement in functionality, the
physician reserves the right to wean patient off his/her opioid medications.
Understanding that if these conditions are broken, Dr. _______ may choose to cease writing opioid
prescriptions for me
Patient’s Signature
Physician’s Signature
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Date
Date
Universal Precautions in Pain Medicine
6. Appropriate trial of opioid therapy
› +/- adjuvants
› Replace short-acting opioid with long-acting opioid at equivalent dose
› Limit the number of pills/patches that a patient may have at one time
7. Reassessment of pain score and level of function
8. Regular assess the “Six A’s” of pain medicine
› Analgesia
› Activities
› Adverse effects
› Ambiguous drug taking behaviur
› Accurate medication record
› Affect
9. Periodically review Pain Diagnosis and co morbid conditions including addictive
disorders
10. DOCUMENT, DOCUMENT, DOCUMENT
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(Passik 2000)
Conducting an Opioid Trial Summary – Cluster 2
 Start low, go slow
› Titrate to “optimal dose”
› Remember safety issues when selecting opioids, including altered
pharmacokinetics (e.g. liver/kidney) &/or drug interactions
› Comprehensive review before nearing the “watchful dose”
 Document progress / opioid effectiveness
 Monitor adverse effects, medical complications, risks
› Opioid Manager*
› 6 A’s
 If risks outweigh benefits, then: switch, taper ± discontinue
*Courtesy of: “Toronto Rehabilitation Institute” Available at: http://nationalpaincentre.mcmaster.ca/opioid/.
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Opioid Manager
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Goals Guide Treatment Options
Psychological
Chronic pain
self-management programs
Physical / Rehabilitative
Goals
Medical
Pharmacological
Interventional
Adapted from Jovey RD, 2008
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Complementary and Alternative
Medicine
The Analgesic Toolbox
Nonopioid
Opioid
Acetaminophen, ASA, COXIB, NSAID
Buprenorphine transdermal system,
codeine, fentanyl transdermal system,
hydromorphone, morphine, oxycodone,
tramadol
Choice exists between IR (immediate release) and
CR (controlled release) formulations for many
agents
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Basis for Opioid Selection
Selection Criteria:
Current /past efficacy and side effect profile of short-acting opioid
Convenience and compliance potential
Cost (coverage by drug plan or ability to pay)
Patient preference
History of abuse/misuse/diversion (screen)
Concomitant health conditions necessitating adjustments in dosage
and/or dosing interval of some opioids (e.g., morphine or codeine in
renal failure)
Compromised oral route
Evidence of molecule efficacy for different pain characteristics
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Chou R et al, 2009; Gardiner-Nix; Wisconsin Medical Journal, 2004 ; Jovey RD et al, 2002
Opioids: Initial Dose and Titration
Opioid
Start
Dose
Codeine
15-30mg q4h
CR Codeine
50mg q12h
Tramadol +
Tylenol
1 tab q4-6h prn
(4/d)
CR Tramadol
Zytram XL
150mg
Tridural 100mg
Ralivia 100mg
IR Morphine
5-10mg q4h prn
up to 40mg /d
CR Morphine
10-30 mg q12h
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Convert to CR
when reaching
Minimum
time interval
for increase
100mg daily
1 week
15-30mg/day
(600mg/d)
2 days
50mg/d
(300mg q12h)
1 week
1-2 tab q4-6h prn
(8/d)
1 week
(400mg/d)
2 days
5 days
(300mg/d)
(300mg/d)
1 week
5-10mg/d
Min 2 d
5-10mg/d
3 tabs
20-30mg
Suggested dose
increase
(max)
Opioids: Initial Dose and Titration
Opioid
Start
Dose
Convert to CR
Minimum
when
time interval
reaching
for increase
IR Oxycodone
5-10mg q6h
prn up to
30mg/d
CR Oxycodone
10-20mg q12h
up to 30mg/d
1 week
5mg/day
Min 2 days
10mg/d
1 week
1-2 mg/d
CR
3mg q12h up
Hydromorphone to 9mg/d
Min 2 days
2-4mg/d
OROS
8mg OD
Hydromorphone
2 days
25-100% of
starting dose
IR
1-2mg q4-6h
Hydromorphone prn up to
8mg/d
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20mg daily
Suggested dose
increase
(max)
6mg
Maalis-Gagnon, Elafi Altlas 2010
PO Opioid Analgesic Equivalence table
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Morphine
10mg
Codeine
60mg
Oxycodone
7.5mg
(O:M= 2:1 acute
1.5:1 chronic)
Hydromorphone
2mg(H:M=5:1)
Meperidine
100mg
Methadone
Variable
Transdermal fentanyl
25ug/h = 60-134 mg
37ug/h = 135-179mg
50ug/h = 180-224mg
62ug/h = 225-269mg
75ug/h = 270-314mg
100ug/h = 360-404mg
When to Stop Opioid Therapy
When patient:
 Does not realize meaningful pain relief from therapy
 Has adverse reactions to opioids, such as depression or
respiratory depression
 Does not achieve reasonable therapeutic goals such as improved
physical or social functioning, even with effective pain relief
Ballantyne JC et al, 2003; Benyamin R et al, 2008; Chou R et al, 2009; Porreca F et al,2009; Slatkin NE, 2009
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Tapering Opioid Therapy
 Discuss with the patient and other responsible persons who may
be helpful. Patients with aberrant behaviour or addiction may
refuse to comply and leave treatment, seeking opioids elsewhere.
› Controlled withdrawal from opioids is not dangerous
› May experience discomfort, anxiety, restlessness, nausea,
sweating, etc.
 Reassure patient of alternative plan for pain control.
 Document discussions and provide a written treatment plan
 If the patient is taking a sedative or benzodiazepine, these should
be maintained
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Ballantyne JC et al, 2003; Chou R et al, 2009
Key Learning Points
 2010 National Opioid Use Guidelines (NOUG) serve to improve
the responsible use of opioids in Canada
 When considering the use of long-term opioid therapy, screening
for addiction risk must be a part of the assessment process
 Improvement in function as measured with the BPI is a key factor
supporting the continuation of CR opioids in CNCP
 Management of CNCP is multi-modal using non-opioid
medications, interventional techniques and self-management
strategies.
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Thank You
Questions?
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