Transcript The Opioid Epidemic - Abington Jefferson Health

Opioid prescribing:
Finding the Right Balance in the Face of the
Opioid Epidemic.
Richard M. Sobel, M.D., D.F.A.P.A
Clinical Assistant Professor, Department of Psychiatry and Human Behavior
Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
Past President, Greater Philadelphia Pain Society
Relieving Pain in America:
A Blueprint for Transforming Prevention, Care,
Education, and Research.
Inst of Med of the National Academies. 2011
_______________________________________
 The 2011 IOM report on pain outlined the following principles:
PREPUBLICATION COPY –UNCORRECTED PROOFS
Copyright © National Academy of Sciences. All rights reserved.
 effective pain management is a “moral imperative”
 pain should be considered a disease with distinct pathology
 there is a need for interdisciplinary treatment approaches
 there is a serious problem of diversion and abuse of opioid drugs
Acute Pain
• Duration 3- 6 months
• Causes:
– Spontaneous insult or trauma
– Elective or planned procedures
• Treatment:
– RICE (rest-ice-compression-elevation)
– OTC analgesics
– Limit opioids to <3 day supply
– Opioid treatement not associated with patient satisfaction
Statistics of Chronic Pain
•
•
•
•
Point prevalence: 30% of US population1
More frequent in women, increases with age
Impact on sleep and mood
32% not able to work2
1. Volkow ND, McLellan RA, NEJM, 2016:374 (13)L 1253-1263
2. Portenoy RK et al. The Journal of Pain; 2004;5:317-28
Statistics of Opioid Prescribing
• 245 million prescriptions for opioids in US in 20141
• 37% of drug overdose deaths in 2013 were attributable to
pharmaceutical opioids2
• Substance abuse treatment for opioids other than heroin
increased sixfold betweem 1999 and 20091
1. Volkow ND, McLellan RA, NEJM, 2016:374 (13) 1253-1263
2. Volkow ND, McLellan RA, JAMA 2011: 305 (13) 1346-1347
•
Pain Assessment
Opioid Use Disorder (DSM-5)
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or
more) of the following, occurring within a 12-month period:
 Recurrent substance use resulting in a failure to fulfill major role obligations
 Recurrent substance use in situations in which it is physically hazardous
 Continued substance use despite having persistent or recurrent social or interpersonal problems
 Tolerance, as defined by either of the following:
• A need for markedly increased amounts of the substance to achieve intoxication or desired
effect
• Markedly diminished effect with continued use of the same amount of the substance (Note:
tolerance is not counted for those taking medications under medical supervision such as
analgesics, antidepressants, anti-anxiety medications or beta-blockers)
 Withdrawal, as manifested by either of the following:
• The characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria
set Withdrawal from the specific substances)
• The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
(Note: Withdrawal is not counted for those taking medications under medical supervision such
as analgesics, antidepressants, anti-anxiety medications or beta-blockers)
 The substance is often taken in larger amounts or over a longer period than was intended
 There is a persistent desire or unsuccessful efforts to cut down or control substance use
 A great deal of time is spent in activities necessary to obtain the substance, use the substance, or
recover from its effects
 Important social, occupational or recreational activities are given up or reduced because of substance
use
 The substance use is continued despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or exacerbated by the substance
 Craving or a strong desire to urge to use a specific substance
www.dsm5.org
http://library.fsmb.org/pdf/pain_policy_july2013.pdf
Clinical Guidelines
CDC Guidelines, as of March 2016
•
Nonpharmacologic therapy and nonopioid pharmacologic therapy
are preferred for chronic pain. Clinicians should consider opioid
therapy only if expected benefits for both pain and function are
anticipated to outweigh risks to the patient. If opioids are used, they
should be combined with nonpharmacologic therapy and nonopioid
pharmacologic therapy, as appropriate.
•
Before starting opioid therapy for chronic pain, clinicians should
establish treatment goals with all patients, including realistic goals
for pain and function, and should consider how opioid therapy will be
discontinued if benefits do not outweigh risks. Clinicians should
continue opioid therapy only if there is clinically meaningful
improvement in pain and function that outweighs risks to patient
safety
CDC Guidelines, as of March 2016 - cont.
• Before starting and periodically during opioid therapy, clinicians
should discuss with patients known risks and realistic benefits of
opioid therapy and patient and clinician responsibilities for managing
therapy
• When starting opioid therapy for chronic pain, clinicians should
prescribe immediate-release opioids instead of
extendedrelease/long-acting (ER/LA) opioids
• When opioids are started, clinicians should prescribe the lowest
effective dosage. Clinicians should use caution when prescribing
opioids at any dosage, should carefully reassess evidence of
individual benefits and risks when considering increasing dosage to
≥50 morphine milligram equivalents (MME)/day, and should avoid
increasing dosage to ≥90 MME/day or carefully justify a decision to
titrate dosage to ≥90 MME/day
CDC Guidelines, as of March 2016 - cont.
• Long-term opioid use often begins with treatment of acute
pain. When opioids are used for acute pain, clinicians
should prescribe the lowest effective dose of immediaterelease opioids and should prescribe no greater quantity
than needed for the expected duration of pain severe
enough to require opioids. Three days or less will often
be sufficient; more than seven days will rarely be
needed
• Clinicians should evaluate benefits and harms with patients
within 1 to 4 weeks of starting opioid therapy for chronic
pain or of dose escalation. Clinicians should evaluate
benefits and harms of continued therapy with patients every
3 months or more frequently. If benefits do not outweigh
harms of continued opioid therapy, clinicians should
optimize other therapies and work with patients to taper
opioids to lower dosages or to taper and discontinue opioids
CDC Guidelines, as of March 2016 - cont.
• Before starting and periodically during continuation of opioid therapy,
clinicians should evaluate risk factors for opioidrelated harms.
Clinicians should incorporate into the management plan strategies to
mitigate risk, including considering offering naloxone when factors
that increase risk for opioid overdose, such as history of overdose,
history of substance use disorder, higher opioid dosages (≥50
MME/day), or concurrent benzodiazepine use, are present.
• Clinicians should review the patient's history of controlled substance
prescriptions using state prescription drug monitoring program
(PDMP) data to determine whether the patient is receiving opioid
dosages or dangerous combinations that put him or her at high risk
for overdose. Clinicians should review PDMP data when starting
opioid therapy for chronic pain and periodically during opioid therapy
for chronic pain, ranging from every prescription to every 3 months
CDC Guidelines, as of March 2016 - cont.
• When prescribing opioids for chronic pain, clinicians
should use urine drug testing before starting opioid
therapy and consider urine drug testing at least annually
to assess for prescribed medications as well as other
controlled prescription drugs and illicit drugs.
• Clinicians should avoid prescribing opioid pain
medication and benzodiazepines concurrently whenever
possible
• Clinicians should offer or arrange evidence-based
treatment (usually medication-assisted treatment with
buprenorphine or methadone in combination with
behavioral therapies) for patients with opioid use
disorder.
Weaning guidelines
Medication
Wean Rate
Oxycodone and Morphine Extended
Release
3 days
Fentanyl Patch
9 days
Methadone
14 days
Opioid Equivalenceies
Drug
Morphine
Buprenorphine
Codeine
PO
30
0.4
200
IV
10
0.3
100
Fentanyl*
Hydrocodone
Hydromorphone
-30
7.5
0.1
-1.5
Oxycodone
Oxymorphone
20
10
10
1
Tramadol
120
100
Risks of chronic opioids - situations
requiring extra caution
• Coincident use of benzodiazopines increases the risk of
serious adverse events
• Methadone is associated with increased risk of harm due
to its unique pharmacokinetics
• Women of childbearing age: risk of harm to the newborn
during pregnancy and breastfeeding
• Patient at risk for obstructive sleep apnea (OSA) are at
increased risk for harm with the use of chronic opioid
therapy. Providers should consider the use of a
screening tool for OSA, and ensure patients with OSA
are compliant with treatment.
Methadone
• Can be more effective against neuropathic pain (muopioid agonist and NMDA receptor antagonist
• Risk of QTc prolongation
– EKG at baseline, 4 weeks, 6 weeks, and yearly
– Be aware of other meds patient is on
• Dosing - Pain relief 4-8 hrs duration, but in body 8-59 hrs,
so there can be risk of accumulation.
• Do not start above 10 mg q8h
• Morphine --> methadone, can use 1:10 ratio
• Methadone --> morphine, use 1:3 ratio
Morphine --> Methadone conversion1
24 hour total morphine
Conversation ratio oral
morphine to oral methadone
< 30 mg
2:1
31-99 mg
4:1
100-299 mg
8:1
300-499 mg
12:1
500-999 mg
15:1
> 1000 mg
20:1
1. Fisch and Cleeland. Managing Cancer Pain in Skeel ed. Handbook of Cancer Chemotherapy. 6th ed., Phil, Lippincott, 2003, p 663)
Pensylvania Guidelines on the Use of
Opioids to Treat Chronic Noncancer Pain
• Heffley Resolution of 2014
• Work group consisting of clinicans, representatives of
various state agencies, FOP, Recovery organizations,
District Attorneys, State Police, Coroners Association,
Pharmacists, Nurses, Pain advocacy, American Cancer
Society, Organized Medicine (including PPS)
• Developed first ever guidelines for Pennsylvania
Risk Assessment
Prior to initiating chronic opioid therapy
• Conduct history and physical examination
• Assessment of risk of substance use disorder, misuse, or
addiction - ORT, CAGE, SOAPP-R
SOAPP-R
Screener & Opioid Assessment for Patients with Pain
A score of 18 or greater indicates a patient is at greater risk for abusing opioids
Monitoring for Signs of Opioid Misuse in Patients
Receiving Long-Term Opioid Therapy (>90 day)
• Patient self-administered scales
– COMM - Current Opioid Misuse Measure (Patient)
• Based on past 30 days
• Most commonly used tool
– PDUQp - Prescription Drug Use Questionnaire
• Clinician administered scales
– PADT - Pain Assessment and Documentation Tool
– ABC - Addiction Behavior Checklist
COMM - Current Opioid Misuse Measure
Use of the Opioid Agreement
• Opioid Agreement as “contract”
– Patients feel not trusted
– Enforced feeling of power imbalance, punitive
– Harm to prescriber-patient relationship
– Legal risk to prescriber if not fully enforced
• Opioid Agreement as extension of informed consent
– Focus on patient education on safe use of opioids
– Focus on safety
– Focus on both prescriber and patient having responsibility
– Prescriber “may” vs Prescriber “will”
www.EmergingSolutionsinPain.com
www.EmergingSolutionsinPain.com
www.EmergingSolutionsinPain.com
Urine Drug Screens - Immunoassay
• Urine dip stick in office
• Higher threshold for false negatives
• Higher risk for false positives
– Amphetamines - ranitidine, bupropion
– Cocaine is exception (benzoylecgonine metabolite)
– Benzodiazopines
– Cannabinoids
• Opioid testing
– sensitive for morphine, heroin, codeine
– likelier to miss oxyodone, hydrocodone, hydromorphone,
oxymorphone, methadone, fentanyl, buprenorphone.
– Some of these are tested separately
• Will not identify clonazepam, lorazepam
Urine Drug Screens - Confirmatory Testing
• Gas Chromatography - Mass Spectroscopy
• Identifies specific chemicals and their metabolites
– Need to know metabolites to avoid concluding that patient
is taking multiple drugs (especially benzodiazopines)
• Expensive - some insurers will not cover if rationale not
provided
• Delay in getting results