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Prescription opioid dependence
Dr Bridin Murnion Staff Specialist, Drug Health
Sydney South West Area Health Service
CASE 1
• Mr P
• 44yr old married businessman
• Pain in knee subsequent to sporting injury
• Prior operative intervention 2 years prior but pain persisted
• Ex smoker, alcohol use minimal, occasional stimulant use in past
• Commenced on Panadeine forte
• Subsequent transfer to oxycontin
• Pain Clinic review
• Referred to Drug Health by GP
• Gait-normal
• Knee-unremarkable
• Affect-NAD
• Beliefs-required further operative intervention
• Expectations-to be pain free
• Stated goal to cease opioids
• Discussed options • Gradual weaning• Buprenorphine assisted withdrawal
• Discussed potential difficulties of both approaches
• Gradual weaning preferred option
Treatment agreement
• Single prescriber
• Single dosing point
• Interval dispensing
• Dr Shopping agreements
• No replacement for lost or stolen scripts
• Occasional UDS
Story Evolution
• Use greater than stated
• Dose titrated upwards
• travelling overseas
• Alleged theft
• Decided to trial buprenorphine assisted withdrawal
Case 2
• Mr C
• 27 yr old
• Married, working full time
• MVA 7yrs prior– Low back pain and pain right leg
• Examination-scar on right knee, allodynia R leg/ foot, weakness dorsi-flexion
• Investigations-unremarkable
• Presented for opioid withdrawal management
• Escalating panadeine forte use, commenced nurofen plus use
• Few episodes of heroin use
Progress
• Completed buprenorphine assisted withdrawal
• Continued on buprenorphine patch
• Antidepressant changed from escitalopram to duoloxetine
• Referred pain clinic for multi-disciplinary assessment
CASE 3
• Ms C
• 36yr old woman
• Presented to pain clinic for assessment of pelvic pain
• Relocated from interstate 4 months prior (leaving 6 children)
• On oxycontin 60mg bd
• Denied substance abuse history, current smoker
• Social situation volatile
• Mood-anxious
• Referred to Drug Health for management of opioids
• Options discussed, including OST• Pt did not want OST, wanted to continue
Oxycontin• Agreed to this with significant reservations
– Daily pick-ups– UDS– Dr Shopping– Transfer to OST would be only option
available if current Rx plan not working
• Maintained on this Rx for 6/12
• Wanted to go back to SA
• Legal situation explained
• Lost to treatment for 1 year
• Presented to ED with nausea
• Paracetamol hepatotoxicity and anaemia
• Using OTC panadeine/nurofen plus to excess
• NAC/UGIE/PPI
• Agreed to OST
Principles
• Dependence difficult diagnosis in context of chronic pain and chronic opioid use
• Opioid ADRBs can be difficult to recognise– May need longitudinal observation
• Need to stabilise opioid use and then re-assess pain
• Ensure compliance with legal requirements around prescribing-PSB and PBS
How common is it?
• 2.5% Australians report recent use of pain-killers for non-medical purposes
• 4.45% report lifetime use
• 15.4% had opportunity to use pain-killers for non-medical purposes
• Jurisdictional variations
Aberrant drug related behaviours (ADRB)
Red Flag• Selling prescription drugs• Prescription forgery• Obtaining prescription drugs
from non-medical sources• Injecting oral formulations• Concurrent abuse of related
illicit drugs• Multiple unsanctioned dose
escalations• Evidence of intoxication (e.g.
clinical presentation, driving, forensic)
• Recurrent prescription loss• Acquiring from multiple Drs
Yellow Flag• Aggressive complaining about
need for higher dose
• Drug hoarding during periods of reduced symptoms
• Unsanctioned dose escalations 1-2 times
• Unapproved use of drug to treat other symptoms
• Requesting specific drugs
• Reporting psychic effects not intended by clinician
Portenoy RK. Opioid therapy for chronic nonmalignant pain: clinician's perspective. J Law Med Ethics. 1996;24(4):296-309
What proportion of Chronic Opioid Therapy (COT) patients have ADRBs?
• Varies from 3-30%, depending upon patient sampling, definition of ADRB and level of monitoring– Most controlled trials: 10-15%
• Poor identification of ADRBs unless routinely screened / assessed
Identifying high risk patients• Patient selection-Identify risk factors for developing problems
– Pain diagnosis– History & concomitant conditions
• Psychosocial & mental health issues• History of substance abuse• Prior problems with opioids: adverse events / aberrant
behaviours• History of childhood/sexual abuse in women
– Use of non-opioid treatment approaches to chronic pain• Poor uptake / response to other approaches• Patient expectations
• Screening tools-predictive ( SOAPP, DIRE and ORT) and diagnostic (PMQ, PDUQ and COMM) ( Passik 2008)
Passik SD et al Addiction-Related Assessment Tools and Pain Management: Instruments for Screening, Treatment Planning, and Monitoring Compliance Pain Med 2008 S145-S166
Opioids in Chronic pain: balancing risks and benefits
• COT should only be continued if benefits > harms• Consider ‘trial of opioids’, with clear criteria of what
constitutes successful / unsuccessful treatment • Stop opioid if treatment ineffective or transfer to
more supervised dosing if significant ADRBs• Review indication for (and consider cessation of)
COT every 3-6 months • Clear documentation in medical records
Chou R et al. Clinical Guidelines For the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain. 2009;10(2):113-230.
Structuring Chronic Opioid Therapy (COT)
• COT one aspect of comprehensive Pain Plan
• Identifying COT goals & monitoring outcomes
• Working within teams
• Safer prescribing and dispensing
• Patient agreements
Chou R et al. Clinical Guidelines For the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain. 2009;10(2):113-230.
Assessing Efficacy and Safety of COT- 5 A’s
• Analgesia
• Activities (functional outcomes)
• Affect
• Adverse events
• Aberrant drug behavioursPortenoy RK Opioid therapy for chronic nonmalignant pain: a review of the critical issues. J Pain Symptom Manage. 1996;11(4):203-17
Structuring COT: working within teams
– Chronic pain & Pall care require multidisciplinary approach
– Clarity re: role of different service providers– Who is prescribing/dispensing which medications?– Addressing co-morbidities: importance of non-
medical service providers – Regular communication / case conferencing
Structuring COT: safer prescribing & dispensing
• One doctor prescribing and one pharmacy dispensing opioid– ‘Doctor Shopping Release Of Information form’ for high-risk patients
• Use of Endorsed scripts, fax & mailing • Long-acting > short acting opioids• “Abuse deterrent” formulations may have role• Structured > prn regimens• Interval dispensing
– Limit ‘duration’ of dispensed medications to reduce dose escalation & ‘running short’
– Do not refill prescriptions early if patient runs out
• Have ‘severe pain plan’
Structuring COT: Patient agreements
• Signed agreement with patient addressing– medications from other sources– unauthorised dose escalations & ‘running short’ – use of other drugs (licit & illicit)– diversion of medications to others – attendance at appointments (medical & non-
medical) – communication between health providers– conditions of COT cessation
Chou R et al. Clinical Guidelines For the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain. 2009;10(2):113-230.
On REVIEW• Assess efficacy
• Examine for signs of intoxication & injection
• Corroborative history: family & health care providers
• Prescription monitoring schemes
• Urinary Drug Screens with acknowledgement of limitations
SUMMARY• Identify high risk patients• Identify ADRBs/dependence• Stabilise opioid use
– OST– Non OST opioid with interval dispensing – clinical, laboratory and prescription monitoring
• Re-assess pain• Consider non-opioid analgesics• Consider non-pharmacological interventions• Develop plan for opioids and treatment agreement• Comply with legal requirements• Monitor 5As
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