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

• Melena on presentation

• Hb

• UGIE showed multiple gastric erosions

• Commenced on PPI

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