Embed Size (px)
Citation preview
3/31/2017
1
RESPONSIBLE OPIATE PRESCRIBINGCRESTA JONES MD
DISCLOSURES
No conflicts to report
OBJECTIVES
Understand the scope and extent of the opiate abuse crisis in the United States
Demonstrate appropriate opiate prescribing for both acute and chronic pain
Demonstrate appropriate use of prescription data monitoring programs (PDMPs), including as they apply to Wisconsin state law
3/31/2017
2
THE OPIOID EPIDEMIC : US stats
Opioid overuse/abuse is an epidemicOpioids – leading cause of injury death Continuing to increase
Economic impact
$55 billion – health and social costs related to prescription opioid abuse per year
$20 billion – emergency department and inpatient care for opioid poisonings
hhs.gov/opioids
Just another day in the US….....
650,000 opioid prescriptions dispensed3900 people initiate nonmedical use
prescription opioids580 people initiate heroin use
hhs.gov/opioids
3/31/2017
3
cdc.gov
cdc.gov
cdc.gov
3/31/2017
4
THE OPIOID EPIDEMIC : WI
163,000 opiate use disorder Leading cause of injury deaths in Wisconsin
Motor vehicle accidents, suicide, firearms Prescription opioids – more overdose deaths
than heroin + cocaine
dhs.wisconsin.gov/publications/p01129.pdf
dhs.wisconsin.gov
Who uses opiates?
JAMA Psychiatry 2014
3/31/2017
5
They started with a prescription….
…..and they are women.
HOW DID THIS HAPPEN?
Increased prescriptions
3/31/2017
6
HOW DID THIS HAPPEN?
Increased prescriptions
1991: 76 million RX
HOW DID THIS HAPPEN?
Increased prescriptions
1991: 76 million RX 2014:
HOW DID THIS HAPPEN?
Increased prescriptions
1991: 76 million RX 2014, 240 million RX =
Every US adult - 5 mg hydrocodone every 6 hours for 45 days
hhs.gov/opioids
3/31/2017
7
Opiate use disorder – United States
5% of the world population…..
…...80% of the world’s opiates!
www.samhsa.gov, March 2015
HOW DID THIS HAPPEN?
Increased social acceptability for use
HOW DID THIS HAPPEN?
Increased acceptability for use History – acute and cancer pain only 1996 – extended release for non – cancer pain
Oxycontin - ER “non addictive” Based on 1 year addiction rates 1%Postoperative IV narcotics
3/31/2017
8
HOW DID THIS HAPPEN?
Aggressive marketing by pharmaceutical companies
SINCE 1999, OPIOID PRESCIPTIONS HAVE QUADRUPLED….
BUT REPORTED PAIN REMAINS UNCHANGED!
McNett, M – Wisconsin Medical Society
3/31/2017
9
OPIATE PRESCRIBING GUIDELINES
www.wisconsinmedicalsociety.org
www.cdc.gov
www.dsps.wi.gov
www.painphysicianjournal.com
OPIATE PRESCRIBING GUIDELINES
www.dsps.wi.gov
OPIATE PRESCRIBING GUIDELINES Address acute and chronic pain Chronic – longer than 3 months, past expected
tissue healing Not for active cancer treatment, end-of-life,
palliative care Not designed for pediatric pain
www.dsps.wi.gov
3/31/2017
10
1. EVALUATING PAIN
Pain is subjective Patient reported measures We must accept the patient’s report of pain….
Commensurate with causative factors? Factors adequately evaluated?Already addressed with non-opioid therapy?
2. TREATMENT OF ACUTE PAIN
Consider non-opioid first Opioid – START LOW AND GO SLOW!
Most less than 3 days (MAX: 5 days) CDC = 7 days
Consider med you can refill (APAP/codeine)Consider 2 small Rx, specific refill dates
TREATMENT OF ACUTE PAIN
Cochrane review – acute postoperative pain Number needed to treat (NNT)
50% maximum pain relief 4-6 hours, all types of surgery
Medication Number needed to treatIbuprofen 200mg/APAP 500 mg 1.6Naproxen 2.7Oxycodone 5mg/APAP 325 mg 2.7Oxycodone 15 mg 4.6
Moore et al., 2015
3/31/2017
11
TREATMENT OF ACUTE PAIN
Cochrane review – acute postoperative pain Number needed to treat (NNT)
50% maximum pain relief 4-6 hours, all types of surgery
Medication Number needed to treatIbuprofen 200mg/APAP 500 mg 1.6Naproxen 2.7Oxycodone 5mg/APAP 325 mg 2.7Oxycodone 15 mg 4.6
Moore et al., 2015
Hill MV, et al, 2017 642 outpatient surgical procedures Partial mastectomies, laparoscopic cholecystectomy,
laparoscopic/open inguinal hernia repair Opiate naive patients
Hill et al., 2017
3/31/2017
12
Hill et al., 2017
Hill et al., 2017
Hill et al., 2017
3/31/2017
13
71% of opioid pills prescribed were NOT taken!!
Hill et al., 2017
What to do with all those extra meds?
Fire safe storage DEA National Drug Take-Back Days – April 29,
2017 Sealable plastic bag with water + dirt, cat
litter, coffee grounds Away from children Out of home for open house, social events
etc.
fda.gov
3. IDENTIFY AND TREAT THE CAUSE OF PAIN
Address the underlying condition as the primary objective
Avoid opiates if unwilling to obtain definitive treatment for condition causing pain
Avoid if medical condition present is not reasonably expected to cause pain severe enough for opioids Non-anatomic pain, residual pain at old surgical sites
Refer patient if needed
3/31/2017
14
4. OPIOIDS ARE NOT ALWAYS THE FIRST CHOICE : ACUTE PAIN
Evidence for opioids is weak Try first
Acetaminophen/NSAIDs Lidocaine gel, biofreeze PT/OT Manipulation, massage Cognitive behavioral therapy
If severe enough for opioids, ALWAYS use in combination with other treatments
OPIOIDS ARE NOT ALWAYS THE FIRST CHOICE : ACUTE EXTENDED PAIN
Look for complications of acute pain: Surgical complication Nonunion of fracture Constipation as side effect of treatment
Complication ruled out, transition to non-opioid treatment
OPIOIDS ARE NOT ALWAYS THE FIRST CHOICE : ACUTE EXTENDED PAIN
Weaning opioids for acute extended pain (more than one week)
Decrease 10-25% per week Non-narcotics for acute pain treatment Start treatment for chronic pain – refer if indicated
3/31/2017
15
OPIOIDS ARE NOT ALWAYS THE FIRST CHOICE : CHRONIC PAIN
Past expected healing >3 months Studies– few benefits, substantial increase mortality
72% INCREASE IN CARDIOVASCULAR MORTALITY No quality evidence to support use > 6 months Already initiated
Close monitoring, PDMP Refer for additional treatment Contract – no early fills, no other fills, urine drug screen
Patient obligations : opiate prescribing
I will not increase my dose or use without permission. I will not obtain opioids from other prescribers, or allow them to
adjust my dose. I will use the medication exactly as directed. I will never share, sell or allow others access to my medication. I will not receive early refills. I will not abuse other drugs or alcohol during my treatment. I will bring my pills and medication bottles to each appointment.
Patient obligations: opiate prescribing
I will call the office at least 2 business days before I need a refill. If I miss my appointment, I may not get a refill. I will not call for opioids during evenings, holidays or weekends. I will only use one pharmacy for my opioid prescriptions. I will give a urine drug screen anytime I am asked. I will notify the office as soon as possible of any new medical
condition. I will not drive or use heavy machinery while taking opioids. I will follow up as requested. I agree to allow my provider to contact all my other caregivers as
needed.
3/31/2017
16
wisconsinmedicalsociety.org, Opiate CME programming
OPIOIDS ARE NOT ALWAYS THE FIRST CHOICE : UNWILLING PATIENT
Patient unwilling to accept other treatments Questionable justification for non – use “nothing else works” Intolerance to all other treatments
3/31/2017
17
5. UTILIZE A SINGLE PROVIDER
Dedicated provider – primary care, pain specialist Check PDMP before start Ask about existing pain contracts Plan - acute pain outside office hours
Call immediately next office day Have ED contact primary prescriber
No early refills Fire safe
6. EXACERBATIONS OF CHRONIC PAIN
Avoid chronic pain treatment in the emergency dept.
Contact chronic pain doctor Avoid IV/IM opiates – preferred agent
hydromorphone Refer back to primary provider
7. UTILIZING THE PDMP
Patient history of controlled substance prescriptions
Prescription Data Monitoring Program (PDMP) Currently available in 49 states Prior/ongoing opioid prescriptions Dangerous combinations increasing overdose
risk
3/31/2017
18
www.pdmp.wi.gov
WI ePDMP training materials, pdmp.wi.gov
3/31/2017
19
WI ePDMP training materials, pdmp.wi.gov
WI ePDMP training materials, pdmp.wi.gov
WI ePDMP training materials, pdmp.wi.gov
3/31/2017
20
WI ePDMP training materials, pdmp.wi.gov
WI CSB report, Oct 2016
Utilizing the PDMP
Red flags: Inconsistent use vs. prescribedMultiple/overlapping prescriptionsDramatic changes in doseFrequent early refillsConcurrent opiate and benzo prescribing
3/31/2017
21
Utilizing the PDMP: WI Act 266 (2015)
April 1, 2017 Before prescribing monitored drug Exceptions –
Hospice 3 days or less prescribed Drug administered directly Emergency situation prevents review of PDMP PDMP not operational, technical issue – must notify CSB
Act 266 – opiate CME prior to license renewal
8. PAIN MANAGEMENT PRIOR TO SURGERY AFFECTS RESULTS
Avoid opiates for chronic pain prior to surgery Preop opiate use:
Higher complication rates More postoperative narcotics Lower satisfaction rates after surgery
Chronic dosing will not address acute postsurgical pain Pain will be perceived as more, but should not last longer
9. BEWARE OF BENZODIAZEPINES
AVOID OPIATES + BENZOS 3x increase respiratory depression and annual mortality Neither demonstrates effectiveness more than 2 months Have patient chose, wean the other Concurrent use needs clearly documented rationale Similar effects with alcohol
3/31/2017
22
Treatment Increase annualized mortality
100 morphine mg equivalents (MME) 880%
100 MME + benzodiazepines 2640%
200 MME 2400%
200 MME + benzodiazepines 7200%
Avoid Opiates + Benzos
10. AVOID OXYCODONE
No more effective than other oral opioids More qualities that promote addiction to a greater
degree 2x euphoria of equivalent doses of oral morphine,
hydrocodone Harder to d/c treatment
Wightman et al, 2012
AVOID OXYCODONE
More abused 16 million >12 yrs age – lifetime nonmedical use of
oxycodone Illicit value $1/mg ($0.15/mg if acetaminophen added) Most frequently encountered pharmaceutical Rx by law
enforcement 2x as potent as morphine
Natl Survey on Drug Use and Health, 2014
3/31/2017
23
AVOID OXYCODONE
Meta-analysis RCTs examining abuse liability 9 studies Oxycodone
High subjectiveness attractiveness Increased reinforcing characteristics Increased abuse liability profile
Increased vs. oral morphine and oral hydrocodone
Wightman et al, 2012
AVOID OXYCODONE
”the use of oxycodone is discouraged” Should not be considered first-line Indications
Intolerance of other opioids Evaluated for increased risk of abuse
Zachy 2008, Schoedel 2011
11. OPTIMAL TREATMENT OF CHRONIC PAIN – FIRST EVALUATE
Targeted history/examination – signs of abuse Nature/intensity of pain – baseline, challenge credibility Current/past treatment, response Co-existing diseases Effect of pain on function Substance abuse history (self and family) Psychiatric disorders – bipolar, ADHD, depression Medical indication for opioids documented
3/31/2017
24
drugabuse.gov
12. OPTIMAL TREATMENT OF CHRONIC PAIN – TRIAL OF OPIOIDS
Initiation is a trial, NOT a commitment Objective goals – symptoms and function – prior to start
30% improvement for success Agree on goals before treatment Not met after trial – wean/discontinue opioids
13. OPTIMAL TREATMENT OF CHRONIC PAIN – RISK/BENEFIT
Consider and start and with every refill Reassess risks/benefits Wean/discontinue with increased risk Risk of imminent danger or diverted – stop and treat for
withdrawal
3/31/2017
25
OPTIMAL TREATMENT OF CHRONIC PAIN – RISK/BENEFIT
Exceptions to immediate cessation : Unstable angina Pregnancy
1st trimester - miscarriage3rd trimester –preterm labor
OPTIMAL TREATMENT OF CHRONIC PAIN – Ongoing risk assessment
Review of the Prescription Drug Monitoring Program
Periodic urine drug testing - at least yearly Periodic pill counts – at least yearly Violation review
www.healthpartners.com
3/31/2017
26
www.healthpartners.com
Urine Drug Screening
Medication Used Time detected in UrineCodeine 48 hoursHeroin (detected as morphine) 48 hoursHydromorphone 2-4 daysMethadone 3 daysMorphine 48-72 hoursOxycodone 2-4 days
Healthpartners.com
14. OPTIMAL TREATMENT OF CHRONIC PAIN – INFORMED CONSENT
Adverse effects of treatment Addiction Overdose Death
Treatment agreement Behaviors required of patient to keep them safe from
adverse effects
3/31/2017
27
15. INITIAL OPIOID TREATMENT -SHORT ACTING OPIOIDS
Start low, go slow Titrate dose with short acting – acute and chronic Consider long acting as majority of dose
If stabilized on short acting Chronic therapy
No indication for extended release treatment for acute pain
16. INITIAL OPIOID TREATMENT –LOWEST EFFECTIVE DOSE
Lowest effective dose, shortest duration Convert to morphine milligram equivalents (MME) for risk
assessment 50 MME– additional precautions 90 MME– no evidence for higher doses Must have appropriate documentation to go higher
Agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf
3/31/2017
28
Agencymeddirectors.wa.gov
Agencymeddirectors.wa.gov
17. AVOID METHADONE
Variable metabolism and sensitivity Days to steady state (accumulation) Drug interactions Stronger respiratory depressant Prolonged QTc effect Increased risk overdose and death Use only with extensive training/experience – MAT
program
3/31/2017
29
18. OPIOIDS AND ILLICIT DRUG USE
Increase abuse, overdose, death Strongly discouraged Clear and compelling justification
19. INITIAL OPIOID TITRATION
Re-evaluation 1-4 weeksChronic therapy: 3 months or less
20. HOME NALOXONE Indications for use;
History of overdose (should be contraindication to prescribe)
Opioid dose > 50 MME/day Clinical depression Other measured risk (behaviors, family history, PDMP,
UDS) 0.4 IM/intranasal, repeat if needed Can be prescribed to family members Available without prescription in Wisconsin
3/31/2017
30
HOME NALOXONE
Wisconsin Act 200 (2014) Standing naloxone order – trained WI Pharmacists Request by individual, family member, friend Screened by pharmacist, pharmacy tech
Chronic opioids > 3 months Medication assisted treatment 90 MME/day or higher Medical comorbidities
21. THE RESPONSIBILITIES OF PRESCRIBING
Must care for complications Assess for behaviors of opiate use disorder Assist with addiction treatment
Providing directly Referring to treatment center
Discharging a patient for opioid use disorder alone not acceptable
DAST-10 questionnaire (drugabuse.gov)
3/31/2017
31
22. DISCONTINUING TREATMENT Not effective:
Decrease 10% weekly Discontinue at 5-10 MME
Increased risk: Decrease 25% weekly Discontinue at 5-10 MME Clonidine 0.2 mg oral twice daily Tizanidine 2 mg oral three times daily
Imminent risk of overdose, addiction, or diversion Stop immediately, treat for withdrawal
cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf
Opioid Taper Tips
Who should taper? Requests dose reduction No meaningful improvement pain/function (at least
30%) > 50 MME with no benefit Opioids with benzodiazepines Signs of opiate use disorder Early warning signs for overdose : confusion, sedation,
slurred speech
3/31/2017
32
Opioid Taper Tips
Adjust the rate and duration of the taper based on reponse Don’t reverse the taper Pause or slow and treat withdrawal
When reach smallest available dose Extended interval between doses Stop when taken less than once daily
Address increased overdose risk if revert to original dose
Agencymeddirectors.wa.gov, 2017
cdc.gov, Mar 2016
3/31/2017
33
1. Non-opioid treatment preferred – chronic pain 2. Establish goals of treatment before starting 3. Review risks, benefits and responsibilities before
starting 4. Initiate treatment with immediate release medication 5. Prescribe lowest effective dose 6. Acute pain – 3 days typical, 7 days max
cdc.gov, Mar 2016
7. Evaluate risk of opiate-related harms –start/periodically
8. Re-evaluate benefits and harms – 1-4 weeks, at least every 3 mos.
9. Utilize PDMP at start, at least every 3 mos. 10. Urine drug screen at start, at least annually 11. Avoid opiates and benzodiazepines 12. Offer or arrange evidence based treatment if opiate
use disorder is diagnosed
cdc.gov, Mar 2016
CAN WE MAKE A DIFFERENCE?
FLORIDA 2010
Regulated pain clinics No dispensing of prescription opioids from offices Established PDMP
3/31/2017
34
MORE PROOF! NEW YORK
2010: PDMP before prescribing opiates 75% drop in patients with multiple prescribers
TENNESSEE 2012: PDMP before prescribing opiates 36% decline in patients with multiple prescribers
OREGON Established PDMP, Medicaid pre-auth high-dose methadone,
naloxone education and distribution, provider education 38% decrease prescription opioid overdose 58% decrease methadone overdose
THE OPIOID EPIDEMIC : WI
Heroin, Opiate, Prevention and Education (HOPE) Agenda John Nygren WI Assemblyman 17 pieces of legislation ID to pick up prescriptions (199), drug disposal
programs (198), pilot programs for treatment for underserved populations (195)
legis.wisconsin.gov
3/31/2017
35
Special considerations – our patients
Reproductive plan review Risk of neonatal abstinence Pre-pregnancy consultation
Chronic pain Maternal – Fetal Medicine Neonatology
Effective contraception
Conclusion The United States is currently experiencing an
unprecedented crisis in opiate use disorders Although there is no easy fix, we can contribute to the
solution Progress is made through responsible management of
acute and chronic pain Patient and provider education is key to optimal pain
management while also minimizing unnecessary opiate prescribing
References Ossiander EM. Using textual cause-of-death data to study drug poisoning. Am J
Epidemiol. 2014 Apr 1:179(7).
Hill MV, et al. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg. 2017 Apr; 265(4):709-714.
Manchikanti L et al., Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician 2017 Feb;20(2S): S3-S92.
Moore RA et al., Single dose oral analgesics for acute postoperative pain in adults. Cochrane Database of Systematic Reviews, Sept 2015.
CDC Guideline for Prescribing Opioids for Chronic Pain – United States 2016. Dowell D et al. JAMA 2016 Apr 19/315(15):1624-45.
Zachny J and Gutierrez S. Subjective, psychomotor, and physiological effects profile of hydrocodone/acetaminophen and oxycodone/acetaminophen combination products. Pain Medicine 2008; 9(4):433-443.
Schoedel K et al. Positive and negative subjective effects of extended-release oxymorphone versus controlled-release oxycodone in recreational opioid users. J Opioid Manag 2011; 7(3):179-192.
3/31/2017
36
References Manchikanti et al. Opioid epidemic in the United States. Pain Phys 2012; 15:ES9-ES38
Manchikanti et al. Therapeutic opioids: a 10 year perspective on the complexities and complications of the escalating use, abuse and nonmedical use of opioids. Pain Phys 2008; 11:S63-S88.
National Survey on Drug Use and Health. DEA diversion, March 2014.
Wightman R et al. Likeability and abuse liability of commonly prescribed opiates. J Med Toxicol 2012; 8:335-40.
