Download ppt - Prescription opioid dependence Dr Bridin Murnion Staff Specialist, Drug Health Sydney South West Area Health Service

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


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


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