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B R O O K C A L T O N , M D , M H S A S S I S T A N T P R O F E S S O R O F C L I N I C A L M E D I C I N E D I V I S I O N O F G E R I A T R I C S U N I V E R S I T Y O F C A L I F O R N I A , S A N F R A N C I S C O

Best Practices for Treating Pain and Prescribing Opioids

Disclosures

I have no financial disclosures to report

Pain is…

 Always a subjective experience  As an unpleasant sensation it becomes an

emotional experience

 A significant stress physically and emotionally  Common - an estimated 11% of Americans

experience daily pain

 Potentially very frustrating/challenging for medical

providers “ For internists, if you ask them w ho their m ost frustrating patients are, num ber one is the patient w ith chronic pain. You have to see patients often, there is no perfect answ er as to how to take care of them and alw ays in the back of your m ind is the potential for abuse.”

Michael Fingerhood, FACP

Johns Hopkins Bayview Medical Center

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Outline

 Assessment of Pain  Designing a Treatment Plan  Treatment of Nociceptive vs Neuropathic Pain  Opioid Dosing and Side Effects  Safe Opioid Prescribing Principles

Assessing Pain

 “OPQRS

T”

 O: Onset  P: Palliative or precipitating factors  Q: Quality of pain  R: Region or radiation of pain  S

: S everity

 T: Temporal nature

 Observational signs of distress  Quantify the pain

Focus on Function!

 Effect on function > quantitative rating

 ADLs, IADLs  Hobbies, socialization, exercise  Concentration, appetite, sleep  Mood, energy, relationships  Overall health

 “PEG” Scale: On a scale of 0-10, over the last week:

 What has your average pain been? (0-10)  How much has your pain interfered with your enjoym ent of

life? (0-10)

 How much has your pain interfered with your general

activity? (0-10)

Designing a Treatment Plan  Consider…

The Bio-Psycho-Social Model Co-morbid conditions Is the pain…

Acute or chronic?

Serious illness-related or not?

Nociceptive or neuropathic?

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The Bio-Psych0-Social Model

Bio Social Psycho

Environmental stressors Close personal relationships Distress Anger Fear Dz related mechanisms Biologic mechanisms of psychiatric illness

Gatchel, Am Psychol, 2004; Gatchel, Psychol Bull, 2007

The Bio-Psych0-Social Model

Bio Social Psycho

Gatchel, Am Psychol, 2004; Gatchel, Psychol Bull, 2007

Medications Surgery Interventional strategies Exercise, Sleep Acupuncture PT/ OT Palliative radiation (for CA)

Psychotherapy Mindfulness Relaxation techniques Social support Limiting other stressors

Pharmacologic

Neuroleptics
Antidepressants
Anesthetics (lidocaine patch)
Muscle relaxants
Topicals (capsacin)
Opioid medications
baclofen pumps, lidocaine pumps
Buprenorphine/naloxone

Physical

PT/OT consults
Joint injections
Spine injections
Surgery
Stretching/strengthening exercises
Recommendations for pacing daily activity
Heat or ice
Trigger point injections

CAM

Acupuncture (community and schools)
Mindfulness Based Stress Reduction and

meditation

Community yoga classes
Tai-chi classes
Massage schools
Supplements
Guided imagery
Breathing exercises

Cognitive/Behavioral

Pain Groups
Individual therapy
Brief cognitive and behavioral

interventions in clinic

Visualization, deep breathing, meditation
Sleep hygiene
Gardening, being outdoors, going to

church, spending time with friends and family, etc.

Co-Morbid Conditions

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Acute vs Chronic Pain Neuropathic Pain

 Damage to or pathology within the nervous system,

can be central or peripheral.

 Examples: Diabetes, postherpetic neuralgia, and stroke

 Establish diagnosis  targeted treatment

 AKA alleviate the compression, remove the offending agent

 First line medications: Gabapentin, TCAs, SNRIs,

Topical Lidocaine

Nociceptive Pain

 Caused by stimuli that threaten or provoke

tissue damage

 Examples: MSK conditions, inflammation,

visceral tumor

 Always consider non-pharm and adjuvants  For mild pain can also consider:

Acetaminophen: <3 gm/ day, <2 gm/ day

liver dz; avoid combos

NSAIDS: Good for inflammation and

bony-related pain

For more severe pain, can consider opioids

NSAID Risks GI bleeding – ulceration, platelet inhibition Renal failure –worse if volume depleted, hyperCa, kidney, heart, or liver disease CHF – 2 to 10-fold risk of hospitalization Cardiac –ibuprofen > naproxen risk Hypertension –3/ 2 point increase Feenstra J. Arch Intern Med 2002;162:265 Page J. Arch Intern Med 2000;160:777 CNT Collaboration. Lancet. 2013;382(9894):769

Opioid Selection

1. Choose Medication

2. Choose Route

3. Choose Dose

4. Choose Frequency

5. Patient/ Family Ed

6. Rx Bowel Regimen (Senna to start)

7. Monitor and Adjust

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A Few Important Details

Route Peak analgesic effect Dosing frequency Oral 60-90 min Q1-4h IV 6-15 min Q15-30min SQ 30 min Q15-30min Drug PO IV Morphine 30 mg 10 mg Hydrocodone 30 mg

Oxycodone

20 mg

Hydromorphone

7.5 mg 1.5 mg Fentanyl* See chart 0.1 mg (100 mcg)

“Easier to Stay Out of Pain, Than Get Out of Pain!”

PRN Dosing ATC Dosing Opioid Side Effects

Side effect

 Constipation  Nausea/ vomiting  Pruritus  Sedation  Respiratory depression

Time to Tolerance

 Never  7-10 days  7-10 days  36-72 hrs  Extremely rare when

pioids are dosed

appropriately

Opioid Prescribing Over Time

 Pre-1995: parsimonious with Rx opioids in US  1995-2009: Oxycontin, 5th VS, pt advocacy groups

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 Pre-1995: Parsimonious with opioids in US  1995-2009: Oxycontin, 5th VS, pt advocacy groups  2010-now:

 20% of patients with non-cancer pain symptoms or diagnoses

receive an opioid rx

 Opioid rx per capita increased 7% from 2007 to 2012; rates

increasing more for FP, IM

 >420K ER visits related to misuse/ abuse in 2011 (CHECK)  Great variability across states  Dose limits, Payor/ Pharm restrictions

Opioid Prescribing Over Time

Linked to methadone

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(CNCP)

Audience Poll

 In the community in which I practice, prescription

drug abuse is:

1.

Not a problem at all

2.

A small problem

3.

A moderate problem

4.

A big problem

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Audience Poll

 In terms of my clinical skills regarding opioid

prescribing I am…

1.

Not at all confident

2.

Slight confident

3.

Moderately confident

4.

Very confident

Safe Opioid Prescribing Strategies

 Before prescribing:

 Weigh the potential benefits/ risks  Assess for opioid misuse/ abuse  Set clear expectations!

 When prescribing:

 Consider key prescribing principles  Monitor for effect  Review reasons to discontinue Dowell D. JAMA 2016; 19;315(15):1624-45

Weigh the Potential Benefits/ Risks

 For CNCP, opioids should be considered when:

Other alternative therapies have not provided

sufficient pain relief and

Pain is adversely affecting a patient's

function and/ or quality of life and

The potential benefits of opioid therapy

utweigh potential harms

Potential Benefits

 Opioids can help provide short-term relief of CNCP

compared to placebo

 No studies of opioid therapy vs placebo, no opioid

therapy, or nonopioid therapy evaluated long-term

utcomes (>1 year) like pain, function, or quality of

life.

Furlan. CMAJ 2006; 23;174(11):1589-94.

Chapparo LE. Cochrane Database Syst Rev 2013; (8):CD004959

Chou. Annals of Int Med 2015; 162(4):276-86

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Potential Risks

 Constipation  Sedation1,2  Opioid overdose2  Death from overdose1,2  Aberrant use, addiction2  ED visits2  Depression2  Psychosocial problems2  Falls and fractures1,2  Less likely to return to work  Immune dysfunction2  Decreased GNRH, low

libido2

 Hyperalgesia2  Difficult interactions with

the care providers2

1Mixing with other sedating drugs

associated with increased risk

2Higher doses associated with increased

risk

I prescribe

pioids

to my patient Opioid Use Disorder (abuse, dependency) Diversion HARM

Assess Risk of Opioid Misuse/ Abuse Assessment of Opioid Misuse and Abuse

 Misuse: Using meds different than rx’ed  Abuse: Using meds to alter consciousness  Addiction: Neurobiological disease, 4C’s

Fishbain DA. Pain Med 2008; 9(4):444-59

Population Abuse/ addiction rate Misuse rate All pt CNCP 3.27% 11.5% Without past/ current SUD dx 0.19% 0.59%

Opioid Misuse/ Abuse Risk Assessment

 No standardized approach  Consider high risk factors

 Younger Age 1, 2, 3, 4, 5, 6  Male gender 2, 4  Caucasian/ White 1  Mental Health Disorders 1, 3, 4, 5, 6, 7  Large dose or supply 3, 4, 8  Drug Cravings 7   relation to pain severity 2

1. Dowling et al, 2006. 2. Ives et al, 2006. 3. Edlund et al, 2010. 4. White et al, 2009. 5.

Fleming et al, 2007. 6. Reid et al, 2002. 7. Wassan et al, 2007. 8. Dunn et al, 2010.

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 Single Item Screeners

NIDA: “How many times in the past year have you used an

illegal drug or used a prescription medication for non-medical reasons?”

NIAAA: “How many times in the past year have you had more

than 4/ 3 drinks in a day?”

Formal opioid misuse/ abuse risk assessment tools

may add to your assessment

Opioid Misuse/ Abuse Risk Assessment Opioid Risk Tool (ORT)

Webster LR. Pain Med 2005;6(6):432-442

Scoring patients:

low risk (0-3)
medium (4-7)
high (≥ 8)

High risk:

91% sensitivity

for ADRB

Positive LR 14

Assessment of Opioid Misuse/ Abuse

 Urine Drug Testing

 Test everyone at initial rx* then determine frequency based on

to risk assessment (or OME/ day)

 Order:  “Adherence” labs: opiate tests (GC/ MS), Oxycodone, Methadone  “Abuse” labs: Amphetamine, Benzodiazepines, Cocaine

 State Prescription Drug Monitoring Programs

 At initial rx and then periodically *  www.namsdl.org/ prescription-monitoring-programs.cfm Dowell D. JAMA 2016; 19;315(15):1624-45

Set Clear Expectations

 Key Talking Points

 Pain management includes pharm and non-pharm strategies

No good evidence long-term use of opioids improves pain/ function

 Unlikely to completely relieve pain

 Review clinic processes

 Regular visits (within 1-4 wks of starting therapy; at least q3

mo thereafter*)

 Routine evaluation of treatment goals and risks/ benefits  Additional procedures in your clinic

 Written opioid agreements

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Consider Key Prescribing Principles

 Low and slow  Start with short-acting agents  Mandatory to keep meds out of reach and/ or locked  Consider dosing limits for chronic non-malignant

pain. CDC suggests *:

 Careful reassessment of individual risks/ benefits > 50 OME  Typically avoid prescribing > 90 OME

 Consider Narcan Rx (esp > 50 OME *)  Avoid Methadone unless formally-trained

Risk of fatal overdose for patients with pain

Bohnert AS. JAMA 2011; 305(13):1315-1321

Daily Opioid Dose (OME) Chronic Pain HR Cancer Pain HR 1 to <20 mg 1 1 20 to <50 mg 1.9 1.7 50 to <100 mg 4.6 6 100+ 7.2 12  Codeine 60 mg q4h  Oxycodone/ APAP 10/ 325 tid  Hydrocodone/ APAP 10/ 500 5 times a day  Methadone 5 mg tid  Hydromorphone 4 mg tid  Fentanyl 12 mcg/ hr patch

50 OME is equivalent to…

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Monitor for Effect

 Monitor for: Benefit, toxicity, misuse, abuse  The Four A’s

Analgesia ADLs Adverse Events Aberrant Behaviors

 PEG Scale

Passik SD. Adv Ther. 2000;17(2):70-83.