Best Practices for Treating Pain and Prescribing Opioids I have no - PDF document

3/22/2017 Disclosures Best Practices for Treating Pain and Prescribing Opioids I have no financial disclosures to report 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 Pain is…  Always a subjective experience “ For internists, if you ask them w ho their m ost frustrating patients are, num ber one is the patient  As an unpleasant sensation it becomes an w ith chronic pain. You have to see patients often, emotional experience there is no perfect answ er as to how to take care of  A significant stress physically and emotionally them and alw ays in the back of your m ind is the  Common - an estimated 11% of Americans potential for abuse.” experience daily pain  Potentially very frustrating/challenging for medical - Michael Fingerhood, FACP providers Johns Hopkins Bayview Medical Center 1

3/22/2017 Outline Assessing Pain  “ OPQRS T ”  Assessment of Pain  O: Onset  Designing a Treatment Plan  P: Palliative or precipitating factors  Q: Quality of pain  Treatment of Nociceptive vs Neuropathic Pain  R: Region or radiation of pain  Opioid Dosing and Side Effects  S : S everity  Safe Opioid Prescribing Principles  T: Temporal nature  Observational signs of distress  Quantify the pain Focus on Function! Designing a Treatment Plan  Effect on function > quantitative rating  Consider…  ADLs, IADLs  Hobbies, socialization, exercise  The Bio-Psycho-Social Model  Concentration, appetite, sleep  Co-morbid conditions  Mood, energy, relationships  Overall health  Is the pain…  “PEG” Scale: On a scale of 0-10, over the last week:  Acute or chronic?  What has your average pain been? (0-10) • Serious illness-related or not?  How much has your pain interfered with your enjoym ent of life? (0-10)  Nociceptive or neuropathic?  How much has your pain interfered with your general activity ? (0-10) 2

3/22/2017 The Bio-Psych0-Social Model The Bio-Psych0-Social Model Medications Surgery Interventional strategies Exercise, Sleep Dz related mechanisms Acupuncture Bio Bio Biologic mechanisms of PT/ OT psychiatric illness Palliative radiation (for CA) Psychotherapy Mindfulness Environmental Relaxation Distress Psycho Social Psycho Social Social support stressors techniques Anger Limiting other Close personal Fear stressors relationships Gatchel, Am Psychol, 2004; Gatchel, Psychol Bull, 2007 Gatchel, Am Psychol, 2004; Gatchel, Psychol Bull, 2007 Pharmacologic Physical •PT/OT consults •Neuroleptics Co-Morbid Conditions •Antidepressants •Joint injections •Anesthetics (lidocaine patch) •Spine injections •Muscle relaxants •Surgery •Topicals (capsacin) •Stretching/strengthening exercises •Opioid medications •Recommendations for pacing daily activity •baclofen pumps, lidocaine pumps •Heat or ice •Buprenorphine/naloxone •Trigger point injections CAM Cognitive/Behavioral •Pain Groups •Acupuncture (community and schools) •Individual therapy •Mindfulness Based Stress Reduction and •Brief cognitive and behavioral meditation interventions in clinic •Community yoga classes •Visualization, deep breathing, meditation •Tai-chi classes •Sleep hygiene •Massage schools •Gardening, being outdoors, going to •Supplements church, spending time with friends and •Guided imagery family, etc. •Breathing exercises 3

3/22/2017 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 Opioid Selection Nociceptive Pain  Caused by stimuli that threaten or provoke Choose Medication tissue damage 1. NSAID Risks  Examples: MSK conditions, inflammation, Choose Route 2. GI bleeding – ulceration, visceral tumor platelet inhibition Choose Dose 3.  Always consider non-pharm and adjuvants Renal failure –worse if volume depleted, Choose Frequency 4.  For mild pain can also consider: hyperCa, kidney, heart, or liver disease • Acetaminophen: <3 gm/ day, <2 gm/ day Patient/ Family Ed 5. CHF – 2 to 10-fold risk of liver dz; avoid combos hospitalization Rx Bowel Regimen (Senna to start) 6. Cardiac –ibuprofen > • NSAIDS: Good for inflammation and naproxen risk Monitor and Adjust 7. bony-related pain Hypertension –3/ 2 point increase • For more severe pain, can consider opioids Feenstra J. Arch Intern Med 2002;162:265 Page J. Arch Intern Med 2000;160:777 CNT Collaboration. Lancet. 2013;382(9894):769 4

3/22/2017 “Easier to Stay Out of Pain, Than Get Out of Pain!” A Few Important Details PRN Dosing ATC Dosing 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) Route Peak analgesic Dosing effect frequency Oral 60-90 min Q1-4h IV 6-15 min Q15-30min SQ 30 min Q15-30min Opioid Side Effects Opioid Prescribing Over Time Side effect Time to Tolerance  Pre-1995: parsimonious with Rx opioids in US  Constipation  Never  1995-2009: Oxycontin, 5 th VS, pt advocacy groups  7-10 days  Nausea/ vomiting  Pruritus  7-10 days  Sedation  36-72 hrs  Respiratory depression  Extremely rare when opioids are dosed appropriately 5

3/22/2017 Opioid Prescribing Over Time  Pre-1995: Parsimonious with opioids in US  1995-2009: Oxycontin, 5 th 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 Linked to methadone 6

3/22/2017 (CNCP) Audience Poll  In the community in which I practice, prescription drug abuse is: Not a problem at all 1. A small problem 2. A moderate problem 3. A big problem 4. 7

3/22/2017 Audience Poll Safe Opioid Prescribing Strategies  In terms of my clinical skills regarding opioid  Before prescribing: prescribing I am…  Weigh the potential benefits/ risks Not at all confident  Assess for opioid misuse/ abuse 1.  Set clear expectations! Slight confident 2.  When prescribing:  Consider key prescribing principles Moderately confident 3.  Monitor for effect  Review reasons to discontinue Very confident 4. Dowell D. JAMA 2016; 19;315(15):1624-45 Weigh the Potential Benefits/ Risks Potential Benefits  Opioids can help provide short-term relief of CNCP  For CNCP, opioids should be considered when: compared to placebo  Other alternative therapies have not provided  No studies of opioid therapy vs placebo, no opioid sufficient pain relief and therapy, or nonopioid therapy evaluated long-term outcomes (>1 year) like pain, function, or quality of  Pain is adversely affecting a patient's life. function and/ or quality of life and  The potential benefits of opioid therapy outweigh potential harms 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 8

3/22/2017 Assess Risk of Opioid Misuse/ Abuse Potential Risks  Constipation  Falls and fractures 1,2  Less likely to return to work  Sedation 1,2 Opioid Use  Immune dysfunction 2  Opioid overdose 2 Disorder (abuse,  Decreased GNRH, low dependency )  Death from overdose 1,2 I libido 2  Aberrant use, addiction 2  Hyperalgesia 2 prescribe  Difficult interactions with opioids Diversion  ED visits 2 the care providers 2 to my  Depression 2 patient  Psychosocial problems 2 1 Mixing with other sedating drugs associated with increased risk 2 Higher doses associated with increased risk HARM Assessment of Opioid Misuse and Abuse Opioid Misuse/ Abuse Risk Assessment  No standardized approach  Misuse : Using meds different than rx’ed  Consider high risk factors  Abuse : Using meds to alter consciousness  Younger Age 1, 2, 3, 4, 5, 6  Addiction : Neurobiological disease, 4C’s  Male gender 2, 4  Caucasian/ White 1 Population Abuse/ addiction rate Misuse rate  Mental Health Disorders 1, 3, 4, 5, 6, 7 All pt CNCP 3.27% 11.5%  Large dose or supply 3, 4, 8 Without past/ current 0.19% 0.59%  Drug Cravings 7 SUD dx   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. Fishbain DA. Pain Med 2008; 9(4):444-59 Fleming et al, 2007. 6. Reid et al, 2002. 7. Wassan et al, 2007. 8. Dunn et al, 2010. 9