[PPT] - Best Practices for Treating Pain and Prescribing Opioids I have no PowerPoint Presentation

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8/9/2018 1

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 TY 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 who their most frustrating patients are, number one is the patient with chronic pain. You have to see patients often, there is no perfect answer as to how to take care of them and always in the back of your mind is the potential for abuse.”

Michael Fingerhood, FACP

Johns Hopkins Bayview Medical Center

I estimate the percentage of patients in my practice with some form of pain is:

A. 0%
B. 1-10%
C. 25%
D. 50%
E. It feels like everyone!

0% 1-10% 25% 50% It feels like everyone!

0% 9% 14% 38% 38%

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8/9/2018 2

For me, the hardest thing about managing patients with pain is:

A. Patient complexity
B. Managing opioids safely
C. Concerns re: federal regulation and

liability

D. Lack of community resources
E. Lack of education and training on

pain management

P a t i e n t c

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c e r n s r e : f e d e r a l r e g u . . . L a c k

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m u n i t y r e s

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e d u c a t i

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39% 19% 8% 18% 17%

Managing pain is really hard

 Highly prevalent  The ultimate bio-psycho-social problem  Regulatory complexity  Therapeutic options inadequate  Some interventions may exacerbate chronic pain  Patient experience of pain is real

 But so are addiction, disengagement, diversion

 PCPs under-trained & under-resourced

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

 “OPQRST”

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

 Observational signs of distress  Quantify the pain

SLIDE 3

8/9/2018 3 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 enjoyment 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?

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

Psychotherapy Mindfulness Relaxation techniques Social support Limiting other stressors

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8/9/2018 4

Co-Morbid Conditions

PHQ-9 GAD

Single item screeners

Acute vs. Chronic Pain

Days to weeks Months to Years (>3 mos or past time of normal healing)

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 

threaten/provoke tissue damage

 Examples: MSK conditions,

inflammation, visceral tumor

 Always consider non-pharm and

adjuvants

 Acetaminophen: <3 gm/day, <2

gm/day liver dz; avoid combos

 NSAIDS: Good for inflammation and

bony-related pain

For more severe pain, could consider
pioids

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

SLIDE 5

8/9/2018 5 Opioid Selection

1. Choose Route

2. Choose Medication

3. Choose Dose

4. Choose Frequency

5. Patient/Family Ed

6. Rx Bowel Regimen (Senna to start)

7. Monitor and Adjust

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

SLIDE 6

8/9/2018 6 Opioid Prescribing Over Time

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

groups

 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  Great variability across states  Dose limits, Payor/Pharm restrictions

Opioid Prescribing Over Time

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8/9/2018 7

Linked to methadone

(CNCP)

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8/9/2018 8

In the community in which I practice, abuse of

pioid pain medications is:

A.

Not a problem at all

B.

A small problem

C.

A moderate problem

D.

A big problem

N

t

a p r

b

l e m a t a l l A s m a l l p r

b

l e m A m

d

e r a t e p r

b

l e m A b i g p r

b

l e m

2% 49% 36% 13%

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

 There is a role for opioids in management of

acute pain and pain during terminal illness.

 For CNCP, opioids could 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 outweigh

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 non-opioid 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

SLIDE 9

8/9/2018 9 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

Assessment of Opioid Misuse and Abuse

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

(compulsion, craving, consequences, control)

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

 History of substance use disorder 2, 4  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.

 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?”

Formal opioid misuse/abuse risk assessment tools

may add to your assessment

Opioid Misuse/Abuse Risk Assessment

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8/9/2018 10 Opioid Risk Tool (ORT)

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

Scoring patients:

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

Assessment of Opioid Misuse/Abuse

 Urine Drug Testing

 Test everyone at initial rx and then at least annually*.

Determine frequency based on risk assessment (or OME/day)

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

 State Prescription Drug Monitoring Programs

 www.namsdl.org/prescription-monitoring-programs.cfm Dowell D. JAMA 2016; 19;315(15):1624-45

Mandatory Cures Checks as of 10/2/18

 When must I check CURES?

 First rx of controlled substance

(unless exempt)

 Within 24h period, or the

previous business day, before prescribing, ordering, administering, or furnishing a controlled substance

 At least q4 mo prescribing same

med

http://www.mbc.ca.gov/License es/Prescribing/CURES/

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  Any additional procedures in your clinic

 Written opioid agreements

SLIDE 11

8/9/2018 11 Consider Key Prescribing Principles

 Low and slow  Start with short-acting agents  Mandatory to keep meds out of reach and/or locked  Avoid Methadone unless formally-trained  Consider dosing limits for CNCP. CDC suggests *:

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

 Consider Narcan Rx (esp > 50 OME *)

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…

SLIDE 12

8/9/2018 12 Monitor for Effect

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

Analgesia ADLs Adverse Effects Aberrant Behaviors

 PEG Scale

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

Review Reasons to Discontinue

 <30% improvement in pain and function  Pain unimproved on upward titration  Unmanageable side effects  Recurrent non-adherence to treatment plan or

agreement

 Non-resolution of risky drug behaviors with tight

controls ALWAYS DISCONTINUE IF RISK > BENEFIT

Tapering/Weaning Opioids

 Risk of w/d based on duration of use, frequency of

use, half-lives of meds

 Common withdrawl sx: abd pain, diarrhea, N/V,

lacrimation, diaphoresis, piloerection, anxiety, tachycardia, mild hypertension

 Physical dependence does NOT mean

addiction/opioid use disorder

What to Say

 Center discussion on health concerns  SAY:

 “I believe it is unsafe for you to continue because ____” (cite

specific examples)

 ”I believe the opioids may be increasing your pain” (note

increasing doses and increasing pain)

 ”We are not achieving the goals we targeted” (cite goals)

 AVOID:

 “Guidelines won’t let me prescribe”  ”I’m not allowed to prescribe these doses”

SLIDE 13

8/9/2018 13 What to Do

 W/d onset 2-5 half-lives  Reassurance (hurtful, not harmful)  Hydration  Symptomatic Treatment  Speed of taper depends on level of concern (days to

weeks vs months to even years)

 Reduce to lowest available dose first then increase time

between doses

 For long taper, 10% per week (go slower after at 20-30%

f total dose)

 Ramp up other treatments

Want more? www.scopeofpain.com