Opioids: What You Should Know About Opioid Prescribing Denis G. - - PowerPoint PPT Presentation

Opioids: What You Should Know About Opioid Prescribing

Denis G. Patterson, DO Nevada State Medical Association October 19, 2016

Contact Information

Denis G. Patterson, DO Nevada Advanced Pain Specialists www.nvadvancedpain.com patterson@nvadvancedpain.com

• Prevalence of Pain

Unrelieved pain is recognized as a significant health problem in the United States 100 million Americans suffer from chronic pain Less than 40% of people with severe chronic non-cancer pain reported that their pain was under control

• Changes in Pain Treatment

Paradigms

1986 Portenoy and Foley published a seminal paper 1995 American Pain Society set guidelines for treating pain 1997 FDA allows direct-to-consumer marketing 1999 the VA Department launched a campaign known as “Pain is the Fifth Vital Sign” Joint Commission endorsed the VA campaign Subspecialty of Pain Management is born

Changes in Pain Treatment Paradigms Outcome

Statistics

• 20% of patients who present to a

physicians office for pain receive an opioid prescription

• In 2012, 259 million prescriptions for
• pioid pain medications were written in the

United States

The Dark Side

• Since 1999, 140,000 people have died

from an overdose related to opioid pain medication in the US

• More than 16,000 deaths occurred in

2013, four times the number of overdose deaths related to these drugs in 1999

• Unintentional Opiate Overdose Deaths Parallel

Opioid Sales in United States, 1997–2007

Overdose deaths – 2,901 in 1999 – 11,499 in 2007 Distribution by drug companies – 96 mg/person in 1997 – 698 mg/person in 2007

System Source: National Vital Statistics multiple cause of death data set and Drug Enforcement Agency ARCOS

Prescription Drug Misuse and Abuse: Hype or an American Epidemic?

Time for Change

• March of 2016, The CDC published it’s

Guideline for Prescribing Opioids for Chronic Pain

Target Audience

• Opioid prescribing rates have increased

more for family practice, general practice, and internal medicine compared to other specialties from 2007 - 2012

• Presciptions by PCP’s account for nearly

half of all dispensed opioid prescriptions

Guideline Goals

• Provide recommendations for primary care

providers who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care

• 1.

2. 3.

Recommendations

Grouped into 3 areas of consideration: Determining when to initiate or continue

• pioids for chronic pain

Opioid selection, dosage, duration, follow up and discontinuation Assessing risk and addressing harms of

• pioid use

• Twelve Step Opioid Protocol

Step 1

• Assessment of Pain (VAS 0 -10)

• Twelve Step Opioid Protocol

Step 2

• Clear documentation of rationale for
• pioid use (i.e. chronic pain)

• Twelve Step Opioid Protocol

Step 3

• Clear documentation of beneficial

clinical response to opioid use (i.e. decrease in pain)

• Twelve Step Opioid Protocol

Step 4

• Establish goals of opioid treatment

and review of goals (i.e. patient wants to increase function)

• Twelve Step Opioid Protocol

Step 5 Current and updated medication list

• Twelve Step Opioid Protocol

Step 6

• Documentation of substance

abuse (i.e. patient denies an history

• f prescription drug abuse issues)

• Twelve Step Opioid Protocol

Step 7 Physical examination of painful area

• Twelve Step Opioid Protocol

Step 8

• Documentation of risks and benefits

(risks explained to patient)

• Twelve Step Opioid Protocol

Step 9

• Appropriate referral for additional

evaluation and treatment

• Twelve Step Opioid Protocol

Step 10 Updated Board of Pharmacy review

• Twelve Step Opioid Protocol

Step 11

• Current and consistent UDS within the

last 30 days

• Twelve Step Opioid Protocol

Step 12

• Patient has signed and Opioid

Agreement with the last 6 months

• Strategies for High Dose

Opioids Patients

Educate patients on CDC recommendations Get behavioral health involved Determine what they are “actually” on Use Opioid Calculators to determine Morphine Equivalent dose Wean slowly to recommended levels Utilize Opioid Rotations

• Strategies for High Dose

Opioids Patients

Eliminate Benzodiazepines Access PMP reports Utilize urine drugs screens Consider using pill counts for problematic patients Get them involved in “active treatments”

Bottom Line

• As a provider, you have no legal, ethical,
• r moral obligation to accept or treat these

patients

• Be upfront with them and let them know

what your expectations and treatment plans are

Bottom Line

• If the patient is unwilling to accept your

plan and expectations, it is better to part ways from the start

Questions

Discussion

Nevada Advanced Pain Specialists Opioid Approach

• Nevada Advanced Pain

Specialists Opioid Approach

Medication Agreement Sent out before the appointment Sets the “rules” before there can problems

• Nevada Advanced Pain

Specialists Opioid Approach

Urine Drug screens Always done at first appointment Done randomly and when issues arise or changes occur

• Nevada Advanced Pain

Specialists Opioid Approach

Utilize the Nevada Task Force Inquiry

• Risk stratification done for every new

patient seen

Nevada Advanced Pain Specialists Opioid Approach

• Only prescribe medications you feel

comfortable with

• I personally avoid Methadone, Soma, the

D’s and Benzodiazepines

Nevada Advanced Pain Specialists Opioid Approach

• Try to manage pain with as little

medication as possible

• This includes the number of medications

and the number of pills

• Nevada Advanced Pain

Specialists Opioid Approach

Consistency Consistency Consistency