Patient-Centered Prescription Opioid Tapering Beth Darnall, PhD - - PowerPoint PPT Presentation

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Patient-Centered Prescription Opioid Tapering Beth Darnall, PhD - - PowerPoint PPT Presentation

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Patient-Centered Prescription Opioid Tapering Beth Darnall, PhD Clinical Professor, Stanford University School of Medicine Twitter: @BethDarnall November 1, 2018 #PCORI2018 Beth Darnall, PhD Disclosures Relationship Companies Federal

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Patient-Centered Prescription Opioid Tapering

Beth Darnall, PhD

Clinical Professor, Stanford University School of Medicine Twitter: @BethDarnall November 1, 2018

#PCORI2018

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2 • November 21, 2018

Beth Darnall, PhD

Disclosures

Relationship Companies Federal Grants & Contracts

  • PCORI (PI) Patient-Centered Opioid and Pain Reduction

Comparative Effectiveness)

  • NIH / NCCIH: R01 (Co-PI) Mechanisms & Efficacy of Pain

Catastrophizing Treatment for Chronic Pain

  • NIH / NICHHD: (Stanford Site PI)

Advisory Board AppliedVR, Clinical Pain Advisor, Axial Healthcare Ownership Interests Optimized Psychology Consulting

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BETH DARNALL

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4 • November 21, 2018

Objectives

At the conclusion of this activity, the participant should be able to:

  • Describe the current landscape regarding opioid de-prescribing

for chronic pain

  • Describe patient-centered approaches to prescription opioid use,
  • pioid tapering, and pain management
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2011 IOM Report: Relieving Pain in America

  • 100 million Americans have ongoing pain
  • $635 billion annually
  • Erodes quality of life, confers suffering
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5.4 % of the U.S. population

17.8 Million

Mojtabai R 2017

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Prescription Opioid Risks

  • Opioid sales associate with opioid-related mortality
  • Iatrogenic risks Darnall et al, Arch Int Med 2012 (JAMA Int Med)

Darnall et al, Pain Med 2012

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PATIENT-CENTEREDNESS

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IASP Definition of Pain

Pain Definition: A noxious sensory and emotional experience

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Cognitive Behavioral Therapy for Chronic Pain

Topics and Skills

  • Pain and the brain
  • Mood and pain
  • Sleep and pain
  • Pleasant activities
  • Goal setting
  • Problem solving
  • Movement
  • Social connection
  • Diaphragmatic Breathing
  • Relaxation Response
  • Cognitive Restructuring
  • Mindfulness
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Stopping Opioids

Patients’ number one concern/fear?

Not Interested!

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Tapering the wrong way

Aggressive Taper Forced Taper

  • Withdrawal Symptoms
  • Discomfort
  • Distress
  • Attrition
  • Failed tapers
  • False belief that outpatient tapering

is impossible

  • Remaining on opioids indefinitely
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Community-Based Solutions are Needed

  • Low-cost
  • Low-risk
  • Scalable
  • Effectively reduces health risks
  • Provides education and support
  • Structured
  • Addresses anxiety of patients and prescribers alike
  • Promotes trust and a good doctor-patient bond
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Opioid Reduction vs. Opioid Cessiation

VS.

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Study Variables

  • Demographics (Gender, Age)
  • Pain Treatment History (Pain Dx, Duration of Opioid Use)
  • Opioid Dose (MEDD)
  • Average Pain Intensity (0-10)
  • Pain Catastrophizing Scale
  • PROMIS Measures
  • Marijuana use (Y/N)

16 Weeks

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Sample Characteristics (N=51)

  • 55% female
  • 52 years of age (range = 25 – 72)
  • 6 years on opioids (range = 1 – 38)
  • Moderate pain intensity
  • Marijuana: 37% (18)
  • Opioid MEDD = 288 (60, 1005)

Darnall BD, Ziadni MS, Mackey IG, Kao MC, Flood P (FEB 2018; JAMA Int Med)

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Variable Baseline Median (IQR) 16 weeks Median (IQR) P-val Opioid Dose (MEDD) 288 (153, 587) 150 (54, 248) 0.002 Pain Intensity (NRS) 5.0 (3.0, 7.0) 4.5 (3.0, 7.0) 0.29 PCS (catastrophizing) 22 (10, 30) 15 (7, 23) 0.04 Fatigue 61 (54, 65) 59 (51, 65) 0.64 Anxiety 60 (53, 64) 54 (46, 62) 0.06 Depression 56 (49, 64) 55 (48, 61) 0.31 Sleep Disturbance 59 (54, 70) 56 (50, 64) 0.13 Pain Interference 63 (58, 67) 63 (57, 67) 0.44 Pain Behavior 60 (57, 63) 59 (56, 64) 0.47 Physical Function 39 (34, 41) 39 (34, 43) 0.78

Kruskal-Wallis rank sum test

Median (IQR)

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Comparative Effectiveness of Pain Cognitive Behavioral Therapy and Chronic Pain Self- Management Within the Context of Opioid Reduction

Darnall BD (Principal Investigator)

  • $8.8M
  • Funded by PCORI
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1365 patients taking long term opioids for chronic pain

  • Stanford Pain Management Center (CA)
  • Stanford Primary Care (CA)
  • Intermountain Health (Salt Lake City)
  • Veterans Affairs (Phoenix)
  • Dr. Stieg (Frisco, CO)
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Chronic Pain Self-Management Program

  • Two certified trained

peer leaders

Patient invited to study Optimize expectations for a successful taper Enrollment, Baseline Survey Treatment Group Allocation Co-Create Patient-Centered Opioid Taper Follow-Ups every 3 weeks

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Patient Stories

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Colleagues and Collaborators

Sean Mackey, MD, PhD Jesmin Ram Lanja Sinjary Ming-Chih Kao, PhD, MD Ian Mackey Aram Mardian, MD Ming-Chih Kao, PhD, MD Tarah Venn, RD Kate Lorig, PhD Wendy Schadle Anu Roy, MA Lu Tian, PhD Joel Porter, MD Penney Cowan Mark McGovern, PhD Luana Colloca, MD, PhD Maisa Ziadni, PhD Pamela Flood, MD Heather King, PhD Sophia You, PhD Corinne Jung, PhD Richard Stieg, MD, MPH Korina DeBruyne, MD Phil Lavori, PhD

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39 • November 21, 2018

Learn More

  • www.pcori.org
  • info@pcori.org
  • #PCORI2018
  • https://empower.stanford.edu
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40 • November 21, 2018

Thank You!

Beth Darnall, PhD

Clinical Professor Stanford University School of Medicine Twitter: @BethDarnall