SLIDE 1
Using Pain Phenotyping To Reduce Opioid Exposure
Paul Coelho, MD Josh Steenstra, MBA
Disclosures
- Dr. Coelho & Mr. Steenstra have no relevant disclosures. We will not be discussing any
- ff-label uses of medications or devices.
Using Pain Phenotyping To Reduce Opioid Exposure Paul Coelho, MD - - PowerPoint PPT Presentation
Using Pain Phenotyping To Reduce Opioid Exposure Paul Coelho, MD - - PowerPoint PPT Presentation
Using Pain Phenotyping To Reduce Opioid Exposure Paul Coelho, MD Josh Steenstra, MBA Disclosures Dr. Coelho & Mr. Steenstra have no relevant disclosures. We will not be discussing any off-label uses of medications or devices. Table of
SLIDE 2
SLIDE 3
Table of contents:
- Epidemiology of the opioid epidemic
- Oregon opioid prescribing
- Pain phenotyping
- Salem Clinic 18mo data
- Sample Case
- Evidence-Based Treatments
- ICD10 Codes
SLIDE 4
Epidemiology of the Opioid Epidemic
SLIDE 5
US Overdose Deaths 1980-2017
50000 37500 25000 12500
Peak Incidence of Prescription ODD Age 45-54* 2017 1980 Peak Incidence Ages 45-54 6K 67K
SLIDE 6
OD’s Vs Guns Vs MVA’s
SLIDE 7
US OD Hospitalizations By Race
https://www.cdc.gov/nchs/products/databriefs/db294.htm
SLIDE 8
International Opioid Prescribing
https://www.ncbi.nlm.nih.gov/pubmed/28792397
2012-2014
SLIDE 9
International Oxycodone Prescribing
SLIDE 10
International Prevalence of Chronic Pain
https://www.ncbi.nlm.nih.gov/pubmed/28792397
SLIDE 11
Oregon & Prescribed Opioids
SLIDE 12
2011 Oregon Opioid Prescribing for SSD Recipients < 65yrs
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151179/
SLIDE 13
Opioid Prescribing for Fibromyalgia 2007-09
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346177/
SLIDE 14
Pain Phenotyping to Reduce Opioid Exposure
SLIDE 15
2018 Model of MSK Pain
Nociceptive Neuropathic Nociplastic
Primarily due to inflammation or tissue damage in the periphery Damage or entrapment of peripheral nerves. Primarily due to a central disturbance in pain processing. NSAID/Opioid Responsive Responds to both peripheral and central pharmacotherapy. Tricyclic neuro-active
- compounds. Opioid
unresponsive. Responds to procedures. Does not respond to procedures. Does not respond to procedures. Behavioral factors minor. Behavioral factors minor. Behavioral Factors Prominent. Examples: Osteoarthritis, Rheumatoid arthritis, cancer pain. Examples: Diabetic peripheral neuropathy, post-herpetic neuralgia. Examples: FMS, cLBP, cHA, IBS.
https://www.ncbi.nlm.nih.gov/pubmed/26266995
SLIDE 16
Identifying the Nociplastic- AKA “Central” – Pain Phenotype
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
- 1. Pain in many body regions.
- 2. Higher current and lifetime history of chronic pain in several
body regions.
- 3. Multiple somatic symptoms (e.g., fatigue, memory difficulties,
sleep problems, mood disturbance)
- 4. Negative Affect, dispositional pessimism, pain catastrophizing.
- 5. More sensitive to other sensory stimuli (e.g., bright light, loud noises,
- dors, other sensations in internal organs)
- 6. 1.5 to 2x more common in women.
- 7. Strong family history of chronic pain.
- 8. High self-reported pain & distress (VAS/NPS/PSD/PCS)
- 9. Pain triggered or exacerbated by stressors.
- 10. Peak prevalence of FMS age 30-59 (working-age).*
- 11. Essentially normal physical examination +/- diffuse tenderness.
SLIDE 17
Pain Catastrophizing Scale
http://sullivan-painresearch.mcgill.ca/pdf/pcs/PCSManual_English.pdf
Abnormal if > 20
SLIDE 18
2016 Fibromyalgia Survey Questionnaire
https://www.ncbi.nlm.nih.gov/pubmed/27916278
FMS + if Total Score > 13
SLIDE 19
Salem Clinic Data
SLIDE 20
Demographics: Sex
978 Referrals 615 (63%) women 363 (37%) men
SLIDE 21
Demographics: Age
978 Referrals 539 (55%) 45-64 250 (26%) 18-44 233 (24%) > 65
SLIDE 22
Demographics: Payer
SLIDE 23
18mo Look Back At The Nociplastic Phenotype
987 Referrals 682 (69%) FMS+ PCS + 553 (56%) FMS+ 481 (48%) PCS+ 305 (31%) FMS- PCS-
SLIDE 24
18mo Look Back Opioid Exposure
977 Referrals 671 (66%) FMS+ or PCS + 422 of 671 (63%) Rx’d a schedule II
SLIDE 25
18mo Look Back @ PCS & Opioid Use Disorder (F11.2)
https://www.medcalc.org/calc/odds_ratio.php
131 Dx of OUD 91 (69%) PCS > 20 40 (31%) PCS < 20 OR = 2.5, CI[1.6-3.9] p < 0.0001
SLIDE 26
OR High Utilizer ED Visits
http://www.orhealthleadershipcouncil.org/wp-content/uploads/2017/09/EDIE-Evaluation-Report-Final-8-21-17-v.1.pdf
6 of top 10 Visits for Pain
SLIDE 27
18mo Look Back ED Visits
472 ED Visits 397 (84%) FMS+ PCS+ 75 (16%) FMS - or PCS – OR = 2.4, CI [1.8-3.2] p < 0.0001
https://www.medcalc.org/calc/odds_ratio.php
SLIDE 28
18mo Look Back HA & Migraine
310 HA or Migraineur 253 (80%) FMS+ PCS+ 62 (20%) FMS - or PCS – OR = 1.86, CI [1.4-2.5] p = 0.0001
https://www.medcalc.org/calc/odds_ratio.php
SLIDE 29
18mo Look Back > 4 Opioid Prescribers (Z72.89)
76 Occurrences of doctor shopping 63 (83%) FMS+ PCS+ 13 (17%) FMS - or PCS – OR = 2.2,CI [1.19-4.1] p = 0.011
https://www.medcalc.org/calc/odds_ratio.php
SLIDE 30
18mo Look Back Cervical & Lumbar MRIs
136 Cervical & Lumbar MRIs 107 (79%) FMS+ PCS+ 29 (21%) FMS - or PCS – OR 1.7, CI[1.1-2.6] p = 0.0018
https://www.medcalc.org/calc/odds_ratio.php
SLIDE 31
Sample Case
SLIDE 32
Joyce
Joyce is a 45y/o woman who recently moved from CA to Jackson, County to retire. Her past medical history is significant for a work related back injury for which she was medically retired. She now receives SSD and seeks to establish care with you for primary care needs as well as pain management. Her medication regimen consists of Lisinopril for HTN. She is requesting “Percocet” for pain.
SLIDE 33
Joyce
>13 = FMS
7 10 17
>13 = FMS
SLIDE 34
Joyce
>30 Abnl 4 4 3 4 4 3 4 3 3 4 4 4 4 48/52
SLIDE 35
Evidence-Based Treatments
SLIDE 36
Evidence-Based Treatments for FMS
https://www.ncbi.nlm.nih.gov/pubmed/28077978
Treatment Evidence Level Patient Education 1A Graded Exercise 1A CBT 1A Tricyclics 1A SNRI’s 1A Gabapentenoids 1A NSAIDS 5D Opioids 5D
SLIDE 37
Evidence-Based Treatments for Pain Catastrophizising
SLIDE 38
Supporting ICD-10/DSM 5 Codes
SLIDE 39
ICD-10 & DSM 5 Codes
Diagnosis ICD-10/DSM 5 Fibromyalgia M79.7 Pain Catastrophizing F45.1
SLIDE 40