Opioid prescribing for chronic non-malignant pain.

transcript

Responsible Opioid Prescribing for

Chronic Non-Malignant Pain

Paul C. Coelho, MD Board Certified PM&R

Subspecialty Certified Pain Medicine

Nothing To Disclose

Table Of Contents

1. Prescription Opioid Abuse Nationally

2. Prescription Opioid Abuse In Oregon 3. Cautious, Evidence-Based Opioid Prescribing: a. Primary Prevention b. Secondary Surveillance

Prescription Drug Abuse in the US

http://tinyurl.com/6d9yxgz

Prescription Drug Abuse in the US

http://www.cdc.gov/homeandrecreationalsafety/rxbrief/

Wide Variation in Prescribing Patterns

http://www.ncbi.nlm.nih.gov/pubmed/23031398

Who is doing all the Prescribing?

http://tinyurl.com/lrkcdql

What Are They Prescribing For?

http://tinyurl.com/lrkcdql

1/3rd Of Patients Treated in Addiction Clinics Come

From Pain Clinics

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3129653/

Prescription Opioid Deaths & Addiction Treatment

Parallel Opioid Prescribing

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm

More than ½ of patients receiving opioids for 90d

remain on opioids for years.

Total Opioids Prescribed By Age

http://www.fda.gov/downloads/Drugs/NewsEvents/UCM300859.pdf

Average Age of Unintentional Opioid ODs

Risk Factors for ODD Doctor/NP/PA Shopping

Risk Factors for Unintentional ODD

Summary of Risk Factors for Unintentional ODD

Oregon Ranks #1 in the Nation in Prescription

Opioid Abuse

http://www.samhsa.gov/data/2k12/NSDUH115/sr115-nonmedical-use-pain-relievers.htm

Oregon’s ODD Rate is Higher than National Avg

http://www.cdc.gov/nchs/data/databriefs/db22.pdf

Top Oregon Counties for Opioid Prescriptions

County

http://tinyurl.com/mr9dttb

Prescription Opioid Deaths In Oregon 2000-2011

http://preview.tinyurl.com/mza7766

Cautious, Evidence-Based Opioid Prescribing

Primary Prevention

OMB’s11 Contra-Indications to Treatment

with Opioids 1. Any history of diversion 2. A history of suicide attempts with medication 3. Current methadone or suboxone maintenance 4. No functional improvement after a trial or chronic use of opioids 5. A history of misuse or over use as defined by multiple prescriptions from multiple different providers or sites 6. A history of frequent utilization of the emergency room for attaining opioids 7. Prior dismissal violation of an opioid agreement 8. Active substance abuse, including alcohol, in the past 12 months 9. The use of marijuana, regardless of authorization status 10. Untreated or undertreated mental health condition 11. Opioid risk score > 7

http://tinyurl.com/lr9hwhh

Minimize Opioid Use In Conditions For Which There Is No Objective

Marker Of Disease Chronic LBP Fibromyalgia Syndrome Chronic HA Chronic Abdominal Pain Chronic Pelvic Pain Phantom Limb Pain

Stratify Patients for Risk of Abuse

DIRE SOAPP-R COMM

Diagnosis, Intractability, Risk, Efficacy

http://tinyurl.com/lks94bf

Adopt WA State Dosing Guidelines

1. Low Dose = <60 MED

2. Intermediate Dose = 60 -120MED

3. High Dose = > 120MED Milligrams Equivalent Dose (MS04)

http://preview.tinyurl.com/lhxtoju

Examples of 120MED

MSContin 40mg TID Oxycontin 40mg po BID Fentanyl Patch 50mcg/72hrs Opana 20mg po BID Nucynta 150mg po BID *Methadone 15mg po BID

http://agencymeddirectors.wa.gov/mobile.html

Limiting Opioids to 120MED for CNP Saves Lives

http://tinyurl.com/mmazr8y

Limiting Opioids to 120MED for CNP Saves Lives

Prescribe Nasal Naloxone to High Dose Patients

http://tinyurl.com/kzvs443

Prescribe Nasal Naloxone to High Dose Patients

http://gov.oregonlive.com/bill/2013/SB384/

Avoid Methadone

http://tinyurl.com/mb2lj6r/

Avoid Methadone

http://tinyurl.com/kpuh547

Avoid Co-administration of Benzodiazepines

http://tinyurl.com/abnywac

Urge Caution With Alcohol Use

http://tinyurl.com/ly6o6vj

Set Reasonable Expectations For

Treatment

http://www.ncbi.nlm.nih.gov/pubmed?cmd=historysearch&querykey=5

Utilize a Formal Material Risk Notice

http://www.oregon.gov/omb/pdfforms/materialrisknotice.pdf

Utilize a Formal Treatment Agreement

http://www.oregon.gov/omb/newsletter/winter2011.pdf

Secondary Surveillance

Document the 5 A’s With Each Visit & the 6th 2x/yr

1. Activity Level 2. Adverse Effects 3. Analgesia (NRS) 4. Aberrant Behavior 5. That you Accessed & Reviewed the PDMP 6. *Acquire random UTS/STS a minimum of 2x/yr

http://www.fda.gov/ohrms/dockets/ac/02/slides/3820s2_05_passik.ppt

Activity Level

1. Activity Level: 1. ADLs 2. Exercise 3. Walking 4. Objective evidence of functional improvement.

Adverse Effects

1. Adverse Effects: 1. Constipation 2. Somnolence 3. SOB 4. Falls 5. Automobile Accidents/DUI’s 6. ER Visits

Analgesia

1. Analgesia: 1. NRS (0-10) 2. VAS

Document Aberrant Behaviors

1. Forging, altering, or stealing prescriptions 2. Stealing, borrowing, trading, buying, or selling drugs 3. Injecting or snorting oral drugs or fentanyl/suboxone patches 4. Doctor shopping/ER visits for opioids 5. Concurrent abuse of alcohol or illicit drugs 6. Falls, accidents, or other sedation related consequences of opioid overuse 7. Frequent stolen or lost prescriptions 8. Resisting changes to medications in spite of adverse effects 9. Aggressively complaining about the need for more drugs 10. Drug hoarding 11. Unsanctioned drug escalations 12. DUI’s 13. Frequent calls to the office to request more medications or early refills 14. Requesting specific drugs by name 15. Multiple reported NSAID or opioid allergies/sensitivities 16. Clinical ambushes with aggressive, hovering family members arguing for dose escalations http://www.ncbi.nlm.nih.gov/pubmed/14635824

25% of CNP Patients Exhibit Aberrant Behavior

38% of UDS Samples Showed No Drug

Aberrant Behavior is a Predictor of OD

Access the PDMP

https://orpdmp-ph.hidinc.com/ Document your access to the PDMP with each

Quarterly or Half-yearly f/u visit.

Acquire Random UTS/STS

Oregon Medical Marijuana Program

http://tinyurl.com/klx8vn5

OMMP Patient Demographics

http://tinyurl.com/modae4l

NSDUH Data 70% Male < 35yrs

http://preview.tinyurl.com/k48rkys

30% of Heavy Users Co-Utilize other Illicits

40% of Heavy Users Use Alcohol Heavily

20% of Users Consume 80% of the Product

OMMP Has Not Diminished Opioid Prescribing

http://www.martin.uky.edu/centers_research/Capstones_2012/Farley.pdf

OMMP Has Not Diminished Suicide Rates in OR

http://preview.tinyurl.com/lweycl7

Fatal MVAs Involving THC have Tripled over 10yrs

Cannabis Impairs Driving Skills

Marijuana As a Harbinger of Prescribed Opioid Misuse

Marijuana & the OMB

http://tinyurl.com/lr9hwhh

Quarterly Follow-Up

http://www.deadiversion.usdoj.gov/fed_regs/rules/2006/fr0906.htm

Special Thanks To • Dr. Rick Deyo, OHSU • Dr. Andrew Kolodny, PROP • Dr. Barry Egener, Foundation for

Medical Excellence • Dr. Jim Shames, Jackson/Josephine Co • Medical Director • Dr. Joe Thaler, OMB • Ms. Kathleen Haley, JD OMB

Copies of This Presentation:

http://www.slideshare.net/101N

Thank You

www.supportprop.org

Opioid prescribing for chronic non-malignant pain.

Health & Medicine