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THE HIGHS AND LOWS OF OPIATES
A REVIEW OF THE CPSO GUIDELINES
Leon Rivlin MD, CCFP (EM)
OBJECTIVES
Evaluate opioids in the management of chronic pain
Define an approach to the recognition of opioid misuse in the chronic pain patient
Evaluate protocols for safe and effective prescribing of opioids in chronic pain
Discuss the pitfalls of opiate management
WHY IS OPIATE MANAGEMENT SUCH A GREAT CONCERN ?
WHY IS CHRONIC PAIN IMPORTANT?
Canadian National Pain Study 2002
Chronic pain is present in 22 – 39% adults #1 reason for chronic pain: arthritic
conditions Prevalence of pain increases with aging Only 36% of patients felt that their pain
was effectively Rx 68% of MD’s believed that chronic pain
could be treated more effectively
Moulin D., PR&M, 2002,2003
ECONOMIC IMPACT
13% of workers lose a mean of 4.6 hours /wk of productive work time due to common pain conditions
Costs to industry $6.2 B/yr (US) 76 % due to reduced performance at work
Costs of depression to industry $31 B/yr
Equal to impact of CV disease, or Cancer
Stewart et al. JAMA 2003
BARRIERS for PHYSICIANSto TREATING CHRONIC PAIN
Limited training in medical schools Insufficient knowledge and
understanding Disease centred model of care does not
prioritize the management of pain Biopsychosocial model of pain
underutilized Fears about regulatory bodies Biases and fears about opioid use &
addiction
BIASIS & FEARS ABOUT OPIOID ANALGESICS 2004 DATA
Study of Wisconsin physicians' knowledge and attitudes about opioid analgesic regulations David E. Weissman, MD; David E. Joranson, MSSW; and Margaret B. Hopwood, MA, RN, Milwaukee and Madison Wisconsin Medical Journal 1991
200 Wisconsin physicians were polled 54% of the respondents indicated that,
due to concern of regulatory scrutiny, they will do one of the following: reduce drug dose or quantity, reduce the number of refills, or choose a drug in a lower schedule
EFFICACY OF OPIOID USE IN THE MANAGEMENT OF CHRONIC PAIN
Some but not all trials show functional improvement (Arkinstall et al., Pain 1995)
Subjective pain ratings show a 20 – 50 % decrease with a wide variation of individual response (Watson & Babul, Neurology 1998, Moulin et al, Lancet 1996)
• Opioids are better than NSAIDS or TCA’s for pain relief but not for improved functional outcomes (Sandoval, Furlan, Fonseca, Tunks, Mailis, submitted for pub)
Quality of life may improve with optimal dosing
ADVERSE EFFECTS of OPIOIDS:GENERAL
Constipation, nausea, narcotic bowel syndrome
Sweating Sleep apnea, COPD,
reduced resp. drive Rebound head aches Fatigue, confusion Cognitive
impairment
Endocrine & Reproductive effects (suppression of testosterone, menstrual irregularities)
Lowered pain threshold (long term hyperalgesia due to altered pain receptors)
Neurotoxicity (Demerol)
ADVERSE EFFECTS: OVERDOSE
Decreased LOC RR < 12/min Bradycardia Speech slow &
drawling “Nodding off” appear
to fall asleep momentarily during conversationPatients may appear to be relatively alert when surrounded by others in a stimulating environment, only to drift into coma and die when going for a nap
Pinpoint pupils Ataxia and falling Emotional lability Disinhibition Profuse sweating
ADDICTION
ADDICTION
Addiction occurs when a patient finds a drug effect so reinforcing that he has difficulty controlling its use
Characterized by the four C’s: Loss off over use Control Use despite knowledge of harmful Consequences
Compulsion to use the drug Craving
ADDICTION & OPIOIDS
50% chronic pain patients are addicted to opioids
More formal studies found addiction rates to be 3 – 19%
54% of injection users inject morphine and hydromorphone, 42% inject heroin
7-31% prevalence for opioid misuse behaviors (running out, double doctoring)
CLINICAL FEATURES of ADDICTION
Use of higher doses than needed for pain control
Run out early Reluctant to try alternatives to drug of choice Acquire opioids from friends or other doctors Tendency to binge on opioids Deterioration in functional status Daily cycle of intoxication and withdrawal Experimenting with opioids (routes of
administration)
OPIOID OVERDOSE:RISK FACTORS
Dose, potency, underlying tolerance Age (extremes), renal insufficiency,
respiratory disease Restarting opioids
When a patient has been off of an opioid for 3 days or longer, restarting at the same dose may produce an overdose due to rapid decline in tolerance.
Restarting the medication should be at 50% of the previous dose with gradual titration up.
OVERDOSING
17% opioid users had an overdose in past 6 months
Risk for overdosing: injecting high potency opioid useconcurrent use of prescription opioids &
benzos tolerancedepression participation in abstinence based programs
GUIDELINES TO OPIOID PRESCRIBING
PREPARE A TREATMENT PLAN
Collect information and formulate a diagnosis
Define and priorize treatment targets Devise a COMPREHENSIVE treatment plan
Lifestyle changes Social changes Consider Psychological/Psychiatric
intervention Integrate paramedical care providers Pharmacotherapy Interventional medical therapy
START WITH NON-OPIOIDS
Opioids should only be initiated after an adequate trial of non-opioid analgesics and other modalities have failed
Treatment success is measured by 25 – 50 % diminished pain, improved mood, and improved function
Abstinence of pain is an unrealistic goal General reluctance to use opioids for
headaches (opioids 2nd/3rd line at best)
INITIATING OPIOIDS
Obtain informed consent (adverse effects, risk of dependence)
Set expectations (25 – 50 % relief of pain)
Identify one prescribing physician Sign a Treatment Agreement
Evidence supports improved complianceSandoval et al., 2005
MAXIMUM OPIATE DOSE IS 200 MG MORPHINE /DAYCPSO TASK FORCE CONCLUSIONS
COMPONENTS OF THE TREATMENT AGREEMENT
Patient will not receive opiates from other sources
Detail the amount of medication, and usage schedule
Will not refill if the patient runs out early
Will not replace if meds or script lost
Patient will attend to regular visits
Urine drug screen will be provided on request
Physician can cease opiate script if agreement broken
A copy of the agreement should be sent to other physicians involved in care
Consequences of breaking the agreement should be specified and adhered to
DOCUMENTATION
Keep an opiate flow sheet (record the amount dispensed and reasons for changes)
Keep copies of scripts on chart Orange paper scripts are hard to photocopy See patient frequently on initiation of
treatment At each visit, document: compliance,
adverse effects, changes in mood and functional status, and analgesic effectiveness (VAS)
OPIATE SELECTION, DOSAGE & TITRATION
There is no evidence that one opiate is superior to another, recommendations are based on specific patient populations
Codeine is usually the initial choice because it is the least potent Be cautious of the acetaminophen
component 4 g/d if healthy, 3.2 g/d if elderly, 2g/d if
EtOH
OPIOID SELECTION
10% of Caucasians can’t convert codeine
Fentanyl patch, oxicodone, & hydromorphone are less likely to cause sedation in elderly
Active metabolites of morphine can accumulate in renal dysfunction
Avoid oxycodone & hydromorphone in patients with addiction history
Methadone is first choice in chronic pain among addicts
Parenteral opioids should not be use in long-term pain due to risk of overdose, addiction, and other problems
Titration
Start low and go slow! Opiates have a graded analgesic
response with greatest benefit at lower doses and plateau at higher dosages
Confirm that with each dosage increase there is a decline in the VAS pain score
Avoid withdrawal especially in pregnancy
Titrate slowly in the elderly, co-sedating med users, renal, resp, hepatic disease
SWITCHING OPIOIDS
Switch if lack of effectiveness or intolerable side effects
Initial dose of new opioid should be 50% of the original opioid used
Discontinue if pain remains unresponsive after 3 or 4 different opioids
SAFE PRESCRIBING
Avoid prescriptions for large amounts Caution with high dependence opiates in
those at risk Use rescue doses sparingly
Should be time dependent rather than pain contingent
Max of 4 – 6 doses per month Reduce next days dose by equal amount
Tamper proof the prescription Keep track of the medications
Running out early is common in addiction
TAMPER PROOFING PRESCRIPTIONS
Use words and numbersUse lines in blank spacesNo repeatsKeep pad in safe placeNumbered, non reproducible pads
(orange is hard to photocopy)Do not allow phone repeats
FEATURES OF OPIOID MISUSEPatients are reluctant to acknowledge their addiction for fear their opioid will be discontinued and they will experience withdrawal & pain
Past history of recreational drug & EtOH use
Patient or family have concerns about use
Patterns of use (binge, running out early)
Overstating effectiveness, dramatic and unlikely analgesic effect of pain
Psychological dependence; mood levelling effect, relief of anxiety, sense of calm
Withdrawal symptoms
Withdrawal mediated pain
Psychiatric history Psychosocial Status
(family conflict, deterioration at work)
Double doctoring Physical findings Lab findings (CBC,
AST,ALT, HepB,C, GGT, MCV)
IN SUMMARY
Formulate a comprehensive treatment plan Include the patient & family in the decision
making Consider opioids late in treatment of pain
& use sparingly Monitor use of opioids closely Dispense small quantities of medication on
any one visit Frequently evaluate effectiveness of
treatment models & guidelines
THE END