Opioid Harm Reduction Strategies

Paul C. Coelho, MD Board Certified PM&R

Subspecialty Certified Pain Medicine

Table Of Contents

1. Reducing Harms to High Dose Patients

2. Preventing Harms to Opioid Naive Patients

High Dose (>120MED) Patients

1. Identify the high risk patients.

2. Explain to the patients that their dose has become dangerously

high and it will need to change.

3. Prescribe nasal naloxone and train a loved one in the

patient’s household on administration.

4. If the MED is < 240 offer the patient a 6mo taper.

5. If the MED is > 240 consider a taper or conversion to

buprenorphine for PAIN.

Example 1: Cleatus

68y/o retired millwright with failed back syndrome. Lives with spouse Rx’d MS04 ER 60mg QID. No aberrant behavior.

Example 1: Cleatus

1. Call Cleatus & Mabel into clinic to explain that new literature has suggests that Cleatus’ dose has become unsafe and it will need to change.

2. Rx nasal naloxone and train Mabel in it’s administration.

3. Offer a 15mg/mo taper over 6mo to 120MED.

Example 2: Loretta

52y/o disabled woman with FMS and chronic Hep C, on Transplant List @ OHSU. Medications include a Fentanyl patch 100ucg/hr Q48, Soma 350mg QID, and Xanax .5mg QID. Has an OMMP card. (MED 360)

Example 2: Loretta1. Call Loretta and her adult daughter/care-giver

into clinic to explain that new literature has suggests that Loretta’s dose has become unsafe and it will need to change.

2. Consider an addiction medicine consult given the complex PMH, Hep C, & Transplant status.

3. Rx nasal naloxone and train Frisbee - her daughter- in it’s administration.

4. Load with Gabapentin over 1mo to 1200mg/day 5. Convert from alprazolam to clonazepam - 1:1

conversion and begin a 6mo taper. Consider non-addictive alternatives for anxiety (citalopram).

Example 2: Loretta

6. Stop the Soma - it is an addictive barbiturate - and offer a conventional muscle relaxant. 7. Consider a conversion to Buprenophine for pain : Induction, stabilization, maintenance. 7a. Or offer a 12ucg/mo taper to 50ucg/hr. 8. Explain that our clinic policy is either THC or opioids but not both and let her choose.

Addiction Services In Oregon By County

Drug & Alcohol Services by County: http://www.oregon.gov/oha/amh/publications/provider-directory.pdf

Nasal Naloxone

1. SB 384 legalized for lay administration in 2013.

2. Stock in your pharmacies. 3. Some patients must pay out of

pocket ($25.00.) 4. http://www.prescribetoprevent.org/

wp-content/uploads/2012/11/naloxone-one-pager-in-nov-2012.pdf

Buprenorphine

1. Schedule III opioid. 2. Morphine Equivalence 30:1. 3. FDA approved for pain - Butrans & addiction - Suboxone. 4. Ceiling effect for respiratory

suppression. 5. Follow the QTc. 6. Contra-indications: coprescribing

benzo’s, sedatives, or alcohol use.

Pain or Fear of Withdrawal?

It’s Easier Not to Start Opioids, Than to Stop Em.

It’s Easier Not to Start Opioids, Than to Stop.

More than ½ of patients receiving opioids for 90d

remain on opioids for years.

1/3rd Of Patients Treated in Addiction Clinics Come

From Pain Clinics

Oregon Ranks #1 in the Nation in Prescription

Opioid Abuse

Prescription Opioid Deaths

Addiction Tx By Age

Age of Opioid ODD

Prescription Opioid Deaths & Addiction Treatment

Parallel Opioid Prescribing

Top Oregon Counties for Opioid Prescriptions

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52.5000

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210.0000

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Dougla

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Sher

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Linco

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Marion Po

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County

Special Thanks To:

• Andrew Kolodny, MD, Chief Medical Officer Phoenix House

• Jim Shames, MD, Medical Director Jackson County, OR Health & Human Services

• Andrew Mendenhall, MD, Medical Director Hazelden, Beaverton, OR

Thank You

www.supportprop.org