Post on 09-Jul-2020
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
TaperingLong-TermOpioidTherapyJosephW.Frank,MD,MPH
VAEasternColoradoHealthCareSystemUniversityofColoradoSchoolofMedicine
CSAMWebinar,April28,2017
Disclosures/ConflictsofInterest
Thespeakersandplannersofthiswebinarhavenorelevantfinancialrela4onshipstodisclose.
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
SessionOverview
• Theevidence• Theguidelines• Theprocessofopioiddosereduc4on
Case
• 52-year-oldmanwithchroniclowbackpainforthepast11yearsfollowingworkinjury,ondailyopioidtherapyfor9years
• Presen4ngtodaytoanewprimarycareprovidera[erpriorPCPre4red• Currentlyonlong-ac4ngmorphine90mg3XD&short-ac4ngoxycodone20mg4XDPRN
• Ibuprofen,naproxen,topicalsnoteffec4veonpriortrials• Walksthedogseveral4mesweekly,par4cipatedinPT2yearsago
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
Ini4a4onofopioids
Con4nua4on,monitoring&riskmi4ga4on
3-6months Months-Years
Tapering&discon4nua4on
Weeks-Months-Years
PhaseofLTOT
Dura/on
Risks&benefits
??? Benefits>>>Risks Risks>>>Benefits
Mul4disciplinary,mul4modalpaincare
Non-opioidpaincare
THEEVIDENCE
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
Ques4on
From1-10,howdifficultisyourtypicalconversa4onwhenrecommending&implemen4ngopioiddosereduc4on?
Pa/ents(N=24)• Barriers
– Lowperceivedriskofoverdose
– Pessimismre:non-opioidtherapies
– Prioropioidwithdrawalsymptoms
Frank et al. Pain Med 2016; Kennedy et al. 2017 Under review
Opioidtaperingischallenging
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
AddquotesPa4ent:“Idon’tthinkpeopleinchronicpainthinkaboutlongterm.Wearebasically,howdoIgetthroughtoday?Ijustgo>agetthroughtoday.”
Pa4ent:“Ihadtakenibuprofen,Aleve,everythingoverthecounter,anditdidnothingtohelpmeatall.SoIknewIneededmorehelp,strongerhelp.”
WithdrawalquotePa4ent:“Idon’tthink[doctors]areawareofhowbadwithdrawalsare.Imeanthere’svomiFngbile.There’sstomachcramps,there’sthecoldshakesandfever...Imean,it’spre>ybad.”
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
Pa/ents(N=24)• Barriers
– Lowperceivedriskofoverdose
– Pessimismre:non-opioidtherapies
– Prioropioidwithdrawalsymptoms
Frank et al. Pain Med 2016; Kennedy et al. 2017 Under review
Primarycareproviders(N=40)• Barriers
– Emo4onalnatureofdiscussion
– Inadequatetraining&resources
– Lackoftrustbetweenpa4ent&provider
Opioidtaperingischallenging
PCP:“Amajorissue…isFmeandresources.And,there’snowayyoucanconsistentlyput20poundsofpotatoesinafivepoundbag…IthinkeveryonearoundthetableisveryconscienFous,veryawareoftherisks.It’sama>erofresources,Fme,thatisnotallocated,andthat’sthenatureofmedicinetoday,andit’sthenatureofprimarycare.”
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
Dose-dependentrisksofopioid-relatedharms
0
1
2
3
4
5
6
7
8
9
10
<19mg/day
20-49mg/day
50-99mg/day
>=100mg/day
RiskRa/
o Dunn2010
Bohnert2011
Gomes2011
Gomes2013
Zedler2014
Dunn et al. Ann Int Med 2010; Bohnert et al. JAMA 2011; Gomes et al. Arch Int Med 2011; Gomes et al. JAMA Int Med 2013; Zedler et al. Pain Med 2014
• Riskofopioid-relatedharmsassociatedwithhighopioiddose
• Dosereduc4onmaydecreaserisk
• Lipleevidenceonbenefits&risksofopioidtapering
Risks&benefitsoftapering?
• Twopublishedsystema4creviewsincluded5smallrandomizedtrialsofopioidtaperinginterven4ons– Noconclusionsdrawn
• Oursystema4creviewincluded62controlledanduncontrolledstudies– Mul4disciplinaryinterven4onsappeareffec4ve
• Fewstudiesinprimarycareserngs
– ‘Verylow’qualityevidencesugges4ngbenefitsonpainandfunc4on• Fewstudiesassessedinvoluntarytaperingorriskofsubsequentsubstanceuseoradverseevents
Chou et al Annals 2015; Windmill et al. Cochrane Review 2013; Frank et al. 2017 Under review
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
• Short-termrisks:– Opioidwithdrawalsymptoms,increasedpain,andlosstofollow-up
• Long-termissues:– Relapse,func4onandmedicolegalimplica4ons
• “Aplanthatanindividualpa4entcanembracewithasignificantdegreeofpersonalengagementmightbemoreimportantthanfollowingaspecificprotocol”
Berna et al. Mayo Clin Proc 2015
Risks&benefitsoftapering?
THEGUIDELINES
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
Dowell et al. JAMA 2016
• #2:Beforestar4ng,considerhowopioidswillbediscon4nued• #5:Carefullyreassessrisks&benefitswhenconsideringdoseincreases≥50mgMEDD&avoiddoseincreases≥90mgMEDD
• #7:Ifbenefitsdonotoutweighharms,op4mizeothertherapies&workwithpa4entstotaperand/ordiscon4nue
• #12:Offerorarrangeevidence-basedtreatmentforpa4entswithopioidusedisorder
• Recommendsagainstdoses>90mgMEDDforchronicpain• Recommendsevalua4onfortaperingforpa4entstaking>90mgMEDD
• Recommendsevalua4onofrisksandbenefitsofcon4nuingLTOTalongwithrisksandbenefitsoftaperingLTOT
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
• Suggeststaperingopioidtothelowestpossibledose,includingdiscon4nua4on,forpa4entsusing≥90mgMEDDwithpersistent,problema4cpainorsideeffects– Weakrecommenda4on:Providersshouldindividualizetogoals,values&preferencesofpa4ents
http://nationalpaincentre.mcmaster.ca/documents/Opioids%20guideline%20English_30Jan2017_correctnumbering.pdf
THEPROCESSOFOPIOIDTAPERING
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
PreparingforEndattheBeginning
• Op4mizenon-pharmacologic&non-opioidpharmacologictherapiesforchronicpain
• Establishrealis4ctreatmentgoalsforpain&func4on• Discussrisks,especiallyhigh-dosetherapy• Considerhowopioidtherapywillbediscon4nuedifbenefitsdonotoutweighrisks• Responsetoaberrantbehaviors• Treatmentofopioidusedisorder
Dowell et al. JAMA 2016
• Atini4a4on,doctorsdidnottalkabout:– Non-opioidtreatmentop4ons 32%– Addic4on&dependence 28%
– Possiblesideeffects 23%– Planfordiscon4nuing 60%
http://apps.washingtonpost.com/g/page/politics/washington-post-kaiser-family-foundation-long-term-opioid-users-poll/2142/
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
Discuss,Ask&Educate
Discuss• Listentopa4ent’sstory
• Validatepain• Involvesocialsupport
VA PBM Academic Detailing Service. Opioid Tapering Decision Tool. www.pbm.va.gov
Educate• Biopsychosocialmodel
• Non-opioidtreatments
• Taperplanning
Ask• Func4onalgoals• Sideeffects• Priorexperiencewithtapering
• Importanceoftapering– Confidence– Readiness
Ambivalenceinlong-termopioidtherapy
• Amongadultsonmoderate-highdoseLTOT(≥50mgMEDD),
– 93%reportedopioidsatleastmoderatelyhelpful
– 42%reportedsideeffectsasatleastmoderatelybothersome
– 49%reportedadesiretocutdownorstop
Thielke et al. Clin J Pain 2013
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
Ques4on
Inyourexperience,whatpropor4onofopioidtapershavebeenclinician-ini4atedratherthanpa4ent-ini4ated?A. 0%(i.e.,allpa4ent-ini4ated)B. ~25%C. ~50%D. ~75%E. 100%(i.e.,allclinician-ini4ated)
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
Indica4onsforOpioidTapering1. Pa4entpreference2. Benefits
– Lackofmeaningfulfunc4onalimprovement
– Improvementinunderlyingpaincondi4on
– Paincondi4onnotopioid-responsive
3. Risks/Harms
– Unmanageablesideeffects
– Concurrenthigh-riskmedica4ons(e.g.,benzos)
– Comorbidi4es– Concernforopioidusedisorder– Non-adherencetoriskmi4ga4onstrategies
– Inadequatepar4cipa4onincomprehensivepaincareplan
– High-dosetherapy4. Diversion
VA/DoD 2017 Clinical Practice Guideline
PCP:“SomeoneneedstocomeoffbecauseofdualdippingormaybetheycameupwithaposiFveUDSorsomethinglikethat,sothosearethesomewhateasyones.”
PCP:“YoufindoutonthePDMPthatthepersonisgeTngstufffromotherpeople.That’saveryeasytaper‘causeyoujustsay,‘You’redone.’”
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
Case
• Atyoursecondvisit,yourpa4entreportsthathisleveloffunc4onhasdeclinedsubstan4allyinthepastyear.Hislong-ac4ngmedica4onishelpfulbutlasts3-4hours.Henotesfrequentbutmanageablecons4pa4on.
• Hiswifejoinshimtoday.Sheexpressesconcernabouthisfrequentday4menapping&tellsyouthathehadaminorcaraccidentlastweek.
• Hedidnotcompleteaurinedrugscreenbutagreestodosotoday.• HemissedaPhysicalTherapyappointmentlastweek.
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
Ques4on
Yourecommendwhichofthefollowing?A. IncreaseMSSRto4XDB. Con4nuecurrentmedica4onsC. BeginslowtaperwithnextfillD. Rapiddiscon4nua4ond/tadverseevent
UnilateralDecision-Making
SharedDecision-Making
PCP:“It’smylicensethat’sonthelineforthissoIulFmatelydogettochoose.
Obviously,Idowanttodoshareddecision-making.Absolutely.ButifapaFentsnot,
youknow…It’sonmeulFmately.”
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
PCP:“’Iamuncomfortableprescribingthathighofadose’couldbeperceivedas‘Well,whatcouldIsaytomakeyoucomfortable?Imean,youknow,it’sbeenworkingforme’.ItbecomesaYouvs.MeconversaFon”
PCP:“Youseethepersononyourscheduleandyouknowit’sgoingtobe…oneofthosejustdrainingconversaFons.”
Pa4ent:“IhaveatremendousfearinadoctorsayingIwantyoutotaperoffthemethadoneandgettotallyoffthemethadonewithnoalternaFvewhatsoever.”
Pa4ent:“Ialsohadlotsoffearsabout,let’ssaytherewasanapocalypseinoursociety…Whatwouldhappentome?WherewouldIgetmymedicaFonfrom?Whatwasgoingtohappen?”
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
VA/DoD 2017 Clinical Practice Guideline
ModuleC:TaperingorDiscon4nua4onofOpioidTherapy
VA PBM Academic Detailing Service. Opioid Tapering Decision Tool. www.pbm.va.gov
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
Decision-MakingDuringOpioidTapering
• Goals• Timingofini4a4on• Speed• Medica4onorder• Painmanagement• Opioidwithdrawalmanagement• Comorbiditymanagement• Educa4on
• Goals• Timingofini4a4on• Speed• Medica4onorder• Painmanagement• Opioidwithdrawalmanagement• Comorbiditymanagement• Educa4on
Sideeffects?
Func4onalgoals?
Opioidwithdrawal?
Dose?
Discon4nua4on?
Decision-MakingDuringOpioidTapering
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
• Goals• Timingofini/a/on• Speed• Medica4onorder• Painmanagement• Opioidwithdrawalmanagement• Comorbiditymanagement• Educa4on
Today?
Nextrefill?
Pa4ent-driven?
Decision-MakingDuringOpioidTapering
• Goals• Timingofini4a4on• Speed• Medica4onorder• Painmanagement• Opioidwithdrawalmanagement• Comorbiditymanagement• Educa4on
CDC2016:• 10%perweek• 10%permonthiflong-termVA/DoD2017:
• 5-20%per28days
VA PBM Academic Detailing Service. Opioid Tapering Decision Tool. www.pbm.va.gov
Decision-MakingDuringOpioidTapering
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
• Randomizedcontrolledtrialof22-weekopioidtapersupportinterven4on– WeeklyvisitswithPA– Mo4va4onalInterviewing– Self-managementtraining
Sullivan et al. J Pain 2017.
%reduc/on@22weeks
Interven/on(N=18)
UsualCare(N=17)
0% 4(22%) 8(47%)
1-49% 6(33%) 5(29%)
50-99% 7(39%) 2(12%)
100% 1(6%) 1(6%)
• CohortstudyofVeteransundergoingvoluntaryopioiddosereduc4on(N=50)
• Averagedosedecreasedby46%over12months– Discon4nua4oninonly6pa4ents– Dosereduc4on“paused”foratleast3monthsin25pa4ents– Dose“readjustedhigher”in6pa4ents
Harden et al. Pain Medicine 2015.
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
• Goals• Timingofini4a4on• Speed• Medica4onorder• Painmanagement• Opioidwithdrawalmanagement• Comorbiditymanagement• Educa4on
VA PBM Academic Detailing Service. Opioid Tapering Decision Tool. www.pbm.va.gov
Decision-MakingDuringOpioidTapering
• Goals• Timingofini4a4on• Speed• Medica/onorder• Painmanagement• Opioidwithdrawalmanagement• Comorbiditymanagement• Educa4on
Long-ac4ng
vs.
Short-ac4ng
Decision-MakingDuringOpioidTapering
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
• Goals• Timingofini4a4on• Speed• Medica/onorder• Painmanagement• Opioidwithdrawalmanagement• Comorbiditymanagement• Educa4on
Samplewripeninstruc4ons
Decision-MakingDuringOpioidTapering
• Goals• Timingofini4a4on• Speed• Medica4onorder• Painmanagement• Opioidwithdrawalmanagement• Comorbiditymanagement• Educa4on
• NSAIDs• APAP• Topicals• TCAs• Injec4ons• CBT• MBSR• Massage• Acupuncture• Exercise• Aquatherapy• Physical
Therapy
• Occupa4onalTherapy
• Spinalmanipula4on
• Yoga• Taichi• Heat• Ice• TENS• Autogenic
training• Relaxa4on• Biofeedback
Decision-MakingDuringOpioidTapering
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
• Goals• Timingofini4a4on• Speed• Medica4onorder• Painmanagement• Opioidwithdrawalmanagement• Comorbiditymanagement• Educa4on
Decision-MakingDuringOpioidTapering
• Goals• Timingofini4a4on• Speed• Medica4onorder• Painmanagement• Opioidwithdrawalmanagement• Comorbiditymanagement• Educa4on
Decision-MakingDuringOpioidTapering
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
• Goals• Timingofini4a4on• Speed• Medica4onorder• Painmanagement• Opioidwithdrawalmanagement• Comorbiditymanagement• Educa4on
MentalHealth
SubstanceUse
Sleep
Weight
Othermedicalcondi4ons
Decision-MakingDuringOpioidTapering
• Goals• Timingofini4a4on• Speed• Medica4onorder• Painmanagement• Opioidwithdrawalmanagement• Comorbiditymanagement• Educa/on
Overdoserisk
– Lossoftolerance&naloxone
– IllicitopioiduseFollow-upplan
– Visitfrequency– Pointofcontact
Decision-MakingDuringOpioidTapering
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
Case
• Overthepast6months,yourpa4enthasdecreasedfrom390mgMEDDto120mgMEDD.
• Heistearfultodayandreportsthathispainlevelhasincreasedinthelastmonth.Hemissedhislastappointmentwithyou.
• Heranoutofmedica4on1weekago,experiencewithdrawalsymptomsandboughtopioidmedica4onsfromaneighbor.
• Heacknowledgesalossofcontrolandnega4veconsequencesimpac4nghismarriage.
Ques4on
Yourecommendwhichofthefollowingdosingstrategies?A. PauseopioidtaperatcurrentdoseB. Con4nueslowtaperC. Rapiddiscon4nua4onD. Switchtobuprenorphine
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
DSM-VOpioidUseDisorderDiagnosis1. Largeramountsoroveralongerperiodthanintended2. Unsuccessfuleffortstocutdownorcontroluse3. Timespentobtaining,usingorrecovering4. Craving5. Failuretofulfillmajorroleobliga4ons6. Socialorinterpersonalproblems7. Ac4vi4esgivenuporreduced8. Usewhenitisphysicallyhazardous9. Physicalorpsychologicalproblem10. Tolerance*11. Withdrawal*
Mild=2-3Moderate=4-5Severe≥6
Degenhardtetal.LancetPsychiatry2015;2(4):314-322
Obtainingawaiver
• Buprenorphinetraining– Eighthours,availableinonlineformat– Peer-to-peermentoring
• CDC:“Incommuni4eswithoutsufficienttreatmentcapacity”,physiciansshould“stronglyconsider”obtainingawaiverfromSAMHSAthatallowsthemtoprescribebuprenorphine
Dowell et al. JAMA 2016
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
Takehomepoints
• Adiscussionofopioidtaperingshouldbeginandcon4nueduringlong-termopioidtherapy
• Opioidtaperingshouldseektoop4mize:
– Benefits&risksofopioidmedica4onsandopioidtapering– Func4onandqualityoflife– Pa4entengagement
• Thecomplexityofopioidtaperingofferschallengebutalsoopportuni4esforshareddecision-making
Materials• VA/DoD2017ClinicalPrac4ceGuidelinesontheManagementofOpioidTherapyforChronic
Pain– hpps://www.healthquality.va.gov/guidelines/pain/cot/index.asp
• VAOpioidTaperDecisionTool– hpps://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/
Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf• VAOpioidSafetyQuickReferenceGuide(2014)
– hpps://www.va.gov/PAINMANAGEMENT/docs/PainProviderADQuickReferenceGuide508.pdf• CDCOpioidGuidelineResources
– hpps://www.cdc.gov/drugoverdose/prescribing/resources.html• CDCPocketGuideforTaperingOpioidsforChronicPain
– hpps://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf• FebruaryCSAMWebinaron‘Psychological/BehavioralStrategiesforPainControl:Toolsfor
PCPstoUseina20MinuteVisit’– hpps://tapcprogram.files.wordpress.com/2017/03/csam-pain-webinar-resource-list-final.pdf
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
Ques4ons?
joseph.frank@ucdenver.edu
Friday,06/23/2017Friday,07/28/2017Friday,08/18/2017*Friday,09/22/2017
NEXTWEBINAR:Friday,05/19/2017NaloxonePrescribinginPrimaryCare:Why,Who,andHow
Tapering Long-Term Opioid Therapy / Joseph W. Frank, MD, MPH
April28,2017/CSAM–Trea4ngAddic4oninthePrimaryCareSafetyNet(TAPC)WebinarSeries
You can view our previous webinars
for a small fee for CME/CEU on the CSAM Education Center at:
http://cme.csam-asam.org/ OR
Free on the CHCF TAPC Program Resource Page at:https://tapcprogram.com/
Save the date! CSAM Addiction Medicine Review Course
and Board Exam Preparation August 24 – August 27, 2017
Hilton San Francisco Union Square