Bakersfield Pain Management, Inc 2323 16th St, Suite 504, Bakersfield, Ca 93301 (661) 395-1335; Fax 395-1322

J ohn L. Brazill, MD, J DFellowship Trained Pain Management Specialist

Board Certified in Pain Medicine andAnesthesiology by American Board of

Anesthesiology

Guidelines for Prescribing Opioids in California

In November 2014 Medical Board of California published “Guidelines for Prescribing Controlled Substances for Pain”

In June 2013, the California Medical Association issued “Opioid Analgesics in California: Relieving

Pain, Preventing Misuse, finding Balance”

Preamble

In November 2011 Centers for Disease Control and Prevention (November 2011) declared prescription drug abuse a national epidemic.

Preamble

Drug overdose is the leading cause of accidental death exceeding deaths due to motor vehicle accidents.

A majority of overdose deaths involved prescription drugs.

Injuries are occurring among general patient populations, with some groups at high risks (e.g., those with depression).

Preamble

The guidelines are intended to help physicians improve outcomes and prevent overdose deaths due to opioid use.

Focus on use of opioids in treating long term non-malignant chronic pain. Long term opioid therapy should only be

conducted where careful evaluation, regular follow-up and close supervision are ensured

Preamble

Guidelines are not meant to mandate the standard of care.

Physicians are encouraged to document their rationale for each prescribing decision

Understanding Pain

Pain is “an unpleasant sensory and emotional experience associated with actual of potential tissue damage, or described in terms of such damage.”

International Association for the Study of Pain.

Pain is a subjective sensation

Acute versus Chronic Pain

Pain can be Acute or Chronic Acute:

Generally with obvious tissue injury

Chronic:Lasting longer than expected (> 3-6

months)Tissue damage not always obvious

Nociceptive vs Neuropathic

Nociceptive Pain

Caused by activation of nociceptors from physical, chemical or thermal stimulus

Generally short lived and linked to underlying medical condition

Nociceptive vs Neuropathic

Neuropathic Pain: Results from injury to the nervous system or

from inadequately treated nociceptive pain Due to abnormal neuronal firing in the

absence of actual tissue damage. Responds poorly to opioids or NSAIDs Anti-epileptic, antidepressants or local

anesthetics may provide more effective relief.

Terminology

Terminology Relating to Opioid Therapy Tolerance: Reduce effectiveness of drug

over time Physical Dependence: Withdrawal

syndrome if abruptly stop opioid, rapid dose reduction, and/or administering of an antagonist

Addiction: impaired control of drug use, compulsive use, and continued use despite harm and craving.

Special Circumstances:Acute Pain

Acute Pain Opiates used only if pain warrants use

and non-opiate medications or therapy inadequate.

Opiate use should be for short duration Long acting opiates should not be used

for acute pain

Special Circumstances: History of Substance AbusePatients with history of substance abuse

more likely to be involved in drug misuse, abuse and addiction

If patient actively using illicit drugs, risks outweigh benefits and avoid opiates

In other patients risk minimized by Frequent and intense monitoring Limited prescription quantities Consultation or co-management with an

addition medicine specialist

Patient Evaluation and Risk Stratification

When considering long term use of opiates must conduct a careful and thorough patient assessment

Assessment includes: History and Physical Psychological evaluation including

assessment of risk of addictive disorders.

Screening Tools for Addictive Disorders

Screening tools for risks of addictive disorders CAGE-AID PHQ-9 Opioid Risk Tool SOAPP-R

Patient Evaluation and Risk StratificationWhen considering long term use of opiates a careful and thorough patient assessment is critical. Assessment includes:History and PhysicalPsychological evaluation including assessment of risk of addictive disorders.

Patient Evaluation and Risk StratificationWhen considering long term use of opiates a careful and thorough patient assessment is critical. Assessment includes:History and PhysicalPsychological evaluation including assessment of risk of addictive disorders.

Patient Evaluation and Risk Stratification

Establish a diagnosis and medical necessity for opioids Screening tools

Pain Intensity and Interference pain scaleSheehan Disability Scale

Patient Evaluation and Risk Stratification

Opiates are not appropriate first line treatment for pain

Explore non-opiate therapeutic options and document results

Therapeutic Options for Pain Management

Cognitive-Behavioral ApproachesRehabilitative ApproachesComplementary and Alternative

ApproachesInterventional ApproachesPharmacotherapy

Non-Opiate Pain Management Approaches

NSAIDs and AcetaminophenAdjuvant Medications

Antidepressants Anticonvulsants

Physical Therapy and Exercise ProgramsWeight Management ProgramsMassage TherapyAcupuncture TENS Unit

Patient Evaluation and Risk Stratification

Evaluate risks and benefits of opioidsLook for evidence of aberrant or drug

seeking behaviorUrine drug testingControlled Substance Utilization

Review and Evaluation System (CURES)

Consultations

Refer or consult with pain psychiatrist or mental health specialist when: Patients with history of substance abuse Patient with co-occurring mental health

disorder

Treatment Plans and Objectives

It treating long-term chronic non-malignant pain must have treatment plan Goals:

Improvement in pain and functionImprovement in pain associated symptoms

such as sleep disturbances, depression, anxiety and avoidance of unnecessary or excessive use of medications

Treatment Plans and Objectives

Treatment plan should contain information supporting selection of therapies both pharmacological (including non-opiate medications) and non-pharmacologic

Should specify goals and objectives that will be used to assess treatment such as relief of pain and improved physical and psychosocial function

Consent To Opioid Therapy

Written consent should include: Risks and benefits of long term opiate use Potential side effects of medications (nausea,

constipation, decreased libido, sexual dysfunction, hypogonadism with secondary osteoporosis and cognitive impairment)

Likelihood of tolerance and dependency Risks of interactions and over-sedation

Consent for Opioid Therapy

Written consent should include Risks of respiratory depression Risks of impaired motor skills (e.g.

driving) Risks of misuse, dependence, addiction

and overdose Limited evidence of benefit with long

term opiate use

Pain Management Agreement

When is an Agreement needed: If using short acting opiates:

At time of third visit in two months

If using long-acting opiates Expected to require more than three

months of opiates

Pain Management Agreement Contents

Prescribing policies and expectations Policy on early refills and replacement of

lost or stolen medications Reasons why drug therapy may be

changed or discontinued Patient responsibility for safe medication

use (e.g. not use more than prescribed or use with alcohol or other substances, store in a secure location and safe disposal)

Pain Management AgreementContents

Agree to share information with family members to recognize and respond to opiate overdose including administering naloxone.

Obtain opiates from one prescriber and one pharmacy

Undergo periodic drug testing (blood, urine, hair, saliva)

Counseling Overdose Risk and Response

Summon medical assistance if: Snore heavily and cannot be awakened Slow shallow breathing with little chest

movement or no breathing Increased or decreased heart rate Feeling faint, dizzy or confused Blue skin/lips Non-responsive to painful stimulation

Overdose Risk and Response

May prescribe an opiate antagonist for a person at risk of an opiate-related overdose or to a family member, friend, or other person

Initiating Opiate Trial

Trial should not be greater 45 daysContinuation of therapy depends on

making progress towards goals Presence and nature of side effects Pain status Absence of medication misuse, abuse or

diversion

Opioid Trial

Recommended doses for opiate naïve patients

Max 80 mg MED (morphine equivalent dose)/day

Seek consultation if higher doses contemplated

Ongoing Patient Assessment

Assess the 5 “A”s Analgesia: degree of pain relief Activity: level of function Adverse Side Effects Aberrance: compliance with Pain

Management Agreement and no sign of abuse or diversion

Affect: behavior and mood are appropriate

Compliance Monitoring

CURESDrug TestingPill counting

Drug Abuse

If confirmed Consult with an addition medicine

specialist or mental health specialist Refer to substance abuse disorder

program with medication assisted therapy

Discontinuing Opioid Therapy

Reasons for discontinuation Resolution of painful condition Intolerable side effects No pain relief or functional improvement Evidence of non-medical or

inappropriate use Failure to comply with monitoring Failure to comply with Pain

Management Agreement

Discontinuing Opioid Therapy

Exhibit drug seeking behavior or diversion

Selling prescription drugs Forging prescriptions Stealing or borrowing drugs Unsanctioned dose escalation Concurrent use of illicit drugs Getting opiates from multiple prescribers

or pharmacies

Discontinue Opioid Therapy

If discontinue therapy then provide dependant patient with tapering program Can stop opioid abruptly when risks outweigh

benefits Cannot abruptly stop benzodiazepine abruptly,

can be life threatening Withdrawal can be managed by

prescribing healthcare provider or by addiction specialist

Discontinue Opioid Therapy

If termination of treatment necessaryPatient must be given reasonable time to find

another MD and ensure patient has adequate medications if appropriate to avoid withdrawal

If patient abusing medications initiating a detoxification protocol may be necessary.

If terminate for not following Pain Management Agreement, consider referral to addiction resource

Medical Records

Adequate medical record for treating chronic non-malignant pain includes: Medical history Results of examinations and lab tests Patient consent Pain Management Agreement Results of risk assessment with

screening results

Medical Records

Monitoring results regarding pain management and functional improvement

Notes on evaluations by and consultations with specialist

Steps taken in response to any aberrant medication use behaviors

Name, telephone number and address of pharmacy

Supervising Health Care Providers

Section 3502.1 of the Business and Professions Code The medical record of any patient cared

for by a physician assistant for whom the physician assistant's Schedule II drug order has been issued or carried out shall be reviewed and countersigned and dated by a supervising physician and surgeon within seven days.

Questions?