Opioid prescribing for chronic non-malignant pain.
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Transcript of Opioid prescribing for chronic non-malignant pain.
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.
http://www.ncbi.nlm.nih.gov/pubmed/21751058
Total Opioids Prescribed By Age
http://www.fda.gov/downloads/Drugs/NewsEvents/UCM300859.pdf
Average Age of Unintentional Opioid ODs
http://www.fda.gov/downloads/Drugs/NewsEvents/UCM300859.pdf
Risk Factors for ODD Doctor/NP/PA Shopping
http://www.fda.gov/downloads/Drugs/NewsEvents/UCM300859.pdf
Risk Factors for Unintentional ODD
Risk Factors for Unintentional ODD
Dose
http://www.fda.gov/downloads/Drugs/NewsEvents/UCM300859.pdf
Summary of Risk Factors for Unintentional ODD
http://www.fda.gov/downloads/Drugs/NewsEvents/UCM300859.pdf
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
0
50
100
150
200
250
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
http://www.ncbi.nlm.nih.gov/pubmed/22213274
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
http://www.ncbi.nlm.nih.gov/pubmed?cmd=historysearch&querykey=3
38% of UDS Samples Showed No Drug
http://www.ncbi.nlm.nih.gov/pubmed/19663620
Aberrant Behavior is a Predictor of OD
http://www.ncbi.nlm.nih.gov/pubmed/23070654
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
http://preview.tinyurl.com/k48rkys
40% of Heavy Users Use Alcohol Heavily
http://preview.tinyurl.com/k48rkys
20% of Users Consume 80% of the Product
http://preview.tinyurl.com/k48rkys
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
http://www.ncbi.nlm.nih.gov/pubmed/24076302
Cannabis Impairs Driving Skills
http://www.ncbi.nlm.nih.gov/pubmed?cmd=historysearch&querykey=6
Marijuana As a Harbinger of Prescribed Opioid Misuse
http://www.ncbi.nlm.nih.gov/pubmed/19793342
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