Practical Approaches to Opioid Prescribing:

Working Within the Guidelines

Brenda Lau MD, FRCPC, FFPMANZCA, MM

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Incorporate the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain and apply elements into a busy practice

Help you effectively utilize supporting tools such as the

› Brief Pain Inventory (BPI) and the

› Opioid Risk Tool (ORT), and

Implement improved opioid monitoring practices, including documenting the

› 6 A’s and using the Opioid Manager*

› Weaning guidelines

Learning Objectives

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What is it?

› An evidence-based guideline with 24 recommendations outlining how to use opioids to treat patients with CNCP

Why was it developed?

› Existing treatment information and guidelines were found to be outdated

Why was it necessary?

› To improve the safety and care of CNCP patients being treated with opioids, and to safely manage potential side effects (including addiction) and the risk of opioid misuse

The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

http://nationalpaincentre.mcmaster.ca/opioid/,

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Available at: http://nationalpaincentre.mcmaster.ca/opioid/

The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

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CNCP = Chronic Non-Cancer Pain *Courtesy of: “Toronto Rehabilitation Institute” Available at: http://nationalpaincentre.mcmaster.ca/opioid/

The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

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Moods

Depression

Anxiety

Anger

Irritability

Social Functioning

Diminished social relationships (family/friends)

Decreased sexual function/intimacy

Decreased recreational and social activities

Societal Consequences

Health care utilization

Disability

Loss of work days or employment

Substance abuse

Physical Functioning

Mobility

Impaired Immununity

Sleep disturbances

Fatigue

Loss of appetite

Ashburn MA, et al. Lancet. 1999;353:1865-1869. Harden RN. Clin J Pain. 2000;16:S26-S32. Agency for Health Care Policy and Research. Clinical Practice Guideline No. 9. 1994. Meyer-Rosberg, K et al. Eur J Pain. 2001;5:379-389. Zelman D, et al. J Pain. 2004;5:114. Manchikanti L, et al. J Ky Med Assoc. 2005;103:55-62. Hoffman NG, et al. Int J Addict. 1995;30:919-927.

Effects of Chronic Pain on the Patient

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Pain is moderate to severe

Pain has significant impact on function and QOL

Non-opioid pharmacotherapy has been tried and failed

Opioids indicated for specific pain condition

Opioid risk assessment has been done & documented

Informed consent (goals, risks, benefits, AEs, complications …)

Patient agreeable to have opioid use closely monitored (UDS, treatment agreement, freedom of information …)

Responsible prescribing of opioids

Deciding to Initiate Opioid Therapy – Cluster 1

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Opioid Risk Tool & Checklist

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1. Diagnosis with appropriate differential

2. Psychological assessment

› Including risk of addictive disorders

3. Informed consent

› Verbal v. written/signed

4. Treatment agreement

› Verbal v. written/signed

5. Pre trial assessment of pain/function and goals

Universal Precautions in Pain Medicine

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One prescriber (include name) One dispensing pharmacy (include name) Will comply with safe/secured storage of opioid; Will comply with no driving while titrating No sharing/selling of opioid; No accepting of any opioid medications from anyone else Will not change the dose or frequency of taking the medication without consulting the doctor Strict rules with respect to medication loss, early refills, possible abuse or diversion

(e.g. Dr._________ will not prescribe extra medication for me. I will have to wait until the next prescription is due.)

Strict rules with respect to concomitant usage of other sedating medications, OTC/prescription opioids, recreational drugs (e.g. 222’s, Tylenol® #1 …)

Will comply with scheduled office visits and consultations Will comply with pill/patch counts and random UDS when requested, and with limited quantity of opioid

dispensed per prescription Adverse effects, medical complications and risks (including addiction) of opioids understood Freedom of information permitted Understanding and agreement that if there is no demonstrable improvement in functionality, the physician

reserves the right to wean patient off his/her opioid medications. Understanding that if these conditions are broken, Dr. _______ may choose to cease writing opioid prescriptions

for me

Patient’s Signature Date Physician’s Signature Date

Content of a Treatment Agreement

11(Passik 2000)

6. Appropriate trial of opioid therapy

› +/- adjuvants

› Replace short-acting opioid with long-acting opioid at equivalent dose

› Limit the number of pills/patches that a patient may have at one time7. Reassessment of pain score and level of function

8. Regular assess the “Six A’s” of pain medicine

› Analgesia

› Activities

› Adverse effects

› Ambiguous drug taking behaviur

› Accurate medication record

› Affect

9. Periodically review Pain Diagnosis and co morbid conditions including addictive disorders

10.DOCUMENT, DOCUMENT, DOCUMENT

Universal Precautions in Pain Medicine

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Start low, go slow

› Titrate to “optimal dose”

› Remember safety issues when selecting opioids, including altered pharmacokinetics (e.g. liver/kidney) &/or drug interactions

› Comprehensive review before nearing the “watchful dose”

Document progress / opioid effectiveness

Monitor adverse effects, medical complications, risks

› Opioid Manager*

› 6 A’s

If risks outweigh benefits, then: switch, taper ± discontinue

*Courtesy of: “Toronto Rehabilitation Institute” Available at: http://nationalpaincentre.mcmaster.ca/opioid/.

Conducting an Opioid Trial Summary – Cluster 2

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Opioid Manager

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Physical / RehabilitativePsychological

MedicalPharmacologicalInterventional

Goals

Adapted from Jovey RD, 2008

Complementary and Alternative Medicine

Chronic pain self-management

programs

Goals Guide Treatment Options

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The Analgesic Toolbox

Non-opioid

Acetaminophen, ASA, COXIB, NSAID

Opioid Buprenorphine transdermal system, codeine, fentanyl transdermal system, hydromorphone, morphine, oxycodone, tramadol

Choice exists between IR (immediate release) and CR (controlled release)

formulations for many agents

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Basis for Opioid SelectionSelection Criteria:

Current /past efficacy and side effect profile of short-acting opioid

Convenience and compliance potential

Cost (coverage by drug plan or ability to pay)

Patient preference

History of abuse/misuse/diversion (screen)

Concomitant health conditions necessitating adjustments in dosage and/or dosing interval of some opioids (e.g., morphine or codeine in renal failure)

Compromised oral route

Evidence of molecule efficacy for different pain characteristics

Chou R et al, 2009; Gardiner-Nix; Wisconsin Medical Journal, 2004 ; Jovey RD et al, 2002

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Opioids: Initial Dose and Titration

18Maalis-Gagnon, Elafi Altlas 2010

Opioids: Initial Dose and Titration

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Morphine 10mg

Codeine 60mg

Oxycodone 7.5mg (O:M= 2:1 acute1.5:1 chronic)

Hydromorphone 2mg(H:M=5:1)

Meperidine 100mg

Methadone Variable

Transdermal fentanyl 25ug/h = 60-134 mg37ug/h = 135-179mg50ug/h = 180-224mg62ug/h = 225-269mg75ug/h = 270-314mg100ug/h = 360-404mg

PO Opioid Analgesic Equivalence table

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When patient:Does not realize meaningful pain relief from therapy

Has adverse reactions to opioids, such as depression or respiratory depression

Does not achieve reasonable therapeutic goals such as improved physical or social functioning, even with effective pain relief

When to Stop Opioid Therapy

Ballantyne JC et al, 2003; Benyamin R et al, 2008; Chou R et al, 2009; Porreca F et al,2009; Slatkin NE, 2009

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Discuss with the patient and other responsible persons who may be helpful. Patients with aberrant behaviour or addiction may refuse to comply and leave treatment, seeking opioids elsewhere.

› Controlled withdrawal from opioids is not dangerous

› May experience discomfort, anxiety, restlessness, nausea, sweating, etc.

Reassure patient of alternative plan for pain control.

Document discussions and provide a written treatment plan

If the patient is taking a sedative or benzodiazepine, these should be maintained

Tapering Opioid Therapy

Ballantyne JC et al, 2003; Chou R et al, 2009

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2010 National Opioid Use Guidelines (NOUG) serve to improve the responsible use of opioids in Canada

When considering the use of long-term opioid therapy, screening for addiction risk must be a part of the assessment process

Improvement in function as measured with the BPI is a key factor supporting the continuation of CR opioids in CNCP

Management of CNCP is multi-modal using non-opioid medications, interventional techniques and self-management strategies.

Key Learning Points

Thank You

Questions?