RESPONSIBLE OPIATE PRESCRIBINGCRESTA JONES MD

DISCLOSURES

No conflicts to report

OBJECTIVES

Understand the scope and extent of the opiate abuse crisis in the United States

Demonstrate appropriate opiate prescribing for both acute and chronic pain

Demonstrate appropriate use of prescription data monitoring programs (PDMPs), including as they apply to Wisconsin state law

THE OPIOID EPIDEMIC : US stats

Opioid overuse/abuse is an epidemicOpioids – leading cause of injury death Continuing to increase

Economic impact

$55 billion – health and social costs related to prescription opioid abuse per year

$20 billion – emergency department and inpatient care for opioid poisonings

hhs.gov/opioids

Just another day in the US….....

650,000 opioid prescriptions dispensed3900 people initiate nonmedical use

prescription opioids580 people initiate heroin use

hhs.gov/opioids

cdc.gov

cdc.gov

cdc.gov

THE OPIOID EPIDEMIC : WI

163,000 opiate use disorder Leading cause of injury deaths in Wisconsin

Motor vehicle accidents, suicide, firearms Prescription opioids – more overdose deaths

than heroin + cocaine

dhs.wisconsin.gov/publications/p01129.pdf

dhs.wisconsin.gov

Who uses opiates?

JAMA Psychiatry 2014

They started with a prescription….

…..and they are women.

HOW DID THIS HAPPEN?

Increased prescriptions

HOW DID THIS HAPPEN?

Increased prescriptions

1991: 76 million RX

HOW DID THIS HAPPEN?

Increased prescriptions

1991: 76 million RX 2014:

HOW DID THIS HAPPEN?

Increased prescriptions

1991: 76 million RX 2014, 240 million RX =

Every US adult - 5 mg hydrocodone every 6 hours for 45 days

hhs.gov/opioids

Opiate use disorder – United States

5% of the world population…..

…...80% of the world’s opiates!

www.samhsa.gov, March 2015

HOW DID THIS HAPPEN?

Increased social acceptability for use

HOW DID THIS HAPPEN?

Increased acceptability for use History – acute and cancer pain only 1996 – extended release for non – cancer pain

Oxycontin - ER “non addictive” Based on 1 year addiction rates 1%Postoperative IV narcotics

HOW DID THIS HAPPEN?

Aggressive marketing by pharmaceutical companies

SINCE 1999, OPIOID PRESCIPTIONS HAVE QUADRUPLED….

BUT REPORTED PAIN REMAINS UNCHANGED!

McNett, M – Wisconsin Medical Society

OPIATE PRESCRIBING GUIDELINES

www.wisconsinmedicalsociety.org

www.cdc.gov

www.dsps.wi.gov

www.painphysicianjournal.com

OPIATE PRESCRIBING GUIDELINES

www.dsps.wi.gov

OPIATE PRESCRIBING GUIDELINES Address acute and chronic pain Chronic – longer than 3 months, past expected

tissue healing Not for active cancer treatment, end-of-life,

palliative care Not designed for pediatric pain

www.dsps.wi.gov

1. EVALUATING PAIN

Pain is subjective Patient reported measures We must accept the patient’s report of pain….

Commensurate with causative factors? Factors adequately evaluated?Already addressed with non-opioid therapy?

2. TREATMENT OF ACUTE PAIN

Consider non-opioid first Opioid – START LOW AND GO SLOW!

Most less than 3 days (MAX: 5 days) CDC = 7 days

Consider med you can refill (APAP/codeine)Consider 2 small Rx, specific refill dates

TREATMENT OF ACUTE PAIN

Cochrane review – acute postoperative pain Number needed to treat (NNT)

50% maximum pain relief 4-6 hours, all types of surgery

Medication Number needed to treatIbuprofen 200mg/APAP 500 mg 1.6Naproxen 2.7Oxycodone 5mg/APAP 325 mg 2.7Oxycodone 15 mg 4.6

Moore et al., 2015

TREATMENT OF ACUTE PAIN

Cochrane review – acute postoperative pain Number needed to treat (NNT)

50% maximum pain relief 4-6 hours, all types of surgery

Medication Number needed to treatIbuprofen 200mg/APAP 500 mg 1.6Naproxen 2.7Oxycodone 5mg/APAP 325 mg 2.7Oxycodone 15 mg 4.6

Moore et al., 2015

Hill MV, et al, 2017 642 outpatient surgical procedures Partial mastectomies, laparoscopic cholecystectomy,

laparoscopic/open inguinal hernia repair Opiate naive patients

Hill et al., 2017

Hill et al., 2017

Hill et al., 2017

Hill et al., 2017

71% of opioid pills prescribed were NOT taken!!

Hill et al., 2017

What to do with all those extra meds?

Fire safe storage DEA National Drug Take-Back Days – April 29,

2017 Sealable plastic bag with water + dirt, cat

litter, coffee grounds Away from children Out of home for open house, social events

etc.

fda.gov

3. IDENTIFY AND TREAT THE CAUSE OF PAIN

Address the underlying condition as the primary objective

Avoid opiates if unwilling to obtain definitive treatment for condition causing pain

Avoid if medical condition present is not reasonably expected to cause pain severe enough for opioids Non-anatomic pain, residual pain at old surgical sites

Refer patient if needed

4. OPIOIDS ARE NOT ALWAYS THE FIRST CHOICE : ACUTE PAIN

Evidence for opioids is weak Try first

Acetaminophen/NSAIDs Lidocaine gel, biofreeze PT/OT Manipulation, massage Cognitive behavioral therapy

If severe enough for opioids, ALWAYS use in combination with other treatments

OPIOIDS ARE NOT ALWAYS THE FIRST CHOICE : ACUTE EXTENDED PAIN

Look for complications of acute pain: Surgical complication Nonunion of fracture Constipation as side effect of treatment

Complication ruled out, transition to non-opioid treatment

OPIOIDS ARE NOT ALWAYS THE FIRST CHOICE : ACUTE EXTENDED PAIN

Weaning opioids for acute extended pain (more than one week)

Decrease 10-25% per week Non-narcotics for acute pain treatment Start treatment for chronic pain – refer if indicated

OPIOIDS ARE NOT ALWAYS THE FIRST CHOICE : CHRONIC PAIN

Past expected healing >3 months Studies– few benefits, substantial increase mortality

72% INCREASE IN CARDIOVASCULAR MORTALITY No quality evidence to support use > 6 months Already initiated

Close monitoring, PDMP Refer for additional treatment Contract – no early fills, no other fills, urine drug screen

Patient obligations : opiate prescribing

I will not increase my dose or use without permission. I will not obtain opioids from other prescribers, or allow them to

adjust my dose. I will use the medication exactly as directed. I will never share, sell or allow others access to my medication. I will not receive early refills. I will not abuse other drugs or alcohol during my treatment. I will bring my pills and medication bottles to each appointment.

Patient obligations: opiate prescribing

I will call the office at least 2 business days before I need a refill. If I miss my appointment, I may not get a refill. I will not call for opioids during evenings, holidays or weekends. I will only use one pharmacy for my opioid prescriptions. I will give a urine drug screen anytime I am asked. I will notify the office as soon as possible of any new medical

condition. I will not drive or use heavy machinery while taking opioids. I will follow up as requested. I agree to allow my provider to contact all my other caregivers as

needed.

wisconsinmedicalsociety.org, Opiate CME programming

OPIOIDS ARE NOT ALWAYS THE FIRST CHOICE : UNWILLING PATIENT

Patient unwilling to accept other treatments Questionable justification for non – use “nothing else works” Intolerance to all other treatments

5. UTILIZE A SINGLE PROVIDER

Dedicated provider – primary care, pain specialist Check PDMP before start Ask about existing pain contracts Plan - acute pain outside office hours

Call immediately next office day Have ED contact primary prescriber

No early refills Fire safe

6. EXACERBATIONS OF CHRONIC PAIN

Avoid chronic pain treatment in the emergency dept.

Contact chronic pain doctor Avoid IV/IM opiates – preferred agent

hydromorphone Refer back to primary provider