Opioid patienttalk1
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Opioid patienttalk1 Presentation Transcript

  • 1. Opioid Prescribing for Chronic Non-Cancer Pain: Weighing the Benefits & Risks Paul C. Coelho, MD Board Certified PM&R Subspecialty Certified Pain Medicine
  • 2. Table Of Contents 1. Patient Expectations for Pain Relief with Opioids 2. Actual Pain Relief with Opioids 3. Risks of Opioids for Chronic Noncancer Pain 4. Risk Reduction Opioid Clinic
  • 3. 1. Opioids: Realistic Benefits
  • 4. Patients Often Expect 75% for Pain Relief with Opioids
  • 5. Expectation 75% Pain Relief
  • 6. 2. Opioids: Actual Pain Relief
  • 7. Actual Pain Relief with Opioids for Chronic Non- Cancer Pain is about 30%
  • 8. Actual Pain Relief Is More Modest about 30%
  • 9. Expectation (75%) vs Reality (30%) Patient Expectation Medical Reality
  • 10. Rising Opioid Overdose Visits in the ER
  • 11. Medicine Alone Does Not Work Well for Chronic Pain
  • 12. Pain Specialists Consider 30% Relief a Success
  • 13. Pain Specialists Also Use Other Objective Measures of Pain Relief • Improved Sleep • Decreased Depression • Improved Fatigue • Improved Function • Return to Work
  • 14. Pain Specialists Also Use Other Therapies for Pain • Activity Modifications • Life-Style Changes: • Weight-loss • Smoking Cessation • Aerobic Activity • Physical Therapy • Treatment of Depression • Treatment of Anxiety • Treatment of PTSD • Cognitive Behavioral Therapy • Treatment of Addiction/Dependency • Injections • Surgery
  • 15. 3. Opioids: Real Risks
  • 16. Common Opioid Side- Effects Breathing Problems Nausea Heart Attacks Dizziness Falls Worsening Pain Fractures Decreased Sex Drive Immunosupression Dependency Addiction Overdose
  • 17. Oregon Ranks #1 in the Nation in Prescription Opioid Abuse
  • 18. Prescription Opioid Deaths In Oregon 2000-2011
  • 19. Women Are Disproportionately Affected By Overdose Deaths
  • 20. More than 50% of patients receiving opioids for 90d will remain on opioids for years.
  • 21. High Dose Opioids Use Is Associated with Addiction & Depression
  • 22. 1/3rd Of Patients Treated in Addiction Clinics Come From Pain Clinics
  • 23. Prescription Opioid Deaths & Addiction Treatment Parallel Opioid Prescribing
  • 24. 4. Opioids: Risk Reduction
  • 25. Who Can Not Be Treated With Opioids 1. Any history of diversion (selling drugs) 2. A history of suicide attempts with medication 3. Current methadone maintenance (addiction treatment) 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 (doctor shopping) 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
  • 26. 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
  • 27. Stratify Patients for Risk of Abuse
  • 28. Adopt WA State Dosing Guidelines 1. Low Dose = <50 MED 2. Intermediate Dose = 50 -100MED 3. High Dose = > 100MED Milligrams Equivalent Dose (MS04)
  • 29. Examples of 100MED MSContin 30mg TID Oxycontin 30mg po BID Fentanyl Patch 25mcg/72hrs Opana 20mg po BID Nucynta 150mg po BID *Methadone 15mg po BID
  • 30. Limiting Opioids Dose for Non-Cancer Pain Saves Lives
  • 31. Limiting Opioids Dose for Non-Cancer Pain Saves Lives
  • 32. Avoid Methadone
  • 33. Avoid Methadone
  • 34. Avoid Benzodiazepines : Valium, Xanax, Soma
  • 35. Prescribe Rescue Medications & Training To Special Populations
  • 36. Set Reasonable Expectations For Treatment: 30% Relief
  • 37. Utilize a Formal Treatment Agreement
  • 38. Document Adverse Effects Adverse Effects: 1. Constipation 2. Somnolence 3. SOB 4. Falls 5. Automobile Accidents 6. ER Visits 7. DUI’s
  • 39. Document Improvement in Function/Activities Activities: 1. Exercise 2. Playing with kids/grand kids 3. Travel 4. Household chores 5. Socializing 6. Return to work
  • 40. 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 17. Marijuana use regardless of authorization status 18. Refusing random urine , blood, or saliva toxicology tests 19. Refusing or ‘no-showing’ for random pill counts
  • 41. Aberrant Behaviors Lead to Stopping Prescribing 1.Repeated aberrant behaviors necessitate stopping the opioid trial. 2.The Oregon Medical Board considers patients whose aberrant behavior lead to a dismissal violation with one doctor to be unsuitable for opioid treatment with another doctor.
  • 42. Access the Prescription Drug Monitoring Program With Each Visit
  • 43. Acquire Random Urine Toxicology Screening
  • 44. Schedule a Minimum of Quarterly Follow-Up
  • 45. Physicians For Responsible Opioid Prescribing www.supportprop.org