Opioid Prescribing for
Chronic Non-Cancer Pain:
Weighing the Benefits &
Risks
Paul C. Coelho, MD
Board Certified PM&R
Subs...
Table Of Contents
1. Patient Expectations for
Pain Relief with Opioids
2. Actual Pain Relief with
Opioids
3. Risks of Opio...
1. Opioids: Realistic
Benefits
Patients Often Expect 75%
for Pain Relief with Opioids
Expectation
75% Pain Relief
2. Opioids: Actual Pain
Relief
Actual Pain Relief with
Opioids for Chronic Non-
Cancer Pain is about 30%
Actual Pain Relief
Is More Modest about 30%
Expectation (75%) vs
Reality (30%)
Patient Expectation
Medical Reality
Rising Opioid Overdose
Visits in the ER
Medicine Alone Does Not
Work Well for Chronic Pain
Pain Specialists Consider 30%
Relief a Success
Pain Specialists Also Use
Other Objective Measures
of Pain Relief
• Improved Sleep
• Decreased Depression
• Improved Fatig...
Pain Specialists Also Use
Other Therapies for Pain
• Activity Modifications
• Life-Style Changes:
• Weight-loss
• Smoking ...
3. Opioids: Real Risks
Common Opioid Side-
Effects
Breathing Problems
Nausea
Heart Attacks
Dizziness
Falls
Worsening Pain
Fractures
Decreased Sex...
Oregon Ranks #1 in the
Nation in Prescription
Opioid Abuse
Prescription Opioid Deaths
In Oregon 2000-2011
Women Are
Disproportionately Affected
By Overdose Deaths
More than 50% of patients
receiving opioids for 90d will
remain on opioids for years.
High Dose Opioids Use Is
Associated with Addiction &
Depression
1/3rd Of Patients Treated in
Addiction Clinics Come
From Pain Clinics
Prescription Opioid Deaths
& Addiction Treatment
Parallel Opioid Prescribing
4. Opioids: Risk Reduction
Who Can Not Be Treated
With Opioids
1. Any history of diversion (selling drugs)
2. A history of suicide attempts with medi...
Minimize Opioid Use In
Conditions For Which
There Is No Objective
Marker Of Disease
Chronic LBP
Fibromyalgia Syndrome
Chro...
Stratify Patients for Risk of
Abuse
Adopt WA State Dosing
Guidelines
1. Low Dose = <50 MED
2. Intermediate Dose = 50 -100MED
3. High Dose = > 100MED
Milligram...
Examples of 100MED
MSContin 30mg TID
Oxycontin 30mg po BID
Fentanyl Patch 25mcg/72hrs
Opana 20mg po BID
Nucynta 150mg po B...
Limiting Opioids Dose for
Non-Cancer Pain Saves
Lives
Limiting Opioids Dose for
Non-Cancer Pain Saves
Lives
Avoid Methadone
Avoid Methadone
Avoid Benzodiazepines :
Valium, Xanax, Soma
Prescribe Rescue
Medications & Training To
Special Populations
Set Reasonable
Expectations For
Treatment: 30% Relief
Utilize a Formal Treatment
Agreement
Document Adverse Effects
Adverse Effects:
1. Constipation
2. Somnolence
3. SOB
4. Falls
5. Automobile Accidents
6. ER Visi...
Document Improvement in
Function/Activities
Activities:
1. Exercise
2. Playing with kids/grand kids
3. Travel
4. Household...
Document Aberrant
Behaviors
1. Forging, altering, or stealing prescriptions
2. Stealing, borrowing, trading, buying, or se...
Aberrant Behaviors Lead
to Stopping Prescribing
1.Repeated aberrant behaviors necessitate
stopping the opioid trial.
2.The...
Access the Prescription
Drug Monitoring Program
With Each Visit
Acquire Random Urine
Toxicology Screening
Schedule a Minimum of
Quarterly Follow-Up
Physicians For
Responsible Opioid
Prescribing
www.supportprop.org
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Opioid patienttalk1

  1. 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. 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. 3. 1. Opioids: Realistic Benefits
  4. 4. Patients Often Expect 75% for Pain Relief with Opioids
  5. 5. Expectation 75% Pain Relief
  6. 6. 2. Opioids: Actual Pain Relief
  7. 7. Actual Pain Relief with Opioids for Chronic Non- Cancer Pain is about 30%
  8. 8. Actual Pain Relief Is More Modest about 30%
  9. 9. Expectation (75%) vs Reality (30%) Patient Expectation Medical Reality
  10. 10. Rising Opioid Overdose Visits in the ER
  11. 11. Medicine Alone Does Not Work Well for Chronic Pain
  12. 12. Pain Specialists Consider 30% Relief a Success
  13. 13. Pain Specialists Also Use Other Objective Measures of Pain Relief • Improved Sleep • Decreased Depression • Improved Fatigue • Improved Function • Return to Work
  14. 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. 15. 3. Opioids: Real Risks
  16. 16. Common Opioid Side- Effects Breathing Problems Nausea Heart Attacks Dizziness Falls Worsening Pain Fractures Decreased Sex Drive Immunosupression Dependency Addiction Overdose
  17. 17. Oregon Ranks #1 in the Nation in Prescription Opioid Abuse
  18. 18. Prescription Opioid Deaths In Oregon 2000-2011
  19. 19. Women Are Disproportionately Affected By Overdose Deaths
  20. 20. More than 50% of patients receiving opioids for 90d will remain on opioids for years.
  21. 21. High Dose Opioids Use Is Associated with Addiction & Depression
  22. 22. 1/3rd Of Patients Treated in Addiction Clinics Come From Pain Clinics
  23. 23. Prescription Opioid Deaths & Addiction Treatment Parallel Opioid Prescribing
  24. 24. 4. Opioids: Risk Reduction
  25. 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. 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. 27. Stratify Patients for Risk of Abuse
  28. 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. 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. 30. Limiting Opioids Dose for Non-Cancer Pain Saves Lives
  31. 31. Limiting Opioids Dose for Non-Cancer Pain Saves Lives
  32. 32. Avoid Methadone
  33. 33. Avoid Methadone
  34. 34. Avoid Benzodiazepines : Valium, Xanax, Soma
  35. 35. Prescribe Rescue Medications & Training To Special Populations
  36. 36. Set Reasonable Expectations For Treatment: 30% Relief
  37. 37. Utilize a Formal Treatment Agreement
  38. 38. Document Adverse Effects Adverse Effects: 1. Constipation 2. Somnolence 3. SOB 4. Falls 5. Automobile Accidents 6. ER Visits 7. DUI’s
  39. 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. 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. 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. 42. Access the Prescription Drug Monitoring Program With Each Visit
  43. 43. Acquire Random Urine Toxicology Screening
  44. 44. Schedule a Minimum of Quarterly Follow-Up
  45. 45. Physicians For Responsible Opioid Prescribing www.supportprop.org
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