Opioid prescribing for chronic non-malignant pain.

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Safe opioid prescribing recommendations.

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Opioid prescribing for chronic non-malignant pain.

  1. 1. Responsible Opioid Prescribing for Chronic Non-Malignant Pain Paul C. Coelho, MD Board Certified PM&R Subspecialty Certified Pain Medicine Nothing To Disclose
  2. 2. 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
  3. 3. Prescription Drug Abuse in the US http://tinyurl.com/6d9yxgz
  4. 4. Prescription Drug Abuse in the US http://www.cdc.gov/homeandrecreationalsafety/rxbrief/
  5. 5. Wide Variation in Prescribing Patterns http://www.ncbi.nlm.nih.gov/pubmed/23031398
  6. 6. Who is doing all the Prescribing? http://tinyurl.com/lrkcdql
  7. 7. What Are They Prescribing For? http://tinyurl.com/lrkcdql
  8. 8. rd 1/3 Of Patients Treated in Addiction Clinics Come From Pain Clinics http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3129653/
  9. 9. Prescription Opioid Deaths & Addiction Treatment Parallel Opioid Prescribing http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm
  10. 10. More than ½ of patients receiving opioids for 90d remain on opioids for years. http://www.ncbi.nlm.nih.gov/pubmed/21751058
  11. 11. Total Opioids Prescribed By Age http://www.fda.gov/downloads/Drugs/NewsEvents/UCM300859.pdf
  12. 12. Average Age of Unintentional Opioid ODs http://www.fda.gov/downloads/Drugs/NewsEvents/UCM300859.pdf
  13. 13. Risk Factors for ODD Doctor/NP/PA Shopping http://www.fda.gov/downloads/Drugs/NewsEvents/UCM300859.pdf
  14. 14. Risk Factors for Unintentional ODD
  15. 15. Risk Factors for Unintentional ODD Dose http://www.fda.gov/downloads/Drugs/NewsEvents/UCM300859.pdf
  16. 16. Summary of Risk Factors for Unintentional ODD http://www.fda.gov/downloads/Drugs/NewsEvents/UCM300859.pdf
  17. 17. Oregon Ranks #1 in the Nation in Prescription Opioid Abuse http://www.samhsa.gov/data/2k12/NSDUH115/sr115-nonmedical-use-pain-relievers.htm
  18. 18. Oregon’s ODD Rate is Higher than National Avg http://www.cdc.gov/nchs/data/databriefs/db22.pdf
  19. 19. Top Oregon Counties for Opioid Prescriptions County 250 200 150 100 50 0 http://tinyurl.com/mr9dttb
  20. 20. Prescription Opioid Deaths In Oregon 2000-2011 http://preview.tinyurl.com/mza7766
  21. 21. Cautious, Evidence-Based Opioid Prescribing
  22. 22. Primary Prevention
  23. 23. OMB’s11 ContraIndications 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
  24. 24. 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
  25. 25. Stratify Patients for Risk of Abuse DIRE SOAPP-R COMM
  26. 26. Diagnosis, Intractability, Risk, Efficacy http://tinyurl.com/lks94bf
  27. 27. 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
  28. 28. 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
  29. 29. Limiting Opioids to 120MED for CNP Saves Lives http://tinyurl.com/mmazr8y
  30. 30. Limiting Opioids to 120MED for CNP Saves Lives http://www.ncbi.nlm.nih.gov/pubmed/22213274
  31. 31. Prescribe Nasal Naloxone to High Dose Patients http://tinyurl.com/kzvs443
  32. 32. Prescribe Nasal Naloxone to High Dose Patients http://gov.oregonlive.com/bill/2013/SB384/
  33. 33. Avoid Methadone http://tinyurl.com/mb2lj6r/
  34. 34. Avoid Methadone http://tinyurl.com/kpuh547
  35. 35. Avoid Co-administration of Benzodiazepines http://tinyurl.com/abnywac
  36. 36. Urge Caution With Alcohol Use http://tinyurl.com/ly6o6vj
  37. 37. Set Reasonable Expectations For Treatment http://www.ncbi.nlm.nih.gov/pubmed?cmd=historysearch&querykey=5
  38. 38. Utilize a Formal Material Risk Notice http://www.oregon.gov/omb/pdfforms/materialrisknotice.pdf
  39. 39. Utilize a Formal Treatment Agreement http://www.oregon.gov/omb/newsletter/winter2011.pdf
  40. 40. Secondary Surveillance
  41. 41. Document the 5 A’s With th 2x/yr Each Visit & the 6 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
  42. 42. Activity Level 1. Activity Level: 1. ADLs 2. Exercise 3. Walking 4. Objective evidence of functional improvement.
  43. 43. Adverse Effects 1. Adverse Effects: 1. Constipation 2. Somnolence 3. SOB 4. Falls 5. Automobile Accidents/DUI’s 6. ER Visits
  44. 44. Analgesia 1. Analgesia: 1. NRS (0-10) 2. VAS
  45. 45. 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
  46. 46. 25% of CNP Patients Exhibit Aberrant Behavior http://www.ncbi.nlm.nih.gov/pubmed?cmd=historysearch&querykey=3
  47. 47. 38% of UDS Samples Showed No Drug http://www.ncbi.nlm.nih.gov/pubmed/19663620
  48. 48. Aberrant Behavior is a Predictor of OD http://www.ncbi.nlm.nih.gov/pubmed/23070654
  49. 49. Access the PDMP https://orpdmp-ph.hidinc.com/ Document your access to the PDMP with each Quarterly or Half-yearly f/u visit.
  50. 50. Acquire Random UTS/STS
  51. 51. Oregon Medical Marijuana Program http://tinyurl.com/klx8vn5
  52. 52. OMMP Patient Demographics http://tinyurl.com/modae4l
  53. 53. NSDUH Data 70% Male < 35yrs http://preview.tinyurl.com/k48rkys
  54. 54. 30% of Heavy Users CoUtilize other Illicits http://preview.tinyurl.com/k48rkys
  55. 55. 40% of Heavy Users Use Alcohol Heavily http://preview.tinyurl.com/k48rkys
  56. 56. 20% of Users Consume 80% of the Product http://preview.tinyurl.com/k48rkys
  57. 57. OMMP Has Not Diminished Opioid Prescribing http://www.martin.uky.edu/centers_research/Capstones_2012/Farley.pdf
  58. 58. OMMP Has Not Diminished Suicide Rates in OR http://preview.tinyurl.com/lweycl7
  59. 59. Fatal MVAs Involving THC have Tripled over 10yrs http://www.ncbi.nlm.nih.gov/pubmed/24076302
  60. 60. Cannabis Impairs Driving Skills http://www.ncbi.nlm.nih.gov/pubmed?cmd=historysearch&querykey=6
  61. 61. Marijuana As a Harbinger of Prescribed Opioid Misuse http://www.ncbi.nlm.nih.gov/pubmed/19793342
  62. 62. Marijuana & the OMB http://tinyurl.com/lr9hwhh
  63. 63. Quarterly Follow-Up http://www.deadiversion.usdoj.gov/fed_regs/rules/2006/fr0906.htm
  64. 64. 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
  65. 65. Copies of This Presentation: http://www.slideshare.net/101N
  66. 66. Thank You www.supportprop.org

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