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Opioid prescribing for chronic non-malignant pain.

Opioid prescribing for chronic non-malignant pain.



Safe opioid prescribing recommendations.

Safe opioid prescribing recommendations.



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    Opioid prescribing for chronic non-malignant pain. Opioid prescribing for chronic non-malignant pain. Presentation Transcript

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