Review of guidelines for new Washington law on opioid dosing guidelines.

1. Opioids in Chronic
Non-cancer Pain
Jonathan Ploudré
Family Doc @ North Cascade Family Physicians

2. Jonathan Ploudré, MD

3. 2004

4. TFM Pain Policy
• No Refills on Friday afternoon.
• Pulling a knife = kicked out.

5. Red Flag

6. FP Scope

7. What % of prescriptions are opiates?
8
6
# of Providers
4
2
0
0-5% 5-10% 10-15% 15-20% 20-25%
Unpublished: Jonathan Ploudré, 2004
Range: 4-25%

8. Gaussian?
What % of prescriptions are opiates?
8
6
# of Providers
4
2
0
0-5% 5-10% 10-15% 15-20% 20-25%
Unpublished: Jonathan Ploudré, 2004
Range: 4-25%

9. No one knew that.
And we had to keep it confidential

10. Bias

11. Cognitive Biases
• Blind spot Bias
• Confirmation Bias
• False Consensus Effect
• Stereotyping Bias
Wikipedia: Cognitive Biases

12. Limbic Tilt
Scrooge Tiny Tim

13. Trust
Trust no one.
God Bless us, every one.

14. Control
Verify Everything.
Merry Christmas, Sir.

15. Where are you?

16. The Elephant

17. …and Pain is subjective

18. Starting Opioids
• Complete the database (5Ws and H)
• Screen various risks for opioids
• Informed Consent
• Treatment Plan

19. Basic History
• Previous Workup
• Previous Treatments (Dose, etc)
• (Review Prescription Monitoring Program)
• Nature/Location of Pain
• Impact of physical/psychological function
• Respiratory Risks? (OSA, COPD)

20. Basic History
• Previous Workup
• Previous Treatments (Dose, etc)
• (Review Prescription Monitoring Program)
• Nature/Location of Pain
• Impact of physical/psychological function
• Respiratory Risks? (OSA, COPD)

21. Basic History
• Previous Workuprecords before starting.
Get
Verify First.
• Previous Treatments (Dose, etc)
• (Review Prescription Monitoring Program)
• Nature/Location of Pain
• Impact of physical/psychological function
• Respiratory Risks? (OSA, COPD)

22. Starting Opioids
• Complete the database (5Ws and H)
• Screen various risks for opioids
• Informed Consent
• Treatment Plan

23. “Framingham of Risk”

24. Risk Stratification
Etiology Clear Unclear
Psych No Hx Unstable Mood
Addiction No Hx Active Addiction
Medical No Comorbidities COPD, OSA
Social Good Support Isolated/Chaos
Activity Work/Hobbies No Work/Hobbies
Adapted: Stephen Passik

25. Risk Stratification
Etiology Clear Unclear
Psych No Hx Unstable Mood
Addiction No Hx Active Addiction
Medical No Comorbidities COPD, OSA
Social Good Support Isolated/Chaos
Activity Work/Hobbies No Work/Hobbies
Adapted: Stephen Passik

26. Risk Stratification
Etiology Clear
Patients with no Unclear still
risk can
divert or abuse prescriptions
Psych No Hx Unstable Mood
Addiction No Hx Active Addiction
Medical No Comorbidities COPD, OSA
Social Good Support Isolated/Chaos
Activity Work/Hobbies No Work/Hobbies
Adapted: Stephen Passik

27. Risk Stratification
Etiology Clear
Patients with no Unclear still
risk can
divert or abuse prescriptions
Psych No Hx Unstable Mood
Addiction No Hx Active Addiction
Medical No Comorbiditiesmany risksOSA
Patients with COPD, still
need care. Refer to a specialist.
Social Good Support Isolated/Chaos
Activity Work/Hobbies No Work/Hobbies
Adapted: Stephen Passik

28. Opioid Risk Tool (ORT)
Opioid Risk Tool
Patient Form
Name Date
Mark each box that applies Female Male
1. Family history of substance abuse ! Alcohol [ ] [ ]
! Illegal drugs [ ] [ ]
! Prescription drugs [ ] [ ]
2. Personal history of substance abuse ! Alcohol [ ] [ ]
! Illegal drugs [ ] [ ]
! Prescription drugs [ ] [ ]
3. Age (mark box if 16-45 years) [ ] [ ]
4. History of preadolescent sexual abuse [ ] [ ]
5. Psychological disease ! Attention-deficit/
hyperactivity
disorder, obsessive-
compulsive
disorder, bipolar
disorder,
schizophrenia [ ] [ ]
! Depression [ ] [ ]
Webster, 2005. Recommended Tool by Interagency Guidelines. Copyright © Lynn R. Webster, MD. Used with permission.

29. Opioid Risk Tool
Name
Opioid Risk Tool (ORT)
Physician Form
With Item Values to Determine Risk Score
Date
Mark each box that applies Female Male
1. Family history of substance abuse ! Alcohol [ ] 1 [ ] 3
! Illegal drugs [ ] 2 [ ] 3
! Prescription drugs [ ] 4 [ ] 4
2. Personal history of substance abuse ! Alcohol [ ] 3 [ ] 3
! Illegal drugs [ ] 4 [ ] 4
! Prescription drugs [ ] 5 [ ] 5
3. Age (mark box if 16-45 years) [ ] 1 [ ] 1
4. History of preadolescent sexual abuse [ ] 3 [ ] 0
5. Psychological disease ! Attention-deficit/
hyperactivity
disorder, obsessive-
compulsive
disorder, bipolar
disorder,
schizophrenia [ ] 2 [ ] 2
! Depression [ ] 1 [ ] 1
Low (0-3) Moderate (4-7) High (≥8) Scoring totals [ ] [ ]
OR Aberrant Behaviors: Low 0.08, Mod 0.57, High 14.3 Copyright © Lynn R. Webster, MD. Used with permission.
Webster, 2005

30. Opioid Risk Tool
Mark each box that applies Female Male
1. Family history of substance abuse ! Alcohol [ ] 1 [ ] 3
! Illegal drugs [ ] 2 [ ] 3
! Prescription drugs [ ] 4 [ ] 4
2. Personal history of substance abuse ! Alcohol [ ] 3 [ ] 3
! Illegal drugs [ ] 4 [ ] 4
! Prescription drugs [ ] 5 [ ] 5
3. Age (mark box if 16-45 years) [ ] 1 [ ] 1
4. History of preadolescent sexual abuse [ ] 3 [ ] 0
5. Psychological disease ! Attention-deficit/
hyperactivity
disorder, obsessive-
compulsive
disorder, bipolar
disorder,
schizophrenia [ ] 2 [ ] 2
! Depression [ ] 1 [ ] 1
Low (0-3) Moderate (4-7) High (≥8) Scoring totals [ ] [ ]
OR Aberrant Behaviors: Low 0.08, Mod 0.57, High 14.3
Webster, 2005

31. Opioid Risk Tool
Mark each box that applies Female Male
1. Family history of substance abuse ! Alcohol [ ] 1 [ ] 3
! Illegal drugs [ ] 2 [ ] 3
! Prescription drugs [ ] 4 [ ] 4
2. Personal history of substance abuse ! Alcohol [ ] 3 [ ] 3
! Illegal drugs [ ] 4 [ ] 4
! Prescription drugs [ ] 5 [ ] 5
3. Age (mark box if 16-45 years) [ ] 1 [ ] 1
Pain Center Study: Might
4. History of preadolescent sexual abuse [ ] 3 [ ] 0
5. Psychological disease overestimate aberrant
! Attention-deficit/
hyperactivity
behaviors disorder, obsessive-
compulsive
disorder, bipolar
disorder,
schizophrenia [ ] 2 [ ] 2
! Depression [ ] 1 [ ] 1
Low (0-3) Moderate (4-7) High (≥8) Scoring totals [ ] [ ]
OR Aberrant Behaviors: Low 0.08, Mod 0.57, High 14.3
Webster, 2005

32. Depression Screening
Interagency Guidelines Preferred: PHQ-9

33. Alcohol Screening
CAGE adjusted to include drugs
• Have you ever felt you ought to cut down on your drinking
or drug use?
• Have people annoyed you by criticizing your drinking or drug
use?
• Have you ever felt bad or guilty about your drinking or drug
use?
• Have you ever had a drink or used drugs first thing in the
morning (eye-opener) to steady your nerves or to get rid of
a hangover?

34. Starting Opioids
• Complete the database (5Ws and H)
• Screen various risks for opioids
• Informed Consent
• Treatment Plan

35. Informed Consent
• Risks/Benefits
• Alternatives
• Risks of non-treatment

36. Informed Consent
Consent improves
consideration of risks and
alternatives.
• Risks/Benefits
• Alternatives Consent can be used as a
• Risks of non-treatment treatment
barrier to

37. Informed Consent
• Provider Bias can show up in
Risks/Benefits
how consent is performed.
• Alternatives
• Risks of non-treatment

38. Starting Opioids
• Complete the database (5Ws and H)
• Screen various risks for opioids
• Informed Consent
• Treatment Plan

39. Treatment Plan
• Improve Function

40. Treatment Plan
Get back to work.
(Biomedical)
• Improve Function

41. Treatment Plan
Get back to work.
(Biomedical)
• Improve Function Mood, Sleep.
Patient-centered: Physical,
Social,
(Biopsychosocial)

42. How would we know
that this is working for
you without using the
word ‘pain’?
Mark Sullivan, University of Washington

43. Monitoring Opioids
• Documentation Tool (5 A’s)
• Treatment Agreement
• Urine Toxicology

44. The 5 A’s
• Analgesia
• Adverse Reactions
• ADLs Improved
• Aberrant Behaviors
• Assessment
Stephen Passik

45. Chronic Pain Opioid Followup
Current Analgesic Regimen: ________________________________________
_____________________________________________________________________
Analgesia Improved ADLs
What was your average pain over the past Physical Functioning
week? Family Relationships
Social Relationships
What was your worst pain in the past week?
Mood
What percentage of your pain has been re- Sleep patterns
lieved during the past week? Overall Function
Is the amount of pain relief you are now get-
ting enough to make a real difference in your
life?
Adverse Reactions Aberrant Behaviors
Nausea Purposeful Over-sedation
Vomiting Negative mood change
Constipation Appears intoxicated
Itching Increasingly unkempt or impaired
Mental Cloudiness Involvement in car or other accidents
Sweating Requests for frequent early renewals
Fatigue Increasing dose without authorization
Drowsiness Reports lost/stolen prescriptions
Prescriptions from other doctors
Changes route of administration
Uses medications in response to situa-
tional stressors
Insists on certain medications by name
Contact with street drug culture
Abusing alcohol or illicit drugs
Hoarding (Stockpiling) of medication
Arrested by police or Victim of abuse
Assessment:
Yes / No / Uncertain : Benefits of opiates outweigh the risks in this patient.
Continue Same Dose
Titrate Dose
Discontinue/Taper
Change Medications

46. Chronic Pain Opioid Followup
Current Analgesic Regimen: ________________________________________
_____________________________________________________________________
Analgesia Improved ADLs
What was your average pain over the past Physical Functioning
week? Family Relationships
Social Relationships
What was your worst pain in the past week?
Mood
What percentage of your pain has been re- Sleep patterns
lieved during the past week? Overall Function
Having a standard group of
Is the amount of pain relief you are now get-
ting enough to make a real difference in your
life?
Adverse Reactions aberrant behaviors can aid a
Aberrant Behaviors
Nausea
Vomiting team approach to monitoring Purposeful Over-sedation
Negative mood change
Constipation Appears intoxicated
Itching Increasingly unkempt or impaired
Mental Cloudiness Involvement in car or other accidents
Sweating Requests for frequent early renewals
Fatigue Increasing dose without authorization
Drowsiness Reports lost/stolen prescriptions
Prescriptions from other doctors
Changes route of administration
Uses medications in response to situa-
tional stressors
Insists on certain medications by name
Contact with street drug culture
Abusing alcohol or illicit drugs
Hoarding (Stockpiling) of medication
Arrested by police or Victim of abuse
Assessment:
Yes / No / Uncertain : Benefits of opiates outweigh the risks in this patient.
Continue Same Dose
Titrate Dose
Discontinue/Taper
Change Medications

47. Chronic Pain Opioid Followup
Current Analgesic Regimen: ________________________________________
_____________________________________________________________________
Analgesia Improved ADLs
What was your average pain over the past Physical Functioning
week? Family Relationships
Social Relationships
What was your worst pain in the past week?
Mood
What percentage of your pain has been re- Sleep patterns
lieved during the past week? Overall Function
Is the amount of pain relief you are now get-
ting enough to make a real difference in your
life?
Adverse Reactions Aberrant Behaviors
Nausea Purposeful Over-sedation
Vomiting
Constipation It’s Not what Negative mood change
Appears intoxicated
you do but
Itching Increasingly unkempt or impaired
Mental Cloudiness Involvement in car or other accidents
Sweating Requests for frequent early renewals
what you
Fatigue Increasing dose without authorization
Drowsiness Reports lost/stolen prescriptions
Prescriptions from other doctors
document.
Changes route of administration
Uses medications in response to situa-
tional stressors
Insists on certain medications by name
Contact with street drug culture
Abusing alcohol or illicit drugs
Hoarding (Stockpiling) of medication
Arrested by police or Victim of abuse
Assessment:
Yes / No / Uncertain : Benefits of opiates outweigh the risks in this patient.
Continue Same Dose
Titrate Dose
Discontinue/Taper
Change Medications

48. Monitoring Opioids
• Documentation Tool (5 A’s)
• Treatment Agreement
• Urine Toxicology

49. The Document
• Contract or Agreement?
• Universal or High-Risk?
• Reading Level (if College-level are you
really enabling care?)

50. The Document
I like 12 page contracts
written at 15th grade level in
• Contract or Agreement?10 point type.
• Universal or High-Risk?
• Reading Level I(if College-level OK?”.
just say “Be Nice, are you
really enabling care?)

51. NCFP Treatment
Agreement
• Preferred Brief/Simple over complete/legal.
• Preferred low readability requirement
• Reviewed Evidence about Treatment
Agreements.
• Preferred ‘Non-paternalistic’ tone.
Sloane Winkes, Jonathan Ploudré, 2007

52. NCFP Treatment
Agreement
• Preferred Brief/Simple over complete/legal.
• Preferred low readability requirement
• Is this a barrier to care? No
Reviewed Evidence about Treatment
evidence of efficacy. No ‘Best
Agreements.
Practice’. Highly Variable.
• Preferred ‘Non-paternalistic’ tone.
Sloane Winkes, Jonathan Ploudré, 2007

53. You are being prescribed controlled or potentially addictive medications for the
treatment of pain or other health problems. These may include medications that can be
habit-forming. It is our legal responsibility as health care providers, and our responsibility
to you, to do our best to assure that this medication is being used as safely as possible
and for the purpose for which it is intended.
1.
I will take my medications only as prescribed. I will not share them with or sell them
to anyone else. I will not use recreational or illegal drugs.
2.
My doctor may verify this with periodic pharmacy checks, urine drug screens, and/or
discussion with other health care providers.
3.
I will ask for refills only from my primary doctor and will use only one pharmacy.
4.
I will request refills only when due and realize that processing refill requests may
take 3 working days and may require an office visit.
5.
I will not seek pain medications from the ER or Urgent Care unless there is a new,
acute problem that requires a small supply of medications until I can see my primary
doctor.
6.
I will avoid requesting pain medications outside of regular clinic hours.
7.
I realize that my doctor may not replace lost or stolen medications or prescriptions.
8.
I will treat North Cascade Family Physicians doctors, nurses and staff with courtesy
and expect to be treated with courtesy in return. Failure to do so will result in dismissal
from this clinic.
9.
The following behaviors, which may include an abnormal urine drug screen, abusive
behavior toward staff, selling medications or forging a prescription, in addition to abuse or
violation of this agreement and the medication(s) it applies to may result in dismissal from
North Cascade Family Physicians and you will receive no further controlled
medication(s).

54. How’d we do?
A -
• 1 page Document (not 10!)
• 10th grade reading level (could be
improved)
• MQAC: Add Patient’s responsibility to
safeguard medication.

55. Monitoring Opioids
• Documentation Tool (5 A’s)
• Treatment Agreement
• Urine Toxicology

56. Urine Toxicology
~⅓ Addicts missed if you only
look at aberrant behavior.
Self-report of illicit drug use is
unreliable.
Limited evidence shows could
reduce aberrant behaviors.

57. Urine Toxicology
Increases Cost.
If not careful, can be easy to
mis-interpret.
Can still be tricked — limits to
‘hard science’, sooner or later
it comes back to trust.

58. Google: Employee Drug Testing Ace 12 panel
The i-Cup

59. Point of Care Utox
• The ‘iCup’ costs ~$9.
• Photocopyable results.
• Tests: illicit (cocaine, THC, amphetamine,
Meth, PCP) other prescription misuse
(benzo, barbituates, tri-cyclics) and opiates
(opiates, Methadone, Oxycodone,
Propoxyphene.
• Most drugs detected in last 1-3 days.
• Temperature Strip, Checks 3 Adulterants.

60. If only it were that
simple…

61. Point of Care Limits
• Low Sensitivity and Specificity (needs
confirmation in high risk situations)
• Cross Reactions cause false positives
• False Negatives due to higher thresholds.

62. How to Collect?
• AAFP Article 2010: Take off outer clothing,
show what’s in your pockets, wash hands
under supervision, place bluing agent in
toilet and turn off water supply to the
testing site.
• Mayo Clinic Proceedings: If adulteration is
suspected or results fall outside these
ranges, another specimen should be
collected under direct, observed
supervision
Google: “AAFP Urine Drug Screening”, “Mayo Proceedings Urine Drug”

63. How to Collect?
• AAFP ArticleEven with precautions, these
2010: Take off outer clothing,
show what’s in your pockets, wash hands
under supervision, still be bluing agent if
test can place evaded. Easily in
you use Google.
toilet and turn off water supply to the
testing site.
• Mayo Clinic Proceedings: If adulteration is
suspected or results fall outside these
ranges, another specimen should be
collected under direct, observed
supervision

64. How to Collect?
• What’s your pre-test probability?

65. False Positives
• Amphetamines: Buproprion, Propranolol,
Trazadone …
• Barbituates: Phenytoin
• Benzos: Sertraline, …
• LSD: Amitriptyline, Doxepin, Reglan,
Sertraline, Verapamil, …
• PCP: Dextromethorphan, …
• Propoxyphene: Methadone, Doxylamine, …
Google: “Mayo Proceedings Urine Drug” for complete list

66. False Positives
• Amphetamines: Buproprion, Propranolol,
Trazadone …
• Barbituates: Phenytoin
• Benzos: Sertraline, …
• LSD: Amitriptyline, Doxepin, Reglan,
If you’re not careful with
confirmation, false positives
Sertraline, Verapamil, …
can disrupt therapy and trust.
• PCP: Dextromethorphan, …
• Propoxyphene: Methadone, Doxylamine, …

67. False Negatives
• Compliance Caveat: Many opiates are not
well detected with routine urine tox.
Fentanyl, meperidine,Hydrocodone,
methadone, oxycodone, buprenorphene,
and tramadol.

68. Confirmation Tests
• More expensive (~$40 each, may need to
do several to clarify based on drug
metabolism)

69. Just Skip Urine Tox?
• Standard of care in Interagency Guidelines.
• Standard of care in MQAC

70. Consider the 2007 DEA Ruling
on Sequential Prescribing.
“Do Not Fill until __/__/__”
Allows 90 day prescription of
Schedule II Opioids.
The Glamour Shot

71. Thanks
Knife: http://www.flickr.com/photos/abolotnov/3357438961/
Red Flag:http://www.flickr.com/photos/tragically_dork/2649650515/
Speed Limit Sign: http://www.flickr.com/photos/joeshlabotnik/497312470/
The Elephant: http://www.flickr.com/photos/thelivelygirl/5261389796/
Subjective: http://www.flickr.com/photos/evrtstudio/3843749410
Framingham: http://www.flickr.com/photos/chilledsalad/394558980/
Tiny Tim: http://danidraws.com/2009/12/16/12-days-of-a-christmas-carol-tiny-
tim/
Scrooge: http://danidraws.com/2009/12/01/12-days-of-a-christmas-carol-
grumpy-scrooge/