Bend Harm Reduction Talk
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Harm reduction for chronic opioid patients.
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Bend Harm Reduction Talk
- 1. Harm Reduction Strategies for Chronic Pain Patients Paul C. Coelho, MD Board Certified PM&R Subspecialty Certified Pain Medicine
- 2. Disclosures Paul Coelho,MD: No industry financial relationships to disclose. I am a member of the OPG planning committee and on the OPG speakers bureau.
- 3. Table Of Contents 1. Opioid Overdose Deaths (ODD) 2. 2016 CDC Opioid Guidelines 3. Risk Factors for an ODD 4. Risk Factors for Opioid Use Disorder (Addiction) 5. Harm Reduction Strategies 6. Sample Cases
- 4. 0 12500 25000 37500 50000 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 US Opioid Overdose Deaths 1980-2014 Peak Incidence of Prescription ODD Age 45-54*
- 5. Death Rates 2000- 2015 http://www.pnas.org/content/112/49/15078.full.pdf
- 6. 0 12500 25000 37500 50000 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 Injection IncreasesVs Opioid ODD 0 100 200 300 Opioid Overdose Deaths Increased 250% Spinal Injections Increased 375%
- 10. Risk Factors for Overdose Death 1. Opioid Dose 2. Methadone 3. Opioids + Benzodiazepines/Sedative
- 11. Dose as a Risk Factor For ODD https://www.aan.com/uploadedFiles/Website_Library_Assets/Documents/3.Practice_Management/2.Quality_Improvement/ 2.Patient_Safety/2.Patient_Safety_Education/C171%20-%20Franklin.pdf
- 12. Methadone as a Risk Factor for ODD http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6126a5.htm 1/3rd of all ODD
- 13. Co-Rx’d Benzos as a Risk Factor for ODD http://www.ncbi.nlm.nih.gov/pubmed/26890165 1/3rd of all ODD
- 14. Risk Factors for Opioid Use Disorder 1. Age 2. Length of Exposure 3. Dose 4. Psychosocial Factors: a. H/o drug/alcohol tobacco abuse b. Family hx of drug/alcohol abuse c. H/o childhood trauma/abuse d. Intercurrent mental health ds
- 15. Prescribed Opioid Addiction Tx By Age http://www.samhsa.gov/data/sites/default/files/2013_Treatment_Episode_Data_Set_National/ 2003_2013_Treatment_Episode_Data_Set_National_Body.html 2013
- 16. Opioid Use Disorder Dx By Age http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4032801/ 0 10 20 30 40 18-30 31-40 41-50 51-64 >65 N = 570K
- 17. OR Medicaid Opioid Rx’s By Age (86% 18-60yrs) http://www.ncbi.nlm.nih.gov/pubmed/26766755 0 22.5 45 67.5 90 18-39 40-59 60-79 >80 Top 10% Prescribers Rx’d 80% All Opioids
- 18. Dose & Length of Exposure As Risk Factors For OUD http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4032801/ Low Dose 0-36MED Med Dose 37-120MED High Dose > 120MED
- 20. Identify At Risk Patients 1. Morphine Equivalent Dose > 120mg/day 2. Methadone 3. Opioid and co-prescribed benzodiazepine 4. H/o aberrant behavior or addiction
- 24. Coelho’s PDMP Dashboard https://orpdmp-ph.hidinc.com/orlogappl/bdorpdmqlog/pmqhome.html Patient Name Dose >120 MED Methadone Benzodiazepine >90 Days Use > 4 Pharmacies/ Prescribers 167 39 (23%) 4 (2%) 98 (59%) 79 (47%) 4 (2%)
- 26. Examples of 120MED Fentanyl 50ucg/hr Buprenorphine 4mg Methadone 30mg Hydromorphone 30mg Oxycodone 80mg Oxymorphone 40mg Morphine 120mg Codeine 800mg
- 27. MED > 90 Prescribe Nasal Naloxone 1. SB 384 legalized for lay administration in 2013. 2. Stock in your pharmacies. 3. Some patients must pay out of pocket ($35.00 -$75.00) http://www.amphastar.com/assets/naloxone.pdf
- 28. Consider a Data 2000 Waiver: Buprenorphine http://projects.huffingtonpost.com/dying-to-be-free-heroin-treatment/opioid-abuse-outpace-treatment-capacity 17K MD/DO in OR, 400 with Waiver [2%]
- 29. Buprenorphine 1. Schedule III drug, partial mu agonist 2. FDA approved for both pain - Butrans/Belbuca - and addiction - Suboxone/Subutex. 3. Ceiling effect for respiratory suppression (RS).
- 30. Buprenorphine’s Ceiling Effect for R.S.
- 32. Buprenorphine Substitution for High Dose Opioids http://www.ncbi.nlm.nih.gov/pubmed/25220043
- 33. Buprenorphine Is A Powerful Analgesic http://www.compoundchem.com/2014/09/25/painkillers/
- 34. Random Urine Or Saliva Drug Screening https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
- 35. Sample Cases
- 36. Case 1: Teresa 75y/o retiree with diffuse OA. Lives alone in Prineville. Uses Oxycodone-APAP 10/325, five perday (MED 70). No h/o aberrant behavior or addiction.
- 37. Case 1: Teresa Teresa reports that the medications give her comfort. She was started on her current dose years ago. Recommendations: Continue as prescribed.
- 38. Case 2: Cleatus 68y/o retired logger with failed back surgery syndrome. Lives with spouse Rx’d Methadone 10mg po QID (MED 320). No h/o addiction or aberrant behaviors.
- 39. Case 2: Cleatus Recommendations: Call Cleatus & his spouse in. Explain that his dose and medication are both unsafe and will need to change. a. Prescribe nasal naloxone & train spouse in assembly and use. b. Offer a conversion to Morphine Sulfate ER 75mg QD (30,15,30) at his next refill. http://www.prescribetoprevent.org/wp-content/uploads/2012/11/naloxone-one-pager-in-nov-2012.pdf
- 40. Case 3: Jane 55y/o woman with FMS. Lives alone in Redmond. Uses OxyContin 30mg PO BID (MED 80), and alprazolam 0.5mg po QID. No h/o aberrant behavior or addiction.
- 41. Case 3: Jane Recommendations: Call Jane in to clinic. Explain that the combination of alprazolam and Oxycodone is unsafe. a. Offer a conversion to clonazapam 2mg BID. b. Taper clonazepam by .5 -1mg/ mo over 4-8mo. c. Offer non-benzodiazepine alternatives for anxiety/sleep/ panic attacks. http://www.slideshare.net/101N/alternatives-to-benzodiazepines-60678319
- 42. Case 4: Luc 49y/o married restaurant owner with chronic migraine. Prescribed Oxycodone 5mg BID, 30/mo over many years. No h/o addiction or aberrant behavior. Recent review of the PDMP with at a f/u visit reveals visits to 6 other prescribers over the past 3mo for opioids. Patient acknowledges that he is overusing pain medication and wants your help in getting off opioids entirely.
- 43. Case 4: Luc Recommendations: Use your data-2000 waiver to offer Luc treatment of opioid use disorder. Stop opioids. a. Offer conversion to buprenorphine (Suboxone/Subutex) with a planned 6mo taper off. (8mg QD x 2mo, 4mgQD x 2mo, 4mg QOD x 2mo) b. Offer an addiction counseling referral. c. Continue to see frequently for followups with both urine or saliva drug screens and frequent checks of the PDMP to ensure adherence.
- 44. Help with Tough Cases
- 45. Resources Alternatives to Benzodiazepines: http://www.slideshare.net/101N/alternatives-to-benzodiazepines-60701295 Oregon Prescription Drug Monitoring Signup: http://www.orpdmp.com/health-care-provider/ Opioid Withdrawal Attenuation Cocktail: http://www.slideshare.net/101N/opioid-withdrawal-attenuation-coctail Nasal Naloxone: http://www.amphastar.com/assets/naloxone.pdf http://www.narcannasalspray.com/nns-4-mg-dose/how-to-use-nns/ Oregon Drug & Alcohol Services by County: https://www.oregon.gov/oha/amh/publications/provider-directory.pdf