Safe opioidrx

1. Opioids:
Maximizing Patient Safety
Alberto Rivera Sanchez MD
Diplomate of the American Board of Pain Medicine
Fellow of the American Academy of PM&R
Diplomate of the American Board of Disability Analysts

2. Disclosure
 No drug or medical device company has a financial
interest in this lecture.
“I wish they did, but they don’t.”

3. CDC: Injury and Prevention Control:
Prescription drug overdose. April 2015
 16,235 deaths related to opioid use in 2013
 300% increase in opioid sales

4. Evidence Based Medicine for Opioids
“Are they backed up by evidence?”
 Furlan et al 2006:
 Meta analysis of 41 RCT’s
 Opioids are more effective than placebo for pain and
functional outcomes for nociceptive pain, neuropathic pain
and fibromyalgia
 No study was longer than 3 months
 Most were sponsored by drug companies
 Cochrane Review 2010
 The authors concluded that the evidence supporting
opioids for chronic pain was weak

5. Screening for Opioid Use
“There is a method to our madness”
 Like in marriage subject selection is the key
 Select the patient after thorough history and physical

6. Risk of Opioids
Short Term:
 Nausea
 Vomiting
 Constipation
 Drowsiness
 Respiratory depression
Long Term:
 Tolerance
 Dependence
 Addiction
 Hyperalgesia
 Hormonal imbalances
 Hypogonadism
 OP, Depression, Cognitive
Impairment

7. How to maximize safety
 Assess non opioid Tx:
 Delay opioid Tx
 Adequate W/U
 Trials of non-opioid
Manchikanti. Pain physician 2012
 Opioid Risk Tool
 It is recommended that these
tools are used
 Limited evidence in predicting
addiction risk
J. Pain 2006
Pain physician 2012
 History and PE

8. UDT Urine drug testing
 Must be random
 1st do immunoassay
 Test for opioids, BDZ’s,
Barb’s, Cocaine,
Amphetamines, and THC
 Confirm with gas
chromatography

9. Opioid agreements should talk about
 Medication and drug
prescribed
 Goals of therapy
 Potential adverse effects
 Risk of addiction
 Provider may D/C opioids if
risk outweigh benefit
 Someone stole my
prescription
 2 attempts with law
enforcement report
PM&R Journal 2015

10. What opioid to use???
 No opioid has proven to be a
superior option when
starting opioid therapy
 Most common 1st step:
 Hydrocodone
 Oxycodone
 Morphine
Kirpalani 2015
 Tramadol
 MOR like effects
 Serotonin/NE like reuptake
inhibitor
 Some guidelines:
 Most guidelines start short
acting at low doses
 Then convert to long acting
for higher doses
 Long acting and short acting
have similar efficacy
Manchikanti 2012, Chou 2009, VA
2010

11. According to the DEA
 Schedule 2:
 Must be hand written
 Secure prescription paper
 Tamper proof
 Schedule 3-5:
 May be submitted orally, in
writing or fax
 DEA has permitted e-scripts
but for Schedule 2 a
written copy is still needed
Kirpalani 2015

12. Monitoring effectiveness of opioid Tx
 “Keep your enemies closer”
• Monitor high risk patients
closely
• Frequency of visits is not
clearly defined (Chou 2009)
• 5 A’s of monitoring:
• Analgesia
• Adverse Effects
• ADL’s
• Aberrant behaviors
• Affect

13. Aberrant Behaviors (PM&R 2015):
 Self dose escalation
 Frequent visits for medication refills
 Pain medication form multiple provider
 Alcohol or illicit drug abuse
 Unexpected + or – results
 Lost or stolen prescriptions
 Evidence of diversion

14. Inheriting a patient
• Use the 5 A’s
• Do risks outweigh the benefits?
• Evaluate for aberrant behaviors
• Unstable psychological disease?
• If you do not agree, do “Tapering”

15. Tapering Off Opioids
 High dose patients (>200MED morphine) may tolerate taper
rates until reaching 100 MED
 At 100 MED or less they will start having greater symptoms of
side effects
 Most guidelines recommend a slow taper of 10% per week
 Fast taper is 20-50% every few days
Manchikanti 2012
Kirpalani 2015

16. Withdrawal Symptom Treatment
 Clonidine .1-.2mg BID or .1 to .2mg patch/24hr
 Loperamide
 TCA’s (amitriptyline, nortriptilyne) for irritability, sleep
disturbance and neuropathic pain
 Gabapentin for neuropathic pain
 W/D symptoms may last up to 6 months
Manchikanti 2012
California Guidelines for Prescribing Controlled Substances for Pain Nov 2014
Washington Dc VA 2010

17. Conclusion for safe opioid
prescribing
 Proper screening
 History and PE
 Addiction risk
 Psych Eval.
 UDT
 PDMP
 Have functional goals
 Measure risks
 Consider addiction medicine referral