The Opioid Epidemic - N Elkins

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The Opioid Epidemic:
Enhanced Recovery after Surgery –
just the facts
Nicholas Elkins, DO
Elkins.nicholas@mayo.edu
February 23, 2019

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©2011
MFMER |
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Disclosures
• No relationships with industry
• No discussion of off-label use
(physician's lawful ability to prescribe for a
medical purpose and in the interest of the patient
according to his or her best knowledge and judgment)

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Objectives:
• Understand the “opioid epidemic” and it’s societal costs.
• Identify your role and responsibility with the Arizona Opioid
Epidemic Act; SB1001.
• Comply with state law (Education and use of a PMP).
• Recognize ”factors” that influence low and high opiate
consumption.
• Follow guidelines for opiate prescribing: acute, surgical,
chronic pain conditions.

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Indications for Opioid Therapy
• Anesthesia
• Cancer-related pain
• End-of-life care
• Severe acute pain
------------------------------------------------------------
• Chronic non-cancer pain
• Acute intermittent non-cancer related pain
• Chronic severe pain without a diagnosis
WidelyAcceptedControversial
Christopher S. Wie, MD
Medical Director, Pain Rehabilitation Center – Mayo Clinic Arizona

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Why patients use opioids?
• Pain control
• Anxiety
• Depression
• Sleep
• Mood
• “Takes the edge off”

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The Problem
• Quadrupled sales and deaths since 1999
• 1 in 4 patients struggle with addiction
• 49,000 (Rx and heroin, 134/day)
• Neonatal withdrawal q 25 minutes
• 165,000 deaths from overdose related to prescriptions
opioids since 1999
• 343,000 annual ED visits due to non-medicinal opiate
analgesic use
• $78.5B cost to Americans 2013
• “We were wrong”
cdc.gov

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Regulatory, Related Agencies and You!
• CDC
• FDA (Pharmaceutical)
• DEA
• Federation of State Medical Boards
• Medicare
• NIH
• State Medical Board
• State Board of Pharmacy
• Governor
• Societal Guidelines (APS, AAPM)
• You!

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CDC Guideline for Prescribing Opioids for
Chronic Pain – US, 2016
• PCPs: Family Physicians and Internist
• APs: NPs and PAs
• Treating adults with chronic non-cancer pain >3 months
In summary, the categorization of recommendations was based on the
following assessment:
• No evidence shows a long-term benefit of opioids in pain and function versus
no opioids for chronic pain with outcomes examined at least 1 year later (with
most placebo-controlled randomized trials ≤6 weeks in duration).
• Extensive evidence shows the possible harms of opioids (including opioid
use disorder, overdose, and motor vehicle injury).
• Extensive evidence suggests some benefits of nonpharmacologic and
nonopioid pharmacologic treatments compared with long-term opioid
therapy, with less harm.

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Determining When to Initiate or Continue Opioids for
Chronic Pain - CDC
• 1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic
pain.
• Clinicians should consider opioid therapy only if expected benefits for both pain and
function are anticipated to outweigh risks to the patient. If opioids are used, they should be
combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as
appropriate (recommendation category: A, evidence type: 3).
• 2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with
all patients, including realistic goals for pain and function, and should consider how opioid
therapy will be discontinued if benefits do not outweigh risks.
• Clinicians should continue opioid therapy only if there is clinically meaningful improvement
in pain and function that outweighs risks to patient safety (recommendation category: A,
evidence type: 4).
• 3. Before starting and periodically during opioid therapy, clinicians should discuss with patients
known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for
managing therapy (recommendation category: A, evidence type: 3).
• 4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release
opioids instead of extended-release/long-acting (ER/LA) opioids (recommendation category: A,
evidence type: 4).

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Determining When to Initiate or Continue Opioids for
Chronic Pain - CDC
• 5. When opioids are started, clinicians should prescribe the lowest effective dosage.
• Clinicians should use caution when prescribing opioids at any dosage, should carefully
reassess evidence of individual benefits and risks when considering increasing dosage to
≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to
≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day
(recommendation category: A, evidence type: 3).
• 6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for
acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids
and should prescribe no greater quantity than needed for the expected duration of pain severe
enough to require opioids.
• Three days or less will often be sufficient; more than seven days will rarely be needed
(recommendation category: A, evidence type: 4).
• 7. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting
opioid therapy for chronic pain or of dose escalation.
• Clinicians should evaluate benefits and harms of continued therapy with patients every 3
months or more frequently. If benefits do not outweigh harms of continued opioid therapy,
clinicians should optimize other therapies and work with patients to taper opioids to lower
dosages or to taper and discontinue opioids (recommendation category: A, evidence type:
4).

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Determining When to Initiate or Continue Opioids for
Chronic Pain - CDC
• 8. Before starting and periodically during continuation of opioid therapy, clinicians should
evaluate risk factors for opioid-related harms.
• Clinicians should incorporate into the management plan strategies to mitigate risk,
including considering offering naloxone when factors that increase risk for opioid overdose,
such as history of overdose, history of substance use disorder, higher opioid dosages (≥50
MME/day), or concurrent benzodiazepine use, are present (recommendation category: A,
evidence type: 4).
• 9. Clinicians should review the patient’s history of controlled substance prescriptions using state
prescription drug monitoring program (PDMP) data to determine whether the patient is receiving
opioid dosages or dangerous combinations that put him or her at high risk for overdose.
• Clinicians should review PDMP data when starting opioid therapy for chronic pain and
periodically during opioid therapy for chronic pain, ranging from every prescription to every
3 months (recommendation category: A, evidence type: 4).
• 10. When prescribing opioids for chronic pain, clinicians should use urine drug testing before
starting opioid therapy and consider urine drug testing at least annually to assess for prescribed
medications as well as other controlled prescription drugs and illicit drugs (recommendation
category: B, evidence type: 4).
• 11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently
whenever possible (recommendation category: A, evidence type: 3).
• 12. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted
treatment with buprenorphine or methadone in combination with behavioral therapies) for
patients with opioid use disorder (recommendation category: A, evidence type: 2).

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AZ Rx Monitoring Program – PMP AWARE
• A.R.S. § 36-2606 requires each medical practitioner who is
licensed under Title 32 and who possesses a DEA license
to register with the CSPMP.
• This registration includes: MD, DO, DDS, DMD, DPM,
HMD, PA, NP, ND, and OD.
• Medical interns and residents may register using the
hospital DEA number and appropriate suffix.
• Approve a “Delegate”
• Create or Log in:
• Go to https://arizona.pmpaware.net/login

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Surgical Planning
• Pre-operative evaluation: medical/psychiatric
comorbidities; chronic pain-substance abuse
• Set expectations: “pain is NORMAL”-“you’ll be able to
walk and do light activity”- “you’ll gradually get better”
• Set norms: “half of patients who have this procedure
take few than 15 pills”
• Endorse: multimodal analgesia: APAP,
NSAIDs/Celebrex, gabapentinoids, blocks
• Educate: appropriate use, adverse side-effects and
safe disposal

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Results

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Results
• 2486 of 3412 pts completed the survey
• 52.6% required <50 MMEs
• Median of 43 MMEs consumed post discharge
• 77.3% had left over meds
• 61.5% of opioids unused
• 31.4% used no opioids

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http://links.lww.com/SLA/B477

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A word to the wise…
• Tramadol – Ultram (schedule III)
• weak mu receptor agonist and 5HT reuptake
• Buprenorphine (schedule III)– Subutex,
Suboxone, Butrans, Belbuca
• Taper and d/c 1- 2 weeks before surgery
• Methadone (schedule II)
• Variable pharmacokinetics and pharmacodynamics T1/2 = (15-
60 hours)
• Titrated cautiously (up to 12 days)
• QTc prolongation & cardiac arrhythmia (>450 monitor, >500
stop)
• prn/breakthrough use NOT RECOMMENDED

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Tricks of the Trade
• Lowest dose – shortest duration
• Provide what’s medically necessary
• Avoid concurrent use of Benzos and Carisoprodol
(Soma)
• No long acting: ER/SR for acute (surgical) pain
• Re-evaluate outliers – think complications!
• No concurrent opioid use with Cannabis
• Have an “Exit Strategy”
• Re-assure, taper, warm-hand-off, MAT

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Please remember…
• Most post op opioids go unused, unlocked and
undisposed. 2/3 of patients following surgery: general,
ortho, thoracic, OB and outpatient.
• Increased Risk of Death 50-99 OME increase risk OD
by a factor of 1.9-4.6; >100 OME risk factor 2.0-8.9
compared to those dosed <20
• No “just in case” Rx or extra #’s
• MAT-medication assisted therapy is effective and the
best treatment for opioid use disorder Methadone –
Buprenorphine
• Don’t dump, let’s discuss with Pain Medicine

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http://intranet.mayo.edu/charlie/opioid-stewardship-program/

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Thank you
Elkins.nicholas@mayo.edu

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Resources
• https://legiscan.com/AZ/bill/SB1001/2018/X1
• https://www.azmd.gov/Forms/Files/201803091134_545bf47cbc1b483bb95b0330854
bd646.pdf
• https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis
• https://www.azdhs.gov/audiences/clinicians/index.php#clinical-guidelines-and-
references-rx-guidelines
• https://pharmacypmp.az.gov/sites/default/files/Opioid%20Epidemic%20Act%20FAQ
_06062018.pdf
• http://links.lww.com/SLA/B477
• Thiels et al. Results of a Prospective, Multicenter Initiative Aimed at Developing
Opioid-prescribing Guidelines After Surgery Ann Surg 2018;268:457-468

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