This document discusses considerations for choosing between buprenorphine and methadone for opioid agonist treatment. Both medications have shown efficacy in randomized controlled trials, though methadone has been shown to have slightly higher retention rates. Buprenorphine has a safer side effect profile, with a lower risk of overdose death and less impact on cardiac function compared to methadone. Personal factors like a preference for mental alertness or sexual function may favor buprenorphine, while programmatic restrictions or funding considerations could make methadone a better choice depending on the situation. The document reviews evidence on various safety, efficacy, and quality of life factors to help determine the best treatment option given an individual patient's needs
Inner City Addiction Rounds: Abuse-deterrent opioid formulations: Quick fix o...Women's College Hospital
This document discusses abuse-deterrent opioid formulations and whether they are effective in reversing the opioid crisis. It summarizes that while OxyNEO is harder to abuse than previous formulations like OxyContin, overall opioid overdose and addiction rates have not declined. Patients often switch to other opioids like hydromorphone or heroin when unable to abuse newer formulations. Abuse-deterrent formulations alone will not solve the crisis without also addressing over-prescribing and reducing the overall supply of opioids. Local measures like education, naloxone distribution, and buprenorphine treatment can help reduce harms of the opioid epidemic.
When Opioids Fail In Chronic Pain Management: The Role for Buprenorphine.Paul Coelho, MD
This document describes a study where 76 chronic pain patients on high doses of opioids were converted to buprenorphine treatment during a brief hospitalization. Most patients were taking the equivalent of over 400 mg of morphine per day and had serious medical or psychological comorbidities. During hospitalization, patients were gradually converted from their opioid medication to buprenorphine under medical supervision over 2 days on average. Two-thirds of patients reported improvements in pain and function after discharge on a median buprenorphine dose of 8 mg. No adverse events were observed. The study demonstrates that a brief hospitalization can allow safe conversion from high-dose opioids to buprenorphine, improving outcomes for fragile chronic pain patients.
This document discusses issues in assessing and treating patients with co-occurring opiate dependence and chronic pain. It notes that while opiate treatment is commonly used for chronic pain, it can lead to physical dependence, tolerance, and potentially addiction. Assessing for problematic opioid use or addiction involves looking for behaviors like frequent dose increases, non-medical use, doctor shopping, or illicit drug use. Factors like a history of substance abuse or mental health conditions may increase risk. Proper evaluation and treatment should address both the pain condition and risk for opioid misuse or addiction.
Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrosp...Paul Coelho, MD
This study analyzed outcomes for 240 patients with chronic pain who were prescribed long-term opioid therapy above 90 mg morphine-equivalent daily doses. Patients were offered an outpatient opioid taper or transition to buprenorphine if taper was not tolerated. 44.6% successfully tapered, 18.8% transitioned to buprenorphine, and 36.6% dropped out of treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine/z-drug use predicted greater dropout. Pain intensity changes after treatment were mixed, with over half of tapered patients reporting increased pain and about half of transitioned patients reporting decreased pain.
This document summarizes research priorities and findings from the National Institute on Drug Abuse (NIDA) regarding the opioid crisis. It outlines NIDA's focus on alternative pain treatments, preventing opioid use disorder and overdoses, improving treatment for opioid use disorder, and implementing evidence-based solutions. Specific areas of research discussed include biomarkers for pain, abuse-deterrent drug formulations, non-medication pain treatments, universal prevention programs for adolescents, easier-to-use naloxone for overdose reversal, new formulations of addiction medications, increasing access to medication-assisted treatment, and using addiction medications earlier to prevent heroin overdoses and improve treatment retention.
This document discusses considerations for choosing between buprenorphine and methadone for opioid agonist treatment. Both medications have shown efficacy in randomized controlled trials, though methadone has been shown to have slightly higher retention rates. Buprenorphine has a safer side effect profile, with a lower risk of overdose death and less impact on cardiac function compared to methadone. Personal factors like a preference for mental alertness or sexual function may favor buprenorphine, while programmatic restrictions or funding considerations could make methadone a better choice depending on the situation. The document reviews evidence on various safety, efficacy, and quality of life factors to help determine the best treatment option given an individual patient's needs
Inner City Addiction Rounds: Abuse-deterrent opioid formulations: Quick fix o...Women's College Hospital
This document discusses abuse-deterrent opioid formulations and whether they are effective in reversing the opioid crisis. It summarizes that while OxyNEO is harder to abuse than previous formulations like OxyContin, overall opioid overdose and addiction rates have not declined. Patients often switch to other opioids like hydromorphone or heroin when unable to abuse newer formulations. Abuse-deterrent formulations alone will not solve the crisis without also addressing over-prescribing and reducing the overall supply of opioids. Local measures like education, naloxone distribution, and buprenorphine treatment can help reduce harms of the opioid epidemic.
When Opioids Fail In Chronic Pain Management: The Role for Buprenorphine.Paul Coelho, MD
This document describes a study where 76 chronic pain patients on high doses of opioids were converted to buprenorphine treatment during a brief hospitalization. Most patients were taking the equivalent of over 400 mg of morphine per day and had serious medical or psychological comorbidities. During hospitalization, patients were gradually converted from their opioid medication to buprenorphine under medical supervision over 2 days on average. Two-thirds of patients reported improvements in pain and function after discharge on a median buprenorphine dose of 8 mg. No adverse events were observed. The study demonstrates that a brief hospitalization can allow safe conversion from high-dose opioids to buprenorphine, improving outcomes for fragile chronic pain patients.
This document discusses issues in assessing and treating patients with co-occurring opiate dependence and chronic pain. It notes that while opiate treatment is commonly used for chronic pain, it can lead to physical dependence, tolerance, and potentially addiction. Assessing for problematic opioid use or addiction involves looking for behaviors like frequent dose increases, non-medical use, doctor shopping, or illicit drug use. Factors like a history of substance abuse or mental health conditions may increase risk. Proper evaluation and treatment should address both the pain condition and risk for opioid misuse or addiction.
Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrosp...Paul Coelho, MD
This study analyzed outcomes for 240 patients with chronic pain who were prescribed long-term opioid therapy above 90 mg morphine-equivalent daily doses. Patients were offered an outpatient opioid taper or transition to buprenorphine if taper was not tolerated. 44.6% successfully tapered, 18.8% transitioned to buprenorphine, and 36.6% dropped out of treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine/z-drug use predicted greater dropout. Pain intensity changes after treatment were mixed, with over half of tapered patients reporting increased pain and about half of transitioned patients reporting decreased pain.
This document summarizes research priorities and findings from the National Institute on Drug Abuse (NIDA) regarding the opioid crisis. It outlines NIDA's focus on alternative pain treatments, preventing opioid use disorder and overdoses, improving treatment for opioid use disorder, and implementing evidence-based solutions. Specific areas of research discussed include biomarkers for pain, abuse-deterrent drug formulations, non-medication pain treatments, universal prevention programs for adolescents, easier-to-use naloxone for overdose reversal, new formulations of addiction medications, increasing access to medication-assisted treatment, and using addiction medications earlier to prevent heroin overdoses and improve treatment retention.
This document summarizes a study examining risk factors for overdose death from prescription opioids. The study compared 254 decedents who died from prescription opioid overdoses to 1,308 people who used prescription opioids. It found that decedents were more likely to obtain opioids from non-prescription sources, use them more often than prescribed, have chronic pain, smoke daily, have a history of substance abuse or mental illness, and lack social support. The study aims to help clinicians recognize at-risk patients and control opioid exposure to prevent overdoses.
This document summarizes the misconceptions around opioid use and addiction. It discusses how opioids work in the brain to produce both analgesia and euphoria through activation of mu-opioid receptors. Repeated use leads to tolerance and physical dependence, but addiction only occurs in a small percentage of patients and involves distinct molecular mechanisms. Common misconceptions include equating addiction, tolerance and physical dependence. The document advocates for strategies to minimize risks of diversion and abuse through abuse-deterrent formulations.
Tns Nipo European Health & food Study Sept. 2010Sibolt Mulder
This document summarizes the results of a survey on health and nutrition conducted across seven European countries. It finds that lifestyle segmentation based on diet, BMI, exercise, smoking, and alcohol consumption identifies four groups - very healthy lifestyle, healthy lifestyle, unhealthy lifestyle, and very unhealthy lifestyle. Those with healthier lifestyles tend to be younger, follow special diets more, walk/cycle more, and consume organic products weekly. Those with unhealthier lifestyles have higher rates of being overweight, use cars more, follow special diets and organic products less, and are less likely to use alternative medicine. Country-specific results are also analyzed.
This document discusses essentials of methadone prescribing and treatment for opioid dependence. It covers topics such as the harms of illegal opioid use, drug dependence, opioid dependence, and treatment approaches. Methadone treatment aims to reduce opioid use and related harms through a public health approach. Guidelines are provided for effective methadone programs which seek to improve health, social functioning, and quality of life for those with opioid dependence.
Varenicline became available as a prescription stop smoking medication between 2006-2008 in the US, UK, Canada, and Australia. This study uses survey data to examine trends in stop smoking medication use in these countries during this period. The study finds that the use of any stop smoking medication increased significantly over the 3 years in all 4 countries. Varenicline became the second most used medication, behind NRT. Varenicline use increased substantially in each country as it was introduced, from 0.4-21.7% in the US to 0-14.8% in Canada. This suggests varenicline increased overall medication use rather than just gaining market share.
Jeffrey Desmond, interim chief medical officer at the University of Michigan Health System, gave a presentation at an opioid overdose summit on December 1, 2015. He called on physicians to carefully assess addiction risk before prescribing opioids and to prescribe the smallest dose for shortest time possible. He also encouraged open discussions between doctors and patients about opioid risks and alternatives. The presentation discussed issues with controlled substance diversion at UMHS, including a nurse's death and doctor's overdose, and 16,000 missing pills. It outlined comprehensive programs implemented to improve accountability, security, and monitoring of controlled substances. The summit aimed to bring attention to the growing issue of prescription opioid abuse and facilitate research collaborations.
Prescriptions filled following an opioid-related hospitalization.Paul Coelho, MD
This study analyzed prescription drug fills within 30 days of discharge for 36,719 patients hospitalized for opioid misuse. Only 16.7% received medications approved for opioid dependence, while 40.3% filled antidepressant prescriptions and 22.4% filled opioid pain medication prescriptions. Concurrently, 13.9% filled benzodiazepine prescriptions and 7.4% filled both benzodiazepine and opioid prescriptions, indicating a need for improved education on risks. Overall, more effort is required to ensure patients receive recommended post-hospitalization treatment and support services.
- This interim analysis of an ongoing observational study found that topical analgesics may reduce pain severity and interference scores and decrease primary pain complaints and oral pain medication use for patients with neuropathic or musculoskeletal pain.
- Overall patient satisfaction with topical analgesics was high and they were found to be safe and well-tolerated.
- The results were consistent with a previous interim analysis and warrant continuation of the larger OPERA study, though more analysis is still needed.
Tackling the Opioid Problem - Analgesic Prescribing in the Emergency DepartmentSCGH ED CME
This document discusses the opioid crisis and approaches to pain management. It describes how Purdue Pharma aggressively marketed OxyContin in the 1990s, leading to widespread overprescription and misuse. This contributed significantly to the rise in opioid overdoses and deaths in the US. In response, pharmaceutical companies developed abuse-deterrent formulations of opioids like OxyContin and Targin to discourage tampering and injection. However, these formulations did not prove abuse-proof. The document advocates for careful opioid prescribing practices to limit diversion and abuse, including assessing risks, limiting durations, and involving specialist services. Non-opioid options like paracetamol, NSAIDs, and tramadol should be prioritized for mild-moderate pain
1) Dr. Sergey Motov conducted ED shifts without prescribing any opioids as part of research on opioid-free pain management approaches. His website painfree.com provides education on this topic.
2) Swedish EDs have initiated programs to reduce unnecessary opioid prescriptions given risks of addiction, misuse, and overdose.
3) The document discusses alternatives to opioid analgesics for ED patients, including NSAIDs, gabapentinoids, tramadol, buprenorphine, ketamine, and alpha-2 agonists. It emphasizes multimodal, multireceptor approaches to pain management.
This document discusses self-medication in Croatia, including an overview of self-medication worldwide and in Croatia specifically. It notes that over-the-counter (OTC) drugs make up 27% of drugs used in Croatia by unit. The role of pharmacists is expanding to include health consultation to help patients practice responsible self-medication. Future goals include increasing education of both medical professionals and patients about responsible OTC drug use and the differences between OTC drugs and dietary supplements.
Psychotropic medication in a randomly selected group of citizens receiving re...Anne Kathrine Helnæs
This study analyzed the medication lists of 214 citizens receiving residential or home care to summarize patterns of psychotropic medication (PM) use. The key findings were:
1) 64.5% of citizens were prescribed one or more PMs, most commonly antidepressants (43.5%) and anxiolytics/hypnotics (27.1%).
2) Citizens receiving antipsychotics were often also prescribed antidepressants (52.9%), anxiolytics/hypnotics (35.3%), and anti-dementia drugs (20.9%).
3) While improvements have been made regarding doses and drug choices compared to past studies, PM use among the elderly is still not fully aligned with recommendations
This presentation discusses the opioid epidemic, guidelines for prescribing opioids, and strategies for managing postoperative pain with reduced opioid use. It provides objectives about understanding the societal costs of the opioid epidemic, complying with state prescribing laws, and following guidelines for different types of pain. The presentation reviews CDC guidelines for prescribing opioids, the Arizona prescription drug monitoring program, factors influencing opioid use, and results from a study showing most patients use fewer opioids than prescribed after surgery. It emphasizes multimodal analgesia, patient education, and tapering or discontinuing certain medications before surgery to reduce postoperative opioid needs.
Buprenorphine has been used in India for opioid dependence since the early 1990s. Initial experiences found it effective for detoxification and long-term treatment. Over time, higher strength and take-home formulations became available. Research studies conducted in India provided evidence that buprenorphine is superior to clonidine for withdrawal management and blocks the effects of opioids. It was also found to have moderate abuse potential similar to morphine. Sustained release morphine and later buprenorphine-naloxone were explored as additional treatment options. Efforts were made to scale up opioid substitution therapy across India through capacity building, additional treatment centers, and a multi-site effectiveness study.
This document discusses treatment of opioid use disorders. It provides an overview of clinical issues, the basics of treatment, the history of treatment approaches, and specifics on biological, psychological and social aspects of treatment. Key points include defining addiction and distinguishing it from physical dependence. Effective treatment involves separation from substances, a healing environment, psychoeducation, and cognitive-behavioral and community support elements. Medication assisted treatment with agonists like methadone and buprenorphine, and antagonists like naltrexone are discussed. The document also covers policy issues around balancing treatment and criminalization approaches over time.
This study analyzed results from over 900,000 urine drug tests conducted between 2006-2009 on patients prescribed chronic opioids. The results showed:
- 11% tested positive for illicit drugs
- 29% tested positive for non-prescribed medications
- 38% did not detect the prescribed medication
- 15% had lower than expected levels of the prescribed medication
- 27% had higher than expected levels of the prescribed medication
These high rates of potential issues like non-compliance, abuse or diversion demonstrate the importance of periodic urine drug screening for patients on long-term opioid therapy to identify problems and ensure appropriate use of medications.
Patient satisfaction and side effects in primary care: An observational study...home
1) The study compared patient satisfaction and perception of side effects between homeopathic and conventional primary care in Switzerland. It found that patients receiving homeopathic treatment reported significantly higher satisfaction and fewer side effects than those receiving conventional treatment.
2) Specifically, 53% of homeopathic patients reported being completely satisfied with treatment compared to 43% of conventional patients. Homeopathic treatments were also perceived as having 2-3 times fewer side effects.
3) While symptom resolution was slightly higher for conventional patients, homeopathic patients generally had more chronic conditions and reported their health status as better.
The document provides an overview of palliative care, including its goals, definitions, history, and differences from hospice care. Some key points:
- Palliative care focuses on improving quality of life and reducing suffering for those with serious illnesses through comprehensive pain and symptom management.
- It can begin at diagnosis and be provided alongside curative treatment.
- The WHO defines palliative care as relief from pain and symptoms, affirming life, and addressing psychological and spiritual needs.
- It aims to help patients live as actively as possible until death.
1) This case discusses the challenges of managing acute pain in a hospitalized patient on chronic opioids who underwent foot amputation surgery.
2) The patient was prescribed escalating doses of opioids, including extended-release morphine up to 165mg 3 times daily as well as IV and oral hydromorphone. He developed somnolence and hypoxemia.
3) After holding the extended-release morphine, the patient's pain worsened and muscle spasms developed. He was prescribed diazepam which led to respiratory depression and an opioid/benzodiazepine overdose requiring naloxone and ICU admission.
This document summarizes a study examining risk factors for overdose death from prescription opioids. The study compared 254 decedents who died from prescription opioid overdoses to 1,308 people who used prescription opioids. It found that decedents were more likely to obtain opioids from non-prescription sources, use them more often than prescribed, have chronic pain, smoke daily, have a history of substance abuse or mental illness, and lack social support. The study aims to help clinicians recognize at-risk patients and control opioid exposure to prevent overdoses.
This document summarizes the misconceptions around opioid use and addiction. It discusses how opioids work in the brain to produce both analgesia and euphoria through activation of mu-opioid receptors. Repeated use leads to tolerance and physical dependence, but addiction only occurs in a small percentage of patients and involves distinct molecular mechanisms. Common misconceptions include equating addiction, tolerance and physical dependence. The document advocates for strategies to minimize risks of diversion and abuse through abuse-deterrent formulations.
Tns Nipo European Health & food Study Sept. 2010Sibolt Mulder
This document summarizes the results of a survey on health and nutrition conducted across seven European countries. It finds that lifestyle segmentation based on diet, BMI, exercise, smoking, and alcohol consumption identifies four groups - very healthy lifestyle, healthy lifestyle, unhealthy lifestyle, and very unhealthy lifestyle. Those with healthier lifestyles tend to be younger, follow special diets more, walk/cycle more, and consume organic products weekly. Those with unhealthier lifestyles have higher rates of being overweight, use cars more, follow special diets and organic products less, and are less likely to use alternative medicine. Country-specific results are also analyzed.
This document discusses essentials of methadone prescribing and treatment for opioid dependence. It covers topics such as the harms of illegal opioid use, drug dependence, opioid dependence, and treatment approaches. Methadone treatment aims to reduce opioid use and related harms through a public health approach. Guidelines are provided for effective methadone programs which seek to improve health, social functioning, and quality of life for those with opioid dependence.
Varenicline became available as a prescription stop smoking medication between 2006-2008 in the US, UK, Canada, and Australia. This study uses survey data to examine trends in stop smoking medication use in these countries during this period. The study finds that the use of any stop smoking medication increased significantly over the 3 years in all 4 countries. Varenicline became the second most used medication, behind NRT. Varenicline use increased substantially in each country as it was introduced, from 0.4-21.7% in the US to 0-14.8% in Canada. This suggests varenicline increased overall medication use rather than just gaining market share.
Jeffrey Desmond, interim chief medical officer at the University of Michigan Health System, gave a presentation at an opioid overdose summit on December 1, 2015. He called on physicians to carefully assess addiction risk before prescribing opioids and to prescribe the smallest dose for shortest time possible. He also encouraged open discussions between doctors and patients about opioid risks and alternatives. The presentation discussed issues with controlled substance diversion at UMHS, including a nurse's death and doctor's overdose, and 16,000 missing pills. It outlined comprehensive programs implemented to improve accountability, security, and monitoring of controlled substances. The summit aimed to bring attention to the growing issue of prescription opioid abuse and facilitate research collaborations.
Prescriptions filled following an opioid-related hospitalization.Paul Coelho, MD
This study analyzed prescription drug fills within 30 days of discharge for 36,719 patients hospitalized for opioid misuse. Only 16.7% received medications approved for opioid dependence, while 40.3% filled antidepressant prescriptions and 22.4% filled opioid pain medication prescriptions. Concurrently, 13.9% filled benzodiazepine prescriptions and 7.4% filled both benzodiazepine and opioid prescriptions, indicating a need for improved education on risks. Overall, more effort is required to ensure patients receive recommended post-hospitalization treatment and support services.
- This interim analysis of an ongoing observational study found that topical analgesics may reduce pain severity and interference scores and decrease primary pain complaints and oral pain medication use for patients with neuropathic or musculoskeletal pain.
- Overall patient satisfaction with topical analgesics was high and they were found to be safe and well-tolerated.
- The results were consistent with a previous interim analysis and warrant continuation of the larger OPERA study, though more analysis is still needed.
Tackling the Opioid Problem - Analgesic Prescribing in the Emergency DepartmentSCGH ED CME
This document discusses the opioid crisis and approaches to pain management. It describes how Purdue Pharma aggressively marketed OxyContin in the 1990s, leading to widespread overprescription and misuse. This contributed significantly to the rise in opioid overdoses and deaths in the US. In response, pharmaceutical companies developed abuse-deterrent formulations of opioids like OxyContin and Targin to discourage tampering and injection. However, these formulations did not prove abuse-proof. The document advocates for careful opioid prescribing practices to limit diversion and abuse, including assessing risks, limiting durations, and involving specialist services. Non-opioid options like paracetamol, NSAIDs, and tramadol should be prioritized for mild-moderate pain
1) Dr. Sergey Motov conducted ED shifts without prescribing any opioids as part of research on opioid-free pain management approaches. His website painfree.com provides education on this topic.
2) Swedish EDs have initiated programs to reduce unnecessary opioid prescriptions given risks of addiction, misuse, and overdose.
3) The document discusses alternatives to opioid analgesics for ED patients, including NSAIDs, gabapentinoids, tramadol, buprenorphine, ketamine, and alpha-2 agonists. It emphasizes multimodal, multireceptor approaches to pain management.
This document discusses self-medication in Croatia, including an overview of self-medication worldwide and in Croatia specifically. It notes that over-the-counter (OTC) drugs make up 27% of drugs used in Croatia by unit. The role of pharmacists is expanding to include health consultation to help patients practice responsible self-medication. Future goals include increasing education of both medical professionals and patients about responsible OTC drug use and the differences between OTC drugs and dietary supplements.
Psychotropic medication in a randomly selected group of citizens receiving re...Anne Kathrine Helnæs
This study analyzed the medication lists of 214 citizens receiving residential or home care to summarize patterns of psychotropic medication (PM) use. The key findings were:
1) 64.5% of citizens were prescribed one or more PMs, most commonly antidepressants (43.5%) and anxiolytics/hypnotics (27.1%).
2) Citizens receiving antipsychotics were often also prescribed antidepressants (52.9%), anxiolytics/hypnotics (35.3%), and anti-dementia drugs (20.9%).
3) While improvements have been made regarding doses and drug choices compared to past studies, PM use among the elderly is still not fully aligned with recommendations
This presentation discusses the opioid epidemic, guidelines for prescribing opioids, and strategies for managing postoperative pain with reduced opioid use. It provides objectives about understanding the societal costs of the opioid epidemic, complying with state prescribing laws, and following guidelines for different types of pain. The presentation reviews CDC guidelines for prescribing opioids, the Arizona prescription drug monitoring program, factors influencing opioid use, and results from a study showing most patients use fewer opioids than prescribed after surgery. It emphasizes multimodal analgesia, patient education, and tapering or discontinuing certain medications before surgery to reduce postoperative opioid needs.
Buprenorphine has been used in India for opioid dependence since the early 1990s. Initial experiences found it effective for detoxification and long-term treatment. Over time, higher strength and take-home formulations became available. Research studies conducted in India provided evidence that buprenorphine is superior to clonidine for withdrawal management and blocks the effects of opioids. It was also found to have moderate abuse potential similar to morphine. Sustained release morphine and later buprenorphine-naloxone were explored as additional treatment options. Efforts were made to scale up opioid substitution therapy across India through capacity building, additional treatment centers, and a multi-site effectiveness study.
This document discusses treatment of opioid use disorders. It provides an overview of clinical issues, the basics of treatment, the history of treatment approaches, and specifics on biological, psychological and social aspects of treatment. Key points include defining addiction and distinguishing it from physical dependence. Effective treatment involves separation from substances, a healing environment, psychoeducation, and cognitive-behavioral and community support elements. Medication assisted treatment with agonists like methadone and buprenorphine, and antagonists like naltrexone are discussed. The document also covers policy issues around balancing treatment and criminalization approaches over time.
This study analyzed results from over 900,000 urine drug tests conducted between 2006-2009 on patients prescribed chronic opioids. The results showed:
- 11% tested positive for illicit drugs
- 29% tested positive for non-prescribed medications
- 38% did not detect the prescribed medication
- 15% had lower than expected levels of the prescribed medication
- 27% had higher than expected levels of the prescribed medication
These high rates of potential issues like non-compliance, abuse or diversion demonstrate the importance of periodic urine drug screening for patients on long-term opioid therapy to identify problems and ensure appropriate use of medications.
Patient satisfaction and side effects in primary care: An observational study...home
1) The study compared patient satisfaction and perception of side effects between homeopathic and conventional primary care in Switzerland. It found that patients receiving homeopathic treatment reported significantly higher satisfaction and fewer side effects than those receiving conventional treatment.
2) Specifically, 53% of homeopathic patients reported being completely satisfied with treatment compared to 43% of conventional patients. Homeopathic treatments were also perceived as having 2-3 times fewer side effects.
3) While symptom resolution was slightly higher for conventional patients, homeopathic patients generally had more chronic conditions and reported their health status as better.
Patient satisfaction and side effects in primary care: An observational study...
Similar to Toronto Medical Rounds in Addiction: Pain and Chemical Dependency: An approach to the patient with both “legitimate pain” and a substance use disorder
The document provides an overview of palliative care, including its goals, definitions, history, and differences from hospice care. Some key points:
- Palliative care focuses on improving quality of life and reducing suffering for those with serious illnesses through comprehensive pain and symptom management.
- It can begin at diagnosis and be provided alongside curative treatment.
- The WHO defines palliative care as relief from pain and symptoms, affirming life, and addressing psychological and spiritual needs.
- It aims to help patients live as actively as possible until death.
1) This case discusses the challenges of managing acute pain in a hospitalized patient on chronic opioids who underwent foot amputation surgery.
2) The patient was prescribed escalating doses of opioids, including extended-release morphine up to 165mg 3 times daily as well as IV and oral hydromorphone. He developed somnolence and hypoxemia.
3) After holding the extended-release morphine, the patient's pain worsened and muscle spasms developed. He was prescribed diazepam which led to respiratory depression and an opioid/benzodiazepine overdose requiring naloxone and ICU admission.
This document discusses challenges in managing cancer pain and strategies to promote safe and effective pain management. It outlines Joint Commission standards on comprehensive pain assessment, treatment, and reassessment. Barriers to pain management include inadequate processes and education. Effective strategies include standardized policies, electronic tools to support safe opioid prescribing and administration, education and training programs for providers, and monitoring programs to improve patient safety.
Challenges in Managing Cancer Pain: The Role of the Oncology Pharmacistflasco_org
The correct answer is E. All of the strategies listed can be used by oncology or supportive care pharmacists to better manage pain in patients in the hospital setting.
The CDC published guidelines in 2016 for prescribing opioids for chronic pain that included 12 recommendations. The guidelines aimed to reduce risks of long-term opioid use, including overdose risk. They recommended non-opioid therapies as preferred for chronic pain. If opioids are used, immediate-release are preferred over extended-release/long-acting opioids. The guidelines also recommended starting low doses and slowly increasing if needed, establishing treatment goals, considering risk factors, reviewing prescription drug monitoring programs, using urine drug testing, avoiding concurrent benzodiazepines, and offering treatment for opioid use disorder. However, the guidelines received criticism from medical organizations for being too rigid and not accounting for specialist care of individual patients.
This document outlines Stony Brook Medicine's pain management policies and procedures. It discusses assessing and treating acute and chronic pain using multimodal approaches including pharmacological and non-pharmacological methods. It emphasizes the importance of the patient's self-report of pain and educating patients and families on effective pain management.
This document provides an overview of pain management and opioid use for cancer patients. It discusses how cancer pain is common and should be properly assessed and treated. The WHO pain ladder is reviewed as the standard approach for treating pain with non-opioids, weak opioids, and strong opioids. Opioid rotation and treating pain crises are covered, including calculating opioid conversions and administering parenteral opioids. Challenges in treating cancer pain in patients with addiction histories are addressed through transparency, long-acting opioids, and pain contracts. Overall guidelines aim to properly treat pain while avoiding exacerbating addiction issues.
PEG (Pain, Enjoyment, General activity) scale (0-10)
1. What number best describes your Pain on average in the past week? 5 → 5 (no change)
2. What number best describes how much you are Enjoying life?
3 → 7 (worsening)
3. What number best describes your General activity level?
4 → 9 (worsening)
Safe & Effective Management of Chronic Pain chshanah
I do not have access to the video cases you referenced. Could you please provide a brief summary of the key details in each case so I can try to understand and respond to your questions? Without more context it's difficult for me to analyze how the provider handled the situation or determine the diagnosis.
This document provides guidance on safely prescribing opioids in practice. It discusses considerations for new patients versus legacy patients already on chronic opioids. For new patients, it recommends avoiding opioids for conditions where evidence of use is weak, such as nonspecific musculoskeletal pain or headaches. It also discusses assessing risk and determining whether to initiate chronic opioid use. For legacy patients, it suggests applying criteria to determine if tapering is indicated. The document provides signs that indicate when to access addiction treatment and lists pharmacologic and non-pharmacologic alternatives to opioids. It also offers guidance on opioid use in special populations like older adults, pregnant women, and children.
The document discusses guidelines for prescribing opioid analgesics, including considerations for risk assessment, equianalgesic dosing, monitoring patients, guidelines for opioid rotation, and classes of opioids like partial agonists. It provides information on the public health issues surrounding opioid misuse and abuse as well as clinical best practices for safely prescribing opioids for pain management.
The document outlines an upcoming conference on responsible opioid prescribing practices that aims to describe how cautious, evidence-based prescribing can lower overdose deaths while maintaining treatment for chronic pain, identify best practice strategies for pain management, and explain evidence-based practices and patient education programs being used across the US.
The document discusses the management of acute pain, including the introduction of Acute Pain Services in hospitals in Malaysia starting in the 1990s. It describes techniques like patient-controlled analgesia, epidural analgesia, and multimodal analgesia that have improved acute pain management. Factors in choosing a pain management technique include the patient, surgery, nursing needs, costs, and side effects. Common techniques discussed in more depth include patient-controlled analgesia, its programming and problems that can occur. Central neuraxial blocks like epidural and intrathecal analgesia are also covered.
medication Adherence defined as the act of filling a new prescription for the first time.
The extent to which the patients take medications as prescribed by the prescriber.
Conclusions:
74% of patients discharge home with moderate to severe pain --> with or without treatment before
ED patients should receive proper pain management, avoiding delays such as those related to diagnostic testing or consultation
In order to further improve patient care we must now apply our knowledge regarding acute and chronic pain treatment base on pharmacology of the drugs
Ongoing research in the area of ED patient pain management conducted and an algorythm or clinical guidelines in this area should be developed
Effective physician and patient educational strategies should be developed regarding pain management, including the use of pain therapy adjuncts and how to minimize pain after disposition from the ED
This document discusses pain assessment and management. It provides an overview of different pain scales used to assess intensity, location, quality and other factors. It reviews opioid pharmacology including delivery methods, side effects like constipation and nausea/vomiting, and challenges to pain management like barriers to treatment. Common chronic pain syndromes like cancer, low back pain and osteoarthritis are examined in terms of characteristics, diagnosis and treatment considerations.
Clinical edvidence and access for medicinal cannabis productsTGA Australia
This document summarizes the Australian government's approach to medicinal cannabis, which includes treating it as a medicine available by prescription. It outlines reviews finding evidence that cannabis is effective for chronic pain, spasticity, nausea from chemotherapy, and some other conditions. Clinical guidance documents are being developed for conditions like epilepsy, multiple sclerosis, pain, and palliative care. The TGA regulates cultivation, manufacturing, and patient access through schemes like Special Access that require authorization from a prescriber and state health department. Over 170 approvals have been issued under these schemes since 2016.
Pharmacists play important roles in pain management through technical, clinical, and general responsibilities. They obtain, store, and secure pain medications. Pharmacists also prepare medications, dispense them properly, and establish effective distribution systems. Clinically, pharmacists provide Pain Medication Therapy Management services to optimize pain treatment and minimize adverse events. These services include assessing patients, managing medication therapy, and monitoring treatment outcomes. Pharmacists educate patients on appropriate medication use and collaborate with healthcare providers to improve pain management.
Similar to Toronto Medical Rounds in Addiction: Pain and Chemical Dependency: An approach to the patient with both “legitimate pain” and a substance use disorder (20)
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Toronto Medical Rounds in Addiction: Pain and Chemical Dependency: An approach to the patient with both “legitimate pain” and a substance use disorder
1. Pain and Chemical Dependency: An
approach to the patient with both
“legitimate pain” and a substance
use disorder
Wiplove Lamba MD FRCPC Dip ABAM
lambaw@smh.ca
October 1, 2014 – ADDICTION rounds
3. Objectives
• Understand the basics of a pain and chemical dependency
assessment, including: risk factors, pain assessment,
rationalizing pharmacotherapy, universal precautions and
treatment recommendations.
• Discuss topics such as:
– perioperative management of the patient taking buprenorphine,
– “prisoner’s dilemma” in limiting prescription drug abuse, and
– accounting for “opioid debt.”
• Engage in a discussion about what services are needed for
our inner city patient population to help them get care for
both conditions in different treatment settings (family
practice, addiction medicine clinic, or inpatient medicine
and surgery).
4. Outline
• PAIN and CHEMICAL DEPENDENCY assessment
• Perioperative buprenorphine management
• Tips for Acute Pain Management of MMT, SMT
• Prisoner’s dilemma
• Pain Connect - Ottawa
5. Outline
• What I’m not covering
– Comprehensive opioid and non-opioid treatment
strategies
– Methadone/suboxone/structure opioid therapy
initiation/induction/maintenance
– (Some of these can be found at
www.suboxonecme.ca, CPSO guidelines for
methadone/buprenorphine, McMaster Guidelines
for opioids in chronic non-cancer pain)
7. Exercise (5 min)
• Groups of 2
• Share the story of a case you worked with
where the following may have been there
– Pain
– Potential or clear substance use disorder
– Transference/counter-transference issues
– System difficulties to get care needed
– Feelings of helplessness within the patient/within
the care provider/both
8. Think about
• What was the clinical setting?
– Community
– Addiction medicine clinic
– Family practice
– Inpatient
• What was your role?
9. Pain and Chemical Dependency
• Clinical Case
– 45 yr old male, referred for stimulant use to
addiction service
– ++ paranoid, symptoms improved with addition of
atypical antipsychotic while in hospital
– History shows a significant chronic pain and
addiction history
10. Pain and Chemical Dependency
• Clinical Case
– Discharged from hospital on daily dispensing
medications (short acting and long acting opiates)
as he was on prior to coming in.
– was offered buprenorphine/methadone – not
interested
11. Pain and Chemical Dependency
• Clinical Case
– Further visits reveal aberrant behaviour
– GP managing pain meds
– Agrees to get collateral sent
12. Pain and Chemical Dependency
• Clinical Case
– Discharged from hospital on daily dispensing
medications (short acting and long acting opiates)
as he was on prior to coming in.
– was offered buprenorphine/methadone – not
interested
13. Pain and Chemical Dependency
• Clinical Case
– Collateral shows numerous pain consultations and
medication trials
• Was up to 6 tabs of 80 mg oxycontin q6h plus
breakthrough 100 mg of IR morphine q 4 h
• Some suggested increased the dose
• Some suggested no indication for opioid therapy
• Previous trial of methadone (>100mg) with numerous
pain meds for breakthrough pain (long acting and short
acting hydromorphone)
14. Pain and Chemical Dependency
• Clinical Case
– Further history reveals numerous pain conditions
including
15. Pain and Chemical Dependency
• Clinical Case
– Further history reveals numerous pain conditions
including
• Cancer
16. Pain and Chemical Dependency
• Clinical Case
– Further history reveals numerous pain conditions
including
• Cancer (in remission)
• HIV and HIV related pain conditions
• Osteomyelitis
• Hx of avascular necrosis
• Chronic LBP
17. Pain and Chemical Dependency
• Clinical Case
– Think about how your clinical opinion about the
use of opioids changes based on the diagnoses
the patient has
18. Pain and Chemical Dependency
• Clinical Case
– Further history reveals numerous pain conditions
including
• Cancer
• HIV and HIV related pain conditions
• Osteomyelitis
• Hx of avascular necrosis
• Chronic LBP
19. Outline
• PAIN and CHEMICAL DEPENDENCY assessment
• Perioperative buprenorphine management
• Tips for Acute Pain Management of MMT, SMT
• Prisoner’s dilemma
• Pain Connect - Ottawa
20. Pain and Chemical Dependency
• Diagnosing Addiction
– C = lost of CONTROL
– C = COMPULSION to use
– C = continued use despite negative
CONSEQUENCES
– C = CRAVINGS
21. Pain and Chemical Dependency
• Assessment
– RISK ASSESSMENT
• Scales – CAGE, SOAPP, ORT, UDT, interview
– Actual risk is determined over time
“Pain and Prescription Opioid Abuse” Gourlay CSAM review Course 2014
22. Pain and Chemical Dependency
• Assessment
– Clinical Approach
• What is the nature of the problem?
– Is the pain problem alone, an addictive disorder, or a bit of both?
» Which is dominant?
• What is the nature of the pain?
– Acute, chronic, acute on chronic
– Nociceptive, neuropathic
• Is the current pharmacotherapy rational
– Is it doing more to the patient than for the patient?
• Do I have
– The experience to deal with this problem?
– Resources to deal with it?
“Pain and Prescription Opioid Abuse” Gourlay CSAM review Course 2014
23. Pain and Chemical Dependency
• Assessment
– Rationalize Pharmacotherapy
• Sometimes better to achieve pharmacologic stability
than abstinence
– Short acting is problematic
– hyperalgesia
• Retry previously ineffective agents
• Consider non-opioid therapeutics
• Avoid previous drugs of “misuse”
“Pain and Prescription Opioid Abuse” Gourlay CSAM review Course 2014
24. Pain and Chemical Dependency
• Universal Precautions
– Thoroughly inquire about drug and alcohol history
– ORT/CAGE/etc
– Set boundaries around medication use
– Identify aberrant behaviour
– Triage – primary care, specialist support, tertiary
care
– Assess opioid responsiveness
26. Pain and Chemical Dependency
• Assessment
– Set limits carefully from the outset
• Easier to loosen than to tighten
• Limits should be flexible and reasonable
– If set too tightly, patient must step outside them
– Assess risk initially and periodically
• Risk is dynamic in pain and addiction continuum
– Appropriate monitoring
• Urine Drug testing
• Frequent follow-up
• Interval/contingency dispensing
“Pain and Prescription Opioid Abuse” Gourlay CSAM review Course 2014
28. Pain and Chemical Dependency
• Gourlay-isms
– “Opioid Debt”
– “Withdrawal – mediated pain”
– “legitimate pain does not stop risk”
– “un-wise to make pseudo-addiction diagnosis in a
someone with an addiction history”
29. Pain and Chemical Dependency
• WITHDRAWAL MEDIATED PAIN
• Ask about withdrawal symptoms:
– How long has the patient been able to go without opioids?
– Was he or she uncomfortable during this period?
– Has the patient ever used opioids to avoid withdrawal or relieve
withdrawal symptoms?
• Determine whether your patient is experiencing withdrawal-
mediated pain. Consider withdrawal-mediated pain in patients who
report:
– intense magnification of their pain as the opioid wears off
– diffuse myalgias (“pain all over”)
– dysphoria
– severe pain and withdrawal symptoms in the morning, with quick
relief after taking the opioid.
https://knowledgex.camh.net/primary_care/toolkits/addiction_t
oolkit/opioid_toolkit/Pages/faq_assess_patients.aspx
30. Outline
• PAIN and CHEMICAL DEPENDENCY assessment
• Perioperative buprenorphine management
• Tips for Acute Pain Management of MMT, SMT
• Prisoner’s dilemma
• Pain Connect - Ottawa
31. Pain and Chemical Dependency
• Buprenorphine in perioperative management
“An anesthesiologist’s View” Rubinstein, CSAM review course 2014
32. Pain and Chemical Dependency
• Buprenorphine in perioperative management
(why people don’t use it)
– It isn’t an Analgesic
– It has a Ceiling effect for analgesia
– It blocks the effect of other opioids
“An anesthesiologist’s View” Rubinstein, CSAM review course 2014
33. Pain and Chemical Dependency
• Analgesic?
“An anesthesiologist’s View” Rubinstein, CSAM review course 2014
34. Pain and Chemical Dependency
• Ceiling effect?
“An anesthesiologist’s View” Rubinstein, CSAM review course 2014
35. Pain and Chemical Dependency
• Ceiling effect?
“An anesthesiologist’s View” Rubinstein, CSAM review course 2014
36. Pain and Chemical Dependency
• Opioid blocking
– “While patients are taking opioid pain
medications, the administration of buprenorphine
generally should be discontinued. Note that until
buprenorphine clears the body, it may be difficult
to achieve analgesia with short acting opioids”
• “Clinical guidelines for the use of buprenorphine in the
treatment of opioid addiction” TIP 40 SAMHSA
“An anesthesiologist’s View” Rubinstein, CSAM review course 2014
37.
38.
39. Pain and Chemical Dependency
• Buprenorphine in perioperative management
– Opioid blocking effect?
• Unclear where evidence came from
• Anecdotally
• Information from patients that go for dental procedures
from pregnant patients suggest the blocking effect is
not a concern
“An anesthesiologist’s View” Rubinstein, CSAM review course 2014
40. Pain and Chemical Dependency
• Buprenorphine in perioperative management
– General approach for chronic pain patients
• Regional/neuraxial anesthesia
• Ketamine
• Pre-op celecoxib
• Pre-op pregabalin
• Ketorolac
• Local at incision
• Continue baseline opioids plus analgesic dose
– Consider lowering buprenorphine in patient’s on high doses
“An anesthesiologist’s View” Rubinstein, CSAM review course 2014
41. Pain and Chemical Dependency
• Medication Assisted Therapy (MAT) Patients
(in hospital)
– Buprenorphine or Methadone
42. Pain and Chemical Dependency
• MAT Patients in hospital
• MISCONCEPTIONS
– Maintenance dose provides analgesia
– Use of opioids may result in addiction relapse
– Have to watch for respiratory depression with
MAT and additional opiates
– Pain reporting is manipulating or drug seeking
43. Pain and Chemical Dependency
• MAT Patient in hospital
– Methadone
• Continue methadone, Confirm dose
• Continue dose or reduce if needed
• May divide methadone dose
• Provide additional short acting if indicated
• At discharge provide with a last letter dose
– Buprenorphine
44. Pain and Chemical Dependency
• MAT Patients in hospital
– Buprenorphine (2 options)
• Stop buprenorphine
– Start full agonist and/or methadone/long acting
• Continue buprenorphine
– Use additional buprenorphine or full agonists
– Maximize non-opioids
– divide buprenorphine dose (q8h)
– For patient’s on high dose buprenorphine, lower the dose, but
keep them on it. Use opioids for pain
45. Pain and Chemical Dependency
• MAT Patients in hospital
• On Discharge
– Avoid writing one script for post discharge supply (daily or
q2day dispensing
– Involve sober family member or signficiant other to either
dispense or monitor
– Supply enough until followup appointment to reassess pain
– Coordinate with other providers
46. Outline
• PAIN and CHEMICAL DEPENDENCY assessment
• Perioperative buprenorphine management
• Tips for Acute Pain Management of MMT, SMT
• Prisoner’s dilemma
• Pain Connect - Ottawa
48. Prisoner’s Dilemma
Cooperate Defect
Cooperate Both Cooperate:
Physician provides treatment
Patient stays in treatment
Controlled substances are well managed
Physician cooperates,
patient defects
Increased prescription
diversion
Compromised provider
reputation
External controls on
physician decision making
Defect Patient cooperates, physician defects
Physician refuses to treate (permanent
realiation, east of management)
“opioid refugees”
Neither cooperate
Physician refuses to treatet
Patient does not get
treatment
Controlled substances not
dispenses
“The Complex patient” Anna Lembke - CSAM review course 2014
49. Prisoner’s Dilemma
• Strategies
– Always mean
– Always nice
• Axelrod’s winning strategy
– “tit for tat”
– 4 lines of BASIC
“The Complex patient” Anna Lembke - CSAM review course 2014
50. Prisoner’s Dilemma
• Tit for Tat
– Cooperate Cooperate
– Cooperate Cooperate
– Cooperate Defect
– Defect Defect
– Defect Cooperate
– Cooperate Cooperate
“The Complex patient” Anna Lembke - CSAM review course 2014
51. Prisoner’s Dilemma
• Be Nice (never be the first to defect)
• Be Forgiving (be willing to cooperate if
cooperating is offered)
• Be Retaliatory (willing to defect if others
defect against you)
• Be Clear (transparent about your strategy)
“The Complex patient” Anna Lembke - CSAM review course 2014
52. Prisoner’s Dilemma
• - frame shift – addicton a disease
• -method to detect defectors – ODB profile,
UDS
• Reward for cooperation –
“The Complex patient” Anna Lembke - CSAM review course 2014
56. PAIN CONNECT - Ottawa
• Dr. Catherine Smyth And Dr. Lisa Bromley
• Very long waitlist for chronic pain consultations
>12 months
• Most were patients on high dose opiates
• “It’s very rewarding work. I came to that
conclusion that we need to do things differently
in order to have an impact with chronic pain.
Show GP how to do what we are doing. A lot of
the consults were relatively unnecessary. “
57. PAIN CONNECT - Ottawa
• Find GP with several referrals, then go to clinic
• Educational component
• Read over the charts the night.
• Most discussions were focused on opioids and
interventions. Most GP did not understand
anesthesia procedures
• 3 patients in am, then had other cases to
discuss in lunch hour.
58. PAIN CONNECT - Ottawa
• Family docs fill in a referral form.
• Pain history questionnaire, 12 page. Detailed
information and mental health history.
• Standardized questionnaires
• SOAP, ORT, insomnia severity index, insomnia,
Pain catastrophizing index,
• summarize, provide extensive reports.
• Provide long term treatment plan
59. PAIN CONNECT - Ottawa
• Multimodal approach. First on statement –
– “can’t fix pain, but can improve function and establish goals of the patient that
are functional and realistic.”
– Some we have done everything we can. Pushing dose is making things worse.
• Divide up management into pharmacotherapy, interventions (odd patient
would be a good candidate for a spinal cord stimulataor or steroids), self
management programs and exercise.
• Fair number of family physicians wanted help with detox with opioids.
They can prescribe it, but scared to get rid of it.
• Slow titration vs rapid detox on suboxone. Present both as option.
• INITIATION Stop long acting 2 days in advance, short acting 1 day in
advance then at 8 am for pain clinic, in withdrawal, COWS scale, UDT, and
then confirm that not taken opioids in past 12 hours, then first dose under
tongue 4 mg.
60. PAIN CONNECT - Ottawa
• EXAMPLES
• 1 patient today in precipitated withdrawal, team
found helpful. Required extra suboxone, tordol,
lidocaine.
• Usually uneventful, 8 mg total, some get 12,
prescription faxed to community pharmacy,
• Only methadone patients down to 30 mg.
• Other patients, fentanyl pathc 200 mcg,
• 16-24 dilaudid a day.
61. PAIN CONNECT - Ottawa
• If they truly meet criteria for substance
dependence, then connect to Addiction
Medicine Physician - Dr. Bromley
• Most have been on opioids forever, hard to
wean off, may have some misuse, but not
criteria for addiction.
62. PAIN CONNECT - Ottawa
• Most of them, it’s quite clear that pain is no
different
• With 6months to a year for a taper, sometimes
patients forget
• “Realize that a lot of their pain is withdrawal
mediated and opioid mediated pain.”
63. PAIN CONNECT - Ottawa
• New initiatives – Dr. Smyth
– E-consult
– Emerg department, orphan patients
– Pain preceptorship program
64. PAIN CONNECT
• Think about the patients that we see in our
clinical practice
• What can we do to help them get the care
that they need for both conditions?
• What is the knowledge that I need to get in
order to manage these patients?
• Are there colleagues that can be helpful in this
journey?
65. References
• Review Course
– California Society of Addiction Medicine Review
Course and Complex Pain workshop 2014
• www.pcss-o.org (or www.pcss.mat.org)
– Provider’s Clinical Support Systems for Opioid
Prescribers (free webinars from APA, AAAP, AMA,
etc)