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Opiate Prescription, Washington 2011
The document discusses the use of opiates in managing chronic non-malignant pain, highlighting different types of opioids, their dosing, and the associated risks of abuse and overdose. It examines physician prescribing variations and emphasizes the importance of assessing analgesia, function, and possible adverse reactions. Additionally, it touches on guidelines for safe opioid prescribing and considerations for managing aberrant behaviors in patients.
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Opiate Prescription, Washington 2011
- 1. Opiates in Chronic Non-malignantPain Jonathan Ploudré, MD
- 2.
- 3. Fentanyl Tramadol Oxycodone Hydromorphone Oxymorphone Morphine Meperidine Methadone Codeine (Prophxyphene) Hydrocodone
- 4.
- 5. Fentanyl Tramadol Oxycodone Hydromorphone Oxymorphone Morphine Meperidine Methadone Codeine (Prophxyphene) Hydrocodone
- 6. Strong Weak Weak/Re-uptake Fentanyl Codeine Tramadol Hydromorphone Hydrocodone Meperidine (Prophxyphene) Morphine Methadone Oxymorphone Oxycodone
- 7. Strong Weak Weak/Re-uptake Fentanyl Codeine Tramadol Hydromorphone Hydrocodone Meperidine (Prophxyphene) Morphine Methadone Oxymorphone Oxycodone
- 8.
- 9. Fentanyl Tramadol Oxycodone Hydromorphone Oxymorphone Morphine Meperidine Methadone Codeine (Prophxyphene) Hydrocodone
- 10. < 3 hours 4-6 hours > 6 hours Fentanyl Hydromorphone Fentanyl Meperidine Hydrocodone Methadone Morphine Morphine Oxycodone Oxycodone Oxymorphone Oxymorphone Codeine Tramadol (Prophxyphene) Tramadol
- 11. < 3 hours 4-6 hours > 6 hours Fentanyl Hydromorphone Fentanyl Meperidine Hydrocodone Methadone Morphine Morphine Oxycodone Oxycodone Oxymorphone Oxymorphone Codeine Tramadol (Prophxyphene) Tramadol
- 13. Controversies • Different PhysicianStyles of Prescribing • Pain is 100% subjective • Risks of Abuse and Overdose • Risks of Under-treatment • Marijuana • And on and on......
- 14.
- 15.
- 16. WA Law is NationalNews. This starts in 3m More than MVAs NEJM: Nov 2010
- 17. Starting Out • Isthis chronic? • Is this patient high-risk? • Has workup been done?
- 18. Screening Risk Painknowledge.org
- 19. Opioids: Details • No evidence based approach for individualizing for a patient. • Expert opinion prefer long-acting, scheduled dosing over short-acting prn dosing. • Expert opinion avoid high # counts. • VA Study 2011: Scheduled vs PRN are equal risk for accidental overdose • VA Study 2011: High Daily Dose, higher risk of overdose.
- 20. Provider Variation • Residency2005:Variation of experienced prescribers (3rd years, faculty) ranged from 3% of total prescriptions to 25%. • “Default” practices for acute pain vary widely. • “Default” practices for acute/chronic pain vary from guidelines, too.
- 21. Opioids: WA referral levels • Morphine: 120mg daily • Methadone: 40mg daily • Oxycodone: 80mg daily • Hydrocodone: 120mg daily • Hydromorphone: 30mg daily • Oxymorphone: 40mg daily
- 22. The 5 A’s •Analgesia • ADLs (Function) • Adverse Reactions • Aberrant Behaviors • Assessment
- 23. Analgesia • Your averagepain over the past week? • Your worst pain over the past week? • What percentage of pain has been relieved over the past week? • Is the pain relief enough to make a real difference?
- 24. ADLs (Function) Surprisingly Reproducible Validated across 8-10/10 culture 6-7/10 General Activities 5/10 Relationships Relationships Walking Walking 3-4/10 Work Work Work Sleep Sleep Sleep Enjoyment Enjoyment Enjoyment Enjoyment Overall Mood Overall Mood Overall Mood Overall Mood
- 25. Adverse Reactions • Nausea/Vomiting •Constipation • Itching • Mental Cloudiness • Sweating • Fatigue • Drowsiness
- 26. Adverse Reactions • Nausea/Vomiting •Constipation “The hand that writes the prescription should write for something for constipation.” • Itching • Mental Cloudiness • Sweating • Fatigue • Drowsiness
- 27.
- 28.
- 29. Aberrant Behaviors • Purposeful Over-sedation • Negative mood change • Appears intoxicated • Increasingly unkempt or impaired • Involvement in car or other accidents • Requests for frequent early renewals • Increasing dose without authorization • Reports lost/stolen prescriptions • Prescriptions from other doctors • Changes route of administration • Uses medications in response to situational stressors • Insists on certain medications by name • Contact with street drug culture • Abusing alcohol or illicit drugs • Hoarding (Stockpiling) of medication • Arrested by police • Victim of abuse
- 30. Aberrance Prevalence 60 50 40 30 20 10 0 2 4 5+ 1- 3- Passik 2005: Pain Clinic Population
- 31. Does a UtoxWork? Previous No Previous Behaviors Behaviors Urine + 10 26 Urine - 17 69 Katz 2003: Pain Clinic Population (So not generalizable to lower risk populations.)
- 32. Assessment • Benefits outweighrisks:Yes, No, Uncertain • Continue Same Dose • Titrate Dose • Change Medications • Discontinue/Taper
- 33. Discontinuation: in a tweet ?
- 34. Discontinuation: in a tweet David Schumer, MD: These are trust medications and I don’t trust you. So I won’t prescribe them anymore. I believe you have pain but I don’t trust you.
- 35. Self Knowledge • Philosophically:Where will you be on the spectrum of opiate prescribing norms?
- 36. “Interagency Guideline onOpioid Dosing”
- 37.