1. The document discusses strategies for reducing harms from opioid use, including avoiding high doses above 120mg MED, not co-prescribing benzodiazepines or sedatives with opioids, and prescribing nasal naloxone for patients on high opioid dosages. 2. It provides examples of patients on high opioid dosages and strategies for tapering their doses or converting to alternate treatments like buprenorphine, including prescribing nasal naloxone and involving family members. 3. The document also covers preventing harms to opioid-naïve patients, noting that more than half of patients prescribed opioids for 90 days remain on them for years, and a third of addiction treatment patients come from

1. Opioid Harm Reduction
Strategies
Paul C. Coelho, MD
Board Certified PM&R
Subspecialty Certified Pain Medicine
Sunday, August 30, 15

2. Table Of Contents
1. General Principles
2. Reducing Harms to High
Dose Patients
3. Preventing Harms to Opioid
Naive Patients
Sunday, August 30, 15

3. General Principles
1. Avoid doses > 120MED for
CNP
2. Avoid Methadone
3. Avoid co-prescribing Benzo’s/
sedatives and opioids.
4. Prescribe nasal naloxone to
loved ones of pts on high
dosages
Sunday, August 30, 15

4. High Dose (>120MED)
Patients
1. Identify the high risk patients.
2. Explain to the patients that their dose has become dangerously
high and it will need to change.
3. Prescribe nasal naloxone and train a loved one in the
patient’s household on administration.
4. If the MED is < 240 offer the patient a 6mo taper.
5. If the MED is > 240 consider a taper or conversion to
buprenorphine for PAIN.
Sunday, August 30, 15

5. Example 1: Teresa
68y/o retired missionary
with diffuse OA. Lives in
Mennonite Village. Uses
Oxycodone-APAP 10/325,
six per day (MED 80). No
aberrant behavior.
Sunday, August 30, 15

6. Example 1: Teresa
1. Teresa reports the medications give her
comfort.
2. She was started on them years ago by a
doctor long since retired.
3. Leave Teresa alone. She is not who we are
worried about for the purposes of this talk.
Sunday, August 30, 15

7. Example 2: Cleatus
68y/o retired millwright with
failed back syndrome.
Lives with spouse Rx’d
MS04 ER 60mg QID (MED
240). No aberrant behavior.
Sunday, August 30, 15

8. Example 2: Cleatus
1. Call Cleatus & Mabel into clinic to explain that
new literature has suggests that Cleatus’ dose
has become unsafe and it will need to change.
2. Rx nasal naloxone and train Mabel in it’s
administration.
3. Offer a 15mg/mo taper over 8mo to 120MED.
Sunday, August 30, 15

9. Example 3: Loretta
52y/o disabled woman with
FMS and chronic Hep C,
on Transplant List @
OHSU. Medications
include a Fentanyl patch
100ucg/hr Q48, Soma
350mg QID, and Xanax .
5mg QID. Has an OMMP
card. (MED 360)
Sunday, August 30, 15

10. Example 3: Loretta
1. Call Loretta and her adult daughter/care-giver
into clinic to explain that new literature has
suggests that Loretta’s dose has become unsafe
and it will need to change.
2. Consider an addiction medicine consult given
the complex PMH, Hep C, & Transplant status.
3. Rx nasal naloxone and train Frisbee - her
daughter- in it’s administration.
4. Load with Gabapentin over 1mo to 1200mg/day
5. Convert from alprazolam to clonazepam - 1:1
conversion and begin a 6mo taper. Consider non-
addictive alternatives for anxiety (citalopram).
Sunday, August 30, 15

11. Example 3: Loretta
6. Stop the Soma - it is an addictive barbiturate - and
offer a conventional muscle relaxant.
7. Consider a conversion to Buprenophine for pain :
Induction, stabilization, maintenance.
7a. Or offer a 12ucg/mo taper to 50ucg/hr.
8. Explain that our clinic policy is either THC or
opioids but not both and let her choose.
Sunday, August 30, 15

12. Addiction Services In
Oregon By County
Drug & Alcohol Services by County: http://
www.oregon.gov/oha/amh/publications/provider-
directory.pdf
Sunday, August 30, 15

13. Nasal Naloxone
1. SB 384 legalized for lay
administration in 2013.
2. Stock in your pharmacies.
3. Some patients must pay out of
pocket ($25.00.)
4. http://www.prescribetoprevent.org/
wp-content/uploads/2012/11/
naloxone-one-pager-in-
nov-2012.pdf
Sunday, August 30, 15

14. Buprenorphine
1. Schedule III opioid.
2. Morphine Equivalence 30:1.
3. FDA approved for pain - Butrans &
addiction - Suboxone.
4. Ceiling effect for respiratory
suppression.
5. Follow the QTc.
6. Contra-indications: coprescribing
benzo’s, sedatives,
or alcohol use.
Sunday, August 30, 15

15. Pain or Fear of
Withdrawal?
Sunday, August 30, 15

16. It’s Easier Not to Start
Opioids, Than to Stop Em.
Sunday, August 30, 15

17. It’s Easier Not to Start
Opioids, Than to Stop.
Sunday, August 30, 15

18. More than ½ of patients
receiving opioids for 90d
remain on opioids for years.
Sunday, August 30, 15

19. 1/3rd Of Patients Treated in
Addiction Clinics Come
From Pain Clinics
Sunday, August 30, 15

20. Oregon Ranks #1 in the
Nation in Prescription
Opioid Abuse
Sunday, August 30, 15

21. Top Oregon Counties for
Opioid Prescriptions
0
52.5000
105.0000
157.5000
210.0000
Josephine
D
ouglas
Sherm
an
Lincoln
C
latsop
Linn
Lane
Tillam
ook
M
arion
Polk
County
Sunday, August 30, 15

22. Prescription Opioid Deaths
In Oregon 2000-2011
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23. Prescribed Opioid
Addiction Tx By Age
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24. Age of Opioid ODD
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25. Prescription Opioid Deaths
& Addiction Treatment
Parallel Opioid Prescribing
Sunday, August 30, 15

26. Special Thanks To:
• Andrew Kolodny, MD, Chief Medical Officer
Phoenix House
• Jim Shames, MD, Medical Director
Jackson County, OR Health & Human Services
• Andrew Mendenhall, MD, Medical Director
Hazelden, Beaverton, OR
Sunday, August 30, 15

27. Thank You
www.supportprop.org
Sunday, August 30, 15