This document provides harm reduction strategies for chronic pain patients who are at risk of opioid overdose or opioid use disorder. It discusses the opioid overdose epidemic, CDC guidelines, risk factors for overdose and addiction, and presents sample patient cases. For at-risk patients, it recommends strategies like prescribing nasal naloxone, considering buprenorphine treatment, using PDMPs to monitor prescribing, and lowering doses or changing medications if risks are identified. The goal is to continue providing pain relief while reducing risks of overdose or addiction.

1. Harm Reduction
Strategies for Chronic
Pain Patients
Paul C. Coelho, MD
Board Certified PM&R
Subspecialty Certified Pain Medicine

2. Disclosures
Paul Coelho,MD: No industry financial relationships to disclose.
I am a member of the OPG planning committee and on
the OPG speakers bureau.

3. Table Of Contents
1. Opioid Overdose Deaths
(ODD)
2. 2016 CDC Opioid Guidelines
3. Risk Factors for an ODD
4. Risk Factors for Opioid Use
Disorder (Addiction)
5. Harm Reduction Strategies
6. Sample Cases

4. 0
12500
25000
37500
50000
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
US Opioid Overdose Deaths 1980-2014
Peak Incidence of Prescription ODD Age 45-54*

5. Death Rates 2000- 2015
http://www.pnas.org/content/112/49/15078.full.pdf

6. 0
12500
25000
37500
50000
1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014
Injection IncreasesVs Opioid ODD
0
100
200
300
Opioid Overdose Deaths Increased 250%
Spinal Injections Increased 375%

7. 2016 CDC Guidelines
https://www.cdc.gov/drugoverdose/pdf/guidelines_at-a-glance-a.pdf

8. 2016 CDC Guidelines
https://www.cdc.gov/drugoverdose/pdf/guidelines_at-a-glance-a.pdf

9. Mandatory PDMP Use
http://content.healthaffairs.org/content/35/10/1876.abstract

10. Risk Factors for
Overdose Death
1. Opioid Dose
2. Methadone
3. Opioids + Benzodiazepines/Sedative

11. Dose as a Risk Factor For
ODD
https://www.aan.com/uploadedFiles/Website_Library_Assets/Documents/3.Practice_Management/2.Quality_Improvement/
2.Patient_Safety/2.Patient_Safety_Education/C171%20-%20Franklin.pdf

12. Methadone as a Risk
Factor for ODD
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6126a5.htm
1/3rd of all ODD

13. Co-Rx’d Benzos as a Risk
Factor for ODD
http://www.ncbi.nlm.nih.gov/pubmed/26890165
1/3rd of all ODD

14. Risk Factors for
Opioid Use Disorder
1. Age
2. Length of Exposure
3. Dose
4. Psychosocial Factors:
a. H/o drug/alcohol tobacco abuse
b. Family hx of drug/alcohol abuse
c. H/o childhood trauma/abuse
d. Intercurrent mental health ds

15. Prescribed Opioid
Addiction Tx By Age
http://www.samhsa.gov/data/sites/default/files/2013_Treatment_Episode_Data_Set_National/
2003_2013_Treatment_Episode_Data_Set_National_Body.html
2013

16. Opioid Use Disorder Dx By
Age
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4032801/
0
10
20
30
40
18-30 31-40 41-50 51-64 >65
N = 570K

17. OR Medicaid Opioid Rx’s
By Age (86% 18-60yrs)
http://www.ncbi.nlm.nih.gov/pubmed/26766755
0
22.5
45
67.5
90
18-39 40-59 60-79 >80
Top 10% Prescribers Rx’d 80% All Opioids

18. Dose & Length of Exposure
As Risk Factors For OUD
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4032801/
Low Dose 0-36MED
Med Dose 37-120MED
High Dose > 120MED

19. Harm Reduction
Strategies

20. Identify At Risk Patients
1. Morphine Equivalent Dose > 120mg/day
2. Methadone
3. Opioid and co-prescribed benzodiazepine
4. H/o aberrant behavior or addiction

21. Prescription Drug
Monitoring Program
http://www.orpdmp.com/health-care-provider/

22. Prescription Drug
Monitoring Program
http://www.orpdmp.com/health-care-provider/

23. PDMP Dashboard
https://orpdmp-ph.hidinc.com/orlogappl/bdorpdmqlog/pmqhome.html
6mo Look Back

24. Coelho’s PDMP Dashboard
https://orpdmp-ph.hidinc.com/orlogappl/bdorpdmqlog/pmqhome.html
Patient Name Dose >120
MED
Methadone Benzodiazepine >90 Days Use > 4
Pharmacies/
Prescribers
167 39 (23%) 4 (2%) 98 (59%) 79 (47%) 4 (2%)

25. Opioid Dose Calculator
http://www.agencymeddirectors.wa.gov/Calculator/DoseCalculator.htm

26. Examples of 120MED
Fentanyl 50ucg/hr
Buprenorphine 4mg
Methadone 30mg
Hydromorphone 30mg
Oxycodone 80mg
Oxymorphone 40mg
Morphine 120mg
Codeine 800mg

27. MED > 90
Prescribe Nasal Naloxone
1. SB 384 legalized for lay
administration in 2013.
2. Stock in your pharmacies.
3. Some patients must pay out of
pocket ($35.00 -$75.00)
http://www.amphastar.com/assets/naloxone.pdf

28. Consider a Data 2000
Waiver: Buprenorphine
http://projects.huffingtonpost.com/dying-to-be-free-heroin-treatment/opioid-abuse-outpace-treatment-capacity
17K MD/DO in OR, 400 with Waiver [2%]

29. Buprenorphine
1. Schedule III drug, partial mu agonist
2. FDA approved for both pain - Butrans/Belbuca -
and addiction - Suboxone/Subutex.
3. Ceiling effect for respiratory suppression (RS).

30. Buprenorphine’s Ceiling
Effect for R.S.

31. Buprenorphine & ODD
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6126a5.htm

32. Buprenorphine Substitution
for High Dose Opioids
http://www.ncbi.nlm.nih.gov/pubmed/25220043

33. Buprenorphine Is A
Powerful Analgesic
http://www.compoundchem.com/2014/09/25/painkillers/

34. Random Urine Or Saliva
Drug Screening
https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

35. Sample Cases

36. Case 1: Teresa
75y/o retiree with diffuse OA.
Lives alone in Prineville. Uses
Oxycodone-APAP 10/325, five
perday (MED 70). No h/o
aberrant behavior or addiction.

37. Case 1: Teresa
Teresa reports that the medications
give her comfort. She was started on
her current dose years ago.
Recommendations:
Continue as prescribed.

38. Case 2: Cleatus
68y/o retired logger with failed back
surgery syndrome. Lives with spouse Rx’d
Methadone 10mg po QID (MED 320).
No h/o addiction or aberrant behaviors.

39. Case 2: Cleatus
Recommendations:
Call Cleatus & his spouse in.
Explain that his dose and medication
are both unsafe and will need to change.
a. Prescribe nasal naloxone & train spouse
in assembly and use.
b. Offer a conversion to Morphine Sulfate
ER 75mg QD (30,15,30) at his next refill.
http://www.prescribetoprevent.org/wp-content/uploads/2012/11/naloxone-one-pager-in-nov-2012.pdf

40. Case 3: Jane
55y/o woman with FMS.
Lives alone in Redmond. Uses
OxyContin 30mg PO BID (MED
80), and alprazolam 0.5mg po
QID. No h/o aberrant behavior
or addiction.

41. Case 3: Jane
Recommendations:
Call Jane in to clinic.
Explain that the combination of
alprazolam and Oxycodone is
unsafe.
a. Offer a conversion to
clonazapam 2mg BID.
b. Taper clonazepam by .5 -1mg/
mo over 4-8mo.
c. Offer non-benzodiazepine
alternatives for anxiety/sleep/
panic attacks.
http://www.slideshare.net/101N/alternatives-to-benzodiazepines-60678319

42. Case 4: Luc
49y/o married restaurant owner with
chronic migraine. Prescribed
Oxycodone 5mg BID, 30/mo over
many years. No h/o addiction or
aberrant behavior. Recent review of
the PDMP with at a f/u visit reveals
visits to 6 other prescribers over the
past 3mo for opioids. Patient
acknowledges that he is overusing
pain medication and wants your help
in getting off opioids entirely.

43. Case 4: Luc
Recommendations:
Use your data-2000 waiver to offer Luc
treatment of opioid use disorder. Stop
opioids.
a. Offer conversion to buprenorphine
(Suboxone/Subutex) with a planned
6mo taper off. (8mg QD x 2mo,
4mgQD x 2mo, 4mg QOD x 2mo)
b. Offer an addiction counseling
referral.
c. Continue to see frequently for
followups with both urine or saliva
drug screens and frequent checks
of the PDMP to ensure adherence.

44. Help with Tough Cases

45. Resources
Alternatives to Benzodiazepines:
http://www.slideshare.net/101N/alternatives-to-benzodiazepines-60701295
Oregon Prescription Drug Monitoring Signup:
http://www.orpdmp.com/health-care-provider/
Opioid Withdrawal Attenuation Cocktail:
http://www.slideshare.net/101N/opioid-withdrawal-attenuation-coctail
Nasal Naloxone:
http://www.amphastar.com/assets/naloxone.pdf
http://www.narcannasalspray.com/nns-4-mg-dose/how-to-use-nns/
Oregon Drug & Alcohol Services by County:
https://www.oregon.gov/oha/amh/publications/provider-directory.pdf

46. Thank You
wildriversphysiatry@gmail.com