Download Pain management Best practices

PAIN MANAGEMENT PEARLS
FOR 2014 AND BEYOND:
PREVENTION, DETECTION AND TREATMENT OF
SUBSTANCE ABUSE
Moshe Lewis MD, MPH
Chief, Physical Medicine and Rehabilitation Department
California Pacific Medical Center, St Lukes Campus
SCOPE OF PROBLEM
• Each year, millions of patients in
the US are treated with opioid
medication
• Non-medical use (9-15%)
represents a relatively small
percentage of all use of these
medications but it is a problem
that requires attention
A GROWING PROBLEM…
• Between 6 and 7 million Americans have abused pain killers in the past
month.
• Everyday, approximately 2,700 kids between 12 and 17 abuse a prescription
pain killer for the first time.
• In a recent survey, 10% of 12th graders reported using Vicodin without a prescription
in the past year.
• Past year abuse of prescription pain killers now ranks second - only behind marijuana
- as the Nation's most prevalent illegal drug problem.
BUT HOW DOES A CASE PRESENT ?
• Case Scenario
• Ms. Jones, aged 54, presents to a new primary care MD with
complaints of
• HTN, slighly overweight and chronic back pain
• She is currently stating her pain is 8/10
• That she takes 3 and occasionally up to 4 short acting
• Hydrocodone tabs per day
• Meds are not completely effective for her pain
• Quit using Alcohol 10 years ago
• Was exposed to Marijuana in college but never inhaled
PART I: DOCTOR PATIENT ISSUES
• Building trust
• The provider wants to believe the patients presentation
• The patient may assume that doctors don’t believe their
pain
• The provider and patient need to build trust
• The patient is concerned that she will be viewed
negatively
• Fear that medication will be reduced
An Opportunity for Education and Empathy
CHRONIC PAIN HAS A FACE NO MATTER WHAT THE CAUSE
PART II
Understanding the Complex Dynamics of Pain
Treatment
• Genetics (nervous system)
• Environmental stressors
• Role of Exercise
• Social and Cultural Contest of Pain
• Belief about a medication vs. Non medication
approach
• Cognitive Therapy
• Alternative or Complementary Medicine
• Acupuncture, Chiropracty, Osteopathy
CHRONIC PAIN
• Affects over 100 million
people
• 42% will have pain
lasting greater than 1
year
• 33% will have disability
• 63% will present to their
Primary Treating
Physician
COMORBID
CONDITIONS
• Depression 33-54%
• Anxiety 16.5-50%
• Personality Disorders 31-81%
• PTSD 49% (veterans)
• Substance Abuse 15-28%
PART III:WHEN ARE OPIOIDS APPROPRIATE ?
• Pain is moderate to severe
• Pain has a signficant impact
on function
• Pain has a signficant impact
on quality of life
• Non opioid options have
failed
• There is a defined benefit
HOW GOOD ARE OPIOIDS FOR CHRONIC PAIN ?
• Randomized controlled trial have been short,
• Typically less than 8 months, small samples
• Mostly Pharma sponsored
• Better analgesia was noted compared to controls
• Pain relief was modest
• Mixed reports exist on function
• Addiction was not assessed
VARIABILITY EXISTS
• Not all patients respond in the same way
• Not all opioids have the same response
• There are mu receptor subtypes
• There are polymorphisms in the Mu opioid
receptor
• People have different metabolism
• Physician Concerns Exist
•
•
•
•
•
Addiction 89%
Risk of Diversion 75%
Side effects 53%
Legal issues 40%
Refills and Tracking 28%
• Upshur CC, Luckmann RS J Gen Intern Med
2006, June (21) 6: 652-5
PART IV: CRITICAL DEFINITIONS
• Tolerance
• Increasing dose required to produce a
specific effect
• Develops readily for CNS and
Respiratory Depress
• Less so for constipation
• Unclear about analgesia
• Dependence
• Signs and symptoms of withdrawal with
abrupt termination
DEFINITIONS
ADDICTION
• A maladaptive pattern of opioid use leading to clinically
significant impairment or distress in personal, social, or jobrelated responsibilities
• Failure to fulfill major job obligations at work, school, or
home
• Recurrent opioid use in hazardous situations, such as driving
or operating heavy machines while impaired
• Opioid-related legal problems
• Social and interpersonal problems caused by or
exacerbated by opioid use.
OPIOID USE DISORDER DSM V: ANY TWO OF
• Taking larger amounts of opioids or taking opioids over a longer period than was intended
• Experiencing a persistent desire for the opioid or engaging in unsuccessful efforts to cut down or control
opioid use.
• Spending a great deal of time in activities necessary to obtain, use, or recover from the effects of the
opioid.
• Craving, or a strong desire or urge to use opioids.
• Using opioids in a fashion that results in a failure to fulfill major role obligations at work, school, or home.
• Continuing to use opioids despite experiencing persistent or recurrent social or interpersonal problems
caused or exacerbated by the effects of opioids.
• Giving up or reducing important social, occupational, or recreational activities because of opioid use.
• Continuing to use opioids in situations in which it is physically hazardous.
• Continuing to use opioids despite knowledge of having persistent or recurrent physical or psychological
problems that are likely to have been caused or exacerbated by the substance.
• Tolerance, as defined by either a need for markedly increased amounts of opioids to achieve
intoxications or desired effect, or a markedly diminished effect with continued use of the same amount of
an opioid.
• Withdrawal, as manifested by either the characteristic opioid withdrawal syndrome, or taking opioids to
relieve or avoid withdrawal symptoms
FACTORS LEADING TO OVERDOSE
• Younger age,
• The use of sedatives
• Doctors with patients on pain
meds should not prescribe
Benzo’s, Muscle relaxants, Cough
suppressants, Sleep Agents
• “Heath's accidental death serves
as a caution to the hidden
dangers of combining prescription
medication, even at low dosage”
Kim Ledger
• and the lack of a recent opioid
prescription
PART V: DETECTION
• After acknowledgement that there is a problem this is the
next step
ROLE OF HEALTHCARE PROVIDERS
• Treat 200 million Americans (75 percent) at least once
every two years
• In unique positions to:
• Prescribe needed medications
• Encourage compliance
• Identify problems as they arise
• Help patients recognize their problems
• Adopt strategies to address problems
PART VI: RISK MANAGEMENT STRATEGIES
Step I: Physician Education
Step 2: Risk Stratification
Step 3: Patient Education
Step 4: Evidence Based Medicine (UR)
Step 5: Urine Drug Screen/ Contracts
Step 6: Alternative Pain Management Approaches
Step 7: Prescription monitoring programs
Step 8: Functional Restoration Programs
Step 9: Defined Discharge Criteria
1. PHYSICIAN CONTINING MEDICAL EDUCATION
• Several states, including Physicians for Responsible Opioid Prescribing
support Washington’s state guidelines of 100-120mg Morphine
equivalents.
• http://www.agencymeddirectors.wa.gov/opioiddosing.asp
• California’s upper limit is 200mg Morphine equivalents.
• >60 mg Morphine equivalents increases risk of overdose and death 3.7
times.
• >100 mg Morphine equivalents increases risk of overdose and death almost 9
times.
• Ann Intern Med. 2010;152:85-92, 123-125.
2. RISK STRATIFICATION
• Screening for potential comorbidities and risk factors is crucial so that
anticipated risk can be monitored .
• Depression and anxiety disorders are frequently associated with opioid use
• Current and past substance abuse disorders appear to increase the risks of
chronic opioid therapy.
• If substantial risk is identified through screening, extreme caution should be used
and a specialty consultation (e.g. addiction or mental health specialist) is
strongly encouraged.
• High Risk
• Young males, prior substance abuse, increased prescription medicine awareness
• For females: sexual trauma
QUESTION
3. PEER REVIEW: CA MEDICAL TREATMENT GUIDELINES
• Do not support ongoing opioid treatment unless :
• prescriptions are from a single practitioner and
• are taken as directed;
• are prescribed at the lowest possible dose;
• and there is ongoing review and documentation of
• pain relief,
• functional status,
• appropriate medication use,
• and side effects.
• Von Korff M, Kolodny A, Deyo RA, et al. Long-term opioid therapy reconsidered. Ann Intern Med.
2011;155:325-328.
• Grady D, Berkowitz SA, Katz MH. Opioids for chronic pain. Arch Intern Med. 2011;171:1426-1427.
• Dhalla IA, Persaud N, Juurlink DN. Facing up to the prescription opioid crisis. BMJ. 2011;343:d5142.
THE BIGGEST OFFENDERS
• METHADONE
• OXYCONTIN/OXYCODONE
• SOMA
• BENZODIAZEPINES
Medical Solutions ?
• Buprenorphine
METHADONE
Severe morbidity and mortality
Due to secondary to the long half-life of the drug (8-59 hours).
Pain relief on the other hand only lasts from 4-8 hours. (Clinical Pharmacology, 2008)
Pharmcokinetics:
Genetic differences appear to influence how an individual will respond
significantly different blood concentrations may be obtained.
Vigilance is suggested in treatment initiation, conversion from another opioid to
methadone, and when titrating the methadone dose. (Weschules 2008) (Fredheim 2008)
Adverse effects:
Respiratory depression (which persists longer than the analgesic effect). Use caution in
patients with asthma, COPD, sleep apnea, severe obesity).
QT prolongation with resultant serious arrhythmia has also been noted
METHADONE
• Conversion Ratio to Morphine is high (5)
Therefore, patients have to be maintained on very low dosing if at all:
TALKING POINTS FOR PATIENTS
1. Do not be tempted to increase your dose of Methadone on your own
2. Be aware of the fact that this medicine may stop your breathing or your
heart
3. Obtain a pre-prescription EKG and routine surveillance of heart health
OXYCONTIN
• Purdue recently reformulated to prevent initial high
• Conversion ratio of 1.5 for Morphine equivalent
• Often used in combination with short acting,sometimes
dosed too frequently by MD
• Leads to significant opioid tolerance saturating Mu receptor
• If used should be lowest dose possible with plan to titrate
down as patient demonstrates increased function.
• Consider rotation
BENZODIAZEPINES
• Their range of action includes sedative/hypnotic, anxiolytic, anticonvulsant,
and muscle relaxant.
• They Should not be prescribed or approved
• Chronic benzodiazepines are the treatment of choice in very few conditions.
• Tolerance to its effects develops rapidly.
• Long-term use may actually increase anxiety.
• A more appropriate treatment for anxiety disorder is an antidepressant.
SOMA
• Recently changed to Schedule II dosing
• Should not be prescribed
• Tolerance to side effects builds quickly
• Carisoprodol is metabolized to meprobamate an anxiolytic
• This drug was approved for marketing before the FDA required clinical studies to
prove safety and efficacy.
BUPRENORPHINE
• More pain physicians are starting to use Suboxone and Butrans
ISSUES
• Doctors have to watch UDS to make sure that Suboxone is not being
used to confound test results
• Patients may develop reactions to the patch
CONCLUSIONS
• There is not a one size fits all strategy
• The needs of Pain patients must be
counterbalanced with risk
• The population will continue to
age and many will experience
chronic pain
• Alternative Medicine and Treatment
Options should be explored