Download Outpatient Opioid Therapy - UW Department of Family Medicine

TRAUMA AND OPIOIDS SUMMIT
OUTPATIENT OPIOID THERAPY:
MITIGATING RISKS
Perry G. Fine, MD
Professor of Anesthesiology
Department of Anesthesiology
School of Medicine
University of Utah
Objectives
1. Be informed of content, intent and limitation of current
Clinical Guidelines
2. Implement a structured approach toward opioid
prescribing and teaching/mentoring safe prescribing
practices for opioids
3. Define current limitations in pain care in the domains of
education, public policy, neuroscience, and clinical
care.
Basic Precepts: The CDC Guideline
DETERMINING WHEN TO INITIATE OR CONTINUE
OPIOIDS FOR CHRONIC PAIN
• Nonpharmacologic therapy and nonopioid pharmacologic
therapy are preferred for chronic pain. Clinicians should
consider opioid therapy only if expected benefits for both
pain and function are anticipated to outweigh risks to the
patient. If opioids are used, they should be combined with
nonpharmacologic therapy and nonopioid pharmacologic
therapy, as appropriate.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic
Pain — United States, 2016. MMWR Recomm Rep 2016;65:1–49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1
Basic Precepts: The CDC Guideline
DETERMINING WHEN TO INITIATE OR CONTINUE
OPIOIDS FOR CHRONIC PAIN
• Before starting opioid therapy for chronic pain, clinicians
should establish treatment goals with all patients,
including realistic goals for pain and function, and should
consider how opioid therapy will be discontinued if
benefits do not outweigh risks. Clinicians should continue
opioid therapy only if there is clinically meaningful
improvement in pain and function that outweighs risks to
patient safety.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic
Pain — United States, 2016. MMWR Recomm Rep 2016;65:1–49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1
Basic Precepts: The CDC Guideline
DETERMINING WHEN TO INITIATE OR CONTINUE
OPIOIDS FOR CHRONIC PAIN
• Before starting and periodically during opioid therapy,
clinicians should discuss with patients known risks and
realistic benefits of opioid therapy and patient and
clinician responsibilities for managing therapy.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic
Pain — United States, 2016. MMWR Recomm Rep 2016;65:1–49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1
Basic Precepts: The CDC Guideline
OPIOID SELECTION, DOSAGE, DURATION, FOLLOWUP, AND DISCONTINUATION
• When starting opioid therapy for chronic pain, clinicians
should prescribe immediate-release opioids instead of
extended-release/long-acting (ER/LA) opioids.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic
Pain — United States, 2016. MMWR Recomm Rep 2016;65:1–49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1
Basic Precepts: The CDC Guideline
OPIOID SELECTION, DOSAGE, DURATION, FOLLOWUP, AND DISCONTINUATION
• When opioids are started, clinicians should prescribe the
lowest effective dosage. Clinicians should use caution
when prescribing opioids at any dosage, should carefully
reassess evidence of individual benefits and risks when
considering increasing dosage to ≥50 morphine milligram
equivalents (MME)/day, and should avoid increasing
dosage to ≥90 MME/day or carefully justify a decision to
titrate dosage to ≥90 MME/day.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic
Pain — United States, 2016. MMWR Recomm Rep 2016;65:1–49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1
Basic Precepts: The CDC Guideline
OPIOID SELECTION, DOSAGE, DURATION, FOLLOWUP, AND DISCONTINUATION
• Long-term opioid use often begins with treatment of acute
pain. When opioids are used for acute pain, clinicians
should prescribe the lowest effective dose of immediaterelease opioids and should prescribe no greater quantity
than needed for the expected duration of pain severe
enough to require opioids. Three days or less will often be
sufficient; more than seven days will rarely be needed.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic
Pain — United States, 2016. MMWR Recomm Rep 2016;65:1–49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1
Basic Precepts: The CDC Guideline
OPIOID SELECTION, DOSAGE, DURATION, FOLLOWUP, AND DISCONTINUATION
• Clinicians should evaluate benefits and harms with
patients within 1 to 4 weeks of starting opioid therapy for
chronic pain or of dose escalation. Clinicians should
evaluate benefits and harms of continued therapy with
patients every 3 months or more frequently. If benefits do
not outweigh harms of continued opioid therapy, clinicians
should optimize other therapies and work with patients to
taper opioids to lower dosages or to taper and discontinue
opioids.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic
Pain — United States, 2016. MMWR Recomm Rep 2016;65:1–49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1
Basic Precepts: The CDC Guideline
ASSESSING RISK AND ADDRESSING HARMS OF
OPIOID USE
• Before starting and periodically during continuation of
opioid therapy, clinicians should evaluate risk factors for
opioid-related harms. Clinicians should incorporate into
the management plan strategies to mitigate risk, including
considering offering naloxone when factors that increase
risk for opioid overdose, such as history of overdose,
history of substance use disorder, higher opioid dosages
(≥50 MME/day), or concurrent benzodiazepine use, are
present.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic
Pain — United States, 2016. MMWR Recomm Rep 2016;65:1–49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1
Basic Precepts: The CDC Guideline
ASSESSING RISK AND ADDRESSING HARMS OF
OPIOID USE
• Clinicians should review the patient’s history of controlled
substance prescriptions using state prescription drug
monitoring program (PDMP) data to determine whether
the patient is receiving opioid dosages or dangerous
combinations that put him or her at high risk for overdose.
Clinicians should review PDMP data when starting opioid
therapy for chronic pain and periodically during opioid
therapy for chronic pain, ranging from every prescription
to every 3 months.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic
Pain — United States, 2016. MMWR Recomm Rep 2016;65:1–49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1
Basic Precepts: The CDC Guideline
ASSESSING RISK AND ADDRESSING HARMS OF
OPIOID USE
• When prescribing opioids for chronic pain, clinicians
should use urine drug testing before starting opioid
therapy and consider urine drug testing at least annually
to assess for prescribed medications as well as other
controlled prescription drugs and illicit drugs.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic
Pain — United States, 2016. MMWR Recomm Rep 2016;65:1–49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1
Basic Precepts: The CDC Guideline
ASSESSING RISK AND ADDRESSING HARMS OF
OPIOID USE
• Clinicians should avoid prescribing opioid pain medication
and benzodiazepines concurrently whenever possible.
• Clinicians should offer or arrange evidence-based
treatment (usually medication-assisted treatment with
buprenorphine or methadone in combination with
behavioral therapies) for patients with opioid use disorder.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic
Pain — United States, 2016. MMWR Recomm Rep 2016;65:1–49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1
Basic Precepts: The CDC Guideline
PRESCRIPTION DRUG MONITORING PROGRAMS (PDMPs)
• WHAT SHOULD I DO IF I FIND INFORMATION ABOUT A PATIENT IN THE PDMP
THAT CONCERNS ME?
• Confirm that the information in the PDMP is correct.
• Check for potential data entry errors, use of a nickname or maiden name, or
possible identity theft to obtain prescriptions.
• Assess for possible misuse or abuse.
• Offer or arrange evidence-based treatment (usually medication-assisted
treatment with buprenorphine or methadone in combination with behavioral
therapies) for patients who meet criteria for opioid use disorder. If you suspect
diversion, urine drug testing can assist in determining whether opioids can be
discontinued without causing withdrawal.
• Discuss any areas of concern with your patient and emphasize your
interest in their safety.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States,
2016. MMWR Recomm Rep 2016;65:1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1
Basic Precepts: The CDC Guideline
REGISTER AND USE THE PDMP IN YOUR STATE
• Processes for registering and using PDMPs vary from
state to state.
• For information on your state’s requirements, check
The National Alliance for Model State Drug Laws
online:
• www.namsdl.org/prescription-monitoringprograms.cfm
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic
Pain — United States, 2016. MMWR Recomm Rep 2016;65:1–49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1
Algorithm for Opioid Treatment of Chronic Pain
Patient Selection
Initial Patient Assessment
Comprehensive Pain Management Plan
Alternatives
to Opioid
Therapy
Trial of Opioid Therapy
Patient Reassessment
Continue Opioid Therapy
Implement Exit Strategy
Patient Selection for Opioid Trial
• Persistent pain despite reasonable trials of
disease modifying therapies, nonopioid
analgesics, other analgesic adjuvants, or targeted
therapies
or
• Severe pain requiring rapid relief
or
• Patient characteristics contraindicate use of other
analgesics or more targeted treatment modalities
Algorithm for Opioid Treatment of Chronic
Pain
Patient Selection
Initial Patient Assessment
Comprehensive Pain Management Plan
Alternatives
to Opioid
Therapy
Trial of Opioid Therapy
Patient Reassessment
Continue Opioid Therapy
Implement Exit Strategy
Initial Patient Assessment
• Define the pain syndrome as precisely as possible (etiology,
pathophysiology, mechanism, other attributes)
• Previous treatments and results
• Psychosocial history; chemical dependency; other mental
health conditions; social/caregiver/family circumstances
• Patient (specific) perspectives on opioid therapy
Risk Assessment: : Suspected Substance Use Disorder
• Medical history findings associated with
substance abuse: hepatitis C, HIV, TB, cellulitis,
sexually transmitted diseases, elevated liver
function tests, etc
• Social history: motor vehicle accidents, DUIs,
domestic violence, legal history, loss of property
in fire
• Psychiatric history: personal history of psychiatric
diagnosis, outpatient and/or inpatient treatment,
current psychiatric medications
Pain Assessment: The Bottom Line
Patient assessment for opioid therapy should include
• Rationale for opioid therapy
• Previous treatments
• Risk(s) of opioid therapy to patient
• Potential benefit(s) of opioid therapy
• Specific outcomes that will determine ongoing course of
therapy
Algorithm for Opioid Treatment of Chronic
Pain
Patient Selection
Initial Patient Assessment
Comprehensive Pain Management Plan
Trial of Opioid Therapy
Patient Reassessment
Continue Opioid Therapy
33
Implement Exit Strategy
Alternatives
to Opioid
Therapy
Comprehensive
Pain Management Plan Components
• Biomedical Approaches
• pharmacologic and/or
nonpharmacologic and/or
interventional therapies
• Psychological Intervention
• CBT/other modalities (e.g.
mindfulness meditation) to
improve mood
disturbances and coping
skills
• sleep hygiene
• Social/Rehabilitative Issues
• family/social relations
• work issues
• physical rehabilitation and
functional restoration
• physical/
occupational therapy
• home exercise program
Algorithm for Opioid Treatment of Chronic
Pain
Patient Selection
Initial Patient Assessment
Comprehensive Pain Management Plan
Alternatives
to Opioid
Therapy
Trial of Opioid Therapy
Patient Reassessment
Continue Opioid Therapy
Implement Exit Strategy
Alternatives to Opioid Therapy
• Alternative pain management strategies
• adjuvant analgesics
• nonpharmacologic modalities
• complementary medicine
• interventional therapies
• Refer complex or high-risk patients for SUD, mental
health services, interventional pain management
Algorithm for Opioid Treatment of Chronic
Pain
Patient Selection
Initial Patient Assessment
Comprehensive Pain Management Plan
Alternatives
to Opioid
Therapy
Trial of Opioid Therapy
Patient Reassessment
Continue Opioid Therapy
Implement Exit Strategy
Patient Care Agreement/
Informed Consent Components
• Collaborative Process to Optimize Adherence
• Reminder: opioids are one modality in multifaceted approach to
•
•
•
•
•
•
achieving goals of therapy
Detailed outline of procedures and expectations between patient and
doctor
Prohibited behaviors and grounds for tapering or discontinuation
Limitations on prescriptions
Emergency issues
Refill and dose-adjustment procedures
Exit strategy
Algorithm for Opioid Treatment of Chronic
Pain
Patient Selection
Initial Patient Assessment
Comprehensive Pain Management Plan
Alternatives
to Opioid
Therapy
Trial of Opioid Therapy
Patient Reassessment
Continue Opioid Therapy
Implement Exit Strategy
Risk Assessment and When to Refer?
• Prior or ongoing excessive use behaviors
(caffeine, alcohol, tobacco, other)
• Chaotic life
• Conviction of a drug-related crime
• Prior substance abuse or current use of illicit
drugs
• Regular contact with drug high-risk groups
Ongoing dilemmas
• Inadequate pain and substance abuse education
• Insufficient resources for primary care clinicians
• Comprehensive pain care programs
• Behavioral therapists with pain expertise
• Functional restoration (rehab) therapists with chronic pain expertise
• Insufficient funding for comprehensive pain care
• Limited alternatives to opioids (potency, versatility)
• Lack of predictable “assay” for opioid effectiveness
• Highly charged political climate
• Self-medication has become a societal “norm”
• Expectations for “no pain” outweigh biomedical science
• Limitations of neuroscience to “explain” pain chronification
Cum Scientia Caritas
All medication management must be tailored to the
individual patient’s needs and circumstances. Ongoing
critical thinking, sound judgment, and clinical experience
can never be replaced by formulae.