Download Opioid Abuse in Older Adults - Colorado Medical Directors Association

Opiate Dosing and Safe
Reductions
Sunny Linnebur, Pharm.D., FCCP, FASCP, BCPS, CGP
Professor
Skaggs School of Pharmacy and Pharmaceutical
Sciences
Objectives
• Identify concerns regarding opioid use/abuse in
LTCFs
• Discuss strategies for appropriate use and deescalation of opioid treatment in patients living
in LTCFs
• Evaluate alternative strategies to opioids to
reduce pain in older adults living in LTCFs
Pain and Analgesic Use in Older LTCF
Patients in 1997
89 NHs and 2065 residents with pain
• 77% had chronic pain diagnosis
– Most common diagnosis: arthritis (42%)
– No objective or subjective assessment of pain in 41%
• Non-pharmacologic treatment
– 20% received PT, 7% received heat/cold, 69% nothing
• Pharmacologic treatment: 2542 prescriptions, 2/3 PRN
– 68% opioids (propoxyphene 56%, codeine 33%)
– 25% NSAIDs
– 8% tramadol
• Conclusions: inadequate pain assessments, little use of
nonpharm interventions, PRN opioids should be changed
to scheduled LA opioids, little use of other analgesics
Cramer GW et al. J Am Geriatr SOC 48:398-404,2000.
A Lot Has Changed Since 1997…
4
© 2012 Denver Health
Colorado drug overdose death rates by county: 2002
© 2012 Denver Health
Colorado drug overdose death rates by county: 2014
Strategies for Appropriate Use of
Opioids in LTCF Patients
1. Maximize Non-Opioid Pain Relievers
Non-Pharmacologic
Pharmacologic
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Physical therapy
Massage
Hot or cold applications
TENS unit
Relaxation
Positive imagery
Meditation/prayer
Peer group support
Exercise/Tai Chi
Acupuncure
Music Therapy
Scheduled acetaminophen
Topical voltaren gel 1%, 1.5% soln
Transdermal lidocaine 4-5%
Capsaicin
Corticosteroid injections
Duloxetine
Gabapentin
Pregabalin
Naproxen
Tramadol
Makrus UE et al. JAMA. 2014;312(8):825-836; Weiner DK et al. Drugs & Aging 2001; 18 (1): 13-29
Park J, Huges AK. J Am Geriatr Soc 60:555–568, 2012; Malek M. Med Clin N Am 99 (2015) 337–350
Strategies for Appropriate Use of
Opioids in LTCF Patients
2. Evaluate risk/benefit for patient
initiating or continuing opioid therapy
and establish goals for pain and function
– Obtain accurate diagnosis (DORA)
– Determine if opioids were utilized prior to
hospitalization
– Discontinue PRN opioids that were not utilized in the
hospital setting or were new from hospitalization and
pain not acute
Strategies for Appropriate Use of
Opioids in LTCF Patients
2. Evaluate risk/benefit for patient
initiating or continuing opioid therapy
and establish goals for pain and function
– PEG: 3 item pain scale (http://mytopcare.org/wpcontent/uploads/2013/06/PEG-pain-screeningtool.pdf)
– QOL: function, sleep, eating, socializing
– Side effect risk: constipation, confusion, respiratory
depression, falls
PEG
Strategies for Appropriate Use of
Opioids in LTCF Patients
3. Assess risk with screening tools/check
PDMP
– Opioid Risk Tool
(https://www.drugabuse.gov/sites/default/files/files/
OpioidRiskTool.pdf)
– Urine drug screening
– PDMP (https://copdmph.hidinc.com/cologappl/bdcopdmqlog/pmqhome.ht
ml)
Opioid Risk Tool
Utilizing the PDMP in Your Practice
• You can designate a delegate to check for you
• Benefits
– Review fill history for need for new Rx
– Review if patient is doctor/pharmacy shopping
– Review if patient is filling prescriptions through Medicare
Part D or cash-pay
– Review if patient is concomitantly taking benzodiazepines
and other CS
• Limitations:
– Most recent fills are not always in system immediately
– Return to stock fills do not delete out
– ± Mail order scripts
– ± Records for inpatient/LTCF/hospice
– ± scripts from VA/military bases
• Can call pharmacy to mitigate limitations
Strategies for Appropriate Use of
Opioids in LTCF Patients
4. Initiate short-acting opioids—not LA opioids
– Determined by FDA, CDC and DORA as safer
FDA Labeling Changes for ER/LA Opioids
http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM367697.pdf
FDA Post-Marketing Requirements for
ER/LA Opioids
• Requirements for post-marketing studies
– Evaluation of long-term use and known serious risks
• Misuse, abuse, addiction, overdose, and death
• Risks of developing hyperalgesia and tolerance
– Validation of medical coding for opioid ADEs
– Study to define and validate doctor/pharmacy
shopping as outcomes of misuse/abuse
• Study plans due 2014, with final results due in
2018
http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM367697.pdf
Initiation of LA Opioids in NHs
• Analysis of 2004-2005 Rhode Island Medicaid pharmacy
claims data linked to the Minimum Data Set
• 591 Medicaid residents who initiated therapy with an LAO
– 232 (39.3%) were opioid naıve
– Naive initiation was more frequent among those with
advanced age, those with cognitive impairment, and those
with chewing difficulties
– Opioid-naive residents were also more likely to be initiated
on fentanyl relative to other LAOs (60.3% vs. 46.4%) and to
use higher initial dosages
• Given the significance of FDA warning, including a BBW with
transdermal fentanyl, rate of naive LAO initiation concerning
Dosa DM et al. Journal of Pain and Symptom Management 2009;38(4):515-521
Strategies for Appropriate Use of
Opioids in LTCF Patients
4. Initiate short-acting opioids—not LA opioids
– Determined by FDA, CDC and DORA as safer
• SA opioids can be crushed and come in liquid
form for those who have difficulty swallowing
• In patients with dementia, utilize nurses to
observe patients after SA opioids to assess
effects and/or schedule SA opioids for
adequate pain relief
Strategies for Appropriate Use of
Opioids in LTCF Patients
5. Initiate at ¼ to ½ the recommended adult dose and
maintain lowest effective total daily dose
– DORA/Colorado Medical Board: MED ≤ 120
– CDC: MME ≤ 50 per day; avoid ≥ 90 per day
– Examples of ≤ 50 MED
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Morphine 15mg: 3 tabs
Oxycodone/APAP 5/325: 6 tabs
Oxycodone ER 10mg: 3 tabs
Fentanyl transdermal 12.5 mcg/hr: 1 patch Q3 days
Hydrocodone/APAP 5/325: 10 tabs
MME = Morphine milligram equivalents
MED = Morphine equivalents per day
Malek M et al. Med Clin N Am 99 (2015) 337–350; CDC and DORA guidelines (see Resources slide)
Prescribed Doses of Opioids in LongTerm Care Facilities in Australia
• 94% of residents were prescribed opioids at doses below the
max recommended for noncancer pain in Australia (100 MED)
• Fentanyl was prescribed at a higher median daily dose
• Opioid doses did not differ between residents ± dementia
Leung, Brian B et al. JAMDA 2015;16(12):1100-02
Strategies for Appropriate Use of
Opioids in LTCF Patients
5. Initiate at ¼ to ½ the recommended adult dose
and maintain lowest effective total daily dose
• Recognize increasing risk and diminishing benefit curves
as evidence behind the MED’s
• If patient’s dose exceeds, CDC recommends consulting a
pain specialist and/or re-evaluating opioid use and
working on a tapering plan
– More documentation and risk management needed if
continuing dose
• FOR ACUTE PAIN: suggested prescription 3 days
Malek M et al. Med Clin N Am 99 (2015) 337–350; CDC and DORA guidelines (see Resources slide)
Strategies for Appropriate Use of
Opioids in LTCF Patients
6. Monitor appropriately
– Risk-benefit assessment within 1-4 weeks of initiation
– Set specific functional goals and document response
– Follow up more frequently if prescribing ER/LA
opioids, the dose is ≥ 50 MED, or the patient has a
history of mental health conditions, substance use
disorder or overdose
– Make an exit strategy and communicate it
• Taper opioids when improvements are not sustained
• Re-evaluate non-opioid therapies
Malek M et al. Med Clin N Am 99 (2015) 337–350; CDC and DORA guidelines (see Resources slide)
Strategies for Appropriate Use of
Opioids in LTCF Patients
• Additional strategies to mitigate risk
– Consider prescribing naloxone
• Especially for patients on higher doses and those with
history of SUD or prior OD
– Recheck PDMP periodically after initiation
• At least every 3 months
– Recheck urine drug test at least annually
– Avoid co-prescribing opioids & BZDs
– Refer patients with opioid use disorders to evidencebased treatments
CDC and DORA guidelines (see Resources slide)
Pain and Analgesic Use in Older LTCF
Patients in 2004
Data from a survey of 1174 US NHs
• Cancer primary diagnosis in 11.4% of patients
Hanlon JT et al. J Am Med Dir Assoc. 2010; 11(8): 579–583.
Opioid Tapering
• Indicated for patients:
– Who request dosage reduction
– If improvements in pain/functioning are not sustained or
clinically meaningful (e.g. ≥ 30% improvement on 3-item PEG)
– If dosages ≥ 50 MED are used without evidence of benefit
– If opioids are combined with BZDs
– If benefits no longer outweigh risks
– If patient experiences warning signs of harms (e.g drowsiness,
slurred speech, difficulty controlling use)
• Patients generally tolerate weaning to 30%-50% of
original dose
CDC and DORA guidelines (see Resources slide)
General Tapering Principles
• Reduce dosage by about 10% every week or if
patients have been on opioids for years, reduce
dosage by about 10% every month
• When smallest dosage is reached, interval between
doses can be extended
• Non-addicted patients generally tolerate more rapid
weaning schedules
Taper by 20-50 percent per week (of original dose)
The goal is to minimize adverse/withdrawal effects
The rapid detoxification literature indicates that a patient
needs 20% of the previous day’s dose to prevent
withdrawal symptoms.
If patient is using fentanyl 12.5mcg/hr patch, switch to
oral opioid to complete taper
CDC and DORA guidelines; VAMC Opioid Tapering Fact Sheet (see Resources slide)
Example Slow Tapering Schedule
10% reduction
• Starting dose morphine SR 60 mg BID +
oxycodone 5/325 mg 6 tabs/day
1. Start by converting to total morphine
milligram equivalents = 165 mg
2. Taper SA oxycodone weekly as it is >10% total
MED (this will take 5 weeks)
3. Taper LA morphine next (this will take 13
weeks)
https://www.hca.wa.gov/; VAMC Opioid Tapering Fact Sheet (see Resources slide)
Example Tapering Schedule:
Washington Form
Example More Aggressive Tapering
20% Reduction = 30mg MED
Starting dose: morphine SR 60 mg BID + oxycodone 5/325 mg 6
tabs/day
1. Start by converting to total morphine milligram equivalents =
165 mg
2. Week 1: 20% reduction to MED 130 mg
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Morphine SR 60 mg BID + 1-2 oxycodone/apap per day
3. Week 2: 100 mg MED
– Morphine SR 45 mg BID + 1-2 oxycodone/apap per day
4. Week 3: 70 mg MED
– Morphine SR 30mg BID + 1-2 oxycodone/apap per day
5. Week 4: 40 mg MED
– Morphine SR 15 mg BID + 1-2 oxycodone/apap per day
6. Week 5: 10 mg MED: 1-2 oxycodone/apap per day
7. Week 6: no opiates
Opioid Interruptions and Withdrawal
Symptoms in NH Residents
• 66 patients from 3 NH receiving opioids were
followed for a mean of 10.9 months and
experienced a total of 104 acute illnesses
• During 39 (38%) illnesses, patients experienced a
significant opioid interruption
– Mean duration of interruption (range): 3 days (1-118)
– Complete discontinuation, n (%): 22 (21)
• Symptoms were assessed with the Clinical Opioid
Withdrawal Scale
• Withdrawal scores were not associated with opioid
interruption regardless of dose before interruption
Redding SE et al. Clin Ther. 2014;36:1555–1563
Opioid Tapering Success
Krumova EK et al. 2013
• Significant decreases in pain after opioid withdrawal
• 41% relapse rate at 1-2 years
• Significant relation between relapse probability and pain
intensity immediately after opioid withdrawal
Huffman KL et al 2013
• 22.5% relapse rate at 1 year
• Post-treatment depression increased probability of
relapse
• If aggressive tapering is instituted, patient may
need clonidine 0.1-0.2 mg two to four times daily
Krumova EK et al. Clin J Pain 2013;29:760–769; Huffman KL et al. Pain Medicine 2013; 14: 1908–1917;
https://www.hca.wa.gov/; VAMC Opioid Tapering Fact Sheet (see Resources slide)
Want More Info-Use the CDC App!
 Includes major points and links
to resources
 Includes MME Opioid Calculator
 Includes Motivational
Interviewing Questions,
discussion of how to approach
tapering opioids and coping
with withdrawal, and tapering
pocket guide
 Links to SAMHSA Behavioral
Health Treatment Services
Other Resources
• DORA QUAD Policy
– http://www.ucdenver.edu/academics/colleges/PublicHealt
h/research/centers/CHWE/Documents/DORA%20Opioid%
20Policy%20Revised%2010.15.14.pdf
• CDC Guideline for Prescribing Opioids for Chronic Pain
– https://www.cdc.gov/drugoverdose/prescribing/guideline.
html
• Washington Taper Schedule
– https://www.hca.wa.gov/
– Search website for “Medical opioid taper plan calculator”
• VA/DoD Fact Sheet:
– http://www.healthquality.va.gov/guidelines/Pain/cot/Opio
idTaperingFactSheet23May2013v1.pdf
Questions?