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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