Download Opioids

Opioids 101
Lori Montgomery MD CCFP
Clinical Lecturer, Depts of Family Medicine and Anesthesia
Medical Director, AHS Chronic Pain Centre
Disclosure
Grants/Research Support: None
Speakers Bureau/Honoraria: None
Consulting Fees: None
Robin
 Had a flare-up after shovelling
snow
 Went to ED
 Sent home with a six-pack of
Percocet
 Liked it.
Opioids
Do they work?
What’s the downside?
How do we try them
safely?
Pain therapy tool box
Opioids
Canada 753mg/capita
US 693 mg/capita
Canada
US
Ireland
7
US
Canada
UK
8
Austria
Canada
US
9
Do they work?
Opioid Therapy for Chronic Pain,
Ballantyne JC, and Mao J, N Engl J
Med 2003;349:1943-53.
Opioids for Low Back Pain: BMJ State
of the Art Review, Deyo RA, Von
Korff M, Duhrkoop D, BMJ 2015;
350:g6380 doi: 10.1136/bmj.g6380
Efficacy
Meta-analysis of 15 RCTs; duration 4-6 weeks;
pain intensity (including NeP) reduced by about
30%
Kalso et al, Pain 2004
Meta-analysis of 8 RCTs in NeP; duration <28
days; significant benefit
Eisenberg et al, JAMA 2005
Efficacy
Meta-analysis of 41 RCTs; duration 16 weeks;
pain intensity reduced with strong opioids,
not with weak or non-opioids; more than 1/3
abandoned treatment for lack of efficacy
Furlan et al, CMAJ 2006
Meta-analysis of 6 RCTs in LBP; duration <16
weeks; no significant reduction in pain
intensity
Martell et al, Ann Intern Med 2007
Efficacy
Furlan AD et al. A systematic review and meta-analysis of efficacy,
cost-effectiveness, and safety of selected complementary and
alternative medicine for neck and low-back pain. Evid Based
Complement Alternat Med 2012;2012:953139.
Noble M et al. Long-term opioid management for chronic
noncancer pain. The Cochrane database of systematic reviews
2010:Cd006605.
Agency for Healthcare Research and Quality R, MD. The
Effectiveness and Risks of Long- Term Opioid Treatment of
Chronic Pain. http://www.ahrq.gov/research/findings/evidencebased- reports/opoidstp.html2014.
Efficacy
In OA, research demonstrating long-term
improvements in pain/function is lacking.
In elderly patients with OA, the risk of
opioids may be even greater than the risk of
NSAIDs.
Opioids should not be routinely used in
OA; if necessary, they should be used for
short-courses in carefully selected patients.
Ivers, Dhalla, Allan, TFP ACFP 2012
Smith, HS. Pain Physician, 2012;15:ES1-ES7
The
down side
The down side: short term
Constipation
Nausea and vomiting
Sedation during titration (driving, work)
Pruritis
Hyperhidrosis
Dry mouth
Peripheral edema
Sleep disruption
The down side: long term/high dose
GERD symptoms
Myoclonus
Opioid-induced hyperalgesia
Hormonal effects
Direct pituitary and hypothalamic effects
Direct hormone effects
Elevated prolactin, ACTH, ADH
Decreased TSH, FSH, LH, GH, cortisol
(Immune dysfunction) (mood problems)
Addiction and Diversion
Death???
The down side
Long term side effects are beginning to be
elucidated
Problem opioid use is a growing public health issue
They don’t always work in chronic pain
We know less about their use than we think
No long term outcome data
There is likely an upper limit, but we don’t know
what it is (180mg? 200mg? 400mg?)
Who is using opioids?
Opioid users report poorer self-rated health, more severe
pain, more inactivity, more unemployment, higher use of
the health care system
Eriksen et al, Pain 2006
Patients with chronic low back pain are the most likely to
be prescribed opioids (also the most common CP
diagnosis)
Morasco, Pain 2010
22
Who is using opioids?
Patients with higher levels of distress (low mood,
catastophizing ) appear to be less likely to respond to opioid
therapy
Wasan, Pain 2005
Patients with histories of mental illness and substance abuse
are more likely to be started on opioid therapy
These patients are typically excluded from opioid studies
Edlund MJ, Sullivan MD et al, Clin J Pain 2010
23
Starting
Canadian Guideline for Safe and
Effective Use of Opioids for
Chronic Non-Cancer Pain
http://nationalpaincentre.mcmaster.ca/opioid/
Canadian Guideline for Safe and
Effective Use of Opioids for
Chronic Non-Cancer Pain
National guideline sponsored by regulatory
bodies
Evidence-based set of 24 recommendations
Recommendations outline safe and effective
treatment methods.
Canadian Guideline for Safe and
Effective Use of Opioids for
Chronic Non-Cancer Pain
Cluster 1: Deciding to Initiate Opioid Therapy
Cluster 2: Conducting an Opioid Trial
Cluster 3: Monitoring Long-Term Opioid Therapy (LTOT)
Cluster 4: Treating Specific Populations with LTOT
Cluster 5: Managing Opioid Misuse and Addiction in CNCP Patients
An overview of the Guideline’s recommendations
Opioids can be
effective and
should be
considered
Patients have an
important role to
ensure opioids are
used safely
Good
communication
and collaboration
is essential
Opioids are not
indicated in all
CNCP conditions
Prescribers &
dispensers have an
obligation to
prevent risks and
harms
Jane Ballantyne
Decision Phase
Establish a diagnosis
Check on non-opioid treatment response
Check on non-medical treatments
Risk assessment
Informed consent
Plan goals with patient
Ensure patient understands potential outcome
Explain plan “B”
Decision Phase
Establish a diagnosis
Check on non-opioid treatment response
Check on non-medical treatments
Risk assessment
Informed consent
Plan goals with patient
Explain plan “B”
Tools
SISAP
If you drink alcohol, how many drinks do you have on a typical day?
How many drinks do you have in a typical week?
Have you used marijuana or hashish in the past year?
Have you ever smoked cigarettes?
What is your age?
CAGE
Tried to Cut down or Change your patter of drinking or drug use?
Been Annoyed by others’ concerns about your drinking or drug use?
Felt Guilty about the consequences of your drinking or drug use?
Had a drink or used a drug in the morning (Eye-opener) to decrease hangover
or withdrawal symptoms?
TICS Two-item Conjoint Screening Test
In the last year have you ever drunk or used drugs more than you meant to?
Have you ever felt you wanted or needed to cut down on your drinking or drug
use in the last year?
Risk Assessment
Poor stress management with multiple life
stressors
Drug abuse in family or household
Regular contact with high-risk people
History of previous addictive behavior
(gambling, eating, promiscuity, work,
internet etc)
Decision Phase
Establish a diagnosis
Check on non-opioid treatment response
Check on non-medical treatments
Risk assessment
Informed consent
Plan goals with patient
Explain plan “B”
Opioid Treatment Agreement
Measuring outcome
Pain
Self report (behaviour)
Physical function
2-3 Specific relevant goals
Collateral history sometimes
Initiating
Start at low dose (e.g SR morphine 15 bid)
Increase dose slowly based on agreed-upon limits
Watch for increased analgesia and function
Manage side effects immediately (e.g.
constipation)
Consider rotation or taper if no CLEAR benefit.
Choice of opioid
Avoid Demerol
Avoid injectable preparations
Avoid combination preparations
Usually opt for long-acting
preparations over short-acting
No need for “breakthrough” dosing
Talk “flare-up management” instead
Q: I’ve given the patient long-acting
opioids at the same daily dose as
short-acting opioids, but the patient
says “they don’t work”. What’s that
all about?
Red Flags
•
•
•
•
Escalating dose
Early refills
Lost prescriptions
Using drug for reasons
other than pain
• Double doctoring
“Normal”
Problem drug use
• Forging or stealing
prescriptions
• Altering prescriptions
• Altering medication
forms
• Factitious complaints
• Injecting, snorting
Addiction
Aberrant drug behaviour
Not necessarily addiction
Check for end of dose failure
Sometimes q6 or 8h
Look for trends of behaviour
Avoid making judgments
Aim for keeping the patient safe
Maintenance
Monthly refills
Pick up will vary according to patient
need.
Document 5 As (Analgesia, Adverse
effects, Activity, Aberrant drug behaviour,
Accurate records)
Manage side effects
Monitor dose MEDD
Maintenance
Watch for “mission creep”
Watchful dose 200mg OME
Ask for help before going past this dose
Monitor for long term side effects.
Periodic UDT
Ask for help whenever necessary
How to do it safely
Think carefully before you start
Assess risk of problem drug use
Discuss functional goals
Sign/enforce an opioid agreement
Go slowly, aim for no more than
three dose escalations (<200mg
MEDD)
At every visit, 5As
Acetaminophen
NSAIDs
COXIBs
Codeine
Morphine
Oxycodone
Hydromorphone
Fentanyl
Methadone
Buprenorphine
Tramadol
Antidepressants
Anticonvulsants
Cannabinoids
Montgomery 2013, Adapted from Twycross R, et al. Palliative Care Formulary. Radcliffe Medical Press, Oxford; 1998:86
Robin
 Had a flare-up after shovelling
snow
 Went to ED
 Came home with a six-pack of
Percocet
 Liked it.
Resources for Patients
You tube – understanding pain
http://www.youtube.com/watch?v=4b8oB757DKc
Lorimer Moseley
http://www.youtube.com/watch?v=-3NmTE-fJSo
Canadian Pain Coalition
http://www.canadianpaincoalition.ca
Neil Pearson
Web based Pain Self Management
https://www.pathwaythroughpain.com
Doc Mike Evans: Best advice for people taking opioid
medications
https://www.youtube.com/watch?v=7Na2m7lx-hU
Resources for You
Physicians for Responsible Opioid Prescribing
http://www.supportprop.org
Canadian Guideline for Safe and Effective Use of
Opioids for Chronic Non-Cancer Pain
http://nationalpaincentre.mcmaster.ca/opioid
/
Benzodiazepine Tapering
www.benzo.org.uk/manual
Lorimer Mosely (2002). Explain Pain
References
Ballantyne JC, Mao J, Opioid Therapy for Chronic Pain, N Engl J Med 2003;349:1943-53
Deyo RA, Von Korff M, Duhrkoop D, Opioids for Low Back Pain: BMJ State of the Art Review, BMJ 2015;350:g6380
doi: 10.1136/bmj.g6380
Graziotti P, Goucke R, The use of oral opioids in patients with chronic nonmalignant pain: Management strategies,
Australian Pain Society
Kirkpatrick AF, Derasari M, A Protocol-Contract for opioid use in patients with chronic pain not due to malignancy,
Journal of Clinical Anaesthesia 1998; 10:435-443
Schug SA, Large RG, Opioids for chronic non-cancer pain, Pain: Clinical Updates Nov 1995 IASP press, Volume III (3)
A consensus statement and guidelines from the Canadian Pain Society: Use of opioid analgesics for the treatment of
chronic non-cancer pain, Pain Res Manage 2002; Vol 8, Suppl A
Recommendations for the appropriate use of opioids for persistent non-cancer pain, British Pain Society March 2004
Eisenberg E, McNicol ED, Carr DB, Efficacy and safety of opioid agonists in the treatment of neuropathic pain of
non-malignant origin: systematic review and meta-analysis of randomized controlled trials, JAMA 2005; 293: 3043-52
Eriksen , Sjogren P, Bruera E, Ekholm O, Rasmussen NK, Critical issues on opioids in chronic non-cancer pain: an
epidemiological study, Pain 2006; 125: 172-9
Isaacson JH, Hopper JA, Alford, DP, Parran T, Prescription drug use and abuse, Postgraduate Medicine Online 2005;
118(1)
Webster LW, Predicting Aberrant Behaviours in Opioid-Treated Patients, Pain Medicine 2005; 6(6): 432-442
References
Brauna Brands Addiction Research Foundation (ed.), Management of Alcohol,Tobacco and other drug
problems (www.camh.net)
Mark D. Sullivan; Mark J. Edlund; Lily Zhang; Jürgen Unützer; Kenneth B. Wells, Association Between Mental
Health Disorders, Problem Drug Use, and Regular Prescription Opioid Use, Arch Intern Med.
2006;166(19):2087-2093.
Edlund MJ, Martin BC, Devries A, Fan Ming-Yu, Braden JB, Sullivan MD. Trends in use of opioids for chronic
noncancer pain among individuals with mental health and substance use disorders: the TROUP study. Clin J
Pain 2010;26:1-8.
Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E, Opioids for Chronic Non-Cancer Pain: a meta-analysis of
effectiveness and side effects, CMAJ 2006; 174: 1589-94
Gilron I, Bailey JM, Tu D et al, Morphine, Gabapentin, or Their Combination for Neuropathic Pain, NEJM
2005; 352: 1324-34
Kalso E, Edwards J, Moore R, McQuay H, Opioids in chronic non-cancer pain: systematic review of efficacy
and safety, Pain 2004; 112: 327-80
References
Martell, BA, O’Connor PG, Kerns RD et al, Systematic review: opioid treatment for chronic back pain: prevalence,
efficacy, and association with addiction, Ann Intern Med 2007; 146:116-27
Morasco BJ, Duckart JP, Carr TP, Deyo RA, Dobscha SK. Clinical characteristics of veterans prescribed high doses
of opioid medications for chronic non-cancer pain. Pain 2010;151:625-32.
de C Williams, AC, Psychological distress and opioid efficacy: more questions than answers, Pain 2005; 117: 245-6
Weekes J et al, Prescription Drug Abuse FAQs, Canadian Centre on Substance Abuse, www.ccsa.ca, June 2007
Allan L, Richarz U, Simpson K, Slappendel R, Transdermal Fentanyl Versus Sustained Release Oral Morphine in
Strong-Opioid Naive Patients With Chronic Low Back Pain, Spine 30(22):2484–2490