Appropriate Opioid - PowerPoint Presentation

Appropriate Opioid Medication Use as Part of a Comprehensive Pain Management Approach MPhA MTM Fall Symposium Kathryn Perrotta, PharmD , MBA, BCPS November 16, 2012

Disclosure Statement

Define the health economic impact of the use of opioid analgesics in the treatment of pain Apply evidence based guidelines in moderate to severe chronic non-cancer pain management Address abuse, misuse and diversion reduction strategies (proper disposal options and PMP) Explore the role of ambulatory care pharmacists in primary care pain management and opportunities for collaboration with other professionals in the health care team Objectives

Concern: significant increase in opioid prescriptions Sales of opioids quadrupled between 1999 and 2010 (government statistics)The annual cost associated with all types of pain, both direct and indirect costs, is estimated to be in the range of $560 to $635 billion annually in the United States Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492. Health Economic Impact of Opioids in the Treatment of Pain

~60 million Americans have some type of chronic nonmalignant pain ~40% of patients do NOT receive adequate pain relief Health Economic Impact of Opioids in the Treatment of Pain

Detailed HistoryOnset, duration, quality, character of pain Ameliorating and provoking factors Pain Rating Patient self report: most reliable indicator of pain Numerous assessment tools available for pain in adultsNumeric rating scales (1-10) Assessment Is pain due to reversible etiology?Identify cause of painReason for specialist? Rheumatoid arthritis, knee pain, headache, etc. www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain Guidelines Assessment of Pain

Acute vs. Chronic PainHas pain persisted longer than 6 weeks? IAP defines chronic pain as “pain that persists beyond normal tissue healing time, which is assumed to be 3 months” Determine Pain Mechanism (3 general types) Somatic VisceralNeuropathic Different symptoms Different treatment indicatedwww.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain Guidelines. Fifth Edition, November 2011. Assessment of Pain

Result of tissue damage Release of chemicals from injured cells that mediate pain and inflammation via nociceptors Typically recent onset and well localized www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain Guidelines. Fifth Edition, November 2011. Somatic (Inflammatory) Pain Description of Somatic Pain Examples Sharp Aching Stabbing Throbbing Lacerations Sprains Fractures Dislocations

Result from visceral nociception Solid and Hollow organs Fewer nociceptors Result in poorly localized, diffuse and vague complaints www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain Guidelines. Fifth Edition, November 2011. Visceral Pain Description of Visceral Pain Examples Generalized ache/pressure Autonomic symptoms: N/V, hypotension, bradycardia , sweating Ischemia/necrosis Ligamentous stretching Hollow viscous or organ capsule distension

Injury to a neural structure leading to aberrant processingTypically chronic pain caused by damage to peripheral nerves www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain Guidelines Neuropathic Pain Description of Neuropathic Pain Examples Radiating Burning Tingling “Electrical Like” Diabetes Shingles MS Herniated discs From radiation/chemo

Determine Patient’s Pain Goals If chronic pain patient may need to counsel on expectations of pain relief Assess for risk of substance abuse, misuse, or addiction Avoid Unrealistic Expectations in Chronic Pain Patients Improvement with opioids generally average < 2-3 points on average 0-10 scale Concentrate on quality of life and improving therapeutic goals Stress importance of utilizing other modalitiesMedications that are multi-modal in treating pain Alternative therapies www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain Guidelines. Fifth Edition, November 2011. Assessment of Pain

Assessment is Key!

Most Responsive Treatments Somatic Pain Visceral Pain Neuropathic Painacetaminophen cold packs corticosteroids lidocaine patches NSAIDs opioids tactile stimulation corticosteroids intraspinal local anesthetic NSAIDs opioids gabapentin pregabalin corticosteroids neural blockade NSAIDs opioids TCAs duloxetine www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain Guidelines. Fifth Edition, November 2011.

McCaffery M, Pasero C. Pain Clinical Manual. 1999:21. 3. Perception of Pain

Analgesia and the Pain Pathway Descending modulation Dorsal horn Ascending input Spinothalamic tract Dorsal root ganglion Peripheral nerve Peripheral nociceptors Pain Trauma Local anesthetics Opioids  2 -agonists COX-2 selective inhibitors Opioids  2 -agonists Centrally acting analgesics Anti-inflammatory agents (COX-2 selective inhibitors, nonselective NSAIDs Local anesthetics Adapted by Dr. Todd Hess (United Pain Center) from Gottschalk et al. Am Fam Physician. 2001;63:1979-1984. Opioids Local anesthetics Anti-inflammatory agents (COX-2 selective inhibitors, nonselective NSAIDs)

“Wind-up ” Phenomenon Repetitive stimulation of spinal neurons evokes an increasing level of response NMDA receptor antagonists block this effect

Intense pain worsening over timeCauses: most frequently trauma to extremity or surgery/infection Pathophysiological mechanism of CRPS is ongoing nociceptor input from periphery to CNS . Characterized by hyperalgesia, allodynia , vasomotor changes, abnormal regulation of blood flow and sweating, joint stiffness, localized skin edema Treatment of CRPS can be difficult; Often misdiagnosed and can be irreversible if undiagnosed Recommended that combined analgesic regimens (multimodal analgesia) be used to prevent CRPS Reuben, S. Anesthesiology . 2004;101:1215-1224. Burns, A. J Orthop Surgery. 2006; 14(3):280-3. Complex Regional Pain Syndrome

A variety of different and integrated disciplines: Pharmacologic Complementary/synergistic mechanisms of action to inhibit effects of pain mediators and enhance the effects of pain modulation Non- opioids used in combination with opioids can decrease the total amount of opioid needed for pain control Applying the Multimodal Approach of Therapy to Chronic Pain Patients

Acetaminophen Cox-2s, NSAIDs Modulating agents Duloxetine , TCAs, tramadol , etc. Topical agents Lidocaine patches Gabapentin neuropathic pain prevention and treatment Applying the Multimodal Approach of Therapy to Chronic Pain Patients

A variety of different and integrated disciplines: Non-Pharmacologic: Exercise Massage Acupuncture Reiki Cognitive Behavioral TherapyPhysical TherapyTENS therapy Applying the Multimodal Approach of Therapy to Chronic Pain Patients

Incomplete Cross tolerance of opioids: A physiological phenomenon following use of opioids for > 2 weeks State of adaptation in which exposure to a drug decreases its effect over time Due to the different molecular entities of opioids, a person on an opioid for a long perioid of time will not be as tolerant to the effects of a new opioid

Adjunctive Therapy Options Assess if the opioid is right for patient EffectivenessAdverse Effects: N/V, puritis , constipation, respiratory depression Renal metabolism/use in liver failureBe aware of incomplete cross tolerance effect of opioids Tolerance may develop to the opioid in use but may not be as marked relative to other opioids Opioid Management

fentanyl synthetic to non-synthetic hydromorphone , hydrocodone oxycodone morphine, codeine

Comparison of ORAL Opioids Oxycodone Hydromorphone ( Dilaudid ) TramadolOnset of Action (minutes) 10-15 (IR) 60-90 (CR) 15-30 60 Peak Response 1 hour 60-90 mins 2-3 hours Duration of Effect (hours) 4-6 (IR) 8-12 (CR) 4-6 4-6 Renal Elimination Yes Yes Yes Prolonged in Hepatic Failure Yes Yes Yes

Comparison of Opioids Opioid Oral Onset of action Duration of Action Codeine 200 mg 15-30 min 3-4 hrs Hydrocodone 30 mg 15-30 min 4-8 hrs Hydromorphone 7.5 mg 15-30 min 4-6 hrs Methadone Varies* 30-60 min Varies Morphine 30 mg 15-60 min 3-6 hrs Morphine ER 30 mg 60-90 min 8-12 hrs Oxycodone 20 mg 10-15 min 4-6 hrs Oxycodone CR 20 mg 60-90 min 8-12 hrs * Consult APS Guidelines

Morphine and Metabolites Morphine liver M-3-G M-6-G, normorphine Analgesia Confusion, Sedation, Respiratory Depression kidney Hyperalgesia , myoclonus

Methadone1/3 of opioid related overdose deaths while only a few percent of total opioid prescriptions Do NOT use for mild, acute or “break through pain”NOT for opioid naïve patientsClinical Aspects Long and unpredictable ½ life Multiple drug interactionsQT prolongationECG before starting and when doses >200mg/daySwitching from another opioid: 70-90% reduction of equianalgesic dose Morbidity & Mortality Weekly Report. 2012;61(26):493-497. © 2012 Centers for Disease Control and Prevention (CDC) Opioid Management

Fentanyl (Duragesic®) Transdermal system Onset of action: 12-18 hours, used Q 48 or 72 hrs Chronic, stable pain only Elimination after patch removal: 13-22 hrs Fever can result in up to 30% ↑ in drug levels ⊘ Heating pad or hot tub Not best option for catechetic pt weighing <50kg; unpredictable absorption +/or elimination

Opioid Rotation: Change in opioid drug with the goal of improving outcomes Indications for Opioid Rotation:Occurrence of intolerable adverse effectsPoor analgesia despite aggressive dose titrationChange in clinical status Financial or drug availability consideration Deciding Next Specific Opioid:Past experience with different opioids, sensitivities, efficacy, etc. Fine, G. Opioid Rotation: Definition and Indications . Pain Management Today eNewsletter series. American Pain Foundation. , Quadrant HealthCom Inc. ; 2010: (1): 9. http://newsletter.qhc.com/JFP/JFP_pain032411.htm Opioid Management

Opioid Rotation Guidelines : Calculate equianalgesic dose of new opioid Identify automatic dose reduction of 25-50% lower than calculated equianalgesic dose50% reduction if high current opioid dose, elderly, non-white, or frail 25% reduction if patient not above Strategy to frequently assess initial response and titrate new dose Supplemental “rescue” dose for prn : calculate 5-15% and administer at appropriate interval Fine, G. Opioid Rotation: Definition and Indications . Pain Management Today eNewsletter series . American Pain Foundation. , Quadrant HealthCom Inc. ; 2010: (1): 9. http://newsletter.qhc.com/JFP/JFP_pain032411.htm Opioid Management

American Pain Society (APS). Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 6th edition. 2008. Glenview, IL 60025. Equianalgesic Dosing Standard Opioid -PO Opioid Parenteral Oxycodone 20mg Hydrocodone 30mg NA Hydromorphone 7.5mg Hydromorphone 1.5mg Methadone: Consult Expert Morphine 30mg Morphine 10mg

51 year old white female patient with chronic pain due to MVA Current Medications: MS Contin 30mg TID Hydrocodone/APAP 5/500 1-2 tabs qid prn (patient states she take 6 tabs/day) Atenolol 50mg qday Senokot -S 1 tab bid MD asks you to convert this patient to oxycodone due to recent increased itching and ineffective control of pain. Opioid Rotation: Patient Case

1) Conversion: Total oxycodone equivalent/day: 90mg morphine + 30mg hydrocodone 90mg morphine = 60mg oxycodone 30mg hydrocodone = + 20mg oxycodone 80mg (total oxycodone dose) 2) Should we suggest the total oxycodone dose or reduce? Opioid Rotation: Patient Case

2) Reduction of Dose: Total oxycodone equivalent/day: 80mg 80mg x 0.25 = 20 mg so reducing by 25% the total daily dose would be 60mg oxycodone 3) How do we want to give the oxycodone 60mg? Slow versus immediate release? Opioid Rotation: Patient Case

3) How do we want to give the oxycodone 60mg? Oxycontin 15mg TID plus oxycodone 5-10mg tid prn (start with 5mg) Patient would be taking 45mg + 15-30mg = 60-75mg Could switch morphine to oxycodone, keep on hydrocodone prn dose for first few days, reassess then switch to oxycodone Opioid Rotation: Patient Case

Other considerations: What other medications may this patient benefit from? How would you have established this? Does patient need high dose of opioid ? Has patient tried other modes of therapy such as stretching (Physical therapy involvement), massage, TENS unit or cognitive behavioral therapy (non-drug methods)? Opioid Rotation: Patient Case

Essential to identify if:Patient successful Patient might benefit more with restructuring of treatment Need treatment for addiction Benefits outweighed by harm Frequency of monitoring:Patient on stable doses Every 3-6 monthsAfter initiation of therapy, changes in opioid doses, with a prior addictive disorder, psychiatric conditions, unstable social environments Weekly basis may be necessary Chou, R, Fanciullo , G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain: an update of Society-American Academy of Pain Medicine Opioids Guidelines Panel. The Journal of Pain .  2009 Feb;10(2):113-130. Monitoring Patients on Opioids

Should include: Assessment and documentation of pain severity and functional ability Progression towards achieving therapeutic goals Presence of adverse effects Clinical assessment and detailed documentation for aberrant drug related behaviors, substance use and psychological issuesIf suspect above may need to implement: Pill counts Urine drug screeningFamily member/caregiver interviewsUse of prescription monitoring plans Chou, R, Fanciullo , G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain: an update of Society-American Academy of Pain Medicine Opioids Guidelines Panel. The Journal of Pain .  2009 Feb;10(2):113-130. Monitoring Patients on Opioids

Most predictable factor for drug abuse, misuse, or other aberrant drug related behavior: Personal or family history of alcohol or drug abuse Other factors associated with aberrant drug related behaviors: Younger age Presence of psychiatric conditions Opioid therapy in these patients requires intense structured monitoring and management by professionals with expertise in both addiction medicine and pain management ***DOCUMENT***Chou, R, Fanciullo, G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain: an update of Society-American Academy of Pain Medicine Opioids Guidelines Panel. The Journal of Pain.  2009 Feb;10(2):113-130. Assessment of Patient for Addictive Risk

Assessment Tools Available: Webster's Opioid Risk Tool (ORT) DIRE Tool Screener and Opioid Assessment for Patients in Pain (SOAPP®) Current Opioid Misuse Measure (COMM TM) Prescription Drug Use Questionnaire (PDUQ) Screening Tool for Addiction Risk (STAR) Screening Instrument for Substance Abuse Potential (SISAP) Pain Medicine Questionnaire (PMQ) www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain Guidelines. Fifth Edition, November 2011. Assessment of Patient for Addictive Risk

Pseudoaddiction to Opioids: A drug seeking behavior occurring in patients who are receiving inadequate pain control State of adaptation in which exposure to a drug decreases its effect over time Characterized by behaviors that include impaired control over drug use and continuation despite harm to self or others

Repeated Opioid Dose Escalations: When repeatedly occur, evaluate for potential causes: Assess for treatment control ( pseudoaddiction ?)Possible marker for substance abuse disorder or diversion Theoretically no maximum or ceiling High dose definition = >200mg po morphine/dayAAP Opioid Consensus Panel Some studies suggest higher doses of opioids lead to: Hyperalgesia Neuroendocrinologic dysfunctionPossible immune suppression Chou, R, Fanciullo , G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain: an update of Society-American Academy of Pain Medicine Opioids Guidelines Panel. The Journal of Pain .  2009 Feb;10(2):113-130. Opioid Management

Weaning/Tapering Off Opioids: Institute when: Patient engages in serious or repeated aberrant drug-related behaviors or diversion Experience of intolerable side effects Making no progress towards meeting therapeutic goals Approaches to Weaning Opioid:Slow: 10% dose reduction per weekRapid: 25-50% reduction every few daysSlower rate may help reduce unpleasant symptoms of opioid withdrawal Chou, R, Fanciullo , G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain: an update of Society-American Academy of Pain Medicine Opioids Guidelines Panel. The Journal of Pain .  2009 Feb;10(2):113-130. Opioid Management

Diagnosing Addiction in Patients Taking Opioids: Evidence of compulsive drug use, characterized by: Unsanctioned dose escalation Continued dosing despite significant side effectsUse to treat for symptoms not targeted by therapy Use during periods of no symptoms Evidence of one or more associated behaviors:Manipulation of MDs or medical system to obtain additional opioidsAcquisition of drugs from other medical sources or non-medical sources Drug hoarding or sales Unapproved use of other drugs ( alchohol or other) Hojsted , J, Sjogren, P. Addiction to Opioids in Chronic Pain Patients: A Literature Review. European Journal of Pain .  2007;11:490-518. Opioid Management

Consider for patient not well known and/or higher risk of misuse Example of components of opioid agreement: Specified the conditions under which opioids would or would not be prescribed Patient responsibilities Only receive opioids from Dr. ________Will not give medications to anyone elseIf my prescription runs out early for any reason; have to wait until next prescription is due.Example of an Opioid Management Agreement: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829426/figure/Fig1 Opioid Management Agreement

Random urine drug screening performed if recommended by the physician to monitor adherence and possible use of illicit substances. Patients informed that the agreement would be discontinued if patient responsibilities were not met. Responsibilities of the physician and/or clinic staff included providing monthly prescriptions on the due date, monitoring the effects of therapy, and providing ongoing care. Patient signs agreement Opioid Management Agreement

Pharmacies licensed by the MN Board of Pharmacy and other dispensing facilities are required to report the dispensing of controlled substances listed in the state’s Schedules II-IV. Data is submitted electronically. Patient controlled substance prescription history is available to prescribers and pharmacists Available 24/7, 365 days a year, with information such as: Quantity and dosage of controlled substance dispensed, Pharmacy that dispensed the prescriptionIn some cases, the practitioner Assists in checking for potential drug interactions, patterns of misuse, potential diversion or abuse and generally to assist in determining the appropriateness in dispensing. For pharmacist access: http://pmp.pharmacy.state.mn.us/pharmacist-rxsentry- access-form.html Prescription Monitoring Program

Rational Use Reassure patients prescribed opioids or benzos are taking as directed, evidenced by positive resultsMake sure not being misused Stockpiling or selling to unauthorized others Evidenced by negative resultsDetect presence of illicit non-prescribed drugsHeroin, cocaine, non-prescribed opioids, etc. Tenore , P. Advanced Urine Toxicology Testing. Journal of Addictive Diseases , 2010;29:436-448. Urine Drug Screening

Two types of tests used:1. Immunoassay Classify drug as present or absent Any response above the cutoff is deemed positive Any response below the cutoff is negative Subject to cross-reactivitySome detect specific drugs, while others classes, i.e. opioids Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care. Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010. Urine Drug Screening

Immunoassay Pearls:Human urine has a creatinine concentration greater than 20 mg/ dL .In the clinical setting it is important that 300 ng/mL or less be used for initial screening of opiates (Food stuff and poppy seed can make +); Confirm with laboratory test Opiate Class; lower sensitivity to hydromorphone , hydrocodone, oxycodone , oxymorphone, fentanyl, meperidine, and methadone Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care . Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010. Urine Drug Screening

Metabolites Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care . Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010.

Immunoassay Pearls (continued): Amphetamine/methamphetamine are highly crossreactive may detect other ephedrine and pseudoephedrine Further testing may be required by a more specific method, i.e. GCOpiate class: morphine and codeineAbility of opiate immunoassays to detect semisynthetic / synthetic opioids varies among assays because of differing cross-reactivity patterns.Specific immunoassay tests for some semisynthetic/ synthetic opioids may be available (eg, oxycodone , methadone). Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care . Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010. Urine Drug Screening

2. GC/MS (Laboratory Testing)Generally, a more definitive laboratory-based procedure Identify specific drugs; may be needed: (1) Specifically confirm the presence of a given drug; i.e. morphine is the opiate causing the + IA response (2) to identify drugs not included in an immunoassay test (3) when results are contested. Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care. Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010. Urine Drug Screening

Examples of cross-reacting compounds for certain immunoassays Interfering drug Immunoassay affected Quinolone antibiotics OpiatesTrazodone Fentanyl Venlafaxine PhencyclidineQuetiapine MethadoneEfavirenz THCPromethazine Amphetamine Dextromethorphan Phencyclidine Proton pump inhibitors THC Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care . Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010. Urine Drug Screening

Approximate windows of detection of drugs in urineDetection time Drug in urine Amphetamines Up to 3 days THC (Single use) 1 to 3 days (Chronic use) Up to 30 daysCocaine use 2 to 4 days Opiates (morphine, codeine) 2 to 3 days Methadone Up to 3 daysEDDP (methadone metabolite) Up to 6 daysBenzodiazepines Days to weeksGourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care . Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010. Urine Drug Screening

Consult lab regarding anything unexpectedSchedule appointment to discuss with patientBe positive and supportive Use to strengthen the healthcare professional-patient relationship Support positive behavior change What to do with UDT Results?

FDA recommendations for disposalLocate medication take back program in community Example: Dakota County Sherriff’s Office has a drop box at the Burnseville Police Department and the Hastings Sherriff’s Office where people can drop off their prescriptions anonymouslyMany drop box locations in Hennepin county: http://www.hennepin.us/medicine Drug Disposal

Hennepin County Drop Box Example: http://www.hennepin.us/medicine

FDA recommendations for disposalIf no medication take back programMix medications with unpalatable substance Place mixture in container such as sealed bag Throw container in household trash Exception: List of meds recommended to dispose by flushing http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm Drug Disposal

FDA recommended for flushing (examples):Fentanyl (SL tabs, film, lozenge, patch)Morphine Meperidine Hydromorphone Methadone OxycodoneTapentadol Others listed on FDA updated website: http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm Drug Disposal

Federal controlled substance laws and rules prohibit a pharmacy from receiving controlled substances from anyone who is not a registrant of the US DEA. Pharmacists are not allowed to accept controlled substances from patients or members of the public. Drug Disposal

Assessment of pain is key every time you see a patientOpioids can be part of a comprehensive pain management approach for a non-cancer chronic pain patient; document all assessment and communication regarding opioids each office visit Ensure pain is being treated appropriately with a multimodal approach using the best medications and therapy for the individual patientUtilize expertise of other non-pharmacy professionals for additional therapy to synergistically treat pain Summary

  Guidelines: Assessment and management of chronic pain. 2005 Nov (revised 2011 Nov). NGC:008967 Institute for Clinical Systems Improvement - Nonprofit Organization.   Adult acute and subacute low back pain. 1994 Jun (revised 2012 Jan). NGC:008959Institute for Clinical Systems Improvement - Nonprofit Organization  Diagnosis and treatment of headache. 1998 Aug (revised 2011 Jan). NGC:008263Institute for Clinical Systems Improvement - Nonprofit Organization Pain (chronic). 2003 (revised 13 May 2011). NGC:008519 Work Loss Data Institute - For Profit Organization. Guideline for the evidence-informed primary care management of low back pain. 2009 Mar. [NGC Update Pending] NGC:007704Institute of Health Economics - Nonprofit Research Organization; Toward Optimized Practice - State/Local Government Agency [Non-U.S.]. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. 2009 Feb. NGC:007852 American Academy of Pain Medicine - Professional Association; American Pain Society. Other References : 1) American Pain Society (APS). Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 6th edition. 2008. Glenview, IL 60025. 2) Anderson AV, Fine PG, Fishman SM. Opioid Prescribing: Clinical Tools and Risk Management Strategies . Sonora, CA: American Academy of Pain Management; December 31, 2009. http://www.state.mn.us/mn/externalDocs/BMP/New_Article_on_Pain_Management_020110034248_monograph_dec_07_final.pdf. Accessed June 2012 3) Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492. 4) Chou, R, Fanciullo , G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain: an update of Society-American Academy of Pain Medicine Opioids Guidelines Panel. The Journal of Pain .  2009 Feb;10(2):113-130. 5) Clark LG, Upshur CC. Family medicine physicians’ views of how to improve chronic pain management. J Am Board Fam Med. 2007;20(5):479-482. 6) Evans L, Whitham JA, Trotter DR, Filtz KR. An evaluation of family medicine residents’ attitudes before and after a PCMH innovation for patients with chronic pain. Fam Med. 2011;43(10):702-711 References

7) Fine, G. Opioid Rotation: Definition and Indications . Pain Management Today eNewsletter series. American Pain Foundation. , Quadrant HealthCom Inc. ; 2010: (1): 9. http://newsletter.qhc.com/JFP/JFP_pain032411.htm 8) Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care. Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010. 9) Hojsted, J, Sjogren , P. Addiction to Opioids in Chronic Pain Patients: A Literature Review. European Journal of Pain .  2007;11:490-518. 10) Katz NP. Opioid Prescribing Toolkit . Oxford/New York: Oxford University Press; 2010. 11) Leverence RR, Williams RL, Potter M, et al. Chronic non-cancer pain: a siren for primary care—a report from the PRImary care MultiEthnic Network (PRIME Net). J Am Board Fam Med . 2011;24(5):551-561. 12) Matthias MS, Parpart AL, Nyland KA, et al. The patient-provider relationship in chronic pain care: physicians’ perspectives. Pain Med. 2010;11(11):1688-1697 13) The Management of Opioid Therapy for Chronic Pain Working Group. VA/DoD clinical practice guidelines: management of opioid therapy for chronic pain. 2010. Version 2.0-2010. http://www.healthquality.va.gov/COT_312_Full-er.pdf. Accessed June 2012. 14) Patanwala , et. al. Comparison of Opioid Requirements and Analgesic Response in Opioid -Tolerant versus Opioid -Naïve Patients After Total Knee Arthroplasty . Pharmacotherapy 2008;28(12):1453-1460 ne 2012. 15) Pizzo PA, Clark NM, Carter-Pokras O, et al; Institute of Medicine Committee on Advancing Pain Research, Care, and Education. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington, D.C.: National Academies Press; 2011:119-120. 16) Project Lazarus. Community-based overdose prevention from North Carolina and the Community Care Chronic Pain Initiative. http://www.projectlazarus.org. Accessed Ju 17) Reuben, S. Anesthesiology. 2004;101:1215-1224. Burns, A. J Orthop Surgery. 2006; 14(3):280-3. 18) Tenore, P. Advanced Urine Toxicology Testing. Journal of Addictive Diseases, 2010;29:436-448. 19) Upshur CC, Luckmann RS, Savageau JA. Primary care provider concerns about management of chronic pain in community clinic populations. J Gen Intern Med. 2006;21(6):652-655. 20) Wismer B, Amann T, Diaz R, et al. Adapting Your Practice: Recommendations for the Care of Homeless Adults with Chronic Non-Malignant Pain. Nashville, TN: Health Care for the Homeless Clinicians’ Network, National Healthcare for the Homeless Council, Inc; 2011. References (continued)

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