Trauma and Opioids Summit - PowerPoint Presentation

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Trauma and Opioids SummitOutpatient Opioid Therapy: Mitigating Risks

Perry G. Fine, MD Professor of AnesthesiologyDepartment of Anesthesiology School of MedicineUniversity of UtahSlide2

ObjectivesBe informed of content, intent and limitation of current Clinical Guidelines

Implement a structured approach toward opioid prescribing and teaching/mentoring safe prescribing practices for opioidsDefine current limitations in pain care in the domains of education, public policy, neuroscience, and clinical care.Slide3

Basic Precepts: The CDC GuidelineDETERMINING 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.rr6501e1Slide4

Basic Precepts: The CDC GuidelineDETERMINING 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.rr6501e1Slide5

Basic Precepts: The CDC GuidelineDETERMINING 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.rr6501e1Slide6

Basic Precepts: The CDC GuidelineOPIOID SELECTION, DOSAGE, DURATION, FOLLOW-UP, 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.rr6501e1Slide7

Basic Precepts: The CDC GuidelineOPIOID SELECTION, DOSAGE, DURATION, FOLLOW-UP, 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.rr6501e1Slide8

Basic Precepts: The CDC GuidelineOPIOID SELECTION, DOSAGE, DURATION, FOLLOW-UP, 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 immediate-release 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.rr6501e1Slide9

Basic Precepts: The CDC GuidelineOPIOID SELECTION, DOSAGE, DURATION, FOLLOW-UP, 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.rr6501e1Slide10

Basic Precepts: The CDC GuidelineASSESSING 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.rr6501e1Slide11

Basic Precepts: The CDC GuidelineASSESSING 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.rr6501e1Slide12

Basic Precepts: The CDC GuidelineASSESSING 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.rr6501e1Slide13

Basic Precepts: The CDC GuidelineASSESSING 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.rr6501e1Slide14

Basic Precepts: The CDC GuidelinePRESCRIPTION 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.rr6501e1Slide15

Basic Precepts: The CDC GuidelineREGISTER 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-monitoring-programs.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.rr6501e1Slide16

Algorithm for Opioid Treatment of Chronic Pain

Patient SelectionInitial Patient Assessment

Trial of Opioid Therapy

Alternatives to Opioid Therapy

Patient Reassessment

Implement Exit Strategy

Continue Opioid Therapy

Comprehensive Pain Management PlanSlide17

Patient Selection for Opioid TrialPersistent 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 modalitiesSlide18

Algorithm for Opioid Treatment of Chronic Pain

Patient SelectionInitial Patient Assessment

Trial of Opioid Therapy

Alternatives to Opioid Therapy

Patient Reassessment

Implement Exit Strategy

Continue Opioid Therapy

Comprehensive Pain Management PlanSlide19

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 circumstancesPatient (specific) perspectives on opioid therapySlide20

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, etcSocial history: motor vehicle accidents, DUIs, domestic violence, legal history, loss of property in firePsychiatric history: personal history of psychiatric diagnosis, outpatient and/or inpatient treatment, current psychiatric medicationsSlide21

Pain Assessment: The Bottom LinePatient 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 therapySlide22

Algorithm for Opioid Treatment of Chronic Pain

Patient SelectionInitial Patient Assessment

Trial of Opioid Therapy

Alternatives to Opioid Therapy

Patient Reassessment

Implement Exit Strategy

Continue Opioid Therapy

Comprehensive Pain Management Plan

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Comprehensive Pain Management Plan Components

Biomedical Approaches pharmacologic and/or nonpharmacologic and/or interventional therapiesPsychological InterventionCBT/other modalities (e.g. mindfulness meditation) to improve mood disturbances and coping skillssleep hygieneSocial/Rehabilitative Issuesfamily/social relationswork issuesphysical rehabilitation and functional restorationphysical/occupational therapyhome exercise programSlide24

Algorithm for Opioid Treatment of Chronic Pain

Patient SelectionInitial Patient Assessment

Trial of Opioid Therapy

Alternatives to Opioid Therapy

Patient Reassessment

Implement Exit Strategy

Continue Opioid Therapy

Comprehensive Pain Management PlanSlide25

Alternatives to Opioid TherapyAlternative pain management strategiesadjuvant analgesics

nonpharmacologic modalities complementary medicineinterventional therapies Refer complex or high-risk patients for SUD, mental health services, interventional pain managementSlide26

Algorithm for Opioid Treatment of Chronic Pain

Patient SelectionInitial Patient Assessment

Trial of Opioid Therapy

Alternatives to Opioid Therapy

Patient Reassessment

Implement Exit Strategy

Continue Opioid Therapy

Comprehensive Pain Management PlanSlide27

Patient Care Agreement/Informed Consent Components

Collaborative Process to Optimize AdherenceReminder: opioids are one modality in multifaceted approach to achieving goals of therapyDetailed outline of procedures and expectations between patient and doctorProhibited behaviors and grounds for tapering or discontinuation Limitations on prescriptionsEmergency issuesRefill and dose-adjustment proceduresExit strategySlide28

Algorithm for Opioid Treatment of Chronic Pain

Patient SelectionInitial Patient Assessment

Trial of Opioid Therapy

Alternatives to Opioid Therapy

Patient Reassessment

Implement Exit Strategy

Continue Opioid Therapy

Comprehensive Pain Management PlanSlide29

Risk Assessment and When to Refer?

Prior or ongoing excessive use behaviors (caffeine, alcohol, tobacco, other)Chaotic lifeConviction of a drug-related crimePrior substance abuse or current use of illicit drugsRegular contact with drug high-risk groupsSlide30

Ongoing dilemmasInadequate pain and substance abuse educationInsufficient resources for primary care clinicians

Comprehensive pain care programsBehavioral therapists with pain expertiseFunctional restoration (rehab) therapists with chronic pain expertiseInsufficient funding for comprehensive pain careLimited alternatives to opioids (potency, versatility)Lack of predictable “assay” for opioid effectivenessHighly charged political climateSelf-medication has become a societal “norm”Expectations for “no pain” outweigh biomedical scienceLimitations of neuroscience to “explain” pain chronificationSlide31

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.