Saturday April 14 2018 Kelly Bossenbroek Fedoriw MD Opioid Crisis Kral LA Jackson K Uritsky T A practical guide to tapering opioids Ment Health Clin Internet 2015531028 DOI 109740mhc201505102 ID: 698915
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Slide1
Prescribing Opioids in 2018: Reduce, Reduce and Replace
Saturday April 14, 2018
Kelly
Bossenbroek Fedoriw, MDSlide2Slide3
Opioid Crisis?
Kral LA, Jackson K, Uritsky T. A practical guide to tapering opioids. Ment Health Clin [Internet]. 2015;5(3):102-8. DOI: 10.9740/mhc.2015.05.102.Slide4
Objectives
Overview of opioid crisis with the patient at the center
Know how to counsel patients pre and post-op about opioids and their disposal
Be familiar with ways to taper opioids
Commit to learning more about MAT for opioid use disorderSlide5
How many pills for a lap chole?
Median
rx
was 250mg, median use was 30mg
42 – 73% of opioid pills post-op go
unused
> 70% are not stored in locked
container
Introduced guidelines and reduced excessive pills and did not increase refill requests (and pts continued to take <50%!)
Reduce the number of pills in circulation
Bicket
M, Long J,
Pronovost
P et al. Prescription opioid analgesics commonly unused after surgery: A systematic review. JAMA Surg.
doi:10.1001/jamasurg.2017.0831
Howard R,
Waljee
J,
Brummett
C,
Englesbe
M et al. Reduction in opioid prescribing through evidence-based prescribing guidelines. Jama Surg.
doi:10.1001/jamasurg.2017.4436Slide6
Reduce the Exposure and Supply
Prepare your patient for pain
Ask:
What do you do when you have pain?
Make a plan
How many did you take?
Do you have any left over?
How did you dispose of them?Slide7
Disposal
Offer
alternatives for disposal. Find out where there are disposal centers.
UNC
Across NC
And
then get
Deterra
bags!Slide8Slide9
www.ncdoj.govSlide10
Reduce total dose
Overdoses are NOT just due to addiction and misuse
CDC Guideline for Prescribing Opioids for Chronic Pain Slide11Slide12
Reduce total dose
Uncoupling of CO2 drive at high doses, even if taken appropriately
CDC Guideline for Prescribing Opioids for Chronic Pain
Bohnert
A,
Valenstein
M, Bair M, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA April 6, 2011. 305:13, 1315-1321Slide13
Reduce total doses
Overdose risk doubles at 50MME
Overdose death rate per 1000 person-months
Taper patients
CDC Guideline for Prescribing Opioids for Chronic Pain
Bohnert
A,
Valenstein
M, Bair M, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA April 6, 2011. 305:13, 1315-1321
Dose
Chronic
Pain
Acute
Pain
Subs Use Disorders
20-49 MME
0.24
0.36
0.78
50-99 MME
0.66
1.13
1.59
>100 MME
1.24
1.82
2.97Slide14
NC Medicaid pts on high doses
Percent of NC Medicaid claims for prescriptions of long acting opioids:
91 MME – 120 MME/day = 13.7 %
> 120 MME/day = 22.3%
Total on HIGH DOSE = 36% of pts on long acting opioids
Total of 14,600 patients in NCSlide15
Reasons to Consider a Taper
Lack of Efficacy
No improvement in function
Inadequate analgesia
Failure to reach established treatment goals
Opioid-related adverse effects
Cognitive compromise or sedation
Refractory constipation or urinary retention
Concerns about respiratory depression
Hypogonadism or osteoporosis
Opioid-induced hyperalgesia
Unacceptable risk
Obtaining opioids from multiple providers
Inappropriate urine drug screen results
Compulsive overuse
Noncompliant, misusing or abusing
Taking benzodiazepines concurrently
Kral
LA, Jackson K,
Uritsky
T. A practical guide to tapering opioids.
Ment
Health
Clin
[Internet]. 2015;5(3):102-8. DOI: 10.9740/mhc.2015.05.102.Slide16
Who needs to Taper?
No – sporadic use, prn basis
Yes - patients
that use long-acting and/or short-acting agents as a regular daily regimen (≥ 50
MME/day)
There is no single strategy for tapering opioids. The literature is highly variable in dose reductions and schedules for opioid tapers across a variety of published guidelines.
Kral
LA, Jackson K,
Uritsky
T. A practical guide to tapering opioids.
Ment
Health
Clin
[Internet]. 2015;5(3):102-8. DOI: 10.9740/mhc.2015.05.102.
Dowell D,
Haegerich
TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR
Recomm
Rep 2016;65(No. RR-1):1–49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1Slide17
Approaches to Tapering
Slow taper
is better for most patients
Individualize rate and duration of the taper to the
patient
It’s suggested to decrease dose by
10-20%
weekly or
monthly
and then more slowly as dose reaches 30-45
mg
MME/day
to avoid withdrawal
.
Increased monitoring
(visits) is likely
necessary
Kral
LA, Jackson K,
Uritsky
T. A practical guide to tapering opioids.
Ment
Health
Clin
[Internet]. 2015;5(3):102-8. DOI: 10.9740/mhc.2015.05.102.Slide18
Approaches to Tapering
Rapid
Tapering may be necessary
when it
is not safe to further prescribe opioids
To avoid serious withdrawal, reduce dose by 25% every few days
.
The patient should be counseled on withdrawal symptoms and consider medications for the management of opioid withdrawal symptoms
Kral
LA, Jackson K,
Uritsky
T. A practical guide to tapering opioids.
Ment
Health
Clin
[Internet]. 2015;5(3):102-8. DOI: 10.9740/mhc.2015.05.102.Slide19
Withdrawal Symptoms
VA Opioid taper decision tool.
Washington, DC:
Veterans Administration; 2016,
Available from: https://www.pbm.va.gov/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdfSlide20
Pharmacologic management of opioid withdrawal symptoms
Kral
LA, Jackson K,
Uritsky
T. A practical guide to tapering opioids.
Ment
Health
Clin
[Internet]. 2015;5(3):102-8. DOI: 10.9740/mhc.2015.05.102.Slide21
Considerations
Optimize evidence-based
nonopioid
analgesics
to manage pain
Gabapentin,
pregabalin
, APAP, NSAIDs, TCAs,
Skeletal
muscle relaxants,
etc
Coordinate with specialists and treatment experts as needed
Make sure patients receive appropriate psychosocial support
Let patients know that most people have improved function without worse pain after tapering opioids. Some patients even have improved pain after a taper, even though pain might briefly get worse at first.
Dowell D,
Haegerich
TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR
Recomm
Rep 2016;65(No. RR-1):1–49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1Slide22
Is it possible?
110 eligible patients in
outpt
pain clinic
82 agreed to participate
51 completed a 4 month taper
Median MME decreased from 288 to 150
No behavioral health support
Darnall
B,
Ziadni
M, Stieg R, et al. Patient-Centered
Prescription Opioid Tapering in Community Outpatients With Chronic Pain
February
19, 2018. doi:
10.1001/jamainternmed.2017.8709
.Slide23
62 yr old man with severe DDD
H/o severe cervical DDD, s/p surgery for stenosis 6
yrs
ago
Currently taking
oxycontin
120mg
qAM
, 80mg at noon, 120mg
qPM
and oxycodone IR 10mg QID prn.
Also taking
ambien
prn sleep and valium 5mg TID for muscle spasmsShould he be tapered?
How?Slide24
Treatment failure - Unacceptable risk
Very high dose opioids (MME 540),
pt
reporting very limited function as well as uncontrolled pain
Concurrent benzodiazepines:
ambien
and valium
Step 1: stop
ambien
and transition to trazodone
Step 2: taper valium by 5mg every month over 3 months to off and start baclofen instead
Step 3: slowly decrease opioids….Slide25
Original MME: 540
oxycontin
20mg/week for 4 weeks,
pt
seen weekly
oxycontin
20mg/month x 4 months,
pt
seen monthly
oxycontin
10mg/month x 6 months, pt seen q 2 mo more slowly the oxycodone IR 10mg QID to 5mg daily prn
5
yrs
later: MME 158
Oxycontin
40mg AM, 40mg noon, 20mg PM, 5 daily prn
Has naloxone kit at home, knows how to use it
No
ambien
, no valium
No decrease in function, no increase in pain
.Slide26
Therapeutic Alliance
Give
pt
choices
Focus on relationship
Provide support for mental healthSlide27
48 yr
old woman with uncontrolled depression, OSA, chronic non-specific low back pain
Current medications: Cymbalta, MS
contin
60mg TID, oxycodone 10mg QID prn
MME = 240
Do you taper her?
How?Slide28
Lack of indication for opioids / unacceptable risk
Treat depression/OSA – include your specialists when necessary
Slowly taper opioidsSlide29
Original MME: 240
MS
contin
by 10mg/mo
x
9
months (now 30mg TID)
oxycodone to TID instead of QID
MS
contin
by 15mg and inc oxycodone to QID for that month, then back to TID 3 yrs
later: MME 105, still going down
MS
contin
30mg BID, oxycodone 10mg TID
prn
Has naloxone kit at home, knows how to use
it
No decrease in function, no increase in painSlide30
Compassionate Care
Always try to talk to a patient directly about unexpected results (urine
tox
screens
etc
)
Don’t stop a patient’s medications via letter. Attempt a phone call, offer to keep caring for them.
Stopping opioids doesn’t mean discharge from practice
Offer help or referral for misuse and addiction. There are good treatments!!Slide31
Replace
Learn more about Opioid Use Disorder and Medication Assisted Treatment
Buprenorphine/Naloxone (
Suboxone
,
Zubsolv
etc
) is the most well known, but not the only treatment available
Become a provider. Training is free.
http
://www.aoaam.org/?
page=PCSSMAT
Slide32
NC Ranks High on Abuse but Low on TreatmentSlide33
MAT works!
Improve patient survival
Increase retention in treatment
Decrease illicit opiate use and other criminal activity among people with substance use disorders
Increase patients’ ability to gain and maintain employment
Improve birth outcomes among women who have substance use disorders and are pregnant
Decrease relapse
Lower risk of contracting HIV or hepatitis CSlide34
Join ECHO!
Every Wednesday 12:30-2:30 via ZOOM
echo@unc.edu
kbossen@med.unc.edu
Slide35
Motivation
Patients
“saved my life”
“I feel normal”
“I have relationships again”
“I have a job”Slide36
Conclusion
Reduce the supply and diversion by talking with your patient about acute pain
Help patients dispose of medications appropriately
Taper patients compassionately
Learn more about Opioid Use Disorder and Medication Assisted TreatmentSlide37
Patient with no opioid in utox
CONFIRM, CONFIRM, CONFIRM
Make sure you are testing for the right opioid and know your metabolites. When in doubt, call the lab
Fentanyl is separate test, get a confirmation!