Prescribing Opioids in 2018: Reduce, Reduce and Replace - PowerPoint Presentation

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Slide1

Prescribing Opioids in 2018: Reduce, Reduce and Replace

Saturday April 14, 2018

Kelly

Bossenbroek Fedoriw, MDSlide2
Slide3

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!Slide8
Slide9

www.ncdoj.govSlide10

Reduce total dose

Overdoses are NOT just due to addiction and misuse

CDC Guideline for Prescribing Opioids for Chronic Pain Slide11
Slide12

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!