Guidelines for the management of opiate prescribing by physicians.

1. THE HIGHS AND LOWS OF OPIATES A REVIEW OF THE CPSO GUIDELINES Leon Rivlin MD, CCFP (EM)

2. OBJECTIVES Evaluate opioids in the management of chronic pain Define an approach to the recognition of opioid misuse in the chronic pain patient Evaluate protocols for safe and effective prescribing of opioids in chronic pain Discuss the pitfalls of opiate management

3. WHY IS OPIATE MANAGEMENT SUCH A GREAT CONCERN ? WHY IS CHRONIC PAIN IMPORTANT?

4. Canadian National Pain Study 2002 Chronic pain is present in 22 – 39% adults #1 reason for chronic pain: arthritic conditions Prevalence of pain increases with aging Only 36% of patients felt that their pain was effectively Rx 68% of MD’s believed that chronic pain could be treated more effectively Moulin D., PR&M, 2002,2003

5. ECONOMIC IMPACT 13% of workers lose a mean of 4.6 hours /wk of productive work time due to common pain conditions Costs to industry $6.2 B/yr (US) 76 % due to reduced performance at work Costs of depression to industry $31 B/yr Equal to impact of CV disease, or Cancer Stewart et al. JAMA 2003

6. BARRIERS for PHYSICIANSto TREATING CHRONIC PAIN Limited training in medical schools Insufficient knowledge and understanding Disease centred model of care does not prioritize the management of pain Biopsychosocial model of pain underutilized Fears about regulatory bodies Biases and fears about opioid use & addiction

7. BIASIS & FEARS ABOUT OPIOID ANALGESICS 2004 DATA Study of Wisconsin physicians' knowledge and attitudes about opioid analgesic regulations David E. Weissman, MD; David E. Joranson, MSSW; and Margaret B. Hopwood, MA, RN, Milwaukee and Madison Wisconsin Medical Journal 1991 200 Wisconsin physicians were polled 54% of the respondents indicated that, due to concern of regulatory scrutiny, they will do one of the following: reduce drug dose or quantity, reduce the number of refills, or choose a drug in a lower schedule

9. ADVERSE EFFECTS of OPIOIDS:GENERAL Constipation, nausea, narcotic bowel syndrome Sweating Sleep apnea, COPD, reduced resp. drive Rebound head aches Fatigue, confusion Cognitive impairment Endocrine & Reproductive effects (suppression of testosterone, menstrual irregularities) Lowered pain threshold (long term hyperalgesia due to altered pain receptors) Neurotoxicity (Demerol)

10. ADVERSE EFFECTS: OVERDOSE Decreased LOC RR < 12/min Bradycardia Speech slow & drawling “Nodding off” appear to fall asleep momentarily during conversation Patients may appear to be relatively alert when surrounded by others in a stimulating environment, only to drift into coma and die when going for a nap Pinpoint pupils Ataxia and falling Emotional lability Disinhibition Profuse sweating

11. ADDICTION

12. ADDICTION Addiction occurs when a patient finds a drug effect so reinforcing that he has difficulty controlling its use Characterized by the four C’s: Loss off over use Control Use despite knowledge of harmful Consequences Compulsion to use the drug Craving

13. ADDICTION & OPIOIDS 50% chronic pain patients are addicted to opioids More formal studies found addiction rates to be 3 – 19% 54% of injection users inject morphine and hydromorphone, 42% inject heroin 7-31% prevalence for opioid misuse behaviors (running out, double doctoring)

14. CLINICAL FEATURES of ADDICTION Use of higher doses than needed for pain control Run out early Reluctant to try alternatives to drug of choice Acquire opioids from friends or other doctors Tendency to binge on opioids Deterioration in functional status Daily cycle of intoxication and withdrawal Experimenting with opioids (routes of administration)

15. OPIOID OVERDOSE:RISK FACTORS Dose, potency, underlying tolerance Age (extremes), renal insufficiency, respiratory disease Restarting opioids When a patient has been off of an opioid for 3 days or longer, restarting at the same dose may produce an overdose due to rapid decline in tolerance. Restarting the medication should be at 50% of the previous dose with gradual titration up.

17. high potency opioid use

18. concurrent use of prescription opioids & benzos

19. tolerance

20. depression

22. PREPARE A TREATMENT PLAN Collect information and formulate a diagnosis Define and priorize treatment targets Devise a COMPREHENSIVE treatment plan Lifestyle changes Social changes Consider Psychological/Psychiatric intervention Integrate paramedical care providers Pharmacotherapy Interventional medical therapy

23. START WITH NON-OPIOIDS Opioids should only be initiated after an adequate trial of non-opioid analgesics and other modalities have failed Treatment success is measured by 25 – 50 % diminished pain, improved mood, and improved function Abstinence of pain is an unrealistic goal General reluctance to use opioids for headaches (opioids 2nd/3rd line at best)

24. INITIATING OPIOIDS Obtain informed consent (adverse effects, risk of dependence) Set expectations (25 – 50 % relief of pain) Identify one prescribing physician Sign a Treatment Agreement Evidence supports improved compliance Sandoval et al., 2005

25. Maximum Opiate Dose is 200 mg morphine /dayCPSO TASK FORCE CONCLUSIONS

26. COMPONENTS OF THE TREATMENT AGREEMENT Patient will not receive opiates from other sources Detail the amount of medication, and usage schedule Will not refill if the patient runs out early Will not replace if meds or script lost Patient will attend to regular visits Urine drug screen will be provided on request Physician can cease opiate script if agreement broken A copy of the agreement should be sent to other physicians involved in care Consequences of breaking the agreement should be specified and adhered to

27. DOCUMENTATION Keep an opiate flow sheet (record the amount dispensed and reasons for changes) Keep copies of scripts on chart Orange paper scripts are hard to photocopy See patient frequently on initiation of treatment At each visit, document: compliance, adverse effects, changes in mood and functional status, and analgesic effectiveness (VAS)

28. OPIATE SELECTION, DOSAGE & TITRATION There is no evidence that one opiate is superior to another, recommendations are based on specific patient populations Codeine is usually the initial choice because it is the least potent Be cautious of the acetaminophen component 4 g/d if healthy, 3.2 g/d if elderly, 2g/d if EtOH

29. OPIOID SELECTION 10% of Caucasians can’t convert codeine Fentanyl patch, oxicodone, & hydromorphone are less likely to cause sedation in elderly Active metabolites of morphine can accumulate in renal dysfunction Avoid oxycodone & hydromorphone in patients with addiction history Methadone is first choice in chronic pain among addicts Parenteralopioids should not be use in long-term pain due to risk of overdose, addiction, and other problems

30. Titration Start low and go slow! Opiates have a graded analgesic response with greatest benefit at lower doses and plateau at higher dosages Confirm that with each dosage increase there is a decline in the VAS pain score Avoid withdrawal especially in pregnancy Titrate slowly in the elderly, co-sedating med users, renal, resp, hepatic disease

31. BREAKTHROUGH PAIN Opioids should be taken on a regular basis Should be 1/3 of total scheduled dose or less Same opiate should be used for scheduled and breakthrough use No convincing evidence for combining different types of opioids

32. SWITCHING OPIOIDS Switch if lack of effectiveness or intolerable side effects Initial dose of new opioid should be 50% of the original opioid used Discontinue if pain remains unresponsive after 3 or 4 different opioids

33. SAFE PRESCRIBING Avoid prescriptions for large amounts Caution with high dependence opiates in those at risk Use rescue doses sparingly Should be time dependent rather than pain contingent Max of 4 – 6 doses per month Reduce next days dose by equal amount Tamper proof the prescription Keep track of the medications Running out early is common in addiction

35. Use lines in blank spaces

36. No repeats

37. Keep pad in safe place

38. Numbered, non reproducible pads (orange is hard to photocopy)

40. IN SUMMARY Formulate a comprehensive treatment plan Include the patient & family in the decision making Consider opioids late in treatment of pain & use sparingly Monitor use of opioids closely Dispense small quantities of medication on any one visit Frequently evaluate effectiveness of treatment models & guidelines

41. THE END