Cover slide

CDC Guidelines for Prescribing Opioids for Chronic Pain – Part 1 Denis G. Patterson, DO ECHO Project June 15, 2016

Contact Information Denis G. Patterson, DO Nevada Advanced Pain Specialists www.nvadvancedpain.com patterson@nvadvancedpain.com

Prescription Drug Misuse and Abuse: Hype or an American Epidemic?

Unintentional Opiate Overdose Deaths Parallel Opioid Sales in United States, 1997–2007 Distribution by drug companies 96 mg/person in 1997 698 mg/person in 2007 Distribution by drug companies 96 mg/person in 1997 698 mg/person in 2007 Enough for every American to take 5 mg hydrocodone every 4 hrs for 3 weeks Overdose deaths2,901 in 1999 11,499 in 2007 Source: National Vital Statistics multiple cause of death data set and Drug Enforcement Agency ARCOS System

Time for Change March of 2016, The CDC published it’s Guideline for Prescribing Opioids for Chronic Pain

Target Audience Opioid prescribing rates have increased more for family practice, general practice, and internal medicine compared to other specialties from 2007 - 2012 Presciptions by PCP’s account for nearly half of all dispensed opioid prescriptions

Guideline Goals Provide recommendations for primary care providers who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care

Recommendations Grouped into 3 areas of consideration: Determining when to initiate or continue opioids for chronic pain Opioid selection, dosage, duration, follow up and discontinuation Assessing risk and addressing harms of opioid use

Determining when to initiate or continue opioids for chronic pain Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Providers should only consider adding opioid therapy if expected benefits for both pain and function are anticipated to outweigh risks to the patient.

Reasoning No medical evidence exist showing that long term opioid therapy provides sustained pain relief, functional improvement, or quality of life.

Reasoning Evidence exists that many nonpharmacological therapies can ameliorate chronic pain Physical therapy - Accupuncture Weight loss - Massage Manipulation - CBT Interventional Procedures * Cost and time can be an issue

Reasoning Several nonopioid pharmacologic therapies are effective for chronic pain Acetaminophen - Antidepressants NSAIDS - Anitconvulsants * Not associated with drug dependence

Bottom Line Given uncertain benefits and substantial risks, opioids should not be considered first line or routine therapy for chronic pain.

Determining when to initiate or continue opioids for chronic pain Before starting opioid therapy for chronic pain, providers should establish treatment goals with all patients, including realistic goals for pain and function. Providers should not initiate opioid therapy without consideration of how therapy will be discontinued if unsuccessful. Providers should continue opioid therapy only if there is clinical meaningful improvement in pain and function that outweighs risks to patient safety.

Reasoning Typically providers write prescriptions for 30 day increments. An opioid prescription for 30 days represents an initiation or continuation of long-term opioid therapy.

Reasoning Prior to writing an opioid prescription for 30 days, providers should establish treatment goals. Goals should include both pain relief and function. Clinical meaningful improvement has been defined as 30% improvement in scores.

Bottom Line Clinical evidence did not reveal studies evaluating the effectiveness of written agreements or treatment plans Expectations should be put in place on how opioids will be prescribed and monitored

Bottom Line Spell out how opioids will be tapered or discontinued if treatment goals are not met, opioids are no longer needed, or adverse events put the patient at risk

Determining when to initiate or continue opioids for chronic pain Before starting and periodically during opioid therapy, providers should discuss with patients known risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.

Reasoning No studies found that evaluate the effectiveness of patient education or opioid treatment plans as risk-mitigation strategies Contextual evidence review did find that many patients lack information about opioids and providers miss opportunities to effectively communicate about safety

Bottom Line Providers should do the following: Explain that no evidence exists that opioids improve pain or function with long term use and complete pain relief is unlikely Emphasize improvement in function as a primary goal and that function can improve even when pain persists

Bottom Line Discuss serious adverse effects including fatal overdose and development of a serious lifelong opioid use disorder Discuss common adverse effects: constipation, N/V, drowsiness, confusion, tolerance, physical dependence, etc

Bottom Line Advise about increase risk for opioid use disorder, overdose, and death at higher dosages. Conversation should include how self medicating is dangerous Review the increased risks for overdose when taken with Benzodiazepines, alcohol, or other sedatives

Bottom Line Discuss the importance of periodic reassessments to ensure opioids are helping to meet goals and to allow opportunities to intervene if they become harmful Discuss precautions to reduce risks: PMP reviews, UDS, and Naloxone use for overdose reversals

Bottom Line Consider whether cognitive limitations interfere with management and determine if whether a caregiver can responsibly co-mange medication therapy Discuss risks to family members which include the possibility of overdose if shared or unintentional ingested

Bottom Line Discuss storage options and safe disposal or unused opioids

Questions

Discussion

Closing slide