STOP! Safe Treatment of Pain Corey Black, MD FACP

Opioid Epidemic 120 Deaths per day in the US 7000 ED visits per year 245 Mil prescriptions US prescribes 80% world opioids

Centegra’s Data CHM 2,853,000 ml IV Opioids 2013 CHM 3,320,000 ml IV Opioids 2015 (877 G) CHM 72,ooo ml IV Naloxone 2013 CHM 78,000 ml IV Naloxone 2015

Patients Presenting On Opioids Assess Risk Bedside Opioid Overdose Calculator Talk to patients about their overdose risk Document conversation in discharge note

Bedside Opioid-Overdose Calculator Pain Med 2017 April 13. doi 10.1093/pm/pnx038 18 Mil patients from IMS PharMetrics Plus health plan claims database prescribed opioids 2009-2013 Substance Use Disorders (OR=10.2); Depression (OR=3.12); Impaired liver, renal, pulmonary function; mental health disorders

Practice Plan Guidelines CDC Opioid Prescribing Guidelines Look at non pharmacologic pain management options (ie. Heat/cold, message, stress management) Long term treatment starts with acute pain management Need to provide informed consent Prescribing naloxone to high risk patients Avoid prescribing benzodiazepines with opioids

Acute Pain Start with nonopioid medication Informed consent when starting opioids Treat with lowest effective dose Opioid limited to 3 to 7 days

Mild Pain(1-5/10 patient reported) (1-2 Functional Scale) Non-opiods (NSAIDS, Acetaminophen, Hot/ Cold packs, Lidoderm patch Moderate Pain(6-8/10) patient reported (3/5 Functional Scale) Low Dose Opioids (Codeine, Norco, Percocet) Adjuvant Analgesics Antidepressants Gabapentin Anticonvulsants Severe Pain (9-10/10) patient reported) (4-5/5 Functional Scale) High Dose Opiods (IV Opiods, PO Morphine, Oxycodone)

Chronic Pain Patient Selection Failed Non-opioid Analgesics Other Analgesics Contraindicated Not on Unresponsive Dx List Initial Patient Assessment Exam to confirm diagnosis Quick Screen ABCDPQRS Query PMP Comprehensive Pain Management Plan Non pharmacologic measures Non opioid Pain Medications Trial of Opioid Therapy Informed Consent Review Side Effects Exit Strategy Follow up in 3-5 days Patient Reassessment Continue Opioid

Patient Selection Failed non-opioid analgesics NSAIDS Topical Anesthetics Other analgesics contraindicated Not on unresponsive diagnosis list

Diagnoses Not Responsive to Opioids Fibromyalgia Migraine Irritable Bowel Syndrome Cyclic Vomiting Uncomplicated Back and Neck pain

Initial Patient Assessment Exam to confirm diagnosis Assess functional pain scale Quick Screen questions ABCDPQRS Query Patient Monitoring Program

Functional Pain Scale Rating Description No Pain 1 No Pain 1 Tolerable: Doesn’t prevent activity 2 Tolerable but does affect some activity 3 Intolerable but can use phone, watch TV, Read 4 Intolerable and unable to use phone, watch TV, Read 5 Intolerable and unable to verbally communicate because of pain

Quick Screen Questions: In the past year, how often have you used the following? Alcohol For men, 5 or more drinks a day For women, 4 or more drinks a day Tobacco Products Prescription Drugs for Non-Medical Reasons Illegal Drugs

ABCDPQRS Alcohol Benzodiazepines Clearance and metabolism of the drug Delirium, dementia and falls risk Psychiatric comorbidities Query the prescription monitoring program Respiratory insufficiency and OSA Safe driving, work, storage and disposal

Comprehensive Pain Management Non pharmacologic measures Non opioid pain medications Opioid pain medications when indicated

Trial of Opioid Therapy Informed Consent Review Side Effects Exit Strategy if Opioids Ineffective Follow up in 3-5 days

Informed Consent Explain addiction potential of opioids Take with other drugs or alcohol “you may not wake up” Explain Illinois prescription monitoring program Explain use of urine drug screening per CDC guidelines

Patient Reassessment The Four “A’s” Analgesia Activity of Daily Living Adverse Effects Aberrant Drug-Taking Behaviors

Continue Opioids Establish Pain Contract Urine Drug Screening Prescription Monitoring Program Reassess Pain Management

Exit Strategy Document the lack of improvement in functional status/pain Emphasize that the patient is not being abandoned Taper off opioid therapy

Remember Proper Patient Selection Key Proper Patient Assessment is Mandatory Opioids Are Only One Component of a Comprehensive Pain Treatment Plan Prescribing Opioids on a Trial Basis MUST be Monitored Patient Reassessment is KEY Any Medical Therapy can be Continued, Discontinued, or Modified

Kevin MD video