Use of Opioids fro Chronic Pain in Primary Care Norman Wetterau MD

Should you treat chronic nonmalignant pain with opioids? 1. Few studies of long term use. Most show little or no long term benefit. Martell, Bridget et al Annals of Internal Medicine: January 16, Comprehensive treatment including PT, activity patient education and emotional support worked best C Turk et al Lancet June 25, 2011 p A significant number of people have problems from the opioids or still have the pain

The voyage: to the land of improved function and less pain The Ship’s name: Opioid

Opioids for Chronic Pain Navigating a minefield Preparing for the voyage

Don’t let the patient or the doctor drown!

The minefield Some people are trying to obtain opioids for reasons other than pain - for their addiction, to sell, to treat their depression or life stresses. Some people are at risk for developing addiction. In some individuals the narcotics will not really relieve the pain. If the patients continue on the opoiods, it will be difficult for them to stop, even though they are no better. BUT SOME PEOPLE MAY GET PAIN RELIEF AND GET THEIR LIFE BACK

Preparing for the voyage Who is a good candidate? –History shows no indication of substance abuse problems past or current –No or few risk factors

Preparing for the Voyage Who can come, but needs a life jacket and visits to the ship’s doctor? - Past SA problems other than opioids - Risk factors such as FH of SA problems - Use of tobacco - Psychiatric problems - Patients who have had problems in the past but are honest about them.

Preparing for the Voyage Who is likely to drown, so they should stay behind? -Active SA problems --HX of opioid problems in the past --Patients who are not being honest with you

Preparing for the Voyage Where are you going? –To improve functional status, not just lessen pain How will you know if you are off course or lost? - The pain gets no better - The dose needs continual increases - The patient isn’t taking the medication you prescribe

On the Voyage How do you get the information you need to decide if you are off course or lost? - Urine drug screens tell you whether the patient is taking the medication you prescribe - Urine screens tell you if the patient is taking other drugs that put him/her in danger of overdose - Asking about functional improvement - Pill counts

Patients who want to go to the same pain free place, but might consider a different ship. People who were identified as at risk for long term narcotics People who have not already tried other approaches to their pain relief People whose pain is more emotional or related to life stresses. People who understand the risks and benefits and choose not to be prescribed opioids

Patient assessment 1. The Pain: Subjective pain scale, patient’s description, how it effects his/her life 2. The Pain: Objective –What is causing this pain? –What diagnostic tests have been done? –What treatments have been tried and how did they work? –Can it be fixed? Your opinion and patient’s opinion –You need to obtain this information 3. Is the pain from the medical condition or secondary to depression or the stress of life?

Screen for conditions that put people at risk for problems with opioids 1. Past history of SA problems, including drug use and a lot of binge drinking in HS and college. 2. Current alcohol problems, including binge drinking and current drug problems including use of marijuana 3. FH: SA and alcohol problems 4. Depression, especially proceeding the pain 5. Past history of problems with pain medicines 6. Past history of significant legal problems

For all new patients asking for opioids Contact previous physicians, preferably by telephone on the first visit Or to to the state monitoring program on the health departments website

Screening continues: Ask or use a questionnaire Start with alcohol: Quantity and if they have had problems Audit or Cage. Audit asks both quanity and problems Ask if they have ever had alcohol problems in the past Helping patients who drink too much: A Clinician’s Guide NIAAA NIH Publication No , Revised 2007

Screening continues Ask about Smoking: Do you smoke? How much? Do you every smoke anything other than tobacco? Or Do you every smoke marijuana? Both tobacco and marijuana smoking is associated with addictive problems. Tobacco may be associated with alcohol problems. Marijuana smoking is associated with use of other illegal drugs, disrespect for norms and rules, and a desire to have a mind altered state.

Screening continues In the past five years: 1. Have you used drugs to get high? Stimulants, tranquilizers, cocaine, marijuana or narcotics 2. Have you used drugs that were not prescribed for you? 3. Have you ever been treated for a drug or alcohol problem? 4. Do you have a family history of alcohol or drug problems? “Have you ever” questions are triggers and require further information: when, how often, do you still do this?

Urine drug screen Obtain one; tell patient that you periodically do this with patients prescribed controlled substances. I have found some positive screens and obtained help and treatment for the patients. Reference: Urine Drug Testing in Primary Care Goukrlay DA; Heit HH; Caplan Y. Booklet CME Activity of the California Academy of Family Physicians 2004

Other screening questions Mental health: Have you ever been treated for psychiatric problems? Do you have frequent mood swings? Do you often feel sad or down? Have you often been bothered by little interest or pleasure in doing things? Reference: Ebell, M, Routine Screening for Depression, Alcohol Problems, Domestic Violence, from

Other screening questions Have you ever had an accident after drinking or taking drugs? Ask specifically about the accident that caused their chronic pain. How many times in your life have you been arrested?

Triage Low Risk: ( No hx of SA; Few or no risk factors) Primary care physicians treat these patients Medium Risk: (Past history of SA problems but not opioids or multiple risk factors) Primary care physician consults or co-manages. Avoid break through meds or multiple meds. Consider Methadone or suboxone High Risk: Active SA problem or hx of opioid abuse: Primary care physicians do not prescribe; they refer.

Those for whom primary care physicians should not prescribe outpatient opioids 1. Current drug or alcohol addiction –Dangerous: death from alcohol, Valium and Vicodin and other combinations –Refer for SA treatment 2. Past history of opioid addiction : if needed refer. Treat with kappa drug like Talwin, Suboxone, or very structured use of other opioids.

Goals of Treatment Do functional assessment: use a form or ask what they cannot do in terms of job, household work, social activities etc Explain that the medication may not get rid of all their pain Explain that if the narcotics are working, they will be able to do things there are not currently able to do.

Spending 10 or 20 minutes obtaining a careful history, including a detailed SA history, contacting previous physicians and pharmacists, and another 10 minutes carefully reviewing old charts might save you future hours and many future headaches If you don’t have the time, don’t prescribe the opioids!

Educate the patient 1. The use of medication is to reduce pain and increase function 2. The medicine does not always work, and so would be stopped to prevent problems 3. Sharing the medication could result in criminal charges 4. Do not leave medication where others, including teenagers, can find it.

Patient Agreement 1. Use to educate the patient 2. Often give it to patient to read at home, share with SO, and return to the office with SO so as to make sure everyone understands. 3. Give information about usefulness and potential problems of opioids, including dependence and addiction. The problems are presented as medical issues that, if recognized, can be helped, rather than bad behavior.

Patient Agreement 4. Include the fact that use of narcotic is a trial, to be stopped if it is not working or if there are problems 5. Include information on how the medication is prescribed -- need to come to office, single pharmacy 6. Include the side effects of medicine, dangers of overdose or driving if tired. 7. Get the patient’s agreement to give urine tests, and unannounced pill counts if asked.

The Voyage Staying on Course

Follow up 4 or 5 A’s 1. Analgesia 2. Adverse Effects 3. Activities of Daily Living 4. Aberrant behaviors 5. Affect Also consider urine tests, pill counts, talking with significant others

Consultations Question of addiction Poor pain relief Total daily dose is over 90 mg of morphine equivalents. Good evidence that above this level there is a significant increase in overdose and overdose deaths.

Critical General Principles Prescribing narcotics is a trial, as with most other medications. They will be stopped if they do not work or if there are problems.

Critical General Principles 2. There is no ethical obligation to prescribe or continuing prescribing narcotics for chronic pain. Stop if they are not working or if the patient is unable to take them as prescribed. Patients are told they will not be prescribed other medications if there are contraindications, such as Ibuprophen and Coumadin. It is unethical to stop without a taper or referral

Getting off a sinking ship

Have an exit strategy 1. Have a member of your group who has some interest in addiction and can prescribe buprenorphine. 2. Taper slowly yourself 3. Refer out