1. Safe Prescribing of Opioids for the Management of Chronic Nonterminal Pain La Tanya Austin, PGY3

2. Objectives Review initial patient selection Demonstrate the opioid risk tool and scoring Describe the phases for opioid prescribing

3. Background Rx drug abuse is the fastest growing drug problem US Family Physicians behind national epidemic of unintentional prescription opioid overdose, dependence, abuse, and misuse. Increase in unintentional drug overdose death rates More overdose deaths from opioid analgesics than heroin and cocaine. More overdose deaths from opioid analgesics than heroin and cocaine. More deaths from unintentional drug overdose than MVA and suicide.

4. Approach for Opioid Therapy Initiation Identify and treat comorbid conditions first. Consider alternative chronic pain treatment. After these measures are optimized consider trial of opioid therapy.

5. Initial Patient Selection 1.Identify pain type 2.Assess risk of opioid misuse or abuse

6. Initial Patient Selection 1. Identify the pain Chronic somatic or neuropathic pain partially responsive to opioids. Chronic visceral or central pain syndromes less responsive or nonresponsive.

7. Initial Patient Selection 2. Assess risk of misuse or abuse Use Opioid Risk Tool Do not prescribe opioids in actively illicit substance use

9. Initial Patient Selection Scores ≥ 8 = High Risk 1.prescribed opioids only after all other treatment modalities have been exhausted 2.close supervision, and 3.consultation with pain or addiction subspecialist.

10. Phases of Opioid Prescribing DecisionInitiationMaintenance When to stop taper or seek consultation

11. Decision Phase Goal of therapy is improved function Screen for indications Screen for precautions and contraindications

12. Initiation Phase Consolidate opioid therapies into one medication using an equianalgesic calculator (e.g. www.narcalculator.com) Stabilize patient with one opioid Avoid cotreatment with benzodiazepines Avoid cotreatment with benzodiazepines Use controlled substance agreement Consider SR preparations for more consistent drug level Avoid continuous short-acting opioid use for breakthrough therapy OR limit to initiation phase of therapy.

13. http://www.iafp.com/whatsnew/ChronicPainMedicine-Contract.pdf

14. Maintenance Phase Check state Prescription Monitoring Program prior to refills. Document exact doses, pill counts, expected duration of prescription. Reassess goals for maintenance or improvement of function. Repeat urine drug testing at least yearly. Schedule face-to-face visits at least every three months. Write prescriptions with exact refill dates.

15. When to Stop, Taper, or Seek Consultation Stop prescribing immediately if: 1.Positive test for illicit drug use 2.Threatening behavior 3.Forgery or intoxication

16. When to Stop, Taper, or Seek Consultation Taper if: 1. Functional goals not achieved 2.Adverse effects are excessive 3.Medication misused.

17. Consider referral if: functional goals not achieved functional goals not achieved multidisciplinary pain addiction treatment addiction treatment

18. Summary Effective management of chronic nonterminal pain requires more than prescribing medication Effective management of chronic nonterminal pain requires more than prescribing medication In Initial patient selection identify type of pain and assess risk of opioid misuse or abuse Use Opioid Risk Tool to assess patients’ risk of opioid misuse or abuse. Four phases for safe prescribing in chronic nonterminal pain.

19. References Daniel Berland, MD, and Philip Rodgers, MD, University of Michigan Medical School, Ann Harbor, Michigan. Rational Use of Opioids for Management of Chronic Nonterminal Pain. Am Fam Physician. 2012 Aug 1;86(3):252-258 Dawn A Marcus, NM, University of Pittsburgh Medical center, Pittsburgh, Pennsylvania. Treatment of Nonmalignant Chronic Pain. Am Fam Physician. 2000 Mar 1;61(5): 1331-1338 www.iafp.com/safeprescriber Centers for Disease Control and Prevention. CDC Grand Rounds: Prescription Drug Overdose - a US Epidemic Allen R. Last, MD, MPH, and Karen Hulbert, MD. Chronic Low Back Pain: Evaluation and Management. Am Fam Physician. 2009 Jun 15;79(12):1067-1074 Pain (PDQ) - National Cancer Institute. www.cancer.gov/cancertopics/pdq/supportivecare/pain/patient