2. Prepared by Dr. Ramin Safakish, MD, FRCPC – March 2016

3.  Opioid therapy › Challenging › Risks of  Abuse  Addiction  Accidental overdose  Others (break and entry, and bodily harm as a result, in order to steal the narcotics in med cabinet)

4. random survey of 658 primary-care physicians in Ontario  only 44% of physicians reported opioid prescribing to be satisfying  57% agreed that “many patients become addicted to opioids”  58% had at least one patient with an opioid- related adverse event in the past year  58% had concerns about the opioid use of one or more patients Wenghofer 2009 in press

5.  Canada: prescription-opioid by about 50% between 2000 and 2004  Canada was the 3 rd largest opioid consumer (International Narcotics Control Board 2009)  opioid prescribing has been accompanied by simultaneous in › abuse, › serious injuries, and › overdose deaths among individuals taking these drugs (Kuehn 2007)

6.  comprehensive documentation › patient’s pain condition, › general medical condition › psychosocial history › psychiatric status, › substance use history › screening tool

7.  To establish a baseline measure  To monitor compliance Must be aware of › Benefits › Limitations › appropriate test ordering › Interpretation › plan to use results

8.  consider the evidence related to effectiveness › No evidence for fibromyalgia and Chronic Daily Headache  ensure informed consent by explaining › potential benefits, › adverse effects, › complications › risks

9.  If pt is on BENZODIAZEPINES & elderly › Consider Taper benzodiazepines › Taper opioid more slowly

10.  During dosage titration › No driving › No EToH › NO benzodiazepines › NO other sedatives

11.  Start low, go slow  Set goal of treatment at start  monitor opioid effectiveness  looking for optimal dose  If not effective, get ready to announce failed trail  most patients  dosages at or below 200 mg/day of morphine or equivalent

12.  only for well-defined somatic or neuropathic pain conditions.  start with lower doses  titrate in small-dose increments  monitor closely for signs of › aberrant drug-related behaviors.

13.  ask about & observe for › opioid effectiveness, › adverse effects or › medical complications, › Aberrant drug-related behaviours.

14.  If › unacceptable adverse effects › insufficient opioid effectiveness  Change the medicaiton

15. assessing safety to drive in patients on long-term opioid therapy › Consider factors that could impair cognition and psychomotor ability, such as  A consistently severe pain rating,  disordered sleep,  concomitant medications that increase sedation.

16. Opioid therapy for elderly  can be safe and effective with precautions: › lower starting doses › slower titration › Longer dosing interval, › more frequent monitoring, › tapering of benzodiazepines.

17.  Adolescents  Pregnant patients  psychiatric diagnosis › Bipolar disorder › Psychosis › Severe depression Ask experts for advise.

18.  addicted to opioid; 3 options: 1. methadone or buprenorphine treatment 2. structured opioid therapy 3. Non-opioid therapy treatment Ask experts for advise.

19.  We do NOT use narcotic therapy  We are dealing with patients who are on long-term narcotic therapy.  We would use caution and advise the family doctor to use the guidelines.  This presentation is one of the ways to communicate with family doctors.