1. Cover slide

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

3. Contact Information
Denis G. Patterson, DO Nevada Advanced Pain Specialists

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

5. 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

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

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

8. 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

9. 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

10. 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.

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

12. 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

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

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

15. 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.

16. 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.

17. 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.

18. 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

19. 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

20. 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.

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. Bottom Line
Discuss storage options and safe disposal or unused opioids

28. Questions

29. Discussion

30. Closing slide