10/14/2015 Disclosures Best Practices in Prescribing Opioids for - PDF document

10/14/2015 Disclosures Best Practices in Prescribing Opioids for Chronic Non-cancer Pain  No financial disclosures to report S C O T T S T E I G E R , M D , F A C P , D A B A M A S S I S T A N T CL I N I C A L P R O F E S S O R D I V I S I O N O F G E N E R A L I N T E R N A L M E D I C I N E U N I V E R S I T Y O F C A L I F O R N I A , S A N F R A N C I S C O S CO T T . S T E I G E R @ U C S F . E D U Opioid Rx has changed over time Causes of Accidental Death in US  Pre-1995: parsimonious with Rx opioids in US  1995-2009: Oxycontin, 5 th VS, pt advocacy groups 1

10/14/2015 Opioid Rx has changed over time Outline  Pre 1995: parsimonious with opioids in US  1995-2009: Oxycontin, 5 th VS, pt advocacy groups  Benefits of chronic opioid therapy (a little)  2010-now: dose limits, payor/ pharm restrictions  Risks of chronic opioid therapy (a little)  Strategies to m itigate risks of chronic opioid therapy Our case: 54 yo F chronic low back pain 54 yo F LBP: “Pain Contracts”? 54 yo F presents for primary care after her previous PCP  Patient’s insurance plan has introduced incentive payments for having patients on opioids for CNCP re-sign “pain contracts” annually. left the clinic where you work. What effect do “pain contracts” have on patients’ risky PMH: HTN, lumbago (Xray shows DJD behavior while on chronic opioid therapy? Meds: None documented. a) HCTZ 25 mg qday Increased diversion, since the document gives b) Hydrocodone 10/ 325 mg tid PRN #90 per month patients the idea to give their friends meds Patient’s insurance plan has introduced incentive Decreased overuse because patients who are addicted c) payments for having patients on opioids for CNCP re- only need the fear of adverse consequences to sign “pain contracts” annually. prevent overuse. d) Modest decrease in aggregate risky behavior observed in some clinic populations. 2

10/14/2015 54 yo F chronic LBP: “Pain Contracts”? Patient provider agreements have modest effect on rates of opioid misuse from clinic perspective*  7-23% reduction in 4 observational studies with comp  30-43% misuse AFTER agreements *Starrels, 2010 The Risk-Benefit Approach Building a Patient Provider Agreement  Set expectations for benefits  Outline the risks  Describe a process for management See the UCSF Pain Managem ent Com m ittee’s m odel Patient-Provider agreem ent at http:/ / pain.ucsf.edu/ docs/ UCSF_Patient_Provider_A greement_on_Opioids.pdf 3

10/14/2015 46 yo M LBP: benefits of high doses 46 yo M LBP: benefits of high doses 46 yo M on disability for chronic low back pain managed with opioids for >10 years. 46 yo M on disability for chronic low back pain Currently on sustained release oxycodone 80 bid and oxycodone 30 mg tid “PRN” managed with opioids for >10 years. Currently on advises MA that his pain is 9/ 10. He took his medication this morning as prescribed. Which is true of opioids for CNCP at or above the sustained release oxycodone 80 bid and oxycodone 30 equivalent of 200 mg morphine daily (MED)? mg tid “PRN” advises MA that his pain is 9/ 10. He Case series suggest that MED > 200 mg reduce pain by a) took his medication this morning as prescribed. 50% in ~50% of patients Data supporting the benefits of MED > 200 mg in b) CNCP are lacking Patients at very high doses have reported worse pain c) control Both B and C d) The benefits of opioids for CNCP The “PEG” tracks benefits of opioids Cochrane: n>4800 show reduction in pain* On a scale of 0-10, over the last week: 50-66% report reducing pain scores by at least half** What has your average pain been? (0-10) Caveats Max dose 180 mg MED How much has your pain interfered with your enjoym ent of life? (0-10) Few studies longer than 6 months. How much has your pain interfered with your general activity ? (0-10) *Noble 2010 Krebs, 2009 **Chou 2009; Reuben 2015) 4

10/14/2015 Complications of chronic opioids Complications of chronic opioids  Constipation  Falls and fractures 1,2  sedation 1,2  LESS likely to return to work  Opioid overdose 2  Immune dysfunction 2  Death from overdose 1,2  Decreased GNRH, low libido 2  Aberrant use, addiction 2  Hyperalgesia 2  ED visits 2  Difficult interactions with the care providers 2  depression 2 1 Mixing with other sedating drugs associated with increased risk  Psychosocial problems 2 2 Higher doses associated with increased risk Building a Patient-Provider Agreement What is high dose of an opioid? Which of the following regimens describes the highest dose? a) Fentanyl 50 mcg/ h td + oxycodone 10 mg tid b) MS-Contin 30 mg tid + MS-IR 15 mg tid oxycodone 30 mg tid c) d) Extended-release hydrocodone 50 mg bid + hydrocodone/ APAP 10/ 325 mg tid http:/ / pain.ucsf.edu/ docs/ UCSF_Patient_Provider_Agreement_on_Opioids.pdf 5

10/14/2015 What is a high dose of an opioid? What is high dose of an opioid? Which of the following regimens describes the highest  MSO4 50 mg is about the same as… . dose?  Codeine 60 mg q4h  Oxycodone/ APAP 10/ 325 tid a) Fentanyl 50 mcg/ h td + oxycodone 10 mg tid  Hydrocodone/ APAP 10/ 500 5 times a day b) MS-Contin 30 mg tid + MS-IR 15 mg tid  Methadone 5 mg tid oxycodone 30 mg tid c)  Hydromorphone 4 mg tid d) Extended-release hydrocodone 50 mg bid +  Oxymorphone ER 7.5 mg bid hydrocodone/ APAP 10/ 325 mg tid  Fentanyl 12 mcg/ hr patch Opioidcalculator.practicalpainmanagement.com agencymeddirectors.wa.gov/ mobile.html What is a high dose of an opioid? Who is at risk? Which of the following patients is most likely to Daily Opioid dose (MSO4 eq) Hazard Ratio for OD (95% ci) display “aberrant behavior,” divert or misuse None 0.31 (0.12-0.8) prescription opioid medications? 1 to <20 mg 1 a) 42 yo white M with chronic LBP 20 to <50 mg 1.44 (0.57-3.62) b) 35 yo black F with SLE 50 to <100 mg 3.73 (1.47-9.5) 100+ 8.87 (3.99-19.72) 64 yo Latino F with h/ o AUD in remission knee OA c) Any dose 5.16 (2.14-12.48) d) More information would help predict Impossible to predict e) Dunn et al. 2010 Annals 6

10/14/2015 Risk prediction models 46 yo F chronic pain: urine drug testing Many models attempt to predict aberrant behaviors  46 yo F presents for med refill. She is on MS-Contin 30 tid and oxycodone 30 mg bid PRN for ORT, SOAPP a) fibromyalgia. Her insurance plan has introduced incentive payments for urine drug testing patients on “no model adequately predicts … ” (Chou et al, 2009) opioids for CNCP Evidence suggests many adverse consequences in “low risk” patients 46 yo F chronic pain: urine drug testing Urine Drug Testing in COT  46 yo F presents for med refill. She is on MS-Contin 30 tid and oxycodone 30 mg bid PRN for fibromyalgia. Her insurance plan has introduced incentive payments for urine drug testing patients on opioids for CNCP  Recommended by 9 of 10 guidelines (Nuckols et al., What is the direction and magnitude of the effect of 2014) urine drug testing on opioid misuse by patients being treated for CNCP?  Disparities in which patients are tested a) 15 % increase in misuse demonstrated in Philadelphia and SF (Becker, 2010; b) 50% decrease in misuse Bauer, pers comm) 15% decrease in misuse c) d) There is no evidence that urine drug testing affects the rate of opioid misuse in these patients 7

10/14/2015 Urine Drug Testing in COT  Test everyone, with frequency standardized according to risk.  200 mg+ or recent aberrancy: monthly  50-199 mg: quarterly  20-49 mg: annually http:/ / pain.ucsf.edu/ docs/ UCSF_Patient_Provider_Agreement_on_Opioids.pdf But which urine drug tests should I order? Don’t order a simple “U tox” Opiate “screen” m ay be completely nega tiv e in “Adherence” labs patients taking these drugs:  Opiate tests: please order GC/ MS  Oxycodone Codeine Heroin  Methadone Hydrocodone “Abuse” labs Hydromorphone  Amphetamine Oxycodone  Benzodiazeine Methadone  Cocaine Morphine  ?other Fentanyl 8

10/14/2015 Don’t order a simple “U tox” Don’t order a simple “U tox” Opiate “screen” should be completely nega tiv e in Opiate “screen” may be p ositiv e in patients taking patients taking only these medications: these drugs: Codeine Codeine Heroin Heroin Hydrocodone Hydrocodone Hydromorphone Oxycodone Hydromorphone Methadone Oxycodone Morphine Methadone Fentanyl Morphine Fentanyl Don’t order a simple “U tox” “+opiate” can mean a lot of things Opiate “screen” should be p ositiv e in patients taking these drugs: Codeine Heroin Hydrocodone Hydromorphone Oxycodone Methadone Morphine Fentanyl Courtesy UCSF Lab Manual http:/ / labmed.ucsf.edu/ labmanual/ mftlng-mtzn/ test/ test-index.html 9

10/14/2015 “+amphetamine” can mean a lot of things “+benzodiazepine” can mean a lot of things Courtesy UCSF Lab Manual Courtesy UCSF Lab Manual http:/ / labmed.ucsf.edu/ labmanual/ mftlng-mtzn/ test/ test-index.html http:/ / labmed.ucsf.edu/ labmanual/ mftlng-mtzn/ test/ test-index.html +cocaine means only one thing Urine Drug Testing in COT, bottom line  Cocaine screen tests for cocaine metabolite # 1: Test everyone, with frequency (benzoylecognine), which is unique to cocaine standardized according to risk. metabolism  200 mg+ or recent aberrancy: monthly  50-199 mg: quarterly  20-49 mg: annually  # 2: Order the right tests, and get to know your lab m edicine colleagues 10