Controlling the Controlled Substances: How February 15, 20/20 an - PDF document

Controlling the Controlled Substances: How February 15, 20/20 an Optometrist Can Weed Through the Opioid Options Disclosures- Greg Caldwell, OD, FAAO Co Cont ntrolling ng the he Co Cont ntrolled d $ Will mention many products, instruments and companies during our discussion Su Substances: Ho How an Optometrist ¬ I don ’ t have any financial interest in any of these products, instruments or companies $ Pennsylvania Optometric Association –President 2010 Can Can Weed d Thr hrough h the he Opioid d Options ns 2 POA Board of Directors 2006-2011 $ American Optometric Association, Trustee 2013-2016 ¬ Thank you to the members and those who join $ I never used or will use my volunteer positions to further my lecturing career Greg A. Caldwell, OD, FAAO $ Lectured for: Shire, BioTissue, Optovue, Alcon, Allergan, Aerie Tracy Offerdahl, PharmD, BPharm, FAAO $ Advisory Board: Allergan, Sun, Takeda $ Envolve: PA Medical Director, Credential Committee $ OCT Connect on Facebook – Administrator with Dr. Julie Rodman $ Optometric Education Consultants- Scottsdale, Quebec City, and Nashville - Owner Disclosure Statement (next slides) 1 2 Disclosures: Tracy Offerdahl Course Description $ This course will describe how to appropriately choose a pain medication based upon individual patient and drug $ Dr. Offerdahl has the following financial disclosure: factors. Additionally, opioid medications will be evaluated ¬ Boiron: honorarium, webinar/speaker in terms of risk versus benefit, with an emphasis on pain levels and the potential for addiction. Case anecdotes will $ Has not received any assistance from any commercial include management of ocular pain, with specific emphasis interest in the development of this course on oral/systemic medications and how to protect both patient and practitioner. 3 3 4 Learning Objectives Two major types of pain: No Nociceptive Pain – normal processing of stimuli that damages normal tissues; how pain $ When given a patient case, choose an appropriate pain treatment plan for the becomes conscious; management of ocular pain, in terms of drug choices based on pain level, dosing * responsive to non-opioids issues, and a monitoring plan for efficacy and toxicity. * examples: NSAIDs, acetaminophen, steroids $ Identify and describe some of the potential signs, symptoms, and behaviors * responsive to opioids associated with opioid or substance abuse, and describe ways to respond to this issue. * examples: codeine, hydrocodone, tramadol $ List systems available to evaluate a patient for potential opioid/substance abuse. $ Describe the treatment issues and options associated with the treatment of ocular Ne Neuropathic : abnormal processing of sensory input by the peripheral or central pain in a patient with a drug abuse history. nervous system; * treatment includes adjuvant analgesics * sleep aids, nerve pain meds, muscle relaxers, anxiolytics 5 6 Greg- grubod@gmail.com 814-931-2030 Tracy- drofferdahl@gmail.com 267-241- 9146 1

Controlling the Controlled Substances: How February 15, 20/20 an Optometrist Can Weed Through the Opioid Options Pain Assessments and Scales Drug Treatment Options…Neuropathic Pain $ Why is this relevant? $ Adds objective data to a patient’s feeling of pain $ Adjuvants – means “add on” medications ¬ It is a subjective problem to assess! ¬ Some of them have addiction potential ¬ Remember…no patient should needlessly suffer! 2 Anti-seizure medications that address nerve damage/inflammation – MOA: work on the GABA system – similar to benzodiazepines (ex. Xanax) – Gabapentin (Neurontin) – controlled substance in multiple states $ “Does the injury or wound or diagnosis fit the patient’s – Pregabalin (Lyrica) – controlled substance in all 50 states presentation? 2 Anti-anxiety and sleep medications ¬ It is important to be able to assess the degree of pain in a patient. – Zolpidem (Ambien) – Alprazolam (Xanax), Lorazepam (Ativan), Diazepam (Valium) 7 8 Combination Pain Scale… 9 10 Drug Treatment Options… Controlled Substance Schedules Nociceptive Pain Schedule I – not considered to be medically necessary, research only Sc ¬ Heroin ¬ “Medical” Marijuana 3 3 Grou oups of of analgesics 2 State control of marijuana and CBD ¬ Non-opioids ¬ LSD ¬ Mushrooms 2 Acetaminophen (Tylenol) ¬ Ecstasy 2 NSAIDs (Ibuprofen, naproxen sodium) Schedule II – mo Sc more likely to be abused (as comp mpared to Schedule III, IV, V) 2 Glucocorticosteroids (methylprednisolone, prednisone) ¬ Op Opioids, AKA “Narcotics” 2 Ox Oxycodone (Ox OxyContin) 2 Hydrocodone (Vicodin, Lorcet, Norco) ¬ Opioids – 2 Morphine (MSContin, MSIR) 2 Hydromorphone (Dilaudid) 2 Codeine (Tylenol with codeine) 2 Methadone 2 Hydrocodone (Vicodin) 2 Fentanyl (Duragesic) 2 Tramadol (Ultram) ¬ ADD/ADHD meds: 2 Methylphenidate (Ritalin) 2 Mixed amphetamine salts (Adderall) 11 12 Greg- grubod@gmail.com 814-931-2030 Tracy- drofferdahl@gmail.com 267-241- 9146 2

Controlling the Controlled Substances: How February 15, 20/20 an Optometrist Can Weed Through the Opioid Options Controlled Substance Schedules Opioids “ narcotics ” Schedule III - Safer, less likely to be abused (as compared to Schedule II) $ Mainstay of therapy for the treatment of pain ¬ Combination products with APAP or ASA (codeine) ¬ Esketamine – nasal spray for treatment resistant depression Schedule IV – Safer, less likely to be abused (as compared to Schedule II and III) ¬ Tramadol (Ultram) $ NO maximum daily dose limitation ¬ Benzodiazepines (lorazepam, diazepam, oxazepam) ¬ Sleep agents (zolpidem, etc.) Schedule V – safest, least likely to be abused $ Useful for acute and chronic pain ¬ Expectorants with codeine 13 14 Morphine Products Hydromorphone Products Mo Morphine Hy Hydromorphone (Di Dilaudi did) tablets – immediate release ¬ Standard for comparison of other agents Hydromorphone ER (Ex Hy Exal algo) ) tablets – extended release $ MS MSIR (IR caps) (q 3-4 hours prn) Contin (CR tabs) (q 8–12 hours) $ MS MS Co $ Used for severe pain $ Ka Kadian (CR caps) (q 12 – 24 hours) $ Av Avinza (CR caps) (q 24 hours) 15 16 Codeine-Based Codeine tablets $ Codeine – C3; Schedule III $ WEAK analgesic: commonly used, so MOST have heard of it! $ Add acetaminophen/aspirin – Schedule III $ Hydrocodone – C2; Schedule II ¬ Tyl Tyleno nol #3 = 300 mg acetaminophen & 30 mg codeine $ Oxycodone – C2; Schedule II $ Add expectorant – Schedule V ¬ If you think someone won’t try to get their hands on “codeine cough syrup” as a drug of abuse, you’d be surprised!!! 17 18 Greg- grubod@gmail.com 814-931-2030 Tracy- drofferdahl@gmail.com 267-241- 9146 3

Controlling the Controlled Substances: How February 15, 20/20 an Optometrist Can Weed Through the Opioid Options Ox OxyCONt ONtin (Controlled release tablets (q 12 hours…once in a while q 8 hours); Oxycodone Products new formulation is out to help control abuse Lo Long-Ac Acting, g, Ext xtende ded-Re Release OxyContin Im Immediate R Release; s short-ac actin ing tab ablets Ox OxyIR (IR cap) Ro Roxico codone ne solution with Acetaminophen: Pe Percocet and Endocet (oxycodone/APAP dose) 19 20 Hydrocodone Products $ Immediate-Release Products: AS OF AUGUST 2014, hydrocodone products are ALL CII!! Hydr Hy drocodo done 7. 7.5 5 mg g + IBU 20 200 mg g (Vi Vicoprofen) Hydr Hy drocodo done + acetaminophen: $ “ Vi Vicodin ” 5/300; 7.5/300; 10/300 $ Lortab = 2.5/300, 5/300, 7.5/300, 10/300 $ Norco = 5/325, 7.5/325, 10/325 21 22 Miscellaneous Methadone tidbits… $ Fe Fentan anyl Pat atch (Duragesic) $ Chronic pain or opioid abuse deterrent $ 2-phase elimination ¬ MOST potent opioid ¬ Alpha phase = 8 hrs ¬ Black Box Warning against use in acute pain and in opioid 2 Offers pain control ¬ Beta phase = 16+ hrs naïve patients 2 Mitigates withdrawal symptoms $ Patient 1: On a short-acting pain med = likely being used to treat $ Me Methadone chronic pain ¬ Typically reserved for morphine/codeine allergic patients ¬ Twice per day dosing $ Patient 2: On methadone ONLY; lower doses ¬ Once daily dosing 23 24 Greg- grubod@gmail.com 814-931-2030 Tracy- drofferdahl@gmail.com 267-241- 9146 4