6/19/2018 Objectives The New Era of Safe To understand the risks associated with chronic opioid therapy and be able to explain these to Opioid Prescribing: Cases patients To be able to explain to patients about the "four from the Field and Tips quadrants" of chronic pain management and the importance of multi-modal chronic pain for Frontline Providers management To consider the ways we can all prescribe opioids Soraya Azari, MD more safely for patients Associate Professor of Medicine Roadmap Case 1 46yo M with a history of HTN, depression, generalized anxiety disorder, asthma/COPD, chronic low back pain on opioid therapy, HCV, hx “polysubstance abuse”, and homelessness is admitted to the hospital with a COPD flare and acute kidney injury (Cr 1.6, from 0.8). He was taking: gabapentin, venlafaxine ER, and the following opioids: Case 2 Morphine sulfate CR 30mg po tid Case 1 Oxycodone IR 15mg po qid Cases 3 & 4 MED = 180mg daily http://agencymeddirectors.wa.gov/mobile.html 1
6/19/2018 Case 1 continued Case continued He received treatment for his asthma/COPD The patient was transitioned from morphine sulfate exacerbation and IVF creatinine to 1.3. ER to methadone 20mg po TID + hydromorphone 8mg po q4hrs PRN (MME 720mg). He reported doing well – taking his pain pills and abstaining from cocaine. He was buying diazepam Missed his initial follow-up appointment but then off the street (10/d). He is homeless & estranged got repeat labs showing an increase of his from family. Has few trustworthy friends. creatinine back to 1.6. He could not be contacted by phone despite several attempts. His main complaint is severe, uncontrolled pain in his back (sharp and tight, paraspinal), and closely 5 days after discharge he was found dead. watched the clock for his next PRN. Cause of death: acute mixed drug intoxication He was seen by Pain Consult and described poor Serum methadone = 1600ng/mL pain control. He’d been buying methadone off the street and that was helping much more than the morphine. He had been out of his gabapentin. Lessons: the New Epidemic Case continued Which of the following represents the best Drug overdose management plan with regard to his opioids? Surpassed motor veh. accidents as leading cause of accidental death in 25-64 year olds (in 2014) 58% A) Increase opioids A. 64,000 dead in 2016 B) Decrease opioids B. ~40% of overdose deaths involve a prescription C) Maintain current dose opioid C. 32% D) Stop opioids Rx-opioid overdose: quadrupled (2000-2014) now D. fentanyl Increased risk: high dose, hx of substance use or 11% mental health disorder 0% CDC Rx Opioids. D) Stop opioids A) Increase opioids B) Decrease opioids C) Maintain current dose 2
6/19/2018 Response to an Epidemic Payers Number of deaths for leading causes of Starting Jan 1, 2019 Medicare will limit initial death: opioid prescriptions to 7 days , and will require Heart disease: 633,842 “consultation” for approval of MME >90mg (1.6 Cancer: 595,930 million patients) Chronic lower respiratory diseases: 7d limit already true for SFHP Medical Patients 155,041 Medical Boards (in collaboration w/DOJ) Accidents (unintentional injuries): Investigating all doctors/NPs that wrote rx for 146,571 opioid to a patient that died of overdose. Stroke (cerebrovascular diseases): 140,323 Starting in 2011-12 (2600 cases) Alzheimer’s disease: 110,561 Contact your risk management if letter Diabetes: 79,535 received Influenza and Pneumonia: 57,062 Accreditation Bodies Nephritis, nephrotic syndrome and Joint Commission: new Pain Assessment and nephrosis: 49,959 Management Standards for hospitals (rel Jan 2018). Intentional self-harm (suicide): 44,193 Website here: goo.gl/3LP5Mv Media Prescribing Patterns J Pain Res. 2017; 10: 383–387. 3
6/19/2018 Lessons: Pain V. Addiction Lessons: Prevention Distinguishing between pain and an opioid use disorder? Opioid use disorder 4 Rs Benzos + opioids • Risk of bodily harm • Relationship trouble • Role failure Homeless, disconnected from family $45 $500, PA • Repeated attempts to cut back 4 Cs • Loss of Control • Continued use despite harm • Compulsion (time & activities) Time/hustle to buy street pills • Craving I need more; pain pills are not holding me Withdrawal and tolerance *covered by $0 Medicaid Lessons: Communication Addiction Treatment But this pain…do you want me to start shooting dope?? Buprenorphine-certified providers: No, I don’t want you to start injecting heroin. You don’t http://www.samhsa.gov/medication-assisted- want that either. You should feel proud that you don’t treatment/physician-program-data/treatment- use needles anymore. physician-locator Opioid treatment program directory: I don’t think you can safely continue on opioid pain pills. I want to give you a better, safer treatment http://dpt2.samhsa.gov/treatment/directory.aspx because I think you have severe, uncontrolled pain, and Substance use treatment warm line: 1-855-300- an opioid use disorder. 3595 . 10a-6pm EST I’m not going to leave you. You are suffering right now. The treatments I can offer you are methadone maintenance programs, or buprenorphine-naloxone. 4
6/19/2018 Take-Home Point Case 2 continued Which of the following represents the best Unintentional overdose is a significant risk for management plan with regard to his opioids? patients on chronic opioid therapy. 70% Active substance use disorders are a contra- A) Increase opioids A. indication for long-term opioid therapy for pain. B) Decrease opioids Refer patients for treatment. B. C) Maintain current dose C. Be empathic and sensitive when saying “no.” Then 25% see them more, not less. 5% A) Increase opioids B) Decrease opioids C) Maintain current dose Case 2 Case 2 Continued DA is a 57yo M with a history of CVA, HCV, The patient was given escalating doses of depression, cocaine & opioid use disorders, and oxycodone and started on morphine sulfate SR. chronic venous insufficiency ulcers admitted to Ultimately: morphine sulfate SR 30mg po tid + hospital with cellulitis and worsening of LE wounds. oxycodone IR 30mg q4hrs prn pain + IV dilaudid for breakthrough pain (MME 360mg/d). 4 hospitalizations in past 3 months He was later placed on adjunctive agents including: clinical alerts about suspended pain agreements. He has not engaged in prim care. Gabapentin He complains of severe bilateral lower extremity Venlafaxine XR pain. He states that he needs more for pain (the Baclofen oxycodone 5mg tabs you started are not enough). Topiramate The pain is 10/10, localizes to ulcers, feels like knives, and is constant (for months). 5
6/19/2018 Case 2 Continued Lessons: A new era D/C from hospital sees new PCP, requests opioid CDC Opioid Guidelines* Opioids not 1 st line refill PCP explains no refill due to: Non-pharm. and non-opioid tx are preferred Active substance use disorder Chronic opioids often start with Prior difficulty with chronic opioid agreements acute rxs. Use lowest dose, <3d Active mental health disorder Limit MME to <50mg daily Patient because physically aggressive (lunged at Monitor closely: urine drug screen, provider) and verbally abusive. Institutional police PDMP, risk/benefit was called. Surgeon General letter Patient stated that he was told he would receive more (TurnTheTideRx.org) opioids. Provider was trying to explain new “rules” of opioid rx. https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf A new era Primary Care-Based Chronic Opioid Prescribing in the SFHN Active mental health and substance use disorders are contra-indications for chronic opioid therapy (>3 months) No prescriptions on first visit Review of medical records Pain agreement signature annually Regular urine drug screen testing 1997 2015 Regular prescription activity report monitoring Discontinuation for abnormal urine drug screens or other concerning behaviors “stimulant rule” 6
6/19/2018 Opioid Exposure and Hospital Compare Scores Risk of LT Use ER docs “high intensity” v. “low intensity” opioid prescribers (7 v. 24%) in Medicare patients patients treated by “high intensity” providers more likely to be opioids at 1 yr (OR 1.3; NNH = 48) Surgery: Long term use in ~6% following surgery (risk: tobacco, SUD, mood/anxiety d/o, preop pain disorders) High risk procedures TKA, open chole, THA. (risk: M, >50yo, hx SUD, hx depression, BZD or antidepressant use) Hospitalized patients (previously naïve): 25% discharged with opioids; 4% use at 1 year. VA: long- term opioid use in 5% surg, 15% medical d/c (v. 19% o/p). (Risk: # days rx, dose) D/C from rehab : 28% on opioids at 6mo. (higher ORT scores in those on opioids) Barnett et al NEJM 2017. Brummett et al JAMA Surgery 2017. Calcaterra et al. JGIM 2016. Furlan AD J Rehabil Med. 2016 . J. Hosp. Med. 2018 April;13(4):243-248 Opioid Opioid Stewardship Stewardship Pain = Opioids Calcaterra SL et al. JGIM 2016. Deyo et al. JGIM 2016 7
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