I have no disclosures. The New Era of Safe- Opioid Prescribing: Implications for Women’s Health Soraya Azari, MD Associate Professor of Medicine Objectives Case 1 To be able to explain the risks associated with SE is a 64yo F with a h of sciatica, depression, long-term opioid therapy to patients HTN, COPD, tobacco use disorder, and hx of trauma presenting for follow-up. 10 years ago she To understand the current best approach to tapers was started on hydrocodone-APAP for arthritis (low for patients on opioids dose), and then 8 years ago (2010) she was To improve recognition and diagnosis of an opioid admitted for spinal surgery. She had difficult to use disorder in patients with chronic pain on control pain and was discharged on: opioids Oxycodone CR 80mg 1 tab PO 4x/ day To review the “four quadrants” of chronic pain Oxycodone I R 30mg 1 tab PO 4x/ day treatment Morphine equivalent dose: 660mg/ day To develop empathic and sensitive ways of From 2010-2015 she is maintained on this dose. communicating with patients suffering from chronic pain
Case Continued Cases Continued Her primary care provider is worried about the high Which of the following represents the best course dose of opioids that she is on. of action? A) Start tapering due to extremely high dose The patient is/ has: B) Discuss the risks and benefits of high dose opioids Not requesting early refills C) Transition to buprenorphine-naloxone given No reported history of excess sedation or overdose concerns for opioid use disorder Urine drug screens that are intermittently positive for opioids (“from my husband’s hydrocodone when pain is bad”), but also she her prescribed meds Attending most of her appointments, though misses somewhat frequently due to taking care of grandchildren & living far away She is retired, cares for grandkids Risks of High Dose High dose opioids (> 90MME) Concerning Behaviors? Yes Excess mortality (LA opioids, 60% increased risk No all-cause mort) Evaluate for opioid use disorder 1. Bone Density Scan, 2. EKG if on Unintentional overdose (~ 0.7% / year 20-100MED) methadone, 3. Sleep Study, 4. total AM testosterone Opioid use disorder (~ 20% ) Present? Not Present? Secondary Hypogonadism (~ 50% of men) Treat Risks Outw eigh Benefits? Dec bone mineral density & inc. fracture risk Give warning. Sleep-disordered breathing (60-70% of patients) Yes If behavior No continues, re- Pneumonia (case-control) eval OUD Continue I mminent Safety risk? meds & Others monitoring. Opioid-induced hyperalgesia Discuss Yes No taper Cardiac toxicity with methadone NAS : 5/ 1000 births after hx rx opioids during preg Taper quickly Encourage Miller M, et al. JAMA Intern Med. 2015;175(4):608-15. Rose AR, et al. J Clin Sleep Med. 2014;10(8):847-52. Guilleminault C, et al. Lung 2010;188(6):459-68 . Rubinstein AL, et al. Clin J Pain. 2013;29(10):840-5. Dublin Setal. JAGS, 2011;59(10): Slow Taper 1899. Smith HS, Elliott JA. Pain Physician. 2012;15(3 Suppl): ES145-56. Teng Z et al. Plos One. 2015;10(6). Desai et al. BMJ 2015
Document, Document, Safety, Safety, Safety Document Medical Documentation Requirements Full assessment of pain complaint including underlying diagnosis, work-up, and multi-modal treatment approach Mental health and substance use screening Patient-Provider Agreement $500 Urine drug screen monitoring CURES review before rx and q4 months (SB 482) Documentation of the risks/ benefits of treatment Recent Developments State of CA medical board is investigating all providers that wrote prescriptions for patients that have died of overdose COVERED $0 Pharmacies are rejecting high-dose prescriptions without medical justification Naloxone in COT Case Continued Does it Work? The provider and the patient discussed the risks associated with high dose opioid therapy. Nonrandomized intervention study of The patient had never been told about the risks of naloxone provided in the medications and she was concerned. With safety-net primary care some reluctance, she agreed to try and taper her clinics in SF medications for her overall health. Patients receiving naloxone had 63% fewer opioid-related ED events in yr after receipt Communication “worst case scenario” Coffin PO et al. Ann Intern Med 2016. Mueller SR et al. JGIM 2016 Oct 31.
The State of Tapering Tapering Cont’d Evidence-base How to do it Systematic review (Aug 2017) Education & Support 67 studies (3 good, 13 fair, 51 poor) Counsel the patient in advance about the possibility of an OUD and the need to transition to a different treatment • dose reduction is possible • Patient outcomes (low qual evidence): less pain, m ore Team -based care : IPMP?, Behavioral health?, RNs?, PharmD? function, better QOL Alternative agents for pain management CAVEATS Schedule • These w ere VOLUNTARY tapers 10% per week cited by many guidelines (* * no strong evidence • These were SLOW tapers base) • Interventions were somewhat labor-intensive: CDC Taper Guide: – multi-disciplinary (integrative pain programs https: / / www.cdc.gov/ drugoverdose/ pdf/ clinical_pocket_guide_ta w/ behavioral therapies like CBT & meditation) pering-a.pdf – frequent follow-up On-line schedule generator: Do patients want this? Survey of patients on http: / / www.hca.wa.gov/ medicaid/ pharmacy/ > 50MME/ day: 49% wanted to cut back or stop documents/ taperschedule.xls So w hat should I do? Frank et al. Annals Int Med 2017;167:181-91. Tielke et al. Clin J Pain. 2014;30(2) Berna et al. Mayo Clinic Proceedings 2015;90(6):828-842 VA Opioid Taper Decision Tool. See references for URL.
Tapering I will die I will kill if I don’t you if I have continue So what should I do? these these meds. meds The closest I've ever come to describing it to a friend is: You know when you're underwater, and you need to come up for a breath? And it's taking too long to get to the surface? That feeling, of having no oxygen left, your whole body feeling like fire, salty and aching with the desperate need to breathe? That's it, only not exactly, because it's worse. –Sarah Beach xoJane Oct 2013 Tapering Case Continued So what should I do? The patient started a slow opioid taper (~ 10% Be kind & empathetic (remember quote) reduction/ month). There was no integrative pain Use your motivational interviewing skills! program to assist with her taper and she came q 4 Ask permission weeks for refills. • Would it be ok if we talked more about your opioid pain pills? Open-ended questions She complained of worsening pain and running out • How are things going? What do you like about your pills? of her pills early each month. Her urine drug What do you not like? screens were positive for hydrocodone on a Affirmation consistent basis. • You’re attending appointments and taking care of your Alternative pain management interventions were grandchild despite your pain. Reflections attempted with aqua therapy, spine clinic referral, • You are scared to not have the pills, but you’re tired of running and behavioral health, but the patient did not out each month attend any of the appointments. She perseverated Summary on opioids being only acceptable treatment. • It sounds like you think the meds are necessary for your pain She requests that her dose be escalated. on the one hand, and then on the other hand you’re worried about the risks I’ve described. Can I tell you about how we could decrease the dose safely & maybe improve your pain?
Pain v. Addiction Which of the following represents the best course Distinguishing between pain and an opioid use of action? disorder? A) Slow down the taper and refer to behavioral health Opioid use disorder B) Convert the patient to treatment for an opioid use 4 Rs Taking un-prescribed opioids disorder • Risk of bodily harm • Relationship trouble C) I ncrease the dose of her opioids • Role failure Not attending any of her appointments • Repeated attempts to cut back 4 Cs • Loss of Control Going into withdrawal each mo. • Continued use despite harm Borrowing from partner • Compulsion (time & activities) • Craving I need more opioids (not other pain tx) Withdrawal and tolerance Pain v. Addiction Primary Prevention June 2015 OUD Opioid-reduction initiatives in women 2015 estimates Gyn-Onc patients: (NSDUH) Over 6 months: 73% decrease in opioid rxs (open cases) and 97% decrease (minimally invasive 91million (37% procedures). 31 3.5 adults) adults used • Standing APAP 500mg and ibuprofen 600mg number of rx opioids opioids in hospital triggered d/ c rx 11 million(4.5% ) • No change pain scores misuse C-section patients 1.9 million (0.8% 10-min meeting, tablet presentation. Patient chose # pills average chose 20 (not 40). * 50% reduction OUD) ~ 400K heroin use Liposomal bupivicaine + APAP 500 q4 + ibu 800 q8 Medical abortion patients Mar Monte PP pilot; ibuprofen 800mg q8h x24h goo.gl/NNpwgx NOTE: no codeine, tramadol in breast feeding Mark J Gyn Onc Annual Meeting, 2018. Russo and Dieseldorff, PP Mar Monte. Prabhu M et al Ob Gyn 2017 . White K et al. Ob Gyn 2018.
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