Lynn Webster M.D. Medical Director Lifetree Clinical Research and

Lynn Webster M.D.
Medical Director
Lifetree Clinical Research and Pain Clinic
Salt lake City, Utah
[email protected]
What risks need to be minimized?
– Endocrinopathies
– Sleep disordered breathing
– Diversion
– Misuse
– Abuse
– Addiction
– Death
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Who should receive opioids?
Which opioid should be prescribed
How much should be prescribed?
How and when to rotate from one opioid to
another?
• Role of rational polypharmacy and
combination therapies?
• How and when to discontinue therapy
Initial patient assessment
Trial of opioid therapy
Alternatives
to opioid therapy
Continue opioids
Adjust dose/rotate opioid
Add long-acting opioid
Patient
reassessment
Monitor for appropriate use
Consider exit strategy
1.
Diagnosis with appropriate differential
2.
Psychological assessment, including risk of addictive disorders
3.
Informed consent
4.
Treatment agreements
5.
Pain and function assessments
6.
Opioid therapy trial
7.
Reassessment of pain, function, and behavior
8.
Regular reassessment of the 4 A’s: Analgesia, Activities of daily
living, Adverse events, Aberrant drug-taking behavior
9.
Periodic review of diagnosis and co-morbidities
10.
DOCUMENTATION
Misuse 40%
Abuse: 20%
Addiction: 2% to 5%
Webster LR, Webster RM. Pain Med. 2005;6(6):432-442.
Total Pain
Population
Non-Medical
Use
Medical Use
• Recreational
abusers
• Pain patients
seeking more
pain relief
• Patients with
disease of
addiction
• Pain patients
escaping
emotional pain
• Understanding the definitions and that
abuse and addiction are medical diseases
• Knowledge of factors that contribute to
harm in pain patients
• Understanding of how to identify risk
factors for harm (risk assessment)
• Understand how to monitor and manage
risk
• Understand when to consult, refer or
discontinue therapy
Misuse
• Use of a medication (for a medical purpose) other than as directed or as
indicated, whether willful or unintentional, and whether harm results or
not
Abuse
• Any use of an illegal drug
• The intentional self administration of a medication for a non-medical
purpose such as altering one’s state of consciousness, e.g. getting high
Diversion
• The intentional removal of a medication from legitimate and dispensing
channels
Addiction
• A primary, chronic, neurobiological disease, with genetic, psychosocial,
and environmental factors influencing its development and
manifestations
• Behavioral characteristics include one or more of the following:
Impaired control over drug use, compulsive use, continued use despite
harm, craving
Pseudoaddiction
• Syndrome of abnormal behavior resulting from undertreatment of pain
that is misidentified by the clinician as inappropriate drug-seeking
behavior
• Behavior ceases when adequate pain relief is provided
• Not a diagnosis; rather, a description of the clinical intention
Katz NP, et al. Clin J Pain 2007;23:648-660
Biological
• Age =45 years
• Gender
• Family history of
prescription drug
or alcohol abuse
• Cigarette
smoking
Psychiatric
• Substance use
disorder
• Preadolescent
sexual abuse
(in women)
• Major psychiatric
disorder
(eg, personality
disorder, anxiety
or depressive
disorder, bipolar
disorder)
Social
• Prior legal
problems
• History of motor
vehicle accidents
• Poor family
support
• Involvement in a
problematic
subculture
•
•
•
•
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Initial comprehensive evaluation
Risk assessment
Prescription monitoring assessment
Urine drug test
Opioid treatment agreement
Opioid consent form
Patient 8 points of patient education
• Screener and Opioid Assessment for Patients
in Pain (SOAPP)
• Opioid Risk Tool (ORT)
• Diagnosis, Intractability, Risk, Efficacy (DIRE)
• Current Opioid Misuse Measure (COMM)
Low Risk
• No past/current
history of
substance abuse
• Noncontributory
family history of
substance abuse
• No major or
untreated
psychological
disorder
Moderate Risk
High Risk
• History of treated
substance abuse
• Active substance
abuse
• Significant family
history of
substance abuse
• Active addiction
• Past/comorbid
psychological
disorder
Webster LR, Webster RM. Pain Med. 2005;6(6):432-442.
• Major untreated
psychological
disorder
• Significant risk
to self and
practitioner
• Understand spectrum of behaviors
• Understand meaning of aberrant
behaviors
• Understand risk factors for aberrant
behaviors
• Understand how to manage aberrant
behaviors
• Addiction (out-of-control, compulsive drug use)
• Pseudoaddiction (inadequate analgesia)
• Other psychiatric diagnosis
– Organic mental syndrome
(confused, stereotyped drug-taking)
– Personality disorder (impulsive, entitled,
chemical-coping behavior)
– Chemical coping (drug overly central)
– Depression/anxiety/situational stressors
(self-medication)
• Criminal intent (diversion)
Analgesia
Pain relief
Adverse
Effects
Side effects
Activities of
Daily Living
Aberrant
Drug-Taking
Psychosocial
Misuse
Abuse
Diversion
Functioning
QoL
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•
4 A’s
Assess level of stress
PMP with aberrant behaviors
UDT with aberrant behaviors
Reduce boundaries with aberrant behaviors
– More frequent visits
– Less days of prescription
– Consider consultations, referring or discontinue
Drug-Abusing Behavior
Low
Moderate
High
Patient Stress Level
Webster LR, Dove B; Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. 1st ed. North Branch, MN: Sunrise
River Press; 2007.
• Unrelieved severe pain
• Fear of not being believed
• Impact of pain on family and friends
• Financial impact of
chronic pain
• Insurance denials
for treatment
• When to test?
– Randomly, annually, PRN
• What type of testing?
– POC, GS/MS
• How to interpret
– Metabolism of opioids
– False positive and negative results
• What to do about the results
– Consult, refer, change therapy, discharge
Not comprehensive
pathways, but may
explain presence
of apparently
unprescribed drugs
Minor
Dihydrocodeine
Minor
Dihydromorphone
VT
ME
WA*
MT
ND
OR
MN
ID
MI
WY
NE
NV
UT
CO
KS
CA
AZ
OK
NM
IA
IL
TX
IN
PA
OH
WV
VA
KY
MO
NC
TN
SC
AR
MS
AK
NY
WI
SD
NH
MA
RI
CT
NJ
DE
MD
AL
GA
LA
FL
• When to use
• How to
access
• How to
interpret
• What to do
about findings
HI
States with operational PMPs
Legislation pending
States with enacted PMP legislation, but program not yet operational
No PMP
*Washington has temporarily suspended its PMP operations due to budgetary constraints.
Status of State Prescription Monitoring Programs, April 2009. The National Alliance for Model State Drug Laws. http://www.namsdl.org
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Physician Error
Patient Compliance
Unanticipated co-morbidities
Payer Policies
• Over-Prescribing
– Starting dose too high
– Dose escalation too rapid
– Over reliance on conversion tables
– Inadequate risk assessment
• Non-Adherence
– To control pain
– To “cope”
– Substance abuse
• Unanticipated co-morbidities
– QT prolongation
– Pharmacogenetics and methadone metabolism
– Sleep disordered breathing
2
4
2
6
8
3
10
12
4
14
16
5
18
20
6
22
24
7
a (analgesic)
? (non-analgesic)
Morphine Total Daily
Starting Methadone Dose
Healthy adult
<70 yrs
Adult w/ chronic illness
or > 70 yrs
Opioid naïve
5 mg tid
2.5 mg bid
60 mg – 100 mg
5 mg tid
5 mg bid
>100 mg
5 mg qid
5 mg bid
Source: Webster LR. Methadone-Related Deaths.
Accepted in J. of Opioid Mgmt. October 2005.
• Sleep disordered
breathing
• Genetic polymorphism
• Cardiac arrhythmia
(prolonged QT)
90
Patients, %
80
*
70
AHI > 5
60
CAI > 5
50
OMAI > 5
40
30
20
10
0
Sleep apnea – type indeterminate
n = 140
* Bars indicate hi/lo of 95% CI.
1.8
1.7
1.6
Central p<.001
1.5
1.4
Hypopnea p<.001
1.3
Obstructive p<.001
1.2
REM apnea/hypopnea
p=.86
1.1
1
0.9
REM: Rapid Eye Movement Sleep
NREM: Non-Rapid Eye Movement Sleep
0.8
0
25
50
75
100
125
150
175
200
JM Walker, RJ Farney, SM Rhondeau et al. Chronic Opioid Use is a Risk Factor for the Development of
Central Sleep Apnea and Ataxic Breathing. J. Clinical Sleep Medicine, Vol. 3, No. 5, 2007. pp 455-62.
Lethal Dose
Analgesia Dose
Therapeutic Window
Experienced User
Inexperienced User
Time
Adapted from: White, J and Irvine, RJ. Mechanisms of fatal
opioid overdose. Addiction (1999) 94(7), 961-972.
1.
2.
3.
4.
5.
6.
7.
8.
Assess risk for opioid abuse
Assess and treat co-morbid mental health
Use conversion tables cautiously
Avoid benzodiazepines with opioids
Start opioids low and advance slowly
Assess for sleep apnea at > 150 mg/day
Reduce opioids with URI’s, flu and asthma
Avoid long acting opioids with acute pain
8 Ways Patients can Prevent Overdose
1. Never take prescription pain medicine unless it
is prescribed for you
2. Never mix pain medicine with alcohol
3. Never adjust your own pain medicine doses
4. Mixing pain medicines with sedative or antianxiety medications can be dangerous
5. Always tell your healthcare provider about all
medications you are taking from any source
6. Avoid using opioids to facilitate sleep
7. Lock up prescription pain medicines away from
children, other family members, and visitors
8. Dispose of any unused medications
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Snores heavily and cannot be awakened
Has trouble breathing
Exhibits extreme drowsiness and slow breathing
Has slow, shallow breathing with little chest
movement
• Has a speeded up or slowed heartbeat
• Feels faint, very dizzy, confused or has heart
palpitations
An antidote exists that can reverse overdose.
Safe opioid prescribing requires knowing:
-What are the risks
-How to assess for risk
-How to monitor for risk
-How to manage risk
-When to consult, refer or discharge