lojeski slides - wild apricot · 2014-04-03 · prescription refill of new prescription. opioid...
TRANSCRIPT
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Edwin W. Lojeski, D.O.
Chief Anesthesia Service
Boise VAMC
� None
� Identify benefit of opioid treatment in chronic pain.
� Identify risks to patients from chronic opioid treatment.
� Understand risk mitigation strategies to be used in patients on chronic opioid treatment.
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“as to disease, make it a habit of two things- to do good, or at least do no
harm” Hippocrates
RISK BENEFIT
� Risk is the potential loss (an undesirable outcome) resulting from a given action, activity and/ or inaction
Benefit something that has a good effect or promotes well-being.
� Acute pain- Opioids are often very helpful in the treatment of acute pain conditions (trauma/surgery).
� Chronic pain- Opioids can be helpful but there is a lack of evidence for effectiveness and the “evidence for the benefits has remained controversial and insufficient”.
� Federation of State Medical Boards, Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain, July 2013
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� Opioids do help in some chronic pain patients.
� A trial of opioid therapy for chronic pain should only be considered after failure of other treatment options.
� Generally, improvement with chronic opioid therapy is about a 30% decrease in pain when they are helpful.
� Patient
� Provider
� Society
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� Medical management of chronic pain claims have been increasing.
� In 2008, 17% of chronic pain cases involved medical management.
� Death from opioid rotation.
� MVA due to prescription opioids.
� Overdose related to non compliance with guidelines.
� Iatrogenic addiction.
� Lack of informed consent.
� Prescription opioids caused 11,499 deaths in 2007, more than cocaine and heroin combined.
� Prescription pain medications are the second most prevalent type of abused drug after marijuanna.
� Admissions to substance abuse treatment programs increased 400% from 1998-2008.
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� Prescription drug abuse is the fastest growing drug problem in the U.S.
� In an attempt to better treat patient pain, practitioners have greatly increased their rate of opioid prescribing.
� 1997, drug distribution was 96 mg morphine equivalents per person.
� By 2007, it was 700 mg per person (increase 7 times)
� Many providers under-appreciate the risk of opioids and frequently exaggerate the benefitsof high dose chronic opioid treatment.
� It is critical to define the populations at greatest risk to develop and implement effective interventions.
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� Age
� Dose- greater than 100 mg morphine equivalents (ME) per day.
� Patients with underlying lung disease.
� Patients with underlying liver disease.
� Patients with comorbid substance use disorder.
� Patients on benzodiazepines.
� Patients with comorbid mental health disorder.
� Literature shows a consistent increase risk for opioid misuse for younger patients.
� Persons aged 18-30 showed a 4-5 fold increased risk for opioid misuse compared to persons 65 and older(Sullivan, Ballantyne. Arch Intern Med/ Vol 172(#5), Mar 2012:433-4).
� Older patients often have more medical comorbidities, altered pharmacokinetics and pharmacodynamics that can increase their risk.
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� Estimated annual overdose rates:
� 0.2% < 20 ME mg day
� 0.7% 50-99 ME mg day
� 1.8% > 100 ME mg day
� 88% of identified OD were non fatal but required hospitalization.
� Higher in patients over 65, history of sub abuse treatment or a history of depression.
� Highest risk after prescription refill of new prescription.
Opioid Prescriptions for Chronic Pain and Overdose (Ann Intern Med, Jan 2010)
� “It is much more important to know what sort of patient has a disease than what sort of disease the patient has.”
� Sir William Osler
� Structured evidence based review of all studies available on the development of abuse/addiction and ADRB in chronic pain patients exposed to COT.
� Abuse/addiction grouping calculated abuse/addiction rate 3.27%
� Preselected for no previous history 0.19%
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BIOLOGICAL PSYCHIATRIC
� Age < 45
� Gender
� Family history of prescription drug or ETOH abuse (genetic and environmental)
� Cigarette smoking
� Substance use disorder
� Preadolescent sexual abuse (in females)
� Major psychiatric disorder (eg, personality disorder, anxiety or depressive disorder, biploardisorder)
� Social
� Prior Legal problems
� History of MVA
� Poor family support
� Involvement in a problematic subculture
� Life stressors
� Key principle prior to starting a patient on chronic opioid therapy is determining a patient’s risk of abuse/harm.
� There are a number of validated tools available to help assess a patients risk of opioid abuse.
� Ideally they are simple, validated and identify abuse potential prior to initiating COT.
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� 1) Opioid Risk Tool- ORT
� 2)Screener and Opioid Assessment for Patients with Pain- SOAPP
� 3) Diagnosis, Intractability, Risk and Efficacy Score- DIRE
� Self administered.
� Brief, 5 questions, easy to score.
� Validated in pain populations.
� Provides excellent discrimination for patients with low risk (<3) vs high risk (>= 8) scores.
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Opioid Risk Tool
Patient's Sex
Mark each box
that applies
Item
Score
1) Family History of Substance Abuse:
Alcohol 0
Illegal Drugs 0
Prescription Drugs 0
2) Personal History of Substance Abuse
Alcohol 0
Illegal Drugs 0
Prescription Drugs 0
3) Age (Mark Box if 16-45) 0
4) History of Pre-adolescent Sexual Abuse 0
5) Psychological Disease
5a) Attention Deficit Disorder 0
Obsessive Compulsive Disorder
Bipolar
Schizophrenia
5b Depression 0
Total 0
*Total Score Risk Category
Low Risk 0-3
Moderate Risk 4-7
High Risk > or = 8
Male Female
* Score is SEX dependent
Convert To Prog Note Text
� Best psychometrics of any measure designed to predict aberrant behavior before therapy is begun.
� Self administered, 24 and 14 questions forms.
� Possibly better for high-risk populations (time).
� Physician administered, 7 items.
� Easy to use, takes <2 minutes
� Designed for PCP
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Characteristic Low Risk Moderate Risk
High Risk
Substance abuse
Never Past Current
Smoking Never Past Current
FH of addiction
None Past Current
Psych No Major Current Significant
H/O sex abuse
No N/A Yes
Positive UDS Neg Int pos Pos
Dose MED ≤ 40 40-120 >120
ORT 0-3 4-7 8+
SETTING MONITORING
� PCP
� PCP plus consultation
� Pain Management Clinic
� UDS frequency
� Frequency of face to face visits
� Frequency of tools
� Hyperalgesia
� Hypogonadism
� Sedation
� Respiratory depression
� Falls (elderly)
� Immunosurpression
� Cognitive impairment
� Constipation
� Nausea/Vomiting
� Pruritis
� Central Sleep Apnea
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� Borrowed from infectious disease.
� Impossible for the health care professional to reliably assess the risk of infectivity during an initial assessment of the patient.
� We have to apply an appropriate minimum level of precaution to all patients to reduce the risk of transmission of infection.
� Also, impossible to reliably predict the risk of opioids during a initial assessment so same principles apply.
� 1) Diagnosis with appropriate differential.
� 2) Psychological assessment (risk of addictive disorders)
� 3) Informed consent.
� 4) Treatment agreement.
� 5) Pre and Post intervention assessment of pain level and function.
� 6) Appropriate trial of opioid therapy
� 7) Reassessment of pain score and level of function.
� 8) Regularly assess the “4A’S” of pain medicine (analgesia, activity, adverse effects, aberrant behavior).
� 9) Periodically review pain diagnosis and comorbid conditions, including addictive D/O.
� Documentation.
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� Conduct a comprehensive review, including risk stratification.
� Counsel and obtain informed consent.
� Individualize treatment.
� Evaluate potential causes for repeat dose escalations, wean or taper if necessary
� Periodically reassess the patient.
� Anticipate, identify and treat opioid associated adverse events.
� Integrate nonopioidtherapies as adjunctive treatment.
� Consider PRN therapy for breakthrough pain
� 2013 Model Policy on the use of Opioid Analgesics in the Treatment of Chronic Pain.
� The goal is a guideline for “assessing physicians’ management of pain, determine whether opioid analgesics are used in a manner that is both medically appropriate and in compliance with applicable state and federal laws and regulations”.
� 57 of 70 Medical Boards have adopted similar/verbatim language.
� Pain management is important.
� Opioids may be necessary for pain relief.
� Use of opioids for other than medical purpose poses a risk to the individual and society.
� Physicians have a responsibility to minimize potential for abuse and diversions.
� Physicians may deviate from recommended treatment based on good cause.
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� Not meant to constrain or dictate medical decision making.
� “inadequate attention to initial assessment to determine if opioids are clinically indicated and to determine the risks associated with their use in a particular individual with pain.”
� “There are significant risks associated with opioids and therefore benefits and must outweight the risks.”
� Inadequate evaluation to determine risk.
� Inadequate monitoring during use.
� Inadequate attention to patient education and informed consent.
� Unjustified dose escalation without adequate attention to risks or alternative treatments.
� Excessive reliance on opioids.
� Not making use of tools for risk mitigation.
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� 1. Evaluation of the patient.
� 2. Treatment plan.
� 3. Informed consent and agreement for treatment.
� 4. Periodic review.
� 5. Consultation.
� 6. Medical records.
� 7. Compliance with laws and regulations.
FSMBS
Universal Precautions in Pain
APS/AAPM
� Preparation is the best approach.
� Mail intake questionnarie.
� Prompted chart notes.
� Templated notes/dictations.
� Document completely.
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� History and PE.
� Diagnostic tests.
� Pain Diagnosis
� Evaluation and consultation-consider psychosocial.
� Treatment objectives.
� Informed consent-written.
� Treatment Agreement.
� Medications.
� Risk Assessment/Periodic review.
� Experts recommend.
� Evidence is weak in reducing opioid misuse.
� Typically check for evidence of opiate, alcohol, benzodiazepines, cocaine, marijuana, amphetamine and barbiturate use.
� Some opiates may need to be specifically requested (oxycodone, fentanyl, methadone).
� Purpose is to identify aberrant behavior.
� Discover undisclosed drug use and/or abuse.
� Verify compliance with treatment.
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� Low risk by ORT Periodic 1/yr
� Moderate risk by ORT Regular 2/yr
� High Risk by ORT Frequent 3-4/yr
� Aberrant Behavior At time of visit
� Negative for opioid(s) you prescribed.
� Positive for amphetamine/methamphetamine.
� Positive for cocaine or metabolites.
� Positive for drug (benzodiazepines, opioids, etc) that you did not prescribe or have knowledge of.
� Positive for alcohol.
� Experts recommend using and becoming standard of care (FSMBs, VA/DOD).
� Evidence for their effectiveness is weak in decreasing opioid misuse.
� Allows you to have a conversation about risk/benefits, set limits, define responsibilities, set expectations.
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� Patients agree to comply fully with all aspects of treatment.
� Prohibit use of alcohol, other sedating medications and illegal drugs.
� Agree not to drive until sedation resolved.
� One prescriber.
� UDS.
� Agree to keep schedule appointments.
� PDMP is a statewide electronic database which collects designated data on controlled substances dispensed in the state.
� Agency distributes data to individuals who are authorized under state law to receive the information.
� DEA is not involved.
� Each state controls who will have access and for what purpose.
� Support access to legitimate medical use of controlled substances.
� Identify and prevent drug abuse and diversion.
� Facilitate the identification, intervention and treatment of persons addicted to prescription drugs.
� Identify use and abuse trends in a population.
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� Opioids can be effective in chronic pain.
� They have significant risks.
� Must do a risk assessment.
� Need informed consent.
� Approach as a trial and stop if no effect.
� Documentation is important.