mpha mtm fall symposium kathryn perrotta, pharmd, mba, bcps november 16, 2012
TRANSCRIPT
Appropriate Opioid Medication Use as Part of
a Comprehensive Pain Management Approach
MPhA MTM Fall SymposiumKathryn Perrotta, PharmD, MBA, BCPS
November 16, 2012
Disclosure Statement
Define the health economic impact of the use of opioid analgesics in the treatment of pain
Apply evidence based guidelines in moderate to severe chronic non-cancer pain management
Address abuse, misuse and diversion reduction strategies (proper disposal options and PMP)
Explore the role of ambulatory care pharmacists in primary care pain management and opportunities for collaboration with other professionals in the health care team
Objectives
Concern: significant increase in opioid prescriptions
Sales of opioids quadrupled between 1999 and 2010 (government statistics)
The annual cost associated with all types of pain, both direct and indirect costs, is estimated to be in the range of $560 to $635 billion annually in the United States
Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492.
Health Economic Impact of Opioids in the Treatment of Pain
~60 million Americans have some type of chronic nonmalignant pain
~40% of patients do NOT receive adequate pain relief
Health Economic Impact of Opioids in the Treatment of Pain
Detailed History◦ Onset, duration, quality, character of pain◦ Ameliorating and provoking factors
Pain Rating◦ Patient self report: most reliable indicator of pain◦ Numerous assessment tools available for pain in adults
Numeric rating scales (1-10)
Assessment◦ Is pain due to reversible etiology?◦ Identify cause of pain
Reason for specialist? Rheumatoid arthritis, knee pain, headache, etc.
www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain Guidelines
Assessment of Pain
Acute vs. Chronic Pain◦ Has pain persisted longer than 6 weeks?
IAP defines chronic pain as “pain that persists beyond normal tissue healing time, which is assumed to be 3 months”
Determine Pain Mechanism (3 general types)◦ Somatic◦ Visceral◦ Neuropathic
Different symptoms Different treatment indicated
www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain Guidelines. Fifth Edition, November 2011.
Assessment of Pain
Result of tissue damage Release of chemicals from injured cells that
mediate pain and inflammation via nociceptors Typically recent onset and well localized
www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain Guidelines. Fifth Edition, November 2011.
Somatic (Inflammatory) Pain
Description of Somatic Pain
Examples
SharpAching
StabbingThrobbing
LacerationsSprains
FracturesDislocations
Result from visceral nociception◦ Solid and Hollow organs
Fewer nociceptors◦ Result in poorly localized, diffuse and vague
complaints
www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain Guidelines. Fifth Edition, November 2011.
Visceral Pain
Description of Visceral Pain
Examples
Generalized ache/pressureAutonomic symptoms:
N/V, hypotension, bradycardia, sweating
Ischemia/necrosisLigamentous stretchingHollow viscous or organ
capsule distension
Injury to a neural structure leading to aberrant processing Typically chronic pain caused by damage to peripheral nerves
www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain Guidelines
Neuropathic Pain
Description of Neuropathic Pain
Examples
RadiatingBurningTingling
“Electrical Like”
DiabetesShingles
MSHerniated discs
From radiation/chemo
Determine Patient’s Pain Goals ◦ If chronic pain patient may need to counsel on
expectations of pain relief◦ Assess for risk of substance abuse, misuse, or addiction
Avoid Unrealistic Expectations in Chronic Pain Patients◦ Improvement with opioids generally average < 2-3 points
on average 0-10 scale◦ Concentrate on quality of life and improving therapeutic
goals
Stress importance of utilizing other modalities◦ Medications that are multi-modal in treating pain
Alternative therapies www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain
Guidelines. Fifth Edition, November 2011.
Assessment of Pain
Assessment is Key!
Most Responsive Treatments
Somatic Pain Visceral Pain Neuropathic Pain
•acetaminophen•cold packs•corticosteroids•lidocaine patches•NSAIDs•opioids•tactile stimulation
•corticosteroids•intraspinal localanesthetic•NSAIDs•opioids
•gabapentin•pregabalin•corticosteroids•neural blockade•NSAIDs •opioids •TCAs•duloxetine
www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of Chronic Pain Guidelines. Fifth Edition, November 2011.
McCaffery M, Pasero C. Pain Clinical Manual. 1999:21.
3. Perception of Pain
Analgesia and the Pain Pathway
Descending modulation
Dorsal horn
Ascendinginput
Spinothalamic tract
Dorsal root ganglion
Peripheral nerve
Peripheral nociceptors
Pain
Trauma
Local anestheticsOpioids 2-agonistsCOX-2 selective inhibitors
Opioids 2 -agonists Centrally acting analgesicsAnti-inflammatory agents (COX-2 selective inhibitors, nonselective NSAIDs
Local anesthetics
Adapted by Dr. Todd Hess (United Pain Center) from Gottschalk et al. Am Fam Physician. 2001;63:1979-1984.
OpioidsLocal anesthetics Anti-inflammatory agents (COX-2 selective inhibitors, nonselective NSAIDs)
“Wind-up ” Phenomenon
0
20
40
60
80
100
|----0.5 Hz----|
neu
ron
res
po
nse
Repetitive stimulation of spinal neurons evokes an increasing level of response
NMDA receptor antagonists block this effect
Intense pain worsening over time Causes: most frequently trauma to extremity or
surgery/infection
Pathophysiological mechanism of CRPS is ongoing nociceptor input from periphery to CNS. ◦ Characterized by hyperalgesia, allodynia, vasomotor changes,
abnormal regulation of blood flow and sweating, joint stiffness, localized skin edema
Treatment of CRPS can be difficult; ◦ Often misdiagnosed and can be irreversible if undiagnosed
◦ Recommended that combined analgesic regimens (multimodal analgesia) be used to prevent CRPS
• Reuben, S. Anesthesiology. 2004;101:1215-1224. Burns, A. J Orthop Surgery. 2006; 14(3):280-3.
Complex Regional Pain Syndrome
A variety of different and integrated disciplines:
◦Pharmacologic Complementary/synergistic mechanisms of
action to inhibit effects of pain mediators and enhance the effects of pain modulation
Non-opioids used in combination with opioids can decrease the total amount of opioid needed for pain control
◦
Applying the Multimodal Approach of Therapy to Chronic Pain Patients
Acetaminophen
Cox-2s, NSAIDs
Modulating agents◦Duloxetine, TCAs, tramadol, etc.
Topical agents◦Lidocaine patches
Gabapentin ◦neuropathic pain prevention and treatment
Applying the Multimodal Approach of Therapy to Chronic Pain Patients
A variety of different and integrated disciplines:◦Non-Pharmacologic: Exercise Massage Acupuncture Reiki Cognitive Behavioral Therapy Physical Therapy TENS therapy
Applying the Multimodal Approach of Therapy to Chronic Pain Patients
Incomplete Cross tolerance of opioids:
A) A physiological phenomenon following use of opioids for > 2 weeks
B) State of adaptation in which exposure to a drug decreases its effect over time
C) Due to the different molecular entities of opioids, a person on an opioid for a long perioid of time will not be as tolerant to the effects of a new opioid
Adjunctive Therapy Options
Assess if the opioid is right for patient◦ Effectiveness◦ Adverse Effects: N/V, puritis, constipation, respiratory
depression◦ Renal metabolism/use in liver failure
Be aware of incomplete cross tolerance effect of opioids◦ Tolerance may develop to the opioid in use but may not be as
marked relative to other opioids
Opioid Management
fentanyl synthetic to
non-synthetic
hydromorphone, hydrocodone
oxycodone
morphine,
codeine
Comparison of ORAL OpioidsOxycodone
Hydromorphone(Dilaudid)
Tramadol
Onset of Action
(minutes)10-15 (IR)60-90 (CR)
15-30
60
Peak Response
1 hour 60-90 mins 2-3 hours
Duration of Effect
(hours)
4-6 (IR)8-12 (CR)
4-6 4-6
Renal Elimination
Yes Yes Yes
Prolonged in Hepatic Failure
Yes Yes Yes
Comparison of Opioids
Opioid Oral Onset of action Duration of Action
Codeine 200 mg 15-30 min 3-4 hrs
Hydrocodone 30 mg 15-30 min 4-8 hrs
Hydromorphone 7.5 mg 15-30 min 4-6 hrs
Methadone Varies* 30-60 min Varies
Morphine 30 mg 15-60 min 3-6 hrs
Morphine ER 30 mg 60-90 min 8-12 hrs
Oxycodone 20 mg 10-15 min 4-6 hrs
Oxycodone CR 20 mg 60-90 min 8-12 hrs
*Consult APS Guidelines
Morphine and Metabolites
Morphine
liver
M-3-GM-6-G, normorphine
Analgesia
Confusion, Sedation, Respiratory Depression
kidney
Hyperalgesia, myoclonus
Methadone◦ 1/3 of opioid related overdose deaths while only a
few percent of total opioid prescriptions◦ Do NOT use for mild, acute or “break through pain”◦ NOT for opioid naïve patients
Clinical Aspects◦ Long and unpredictable ½ life ◦ Multiple drug interactions◦ QT prolongation
ECG before starting and when doses >200mg/day Switching from another opioid: 70-90% reduction of
equianalgesic dose
Morbidity & Mortality Weekly Report. 2012;61(26):493-497. © 2012 Centers for
Disease Control and Prevention (CDC)
Opioid Management
Fentanyl (Duragesic®) Transdermal system
◦ Onset of action: 12-18 hours, used Q 48 or 72 hrs
◦ Chronic, stable pain only
◦Elimination after patch removal: 13-22 hrs
◦ Fever can result in up to 30% ↑ in drug levels ⊘ Heating pad or hot tub
◦ Not best option for catechetic pt weighing <50kg; unpredictable absorption +/or elimination
Opioid Rotation: Change in opioid drug with the goal of improving outcomes
Indications for Opioid Rotation:◦ Occurrence of intolerable adverse effects◦ Poor analgesia despite aggressive dose titration◦ Change in clinical status◦ Financial or drug availability consideration
Deciding Next Specific Opioid:◦ Past experience with different opioids,
sensitivities, efficacy, etc.
Fine, G. Opioid Rotation: Definition and Indications. Pain Management Today eNewsletter series. American Pain Foundation. , Quadrant HealthCom Inc. ; 2010: (1): 9. http://newsletter.qhc.com/JFP/JFP_pain032411.htm
Opioid Management
Opioid Rotation Guidelines:◦ Calculate equianalgesic dose of new opioid◦ Identify automatic dose reduction of 25-50% lower than
calculated equianalgesic dose 50% reduction if high current opioid dose, elderly, non-white,
or frail 25% reduction if patient not above
◦ Strategy to frequently assess initial response and titrate new dose◦ Supplemental “rescue” dose for prn: calculate 5-15% and
administer at appropriate intervalFine, G. Opioid Rotation: Definition and Indications. Pain Management Today eNewsletter series. American Pain Foundation. , Quadrant HealthCom Inc. ; 2010: (1): 9.
http://newsletter.qhc.com/JFP/JFP_pain032411.htm
Opioid Management
American Pain Society (APS). Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 6th edition. 2008. Glenview, IL 60025.
Equianalgesic DosingStandard Opioid-PO Opioid Parenteral
Oxycodone 20mg
Hydrocodone 30mg NA
Hydromorphone 7.5mg Hydromorphone 1.5mg
Methadone: Consult Expert
Morphine 30mg Morphine 10mg
51 year old white female patient with chronic pain due to MVA
Current Medications:MS Contin 30mg TID
Hydrocodone/APAP 5/500 1-2 tabs qid prn (patient states she take 6 tabs/day)
Atenolol 50mg qday Senokot-S 1 tab bid
MD asks you to convert this patient to oxycodone due to recent increased itching and ineffective control of pain.
Opioid Rotation: Patient Case
1) Conversion:Total oxycodone equivalent/day: 90mg morphine + 30mg hydrocodone
90mg morphine = 60mg oxycodone
30mg hydrocodone = + 20mg oxycodone 80mg (total oxycodone
dose)
2) Should we suggest the total oxycodone dose or reduce?
Opioid Rotation: Patient Case
2) Reduction of Dose:Total oxycodone equivalent/day: 80mg
80mg x 0.25 = 20 mg so reducing by 25% the total daily dose would be 60mg oxycodone
3) How do we want to give the oxycodone 60mg?Slow versus immediate release?
Opioid Rotation: Patient Case
3) How do we want to give the oxycodone 60mg?
◦ Oxycontin 15mg TID plus oxycodone 5-10mg tid prn (start with 5mg)
◦ Patient would be taking 45mg + 15-30mg = 60-75mg
◦ Could switch morphine to oxycodone, keep on hydrocodone prn dose for first few days, reassess then switch to oxycodone
Opioid Rotation: Patient Case
Other considerations:
1. What other medications may this patient benefit from?
2. How would you have established this?
3. Does patient need high dose of opioid?
4. Has patient tried other modes of therapy such as stretching (Physical therapy involvement), massage, TENS unit or cognitive behavioral therapy (non-drug methods)?
Opioid Rotation: Patient Case
Essential to identify if:◦ Patient successful ◦ Patient might benefit more with restructuring of
treatment◦ Need treatment for addiction◦ Benefits outweighed by harm
Frequency of monitoring:◦ Patient on stable doses
Every 3-6 months
◦ After initiation of therapy, changes in opioid doses, with a prior addictive disorder, psychiatric conditions, unstable social environments Weekly basis may be necessary
Chou, R, Fanciullo, G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain: an update of Society-American Academy of Pain Medicine Opioids Guidelines Panel. The Journal of Pain. 2009 Feb;10(2):113-130.
Monitoring Patients on Opioids
Should include:◦ Assessment and documentation of pain severity and
functional ability◦ Progression towards achieving therapeutic goals◦ Presence of adverse effects◦ Clinical assessment and detailed documentation for
aberrant drug related behaviors, substance use and psychological issues If suspect above may need to implement:
Pill counts Urine drug screening Family member/caregiver interviews Use of prescription monitoring plans
Chou, R, Fanciullo, G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain: an update of Society-American Academy of Pain Medicine Opioids Guidelines Panel. The Journal of Pain. 2009 Feb;10(2):113-130.
Monitoring Patients on Opioids
Most predictable factor for drug abuse, misuse, or other aberrant drug related behavior:◦ Personal or family history of alcohol or drug abuse
Other factors associated with aberrant drug related behaviors:◦ Younger age◦ Presence of psychiatric conditions
Opioid therapy in these patients requires intense structured monitoring and management by professionals with expertise in both addiction medicine and pain management ***DOCUMENT***
Chou, R, Fanciullo, G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain: an update of Society-American Academy of Pain Medicine Opioids Guidelines Panel. The Journal of Pain. 2009 Feb;10(2):113-130.
Assessment of Patient for Addictive Risk
Assessment Tools Available:◦ Webster's Opioid Risk Tool (ORT)◦ DIRE Tool◦ Screener and Opioid Assessment for Patients in Pain
(SOAPP®)◦ Current Opioid Misuse Measure (COMMTM)◦ Prescription Drug Use Questionnaire (PDUQ)◦ Screening Tool for Addiction Risk (STAR)◦ Screening Instrument for Substance Abuse
Potential (SISAP)◦ Pain Medicine Questionnaire (PMQ)www.icsi.org Assessment and Management of Acute Pain guidelines and Assessment and Management of
Chronic Pain Guidelines. Fifth Edition, November 2011.
Assessment of Patient for Addictive Risk
Pseudoaddiction to Opioids:
A) A drug seeking behavior occurring in patients who are receiving inadequate pain control
B) State of adaptation in which exposure to a drug decreases its effect over time
C) Characterized by behaviors that include impaired control over drug use and continuation despite harm to self or others
Repeated Opioid Dose Escalations: When repeatedly occur, evaluate for potential causes:
◦ Assess for treatment control (pseudoaddiction?)◦ Possible marker for substance abuse disorder or
diversion
Theoretically no maximum or ceiling◦ High dose definition = >200mg po morphine/day
AAP Opioid Consensus Panel
Some studies suggest higher doses of opioids lead to:◦ Hyperalgesia◦ Neuroendocrinologic dysfunction◦ Possible immune suppression
Chou, R, Fanciullo, G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain: an update of Society-American Academy of Pain Medicine Opioids Guidelines Panel. The Journal of Pain. 2009 Feb;10(2):113-130.
Opioid Management
Weaning/Tapering Off Opioids:
Institute when:◦ Patient engages in serious or repeated
aberrant drug-related behaviors or diversion◦ Experience of intolerable side effects◦ Making no progress towards meeting therapeutic goals
Approaches to Weaning Opioid:◦ Slow: 10% dose reduction per week◦ Rapid: 25-50% reduction every few days◦ Slower rate may help reduce unpleasant symptoms of
opioid withdrawal
Chou, R, Fanciullo, G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain: an update of Society-American Academy of Pain Medicine Opioids Guidelines Panel. The Journal of Pain. 2009 Feb;10(2):113-130.
Opioid Management
Diagnosing Addiction in Patients Taking Opioids:
Evidence of compulsive drug use, characterized by:◦ Unsanctioned dose escalation◦ Continued dosing despite significant side effects◦ Use to treat for symptoms not targeted by therapy◦ Use during periods of no symptoms
Evidence of one or more associated behaviors:◦ Manipulation of MDs or medical system to obtain
additional opioids◦ Acquisition of drugs from other medical sources or non-
medical sources◦ Drug hoarding or sales◦ Unapproved use of other drugs (alchohol or other)
Hojsted, J, Sjogren, P. Addiction to Opioids in Chronic Pain Patients: A Literature Review. European Journal of Pain. 2007;11:490-518.
Opioid Management
Consider for patient not well known and/or higher risk of misuse
Example of components of opioid agreement:◦ Specified the conditions under which opioids would
or would not be prescribed ◦ Patient responsibilities
Only receive opioids from Dr. ________ Will not give medications to anyone else If my prescription runs out early for any reason;
have to wait until next prescription is due.
Example of an Opioid Management Agreement: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829426/figure/Fig1
Opioid Management Agreement
Random urine drug screening performed if recommended by the physician to monitor adherence and possible use of illicit substances.
Patients informed that the agreement would be discontinued if patient responsibilities were not met.
Responsibilities of the physician and/or clinic staff included providing monthly prescriptions on the due date, monitoring the effects of therapy, and providing ongoing care.
Patient signs agreement
Opioid Management Agreement
Pharmacies licensed by the MN Board of Pharmacy and other dispensing facilities are required to report the dispensing of controlled substances listed in the state’s Schedules II-IV. ◦ Data is submitted electronically.
Patient controlled substance prescription history is available to
prescribers and pharmacists Available 24/7, 365 days a year, with information such as:
◦ Quantity and dosage of controlled substance dispensed, ◦ Pharmacy that dispensed the prescription◦ In some cases, the practitioner
Assists in checking for potential drug interactions, patterns of misuse, potential diversion or abuse and generally to assist in determining the appropriateness in dispensing.
For pharmacist access: http://pmp.pharmacy.state.mn.us/pharmacist-
rxsentry-access-form.html
Prescription Monitoring Program
Rational Use
1. Reassure patients prescribed opioids or benzos are taking as directed, evidenced by positive results
2. Make sure not being misused Stockpiling or selling to unauthorized others Evidenced by negative results
3. Detect presence of illicit non-prescribed drugs Heroin, cocaine, non-prescribed opioids, etc.
Tenore, P. Advanced Urine Toxicology Testing. Journal of Addictive Diseases, 2010;29:436-448.
Urine Drug Screening
Two types of tests used:
1. Immunoassay ◦ Classify drug as present or absent◦ Any response above the cutoff is deemed positive◦ Any response below the cutoff is negative ◦ Subject to cross-reactivity◦ Some detect specific drugs, while others classes,
i.e. opioids
Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care. Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010.
Urine Drug Screening
Immunoassay Pearls:
Human urine has a creatinine concentration greater than 20 mg/dL.
In the clinical setting it is important that 300 ng/mL or less be used for initial screening of opiates (Food stuff and poppy seed can make +); Confirm with laboratory test
Opiate Class; lower sensitivity to hydromorphone , hydrocodone, oxycodone , oxymorphone, fentanyl, meperidine, and methadone
Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care. Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010.
Urine Drug Screening
Metabolites
Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care. Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010.
Immunoassay Pearls (continued):
Amphetamine/methamphetamine are highly crossreactive◦ may detect other ephedrine and pseudoephedrine◦ Further testing may be required by a more specific
method, i.e. GC Opiate class: morphine and codeine Ability of opiate immunoassays to detect semisynthetic/
synthetic opioids varies among assays because of differing cross-reactivity patterns.
Specific immunoassay tests for some semisynthetic/ synthetic opioids may be available (eg, oxycodone, methadone).
Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care . Stanford, CT: California Academy of Family
Physicians, PharmaCom Group, Inc; 2010.
Urine Drug Screening
2. GC/MS (Laboratory Testing) Generally, a more definitive laboratory-based
procedure Identify specific drugs; may be needed: (1) Specifically confirm the presence of a given
drug; i.e. morphine is the opiate causing the + IA response(2) to identify drugs not included in an immunoassay test(3) when results are contested.
Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care. Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010.
Urine Drug Screening
Examples of cross-reacting compounds for certain immunoassays
Interfering drug Immunoassay affected
Quinolone antibiotics OpiatesTrazodone FentanylVenlafaxine PhencyclidineQuetiapine MethadoneEfavirenz THCPromethazine AmphetamineDextromethorphan PhencyclidineProton pump inhibitors THC
Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care. Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010.
Urine Drug Screening
Approximate windows of detection of drugs in urine
Detection time Drug in urineAmphetamines Up to 3 daysTHC (Single use) 1 to 3 days (Chronic use) Up to 30 daysCocaine use 2 to 4 daysOpiates (morphine, codeine) 2 to 3 daysMethadone Up to 3 daysEDDP (methadone metabolite) Up to 6 daysBenzodiazepines Days to weeks
Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care. Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010.
Urine Drug Screening
Consult lab regarding anything unexpected
Schedule appointment to discuss with patient◦ Be positive and supportive
Use to strengthen the healthcare professional-patient relationship
Support positive behavior change
What to do with UDT Results?
FDA recommendations for disposal◦ Locate medication take back program in
community
◦ Example: Dakota County Sherriff’s Office has a drop box at the Burnseville Police Department and the Hastings Sherriff’s Office where people can drop off their prescriptions anonymously
◦ Many drop box locations in Hennepin county: http://www.hennepin.us/medicine
Drug Disposal
Hennepin County Drop Box Example:
http://www.hennepin.us/medicine
FDA recommendations for disposal◦ If no medication take back program
Mix medications with unpalatable substance Place mixture in container such as sealed bag Throw container in household trash
◦ Exception: List of meds recommended to dispose by flushing http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm
Drug Disposal
FDA recommended for flushing (examples):◦ Fentanyl (SL tabs, film, lozenge, patch)◦ Morphine◦ Meperidine◦ Hydromorphone◦ Methadone◦ Oxycodone◦ Tapentadol
Others listed on FDA updated website:http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm
Drug Disposal
Federal controlled substance laws and rules prohibit a pharmacy from receiving controlled substances from anyone who is not a registrant of the US DEA.
Pharmacists are not allowed to accept controlled substances from patients or members of the public.
Drug Disposal
Assessment of pain is key every time you see a patient
Opioids can be part of a comprehensive pain management approach for a non-cancer chronic pain patient; document all assessment and communication regarding opioids each office visit
Ensure pain is being treated appropriately with a multimodal approach using the best medications and therapy for the individual patient
Utilize expertise of other non-pharmacy professionals for additional therapy to synergistically treat pain
Summary
Guidelines:Assessment and management of chronic pain. 2005 Nov (revised 2011 Nov). NGC:008967Institute for Clinical Systems Improvement - Nonprofit Organization. Adult acute and subacute low back pain. 1994 Jun (revised 2012 Jan). NGC:008959Institute for Clinical Systems Improvement - Nonprofit Organization
Diagnosis and treatment of headache. 1998 Aug (revised 2011 Jan). NGC:008263Institute for Clinical Systems Improvement - Nonprofit OrganizationPain (chronic). 2003 (revised 13 May 2011). NGC:008519 Work Loss Data Institute - For Profit Organization.Guideline for the evidence-informed primary care management of low back pain. 2009 Mar. [NGC Update Pending] NGC:007704Institute of Health Economics - Nonprofit Research Organization; Toward Optimized Practice - State/Local Government Agency [Non-U.S.]. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. 2009 Feb. NGC:007852 American Academy of Pain Medicine - Professional Association; American Pain Society. Other References: 1) American Pain Society (APS). Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 6th edition. 2008. Glenview, IL 60025.2) Anderson AV, Fine PG, Fishman SM. Opioid Prescribing: Clinical Tools and Risk Management Strategies. Sonora, CA: American Academy of Pain Management; December 31, 2009. http://www.state.mn.us/mn/externalDocs/BMP/New_Article_on_Pain_Management_020110034248_monograph_dec_07_final.pdf. Accessed June 2012
3) Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492.4) Chou, R, Fanciullo, G, Fine, P, et. al. Opioid Treatment Guidelines: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain: an update of Society-American Academy of Pain Medicine Opioids Guidelines Panel. The Journal of Pain. 2009 Feb;10(2):113-130.
5) Clark LG, Upshur CC. Family medicine physicians’ views of how to improve chronic pain management. J Am Board Fam Med. 2007;20(5):479-482.
6) Evans L, Whitham JA, Trotter DR, Filtz KR. An evaluation of family medicine residents’ attitudes before and after a PCMH innovation for patients with chronic pain. Fam Med. 2011;43(10):702-711
References
7) Fine, G. Opioid Rotation: Definition and Indications. Pain Management Today eNewsletter series. American Pain Foundation. , Quadrant HealthCom Inc. ; 2010: (1): 9. http://newsletter.qhc.com/JFP/JFP_pain032411.htm
8) Gourly D, Helt H, Yale C. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care. Stanford, CT: California Academy of Family Physicians, PharmaCom Group, Inc; 2010.
9) Hojsted, J, Sjogren, P. Addiction to Opioids in Chronic Pain Patients: A Literature Review. European Journal of Pain. 2007;11:490-518.
10) Katz NP. Opioid Prescribing Toolkit. Oxford/New York: Oxford University Press; 2010. 11) Leverence RR, Williams RL, Potter M, et al. Chronic non-cancer pain: a siren for primary care—a
report from the PRImary care MultiEthnic Network (PRIME Net). J Am Board Fam Med. 2011;24(5):551-561.
12) Matthias MS, Parpart AL, Nyland KA, et al. The patient-provider relationship in chronic pain care: physicians’ perspectives. Pain Med. 2010;11(11):1688-1697
13) The Management of Opioid Therapy for Chronic Pain Working Group. VA/DoD clinical practice guidelines: management of opioid therapy for chronic pain. 2010. Version 2.0-2010. http://www.healthquality.va.gov/COT_312_Full-er.pdf. Accessed June 2012.
14) Patanwala, et. al. Comparison of Opioid Requirements and Analgesic Response in Opioid-Tolerant versus Opioid-Naïve Patients After Total Knee Arthroplasty. Pharmacotherapy 2008;28(12):1453-1460
ne 2012. 15) Pizzo PA, Clark NM, Carter-Pokras O, et al; Institute of Medicine Committee on Advancing Pain
Research, Care, and Education. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington, D.C.: National Academies Press; 2011:119-120.
16) Project Lazarus. Community-based overdose prevention from North Carolina and the Community Care Chronic Pain Initiative. http://www.projectlazarus.org. Accessed Ju
17) Reuben, S. Anesthesiology. 2004;101:1215-1224. Burns, A. J Orthop Surgery. 2006; 14(3):280-3. 18) Tenore, P. Advanced Urine Toxicology Testing. Journal of Addictive Diseases, 2010;29:436-448.
19) Upshur CC, Luckmann RS, Savageau JA. Primary care provider concerns about management of chronic pain in community clinic populations. J Gen Intern Med. 2006;21(6):652-655.
20) Wismer B, Amann T, Diaz R, et al. Adapting Your Practice: Recommendations for the Care of Homeless Adults with Chronic Non-Malignant Pain. Nashville, TN: Health Care for the Homeless Clinicians’ Network, National Healthcare for the Homeless Council, Inc; 2011.
References (continued)
QUESTIONS????????????