Chronic Opiate Therapy

Benjamin Meeks, FNP

Agenda

• History of Opiate Therapy

• Risks of Opiate Therapy

• Benefits of Opiate Therapy

• Guidelines for Opiate Therapy

• Case Studies

“Give strong drink to those who are about to perish”

- Solomon

Modern History

• Portenoy and Foley 1986– Study of 38 chronic pain patients – 4 – 7 years duration– 66% maintained on 40mg to 60mg morhpine

Modern History

• 1989 Weissman and Haddox introduce concept of pseudoaddiction

• 1995 Introduction of time released oxycodone

• Titrate to effect or side effect

Modern History

• 97% increase in opioid sales from 1997 to 2010• 2010 Misuse or abuse of pharmaceuticals

overtakes alcohol in reason for ED visits• Drug overdose deaths increase 250% 2000 – 2010

• 15.1% increase in American population over the

age of 65 from 2000 - 2010• Estimated 116 million American with chronic pain

Ethical Imperatives

Treat your patients pain.

Do no harm by contributing to abuse and diversion.

Risks of Opiate Therapy

• Constipation/Urinary Retention – 41%

• Tolerance

• Hypogonadism – 11%

• Addiction

• Death

• Falls/Accidents

Tolerance

• Reversible physiologic response to the persistent presence of opiate agonists leading to diminishing therapeutic effect

• Mechanism not fully understood

• Poorly studied

Addiction

• Addiction/Medication Misuse• Addiction rates vary by study 5% to 41% of

chronic pain patients• 20% of general population reports “non-medical

use” of opiates• Aberrant behaviors in 11.5% to 24%• Aberrant behaviors/Addiction appear greater in

those aged <56 years, smokers and unemployed

Falls/Accidents

• Exposure to opiates increased fall risk by 38%

• Greater than 50mg morphine equivalent doubled risk of falls

• More common with new opioid prescription

• Greatest in 18 – 29 year old age group

What risks does my patient have?

Benefits of Opiate Therapy

• Pain Control

• Improved Social Function

• Improved Mental Health

• Improved Physical Function

Benefits of Opiate Therapy

• Meta-analysis of 28 studies with chronic nonmalignant pain demonstrated improvements in pain and function studies only up to five weeks

• Very little long term evidence no studies longer than 2 years, many not controlled

• No long term studies demonstrate strong evidence for opiate therapy

• No evidence showing benefit of long acting versus short acting opiates

Guidelines – ASIPP 2012

• Comprehensive Assessment– Pain Condition

– Medical History

– Physical Exam

– Psychosocial History

– Functional Status

– Sleep

– Psychological Evaluation

– Prescription Monitoring Program

– Urine Drug Screening

Case Study

• 65 year old married white male, 5’10”, 275 lbs, disabled coal miner, 1 ppd smoker, denies alcohol usage, reports chronic worsening back pain without extremity pain, medical history significant for O2 dependent COPD, HTN, diabetes and mild kidney disease, lives with wife and teenage grandchild, no current medications for pain, no recent radiology

• Do you prescribe opiates for this patient?

Case Study

• 40 year old co-habitating white male, 5’10”, 250 lbs, disabled construction worker, 2 ppd smoker, denies alcohol usage, reports five year history of worsening back pain without extremity pain, medical history significant for COPD, lives with girlfriend, failing over the counter NSAIDS/APAP, MRI reveals multilevel disc degeneration and faect arhtropathy without foraminal stenosis.

• Do you prescribe opiates for this patient?

Case Study

• 30 year old married female, 5’5”, 140lbs, non-smoker, employed as elementary school teacher 6 week history of worsening low back and right leg pain began after lifting a box of books, numbness right lateral foot, not improving with physical therapy, missing work due to pain, sleep is disturbed due to pain, MRI demonstrates right L4-5 herniation, lives with husband and 2 children ages 4 and 6. Ibuprofen 800 TID not helpful and causing GI upset.

• Do you prescribe opiates for this patient?

Summary

• Long term opiate therapy has medically proven significant life altering risks

• Long term opiate therapy has not been as yet proven in the research to improve function, mood and reduce pain over a period of years

• Consider risks, benefits and potential duration fo therapy before writing the first prescription for opiates