D R . E R I C A L. W E I N B E R G D E C E M B E R 2 0 17 · d r . e r i c a l. w e ... how does the college get the cases ... c d c g u i d e l i n e f o r p r e s c r i b i n g

D R . E R I C A L . W E I N B E R G

D E C E M B E R 2 0 1 7

COPYRIGHT © 2017 BY SEA COURSES INC.

All rights reserved. No part of this document may be reproduced, copied, stored, or

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Sea Courses is not responsible for any speaker or participant’s statements, materials,

acts or omissions.

CONFLICT OF INTEREST DISCLOSURE

Presenter/Faculty: Dr. Erica L. Weinberg

Relationships with Commercial Interests:

Grants/research support: none

Speaker bureau/honoraria: Sea Courses

Consulting fees: none

Other: none

POTENTIAL FOR CONFLICT OF INTEREST

I have been a member of the National Faculty at the Michael G. Degroote

National Pain Centre since 2012

I am one of the many authors on the Canadian Pain society’s revised

consensus statement on the pharmacological management of chronic

neuropathic pain

I have been a Medical Inspector

(MI) / Independent Opinion (IO)

Provider at the College of

Physicians and Surgeons of

Ontario (CPSO, ‘College’) –

frequently regarding opioid

prescribing practices

MITIGATING POTENTIAL BIAS

Information presented or recommendations made are

evidence/guideline/consensus-based

I have completed the CPFC Mainpro+/Cert+ Declaration of Conflict of

Interest form evidencing compliance with Mainpro+/Cert+ requirements,

a requisite for this program to be given accredited status

I will be discussing “off-label” uses of medications

HOW DOES THE COLLEGE GET THE CASES

Complaints/concerns from colleagues, patients, families, pharmacists,

coroners …

Narcotic Monitoring System (NMS) / Prescription Monitoring Program (PMP)

- Ontario NMS (May 2012)

▪ Limited list of drugs; most doctors do not have own access

▪ eHealth Ontario pilot project (digital health drug repository) = Guelph, ON

▪ Expected all doctors to have access by the end of 2017

WHAT DO I LOOK FOR WHEN ASSESSING THE

MANAGEMENT OF PAIN?

1. Organized approach to diagnosing the pain

2. Patient Engagement

3. Multimodal approach to the treatment

4. Rational prescribing

5. Therapies are being monitored

6. Meets the standard of practice of the profession

1. ORGANIZED APPROACH TO DIAGNOSING THE PAIN

biological physical functional psychological social spiritual

O P Q R S T U Vhttp://www.fraserhealth.ca/media/SymptomAssesment.pdf

Is there a …

Comprehensive Assessment?

1. ORGANIZED APPROACH TO DIAGNOSING THE PAIN

Duration

▪ Acute vs. chronic

Disease Process

▪ Cancer vs. non-cancer

o OA, post-traumatic, post-herpetic neuralgia (PHN)…

Primary Mechanism

▪ Nociceptive, neuropathic, centralized

MECHANISTIC CHARACTERIZATI0N OF PAIN

NOCICEPTIVE NEUROPATHIC CENTRALIZED

Inflammation or

mechanical damage in

tissues

May respond to:

✓ NSAIDs

✓ Opioids

✓ Non-pharmacological,

CAM and procedures

Classic examples:

Acute injury pain, OA, RA

Damage or dysfunction within the nervous

system

May respond to:

✓ Peripheral agents

✓ Central agents

✓ Non-pharmacological, CAM and procedures

Classic examples:

DPNP, PHN

Primarily due to a

central disturbance in

pain processing

May respond to:

✓ Central agents


CAM and procedures

Classic examples:

FM, IBS, TMJD

OA = osteoarthritis; RA = rheumatoid arthritis; DPNP = diabetic peripheral neuropathic pain; PHN = post-herpetic neuralgia; FM = fibromyalgia

IBS = irritable bowel syndrome; TMJD – temporal mandibular joint disease

MECHANISTIC CHARACTERIZATI0N OF PAIN

NOCICEPTIVE NEUROPATHIC CENTRALIZED

Inflammation or

mechanical damage in

tissues

May respond to:

✓ NSAIDs

✓ Opioids


CAM and procedures

Classic examples:

Acute injury pain, OA, RA

Damage or dysfunction within the nervous

system

May respond to:

✓ Peripheral agents

✓ Central agents

✓ Non-pharmacological, CAM and procedures

Classic examples:

DPNP, PHN

Primarily due to a

central disturbance in

pain processing

May respond to:

✓ Central agents


CAM and procedures

Classic examples:

FM, IBS, TMJD

OA = osteoarthritis; RA = rheumatoid arthritis; DPNP = diabetic peripheral neuropathic pain; PHN = post-herpetic neuralgia; FM = fibromyalgia

IBS = irritable bowel syndrome; TMJD – temporal mandibular joint disease

How do you measure pain?

MEASURING PAIN

Pain interference

o Function (recreation & work) and disability

o Sleep

Pain intensity

Mood

Other co-morbid psycho/social/spiritual issues

Risks

Goals and Expectations

2. IS THE PATIENT ENGAGED IN THE PLAN?

GOALS AND EXPECTATIONS OF TREATMENT

Improved Quality of Life

Improvement in function and reduction in disability

Patient SMARTIE goals

Reduction of pain

Tolerable pain score

Minimizing risks

Is the patient reliable enough?o Attending all appointmentso Participating in all recommended therapieso Participating fully in the minimizing risk plan

3. MULTIMODAL TREATMENT OF PAIN

3. THE 3 M’ OF PAIN MANAGEMENTS

Mind Movement Medicine

TENS-Acupuncture

Deep Massage

Trigger Points …

Relaxation

Exercise

Cognitive Therapies

Chewing Gum

Religious Beliefs …

TENS-conventional

Massage …

2

1

3

Hot

Cold

Massage

Dorsal Horn

Brain Stem

Cortex

Mechanism-based Treatment:

Non-Pharmacological

Therapies

TCA

SNRI

NRI

Opioid …

TCA

SNRI

NRI

Opioid …

Gabapentinoid

Antiepileptic/convulsant

NMDA Antagonist

Opioid

TCA

Cannabinoid …

2

1

3

NSAID

COXIB

Steroid

Capsaicin

Cortex

Brain Stem

Dorsal Horn

Mechanism-based Treatment:

Pharmacological

Therapies

4. IS THERE EVIDENCE OF RATIONAL PRESCRIBING?

Nociceptive Neuropathic Centralized

NSAIDs + - -

Opioids + + -

TCA + + +

SNRI + + +

Gabapentinoids - + +

Cannabinoids - + ?

Surgery / Injections + + -

*topical lidocaine (second-line for postherpetic neuralgia), methadone, lamotrigine, lacosamide, tapentadol, botulinum toxin +limited randomized controlled trial evidence to support add-on combination therapy

CANADIAN ALGORITHM FOR THE PHARMACOLOGICAL

MANAGEMENT OF NEUROPATHIC PAIN

Consider adding

additional agents

sequentially if

partial but

inadequate pain

relief +

Gabapentinoids TCA SNRI

Tramadol Opioid Analgesics

Cannabinoids

Fourth-line Agents*

Moulin et al, Pain Res Manag 2014

5. IS THERE EVIDENCE THAT THERAPY IS BEING MONITORED?

Managing Risk – ALL therapies

“Doctors have to be risk managers in any medical

condition. In treating pain, there is no risk-free

treatment option – including doing nothing.”

S. Fishman ICPCD New York, 2007


Monitoring Pain

Pain interference

▪ Function, disability, sleep, relations …

Pain intensity

Periodic focused physical exams

Managing Mental Health Disorders

Depression, anxiety, PTSD, SUD/OUD …

Whole Person Approach

Other co-morbid bio/psycho/social/spiritual issues

Involvement of other Health Care Professionals


Managing Risk - Opioids:

Opioid misuse screening tools/CAGE-AID, NMS/PMP, UDS, circle of care, structured opioid therapy/limiting supply, opioid treatment agreements …

Consultations, collaboration and periodic reassessment

Monitoring adverse effects, medical complications, risks, ADRBs …

Accurate Medication Record

Stopping/tapering therapy if goals are not met or risks outweigh benefits

ADRB=aberrant drug-related behaviour; UDS=urine drug screen

6. STANDARD OF PRACTICE OF THE PROFESSION

What is standard of care?


What do most doctors do?

What does the evidence-based, peer reviewed literature say to do in

the given circumstances?

What would you teach trainees to do in the given circumstances?

What would an ethical doctor do in those circumstances?

What does your College say to do?

2018

2012

2006

6. DOES PRESCRIBING MEET THE STANDARD OF CARE?

Good practices in prescribing Non-pharmacological/non-opioid therapies optimized

Previous/concurrent SUD/OUD and active mental health conditions verified and documented

Accepted indication for opioids in specific pain condition

Informed consent

Factors impairing cognition/psychomotor ability addressed

All Rx and ‘renewals’ are documented

Appropriate action taken when

UDS results are inconsistent or unexpected, ADRBs are identified, Opioid Treatment Agreement

is violated …

Goals are not achieved and/or risks outweigh benefits


C D C G U I D E L I N E F O R P R E S C R I B I N G

O P I O I D S F O R C H R O N I C P A I N ( 2 0 1 6 )

✓ Age ≥18 years

✓ Chronic non-cancer pain (CNCP)

✓ 10 Recommendations (PCP, pain specialists, NPs, Regulatory Agencies, Policy Makers)

✓ 3 Good Practice + 10 Expert Guidance Statements

✓ Optimize non-opioid/non-pharmacological Rx

✓ Active SUD, active MH disorder, Hx SUD = non-opioid

✓ Start ORAL; IR or CR ≤ 50 MED; keep <90 MED or refer

✓Initiation, titration and monitoring of response

✓Discontinuation if ….

✓ Patients currently on ≥ 90 MED

✓ Challenges with problematic pain, AEs, tapering

✓ Good Practice: informed consent, monitoring, contraindications/exchange of information

✓ Expert Guidance: amounts prescribed, IR/CR, co- prescribing, sleep apnea, hypogonadism, urine drug screening, treatment agreements, tamper-resistant formulations, patch exchange, naloxone

T H E 2 0 1 7 C A N A D I A N G U I D E L I N E F O R

O P I O I D S F O R C H R O N I C N O N - C A N C E R P A I N

✓ Age ≥18 years

✓ Chronic pain outside of active cancer treatment,

palliative care and end-of-life care

✓ 12 recommendations (PCP/Internists)

✓ Non-pharmacological, non-opioid Rx preferred

✓ What to do before starting opioids and periodically

during opioid therapy: goals, R/B

✓ Start with IR opioids ≤ 50 MME; avoid ≥ 90 MME /justify

✓ Re-evaluation

✓ Acute pain

✓ Re-evaluation for risk of harm, PMP, UDT, BNZ

✓ Evidence-based Rx for OUD

Available at: https://thewellhealth.ca/wp-content/uploads/2017/03/CEP_CNCP_Main_V1.pdf

UPON COMPLETION, PARTICIPANTS

WILL BE ABLE TO:

List useful tools from the Canadian

Guideline for Safe and Effective Use of

Opioids for Chronic Non-Cancer Pain

Identify tips and risk management strategies that can be

used to avoid regulatory attention from the CPSO when

treating patients with chronic pain

Manage chronic pain more effectively and safely in their

practice

AFTER THIS SESSION, PARTICIPANTS WILL BE ABLE TO:

Identify tips and risk management strategies that can be used to avoid

regulatory attention from their College when treating patients with pain

Manage pain more effectively and safely in their practice

“The stories you are about to hear are true; only the

names (and other identifying details) have been

changed to protect the innocent”

http://www.google.ca/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.gif-maniac.com/ordinateur/fichier/&ei=rN2mVPCMKIKQyATjmYCgAw&bvm=bv.82001339,d.aWw&psig=AFQjCNGfQmtw0d7jRa50BuyXhvoNrEIQTg&ust=1420308247778380

CASE 1: ACUTE PAIN

26 y.o. Patient since age 3

What would you do?

Wiped out on dirt bike 3 weeks prior

• Splint and crutches from ER

• Knee still sore

• “On acetaO and Morphine from a friend”

acetaO = acetaminophen 325 mg/oxycodone 5 mg

CASE 1: ACUTE PAIN


Rx acetaO M:30

Wiped out on dirt bike 3 weeks prior

• Splint and crutches from ER

• Knee still sore

• “On acetaO and Morphine from a friend”


CDC, BC, Yukon

NEW MEASURES TO INFORM CANADIANS OF THE RISKS OF PRESCRIPTION OPIOIDS

June 16, 2017 - Ottawa, ON - Health Canada

Canada is facing an opioid crisis. Overdoses related to opioids are claiming the lives of thousands of Canadians of all ages, and from all walks of life. Some who have become dependent on prescription drugs were not even aware that the drugs they had taken contained opioids. Patients receiving prescription opioids need a clear understanding of the risks associated with these drugs, so they can make informed decisions about how to use them as safely as possible or whether to use them at all.

As part of the Government of Canada’s work to reduce problematic opioid use and its related harms, Health Canada is proposing regulations that would make a

warning sticker and patient information handout mandatory with all prescription opioids at the time of sale. This means that no matter where patients and families across Canada fill their prescriptions, the same handout and sticker would be provided to them.

The sticker would be applied by the pharmacist to the prescription opioid container to warn patients about the potential risks associated with opioid use, including dependence, addiction and overdose. The handout would contain broader information on the safe use of opioids, and on the risks associated with these drugs.

Mandatory risk management plans for opioids are also part of the Government of Canada’s commitment to addressing the opioid crisis. Through the proposed regulations, the Minister of Health would be able to require that pharmaceutical companies develop and implement risk management plans for all opioids to identify, mitigate and monitor risks associated with opioid use.

Companies would be required to keep their risk management plans evergreen by monitoring how their products are being used and develop activities should harms associated with use of these products emerge.

To finalize these regulations, Health Canada is asking Canadians to provide their comments via the Canada Gazette website. These consultations will be open for a period of 75 days, ending August 31, 2017.

https://www.canada.ca/en/health-canada/news/2017/06/new_measures_to_informcanadiansoftherisksofprescriptionopioidsou.html

http://www.gazette.gc.ca/rp-pr/p1/2017/2017-06-17/html/reg8-eng.php

https://www.canada.ca/en/health-canada/programs/consultation-opioids-handout-warning-sticker.html

http://www.gazette.gc.ca/rp-pr/p1/2017/2017-06-17/html/reg8-eng.php

CASE 1: ACUTE PAIN

And the following month … Rx acetaO M:30 x2 no visit

And 1 month later … Missed appointment with orthopedics; knee less sore Rx acetaO M:30

And the following year …

Asking for acetaO; since took for knee using 10-20/day



CASE 1: ACUTE PAIN

1 year prior to “wiping out”

26 y.o. Patient since age 3 Addiction and Mental Health

Clinic note:

Substance use Hx:

▪ Heavy user of MJ and EtOH for

past 4-5 years

▪ Often aggressive/fights on

weekends

▪ Trafficking

▪ Tried mushrooms and aceta/oxy

a few times

▪ Denies iv drugs

▪ Family Hx=EtOH, MJ

ACUTE PAIN MANAGEMENT IN PATIENTS WITH

DRUG DEPENDENCE SYNDROME

P AT I E N T C O N C E R N S

▪ Fear of withdrawal

▪ Fear of pain not being taken

seriously, with restricted access to

analgesia and pain left unrelieved

▪ Fear of discrimination

▪ Fear of relapse, if currently

abstinent

C L I N I C I A N C O N C E R N S

▪ Mistrust of those with SUD

▪ Overtreatment of pain, leading to respiratory impairment

▪ Possibility that reports of pain may be fabricated to acquire opioids for euphoria

▪ Diversion of prescribed opioids

▪ Fear that patients may leave AMA and not complete essential medical care

ACUTE PAIN MANAGEMENT IN PATIENTS WITH

DRUG DEPENDENCE SYNDROME

http://www.hqontario.ca/Evidence-to-Improve-Care/Quality-Standards/View-all-Quality-Standards/Opioid-Prescribing-for-Acute-Pain

HQO – draft statement

People taking BUP/naloxone or methadone for the treatment of OUD

continue their medication during acute-pain events whenever possible

Doses of BUP/naloxone may need to be reduced in order to treat acute pain with additional

opioid therapy

Methadone doses can be divided and given every 8-12 hours to provide better acute pain relief

ACUTE PAIN IN PEOPLE WITH OPIOID USE DISORDER (OUD)

PAIN AFTER SURGERY… IS THERE ANY GUIDANCE?

JAMA Surg. Published online September 27, 2017 doi:10.1001/jamasurg.2017.313

Procedure Median Rx length

Appendectomy 4 days

Cholecystectomy 4 days

Inguinal hernia repair 5 days

Hysterectomy 4 days

Mastectomy 5 days

Anterior cruciate ligament repair 5 days

Rotator cuff repair 5 days

Discectomy 7 days


CASE 2. OSTEOARTHRITIS

Performed MSK exams from time to time

Recommended non-pharmacological therapies

Initially prescribed acetaminophen for pain

87y.o. Hx of OP and OA knees & shoulders, plus DDD with spinal stenosis

OP = osteoporosis; DDD = degenerative disc disease; OA = osteoarthritis; Available at: http://nationalpaincentre.mcmaster.ca/opioid

Available at http://nationalpaincentre.mcmaster.ca/guidelines.html

Hip & Knee Hand



Then …

Rx: acetaCc3 i-ii po qid prn

D:120 q month M:720

Rx: meloxicam 7.5 mg

i-ii od prn M:180

Refer: epidural steroid inj

OP = osteoporosis; DDD = degenerative disc disease; OA = osteoarthritis; cfpc.ca/oatool

Available at: http://nationalpaincentre.mcmaster.ca/opioid ;acetaO=acetaminophen/oxycodone (325/5 mg); acetaCc3=T#3=acetaminophen/codeine/caffeine (300 mg/30 mg/15 mg)



Then …

Rx: acetaCc3 i-ii po qid prn

D:120 q month M:720

Rx: meloxicam 7.5 mg

i-ii od prn M:180

Refer: epidural steroid inj

OP = osteoporosis; DDD = degenerative disc disease

Available at: http://nationalpaincentre.mcmaster.ca/opioid ;acetaO=acetaminophen/oxycodone (325/5 mg); acetaCc3=T#3=acetaminophen/codeine/caffeine (300 mg/30 mg/15 mg)


Discharged from hospital

UTI, ARF on a background of CRF …

Creatinine >250 on admission; 132 on discharge (eGFR ~35)

Post discharge visits

Rx: acetaCc3 ‘as directed’ M:180 then…..

Rx: acetaO i po tid D:100 q30 days M:500

Tel-progress from/to pharmacy

Rx: Meloxicam 7.5 mg i-ii po od prn M:180

acetaO=acetaminophen/oxycodone (325/5 mg); acetaCc3=T#3=acetaminophen/codeine/caffeine (300 mg/30 mg/15 mg)





Visit

• 4 bad days; nausea

• ?pneumonia

P: incr acetaO i-ii qid prn

Admitted to hospital

• Epigastric pain; GI bleed

• Hb=65

• 6 gastric ulcers

• 1 duodenal ulcer



What are some of the

issues in the care?



Prescribing of NSAIDs

o eGFR 35-39; adequate monitoring

Opioid rotation

Opioids of choice in the elderly and persons with significant renal impairment

Collaboration (Good Practice Statement #3)


Available at: http://nationalpaincentre.mcmaster.ca/opioid


Choosing Wisely Canada Canadian Society of Nephrology

The use of NSAIDS, including cyclo-oxygenase type 2 (COX-2) inhibitors, for the pharmacological

treatment of musculoskeletal pain can elevate blood pressure, make antihypertensive drugs less

effective, cause fluid retention and worsen kidney function in these individuals. Other medication

prescribed by a healthcare professional may be safer than and as effective as NSAIDs.

http://www.choosingwiselycanada.org/wp-content/uploads/2014/09/Nephrology.pdf

Don’t prescribe nonsteroidal anti-inflammatory drugs

(NSAIDS) in individuals with hypertension or heart failure or

CKD of all causes, including diabetes.



Opioids - Safety Issues

Renal Failure

Avoid codeine & morphine1 for patients with renal dysfunction (Table 3)

Elderly

Nothing in 2017 guideline

Among strong opioids, oxycodone and hydromorphone may be preferred over

oral morphine1

o Less constipation & sedation

12010 Canadian opioid guideline; Available at: http://nationalpaincentre.mcmaster.ca/opioid




Morphine Equivalent Dose (MED)/day

acetaCc3 ii po bid prn ~ _____ MED/day

acetaO i po tid prn ~ _____ MED/day

How many acetaCc3/day is 50 MED/day?

How many acetaO/day is 50 MED/day?

What about 90 MED/day?



http://www.cmaj.ca/content/189/18/E659; 2Available at: http://nationalpaincentre.mcmaster.ca/opioid


2Table 5: Opioid conversion table

UPDATED OPIOID MANAGER / OPIOID SWITCHING FORM

GOOD PRACTICE STATEMENTS

Acquire informed consent prior to initiating opioid use for CNCP. A discussion about potential benefits, adverse effects, and complications will facilitate shared-care decision making regarding whether to proceed with opioid therapy.

Clinicians should monitor CNCP patients using opioid therapy for their response to treatments, and adjust treatment accordingly.

Clinicians with CNCP patients prescribed opioids should address any potential contraindications and exchange relevant information with the patient’s general practitioner (if they are not the general practitioner) and/or pharmacist.

1

2

3



CASE 3. BACK PAIN

Severe back pain with radiation – 1st visit

CT: L4-5 herniation with encroachment

MRI: above with mass effect (2 months after presentation)

MJ=marijuana

acetaO=acetaminophen/oxycodone (325/5 mg); acetaC3=T#3=acetaminophen/codeine/caffeine (300 mg/30 mg/15 mg)

Red flags not asked/documented

Straight leg raise not documented

No pain score, functional ability/disability recorded …

Non-pharmacological therapies/simple analgesics not part of the plan

40y.o. previous left knee injury; smokes cigarettes & MJ

CASE 3. BACK PAIN

RED FLAGS are described by the mnemonic NIFTI:

Neurological progression, Infection, Fracture, Tumor, Inflammation

http://www.topalbertadoctors.org/download/1885/LBPguideline.pdf?_20160225091721

CORE BACK TOOL: PHYSICAL EXAM

Available from Centre for Effective Practice at www.effectivepractice.org

EXPLAIN THE PAIN SCALE IN FUNCTIONAL TERMS:

N A D I R

Requires immediate medical attention

Incapacitated because you can’t function; You miss work,

cancel social activities or stay in bed

You have Difficulty taking care of your responsibilities, rarely

enjoy yourself and your concentration is impaired

Pain is present and may even require regular medication, but

you are Able to continue performing your daily activities

No pain at all

10

8-9

6-7

1-5

0

Whitten CE, et al. Perm J. 2005;9(2):41–48

CASE 3. BRIEF PAIN INVENTORY - FUNCTION

63

Available at: http://nationalpaincentre.mcmaster.ca/opioid

Available at: http://mytopcare.org/prescribers/

CDC Guideline infographic

CASE 3. BACK PAIN

1st follow-up appointment

o No P/E, pain scale, function, questions re bowel/bladder/function …

o Clinician decides to initiate opioids

MJ=marijuana; P/E=physical examination; Available at: http://nationalpaincentre.mcmaster.ca/opioid; acetaO=acetaminophen/oxycodone (325/5 mg); acetaC3=T#3=acetaminophen/codeine/caffeine (300 mg/30 mg/15 mg)


Would you start a patient on an anti-hypertensive without measuring

the blood pressure?

Available at http://nationalpaincentre.mcmaster.ca/guidelines.html; Available at https://www.cma.ca/Assets/assets-library/document/en/advocacy/2139_cma_opioid_poster_en.pdf

R# Possible Scenario

Trial of

opioids? Strength

2 No current or past SUD AND no other active psychiatric disorder YES Weak

3 Active SUD NO Strong

4 Active psychiatric disorder NO Weak

5 History of SUD NO Weak

PROBLEMATIC CNCP DESPITE OPTIMIZED NON-OPIOID THERAPY

HOW DO YOU KNOW IF A PATIENT HAS/HAD A SUD

Patients with CNCP and probable SUD should be screened with the CAGE

screening tool or similar validated questionnaire of alcohol use, and

validates substance abuse/misuse tools such as COMM

Although not evidence-based, UDS and review of prescription drug

monitoring data is suggested initially and periodically


CAGE – AID

https://www.divisionsbc.ca/CMSMedia/Divisions/DivisionCatalog-nanaimo/Documents/Resources/CAGE%20Questionnaire.pdf

Available at: http://nationalpaincentre.mcmaster.ca/documents/comm_sample_watermarked.pdf

HOW DO YOU KNOW IF A PATIENT HAS/HAD A SUD

Patients with CNCP and probable SUD should be screened with the CAGE

screening tool or similar validated questionnaire of alcohol use, and

validates substance abuse/misuse tools such as COMM




RISK MITIGATION

Expert Guidance Statement 6: Urine Drug Screening

A baseline UDS may be useful for patients currently receiving or being

considered for a trial of opioids.

When ordering a UDS, clinicians should ask patients about all

medications/drugs recently taken, and be aware of local resources to assist

them in assessing for potential false positive and false negative results

Clinicians may repeat UDS on an annual basis and more frequently if the

patient is at elevated risk or in the presence of any ADRBs.


RISK MITIGATION

Expert Guidance Statement 7: Treatment Agreements

A written treatment agreement may be useful in structuring a process of

informed consent around opioid use, clarifying expectations for both patient

and physician, and providing clarity regarding the nature of an opioid trial

with endpoints, goals, and strategies in event of a failed trial.


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SOME GUIDING PRINCIPLES FOR INITIATION OF OPIOIDS

Prescriptions should be provided by the primary treating physician only,

for no more than 28 days at a time. Intervals may be shorter when

initiating therapy, in cases of suspected diversion or during dose

escalation


CASE 3. OPIOID INITIATION CHECKLIST

1st follow-up appointmento No P/E, pain scale, questions re bowel/bladder/function …

o Referral to neurosurgeon

o ORT done

o UDS requested

o No Treatment agreement found

acetaCc3 i po tid prn

M:270 D:90 q30 d

MJ=marijuana; P/E=physical examination; Available at: http://nationalpaincentre.mcmaster.ca/opioid; acetaO=acetaminophen/oxycodone (325/5 mg); acetaCc3=T#3=acetaminophen/codeine/caffeine (300 mg/30 mg/15 mg)


CASE 3. URINE DRUG SCREENING

Two (2) UDS were found in the chart, both with same date

o 1st positive for:

✓ BNZ, opiates, oxycodone, GBP and cotinine

o 2nd positive for:

✓ THC, cotinine

MJ=marijuana; BNZ=benzodiazepine; GBP=gabapentin

acetaO=acetaminophen/oxycodone (325/5 mg); acetaC3=T#3=acetaminophen/codeine/caffeine (300 mg/30 mg/15 mg)


• Always compare the UDS result to the actual patient chart/drugs prescribed -

Are the prescribed drugs/metabolites present?

- Are any prescribed drugs absent?

- Are there any unexpected drugs present?

- Read any comments listed by the laboratory

• If you encounter an inconsistent/unexpected UDS, your first action should be:

To take a careful history of medication/drug use in the past week and discuss

openly with the patient – without being accusatory

• Each type of inconsistent UDS result has a differential diagnosis and actions

for the clinician to take – documentation is key

Don’t rely on

your memory

DO YOU RECOMMEND THE USE OF GABAPENTANOIDS FOR

YOUR PATIENTS WITH ACUTE OR CHRONIC SCIATICA?

TRIAL OF PREGABALIN FOR ACUTE AND CHRONIC SCIATICAMathieson S et al, NEJM 2017 1111-1120

METHODS

We conducted a randomized, double-blind, placebo-controlled trial of pregabalin in patients with sciatica. Patients were randomly assigned to receive either pregabalin at a dose of 150 mg per day that was adjusted to a maximum dose of 600 mg per day or matching placebo for up to 8 weeks. The primary outcome was the leg-pain intensity score on a 10-point scale (with 0 indicating no pain and 10 the worst possible pain) at week 8; the leg-pain intensity score was also evaluated at week 52, a secondary time point for the primary outcome. Secondary outcomes included the extent of disability, back-pain intensity, and quality-of-life measures at prespecified time points over the course of 1 year.

RESULTS

A total of 209 patients underwent randomization, of whom 108 received pregabalin and 101 received placebo; after randomization, 2 patients in the pregabalin group were determined to be ineligible and were excluded from the analyses. At week 8, the mean unadjusted leg-pain intensity score was 3.7 in the pregabalin group and 3.1 in the placebo group (adjusted mean difference, 0.5; 95% confidence interval [CI], −0.2 to 1.2; P=0.19). At week 52, the mean unadjusted leg-pain intensity score was 3.4 in the pregabalin group and 3.0 in the placebo group (adjusted mean difference, 0.3; 95% CI, −0.5 to 1.0; P=0.46). No significant between-group differences were observed with respect to any secondary outcome at either week 8 or week 52. A total of 227 adverse events were reported in the pregabalin group and 124 in the placebo group. Dizziness was more common in the pregabalin group than in the placebo group.

CONCLUSIONS

Treatment with pregabalin did not significantly reduce the intensity of leg pain associated with sciatica and did not significantly improve other outcomes, as compared with placebo, over the course of 8 weeks. The incidence of adverse events was significantly higher in the pregabalin group than in the placebo group.

DO YOU RECOMMEND THE USE OF GABAPENTANOIDS FOR

YOUR PATIENTS WITH CHRONIC BACK PAIN?

• Gabapentin was associated with a small reduction in pain compared with placebo (very-low-quality evidence)

• Pregabalin was less effective than comparator treatments (e.g., amitriptyline, celecoxib) in relieving

pain (very-low-quality evidence)

• Gabapentin was associated with increased risks for dizziness (number needed to harm, 7), fatigue

(NNH, 8), mental difficulties (6), and visual disturbances (6)

• Pregabalin was associated with elevated risk for dizziness (NNH, 11)

Researchers examined eight randomized trials in which gabapentin or pregabalin was compared with active or inactive treatments in adults with low back pain lasting at least 3 months. Doses ranged from 300–3600 mg/day for gabapentin and 100–600 mg/day for pregabalin.

Among the findings:

The researchers conclude, "Given the lack of efficacy, risks, and costs

associated, the use of gabapentinoids for low back pain merits caution."

GUIDANCE ON LOW BACK PAIN

TOP [Toward Optimized Practice - Alberta] (2015)

▪ http://www.topalbertadoctors.org/download/1885/LBPguideline.pdf?_20160225091721

CORE Back Tool (2016)▪ http://effectivepractice.org/resources/low-back-pain-core-back-tool/

Healthy Back Exercises▪ http://www.health.gov.sk.ca/for-patients

Choosing Wisely Canada – Patient brochure▪ http://www.choosingwiselycanada.org/wp-content/uploads/2015/05/Treating-lower-back-

pain-EN.pdf

GUIDANCE ON LOW BACK PAIN

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians▪ http://www.dssimon.com/MM/ACP-low-back-pain-guideline/files/ACP_LBP_Guideline.pdf

Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline▪ http://annals.org/aim/article/2603229/systemic-pharmacologic-therapies-low-back-pain-

systematic-review-american-college

3 minute Back Exam▪ https://www.youtube.com/watch?v=YcivUFHpKo4

NON-OPIOID OPTIONS

2017 Canadian Guideline

▪ CADTH: Alternatives to opioids

▪ https://cadth.ca/evidence-bundles/opioid-evidence-bundle/browse-category#alternatives

▪ Table 2: Non-opioid therapies for CNCP

Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline

▪ http://annals.org/aim/article/2603230/nonpharmacologic-therapies-low-back-pain-systematic-review-american-college-physicians

CDC Nonopioid Treatments for Chronic Pain

▪ https://www.cdc.gov/drugoverdose/pdf/alternative_treatments-a.pdf

FREE ON-LINE BEHAVIOURAL OPTIONS

MoodGYM

▪ https://moodgym.anu.edu.au/welcome

Mindfulness programs

▪ Many free on-line programs

o e.g. https://www.futurelearn.com/partners/monash-university

PAIN BC▪ https://www.painbc.ca/

▪ http://www.selfmanagementbc.ca/chronicpainprogram


CASE 4: POSTAL WORKER

45 y.o. Postal worker CNCP = CLBP + knee pain (L>R)

2010

o On CR OC 40 mg ii tid + aceta/oxy prn

o Recently switched to truck run from walking route

o Wakes SOB at night; stops breathing = witnessed by girlfriend

▪ Sleep study = severe primarily central sleep apnea – likely opiate

o Mood worsening = decrease CR OC 40 mg tid + add TDS F 25 q3d

o No change in mood; start antidepressant + incr TDS F 50 q3d



Ca

Can this postal worker

drive safely on long-term

daily opioid therapy?

SOME GUIDING PRINCIPLES FOR A TRIAL OF OPIOIDS

During dosage titration, advise patients to avoid driving a motor vehicle until a stable dosage is established and it is certain the opioid does not cause sedation. This is especially true when taking opioids with alcohol, benzodiazepines or other sedating drugs.

Other potential AEs of opioids that warrant consideration include falls, fractures, sleep-disordered breathing (including sleep apnea), depression and a worsening of pain itself (OIH).


SLEEP APNEA

Expert Guidance Statement 4: Sleep Apnea

Patients with opioid-induce sleep apnea should be advised of

the associated health risks, and particularly the risk of

operating a motor vehicle. Clinicians may have a statutory duty

to report to governmental licensing authorities.




2011

o 3 notes from sleep clinic = did not show up for titration/reassessment

▪ Expressed concerns re driving/MOH



2012

o Increase in pain meds give him more energy

2013

o Severe depression = short term disability

CR oxycodone 40 mg qid

aceta/oxy ii bid prn

clonazepam 0.5 mg bid

different antidepressant

testosterone replacement



CO-PRESCRIBING WITH OPIOIDS

Expert Guidance Statement 3: Co-prescribing with Opioids

Available studies yield conflicting results regarding the consequences of the

concomitant use of opioids and sedatives such as benzodiazepines (BNZ)

The expert perspective is that opioids and BNZ should

very rarely be prescribe together


CO-PRESCRIBING WITH OPIOIDS

What would the provinces say

Expert Guidance Statement 3: Co-prescribing with Opioids

ASHTON MANUAL

BENZODIAZEPINES: HOW THEY WORK AND HOW TO WITHDRAW

• PROTOCOL FOR THE TREATMENT OF BENZODIAZEPINE WITHDRAWAL• Medical research information from a benzodiazepine withdrawal clinic

Professor C Heather Ashton DM, FRCPRevised August 2002

• Ashton Manual Index Page• Contents Page• Introduction• Chapter I: The benzodiazepines: what they do in the body• Chapter II: How to withdraw from benzodiazepines after long-term use• Chapter II: Slow withdrawal schedules• Chapter III: Benzodiazepine withdrawal symptoms, acute & protracted

http://www.benzo.org.uk/manual/

TAPERING BENZODIAZEPINES

http://www.benzo.org.uk/manual/contents.htm

http://www.benzo.org.uk/manual/bzcha00.htm



http://www.benzo.org.uk/manual/bzsched.htm


HYPOGONADISM

Expert Guidance Statement 5: Hypogonadism

As there is a high prevalence of secondary hypogonadism in this

population, clinicians treating men using chronic opioid therapy should

consider an evaluation for hypogonadism.

Clinicians should advise patients who are diagnosed with opioid-induced

hypogonadism regarding the potential short-term AEs, including: reduced

sexual function, amenorrhea, fatigue, mood changes and the long-term risk of

osteoporosis


HYPOGONADISM

Patients should be offered opioid tapering as the

initial strategy to correct hypogonadism

If opioid tapering is unsuccessful or declined,

clinicians may offer testosterone

supplementation therapy

Expert Guidance Statement 5: Hypogonadism


AND IF YOU ARE PRESCRIBING TESTOSTERONE REPLACEMENT …

PRESCRIBING TESTOSTERONE REPLACEMENT

Follow current guidance

Key recommendations:Diagnosis•Physicians should conduct a thorough patient history and physical examination to identify patients who should undergo biochemical testing.•The initial biochemical test should be measurement of total testosterone levels in samples taken in the morning between 7 am and 11 am (or within 3 hours after waking for shift workers).Treatment and monitoring•Men with a diagnosis of testosterone deficiency and no contraindications should receive testosterone therapy.•If symptoms of testosterone deficiency are convincing but laboratory tests are uncertain, a 3-month trial of testosterone replacement therapy is recommended.•For men who wish to preserve fertility over relieving symptoms, the task force recommends against testosterone therapy.•Men with testosterone deficiency syndrome and stable cardiovascular disease are candidates for testosterone treatment.•For men with metastatic prostate cancer, the task force recommends against treatment for testosterone deficiency.•Assessment of a patient's response to testosterone therapy at 3 and 6 months is recommended, looking at benefits and adverse effects.



2013

o Severe depression = short term disability

CR oxycodone 40 mg qid

aceta/oxy ii bid prn

clonazepam 0.5 mg bid

different antidepressant

testosterone replacement



Consult note from Psychiatrist #1:

o Started smoking again; 5 cups coffee/day

o Actually using CR OC 40 mg 18 tab/day (MED > 1000)

✓ Dx Axis I: likely substance-induced Sx secondary to large dose of narcotics



6 months later ……

Independent Opinion from Psychiatrist #2 (on LTD)

o On CR OC 40 mg 12-16 tab/day

✓ “Depressed mood, lack of energy/motivation, cognitive disturbances with

memory/focus and attention issues; uses lots of caffeine possibly to counteract

sedative effects of opioid use and ends up with Sx of anxiety/palpitations”

WHAT ABOUT …

Depression



Few months later ….

o c/o of gasping for breath; wants to be reassessed/go on CPAP

Sleep clinic

o Dx with OSA >4 years prior = never went on treatment

Available at https://www.cma.ca/Assets/assets-library/document/en/advocacy/2139_cma_opioid_poster_en.pdf

Reduction in opioid dose

may reduce AEs, including

cognitive impairment and

likelihood of nonfatal or

fatal unintentional

overdose.

If not done gradually, dose

reduction may cause

increased pain, decreased

function or highly aversive

symptoms of opioid

withdrawal.


NEW OPIOID SWITCHING FORM


“

“We continue to believe the prescribing of opioids is an important part of clinical practice, with

some patients achieving improvement in pain and function. But it also presents risks.

With the introduction of this guideline, physicians may re-evaluate how they prescribe opioids.

If relevant, particular attention needs to be paid to the guidelines’ recommendation about

tapering. If a dose is not reduced gradually, it may cause increased pain, decreased function or

opioid withdrawal which can be dangerous. Sudden cessation is never acceptable.”

College of Physicians and Surgeons of Ontario. Response to new Guideline; available at: cpso.cn.ca

TAPERING PLAN … BE MOTIVATIONAL

FRAMING THE CONVERSATION

Empathic tone

Concern

Shared responsibility

Optimism

“We know more about safety problems related to

opioids and we are concerned about your health and

safety. We recognize that we/the system prescribed

you these medications so now we want to help you be

safer while still managing your pain. The good news –

many patients feel better once they are on lower

doses”


Other Recommendations

Offer choice/flexibility when possible

▪ Which med would you like to decrease first?

▪ Which dose of the day could you most easily lower?

Success in each step down breed success

Offer patients option to ‘pause’ prn


Fast -

Slow-

Methadone or buprenorphine-naloxone

TO HELP WITH SYMPTOMS DURING TAPERING …

Clonidine has been used the longest to decrease some of the autonomic symptoms of opioid

withdrawal.

The main side effects are orthostatic hypotension and sedation. Prescribe 0.1-0.2 mg po q6h prn

maximum 6 tabs per day. The dose may have to be lowered if the patient reports orthostatic

symptoms or has a BP less than 90/60 mmHg, 1 hour after a dose. Continue clonidine until off of

opioids for 3-5 days then taper over next 3-5 days.

One of the early symptoms of opioid withdrawal is pain –the patient’s usual pain plus additional

arthralgias and myalgias - which may persist longer than other withdrawal symptoms, but will

eventually settle.

Acetaminophen, NSAIDs may be helpful. If attempting to re-evaluate a patient’s pain off of opioids,

the opioids need to be discontinued for at least 3-4 weeks to get through withdrawal pain and allow

opioid receptors to “reset.” It can take longer for an individual’s natural opioids to begin production.

Acupuncture or TENS have been shown in some studies to decrease symptoms of opioid withdrawal.

Short-term use of an antiepileptic such as carbamazepine or gabapentin or pregabalin, or the

cannabinoid nabilone for the first 1-2 weeks may help with sleep and anxiety.

TAPERING OPIOIDS – OTHER GUIDANCE

Alberta https://fmf.cfpc.ca/wp-content/uploads/2016/10/S132052_Motivational-Interviewing-to-

Support-Opioid-Tapering.pdf

WCH/ISMP

https://www.ismp-canada.org/download/OpioidStewardship/Opioid-Prescribing-Skills.pdf

CDC Pocket Guide: Tapering Opioids for Chronic Pain

https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf

Navigating Opioids for CNCP Infographic

http://www.cpd.utoronto.ca/opioidprescribing/navigating-opioids/

TAPERING OPIOIDS – OTHER GUIDANCE

P Squire and R Jovey; Managing Opioid Withdrawal for Physicians

http://med-fom-tcmp.sites.olt.ubc.ca/files/2014/06/For-Physicians-TCMP-2014-Managing-

Opioid-Withdrawal.pdf

P Squire and R Jovey; Manging Opioid Withdrawal for Patients

http://med-fom-tcmp.sites.olt.ubc.ca/files/2014/06/For-Patients-TCMP-2014-Managing-

Opioid-Withdrawal.pdf

OTHER GUIDANCE

Opioids and Driving

http://www.driveable.com/

http://www.mard.ualberta.ca/SIMARDMD.aspx

http://thischangedmypractice.com/drive-on-opioid-medication/

Questionnaires for Sleep Disorders

http://www.topalbertadoctors.org/download/1923/Sleep%20Disorders%20Questionnaire.pdf

http://stopbang.ca/translation/pdf/caeng.pdf


CASE 5. FIBROMYALGIA

SR M 200 mg tid x 2 months

GBP 300 mg tid x 2 months

Zopiclone 7.5 mg ½-i hs M:50 Feb

Zopiclone 7.5 mg i hs x100 days Jun

Zopcilone 7.5 mg i-ii hs x100 days Aug, Oct, Nov

Pain: NRS = 4-5/10 with walking, otherwise 2/10

Pill count: M = 0 left

POC UDS: M

60 y.o. CNCP = FM

SR=sustained release; M=morphine

GBP=gabapentin; FM=fibromyalgia; POC=point of care IA=immunoassay

Feb, Jun, Nov


Available at: https://rheum.ca/images/documents/2012CanadianFMGuidelines_17August2012.pdf

60 y.o. CNCP = FM

Important Safety Information on Zopiclone

Dear Healthcare Professional, November 19, 2014

Subject: New dosage recommendations for IMOVANE® (zopiclone) to

minimize the risk of next-day impairment

The recommended starting dose has been reduced to 3.75 mg (one-half of the

7.5 mg tablet). IMOVANE should be taken once per night at bedtime. The lowest

effective dose for each patient should be used.

The prescribed dose should not exceed 5 mg in elderly patients, in patients with

hepatic or renal impairment or those currently treated with potent CYP3A4

inhibitors. Dose adjustment may be required with concomitant use with other CNS-

depressant drugs.

Patients should be instructed to wait for at least 12 hours after dosing before driving

or engaging in other activities requiring full mental alertness, especially for elderly

patients and for patients who take the 7.5 mg dose.

http://www.dentalvideos.com/









GCMS UDS: codeine, norcodeine, M

60 y.o. CNCP = FM



Feb, Jun, Nov

OTC=over-the-counter

Could the patient be only taking OTC acetaCc1 ?

If so, what might happen if Rx is for SR M 100 mg v/day ?




Zopiclone 7.5 mg ½-i hs M: 50 Feb





Feb, Jun, NovThe patient moves practices and you have now taken over care

60 y.o. CNCP = FM

The patient moves practices, you have now taken over care and you work in BC

https://www.youtube.com/user/HunterBrainman




Is this FM ?

Is this opioid-induced hyperalgesia (OIH) ?

Is this tolerance ?

60 y.o. CNCP = FM

OPIOID-INDUCED HYPERALGESIA (OIH) VS. TOLERANCE

Two occurrences with high dose /chronic opioid therapy:

OIH: Patients paradoxically demonstrate an increased sensitivity

to painful stimuli (i.e. hyperalgesia, allodynia or both)

Tolerance: Prolonged exposure to opioids results in a shift of the

dose-response curve to the right; in other words a larger dose

of opioids is needed over time to produce the same level of

analgesia

Condition Clinical features Onset

Response to

opioid Rx

OIH ▪ Pain may occur at a different

location and can be widespread

▪ Usually poorly defined in terms of

region and quality

Abrupt or

gradual

Pain worsens

Tolerance ▪ Characterized by persistent pain

and is localized

Gradual Pain improves

OPIOID-INDUCED HYPERALGESIA (OIH) VS. TOLERANCE

• 3 wk, daily rehab program

• Established opioid use

• Individual tapering plan

• COWS daily to monitor withdrawal

• Mean opioid dose 99 MED (range 5-600)

• 38% on multiple or combination opioids

• Used pt’s usual opioid

• Faster dose reduction at the beginning

• No adjuvants other than clonidine

✓11/55 used clonidine

• Peak withdrawal when taper was 60-80% complete

• Duration of taper:

<100 MED = mean 10 days

>200 MED = mean 28 days

• No difference based on duration of opioid use

OPIOID TAPERING IN FM – “REAL LIFE” EXPERIENCE

Cunningham et al, Opioid Tapering in FM patients: Experience from an Interdisciplinary Pain Rehab Program. Pain Med 2016 17 (9) 1676-1685

55 consecutive pts with FM admitted to Mayo Clinic Rehab Centre

OPIOID TAPERING IN FM – “REAL LIFE” EXPERIENCE

At admission, pts on opioids had higher pain scores, more depression,

lower functional status

At discharge both groups improved significantly on pain severity,

depression, catastrophizing, health perception, interference with life and

perceived life control

By discharge, no significant differences between groups

Cunningham et al, Opioid Tapering in FM patients: Experience from an Interdisciplinary Pain Rehab Program. Pain Med 2016 17 (9) 1676-1685

55 consecutive pts with FM admitted to Mayo Clinic Rehab Centre

GUIDANCE

OIHo http://ceaccp.oxfordjournals.org/content/14/3/125

o http://www.integration.samhsa.gov/pbhci-learning-community/opioid-

induced_hyperalgesia_article.pdf

Understanding Pain: Brainman stops his opioidso youtube.com/watch?v=MI1myFQPdCE

Fibromyalgia

o https://rheum.ca/images/documents/2012CanadianFMGuidelines_17August2012.pdf

o www.mdpi.com/2227-9059/5/2/20/pdf

GUIDANCE

Neuropathic Paino https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4273712/

o https://www.nice.org.uk/guidance/cg173/evidence/neuropathic-pain-pharmacological-

management-full-guideline-191621341

o http://www.watag.org.au/watag/docs/Advisor_Note_Neuropathic_Pain_Guidelines.pdf

o http://care.diabetesjournals.org/content/diacare/40/1/136.full.pdf

Managing Opioid Withdrawal –Information for Patients o http://www.bcwomens.ca/Professional-Resources-

site/Documents/Opioid%20Taper%20and%20Withdrawal.pdf









GCMS UDS: codeine, norcodeine, M



Feb, Jun, Nov

What else might

you consider for

this patient?

60 y.o. CNCP = FM


60 y.o. CNCP = FM


CNCP Condition Quality of Evidence Therapies with some evidence of

effectiveness

Fibromyalgia (FM) Moderate Regular physical exercise probably

reduces pain in patients with FM

IS THERE EVIDENCE OF RATIONAL PRESCRIBING?

Centralized Pain

NSAIDs -

Opioids -

TCA +

SNRI +

Gabapentinoids +

Cannabinoids ?

Surgery / Injections -

TRICYCLIC ANTIDEPRESSANTS = TCA

Off-label for painPain relief independent of antidepressant effectBenefits evident in 1-2 weeks at adequate dosing

▪Start low dose (10mg)

• Titrate to effect or to maximum tolerated dose

• To decrease morning drowsiness, take at least 10-12 hrs before wake time, not at bedtime

Caution:

▪ Narrow-angle glaucoma, BPH, severe liver disease, suicide risk, severe cardiac conduction

(QTc > 440 msec /AV block)

▪ Baseline ECG recommended

VENLAFAXINE

Acts as SNRI only at higher doses (150-225 mg/day)

Off-label for pain

▪ Metabolism: hepatic (CYP 2D6)

▪ Elimination: renal

• Cautions: increased BP, recent unstable cardiac disease, bone fracture risk …

• Contraindications: MAOIs

Effexor XR® Product Monograph, November 2013 http://www.pfizer.ca/en/our_products/products/monograph/314

Pristiq® Product Monograph, July 2013 http://www.pfizer.ca/en/our_products/products/monograph/226

DESVENLAFAXINE

Active metabolite of venlafaxine MDD=50 mg/day

Off-label for pain

▪13-week RCT fixed-dose study of desvenlafaxine

• 50, 100, 200 or 400 mg/day in adults with painful DPN

• Week 13: mean change from baseline in NRS

o50 mg 0.58 (NS) 100 mg 0.59 (NS) 200 mg 1.10 (p=0.001) 400 mg 0.91 (p=0.027)

• Improvement in function at all doses

• Dose-dependent increase in the incidence of AEs and withdrawals due to AEs

Effexor XR® Product Monograph, November 2013 http://www.pfizer.ca/en/our_products/products/monograph/314

Pristiq® Product Monograph, July 2013 http://www.pfizer.ca/en/our_products/products/monograph/226

DULOXETINE

Pain approvals in Canada*:

▪NeP associated with DPN

▪Pain associated with fibromyalgia

▪Chronic low back pain

▪Pain associated with osteoarthritis of the knee

• Metabolism: hepatic (CYP 1A2, 2D6)

• Elimination: renal

• Titration: 30 mg daily (breakfast/lunch) 60-120 mg daily

▪ Cautions: increased BP & HR, bone fracture risk …

▪ Contraindications: severe liver/kidney disease; MAOIs, linezolid, potent CYP1A2 inhibitors

*Cymbalta® Product Monograph, June 2013, http://www.lilly.ca/cymbaltapm/en

GABAPENTIN

α2/δ ligand in voltage-gated Ca-channelsOff-label for pain in Canada

▪Common adverse effects (AEs)

• Somnolence, dizziness, fatigue, ataxia

▪Slower titration than pregabalin; q3-7d titration

• Start 100-300mg qhs q12h 300mg q8h maximum 2.4-3.2g/d

▪Adjust dosing in renal insufficiency

Neurontin® Product Monograph, December 2013 http://www.pfizer.ca/en/our_products/products/monograph/128

PREGABALIN

Higher affinity for α2/δ than gabapentin

Officially indicated for NeP of PHN & DPN plus pain in FM

Conditionally indicated for central NeP

▪Linear absorption kinetics – q12h dosing

▪Weekly titration starting at 25-75mg qhs q12h 300mg q12h

▪Effects may be seen within 1-2 weeks of adequate dosing

▪Adverse effects similar to gabapentin

• Dizziness, drowsiness, watch for peripheral edema

▪Adjust dosing in renal insufficiency

Finnerup et al. Pain, 2005

Lyrica® Product Monograph, January 2013, http://www.pfizer.ca/en/our_products/products/monograph/141

CANNABINOIDS

▪Compounds that act at cannabinoid receptors

• Endocannabinoids – endogenous ligands

• Phytocannabinoids – plant origin (cannabis/MJ)

▪ At least 80 different cannabinoids in cannabis

▪ Different strains have different relative concentrations

▪ THC - primary psychoactive cannabinoid in cannabis (UDS)

▪ CBD - not psychoactive

• Synthetic cannabinoids

PRESCRIPTION CANNABINOIDS

Nabilone Nabiximol Medical Marijuana (ACMPR)

Source Synthetic

cannabinoid(THC analog)

Δ9-THC:CBD Cannabis sativaTHC + other cannabinoids + other

compounds

Indications ▪ Severe nausea and

vomiting associated

with cancer

chemotherapy

▪*Adjunctive treatment for the

symptomatic relief of neuropathic pain

in multiple sclerosis in adults

▪ Adjunctive analgesic treatment in adult

patients with advanced cancer who

experience moderate to severe pain

during the highest tolerated dose of

strong opioid therapy for persistent

background pain

▪ Authorized HCPs decide which patients are

eligible

▪ The amount of dried marijuana that can be

possessed at any one time is the lesser of 30 x

daily amount stipulated by HCP or 150 g

▪ Through licensed producers (LPs) patients can

access fresh or dried MJ, or cannabis oil

▪ Some Colleges specifically prohibit clinicians

from applying to become LPs

Availability Oral capsule

- 0.25 mg,

0.5 mg, 1 mg

Buccal Spray

(27 mg/mL Δ9-THC : 25 mg/mL CBD)

- 5.5 mL vials; metering pump delivers

100 µL per spray

• Individuals can register with Health Canada to

produce marijuana for their own medical

purposes, or to designate someone else to

produce it for them

• Only LPs are authorized to sell or provide

medical marijuana.

*Approved under the Notice of Compliance with Conditions (NOC/c) Policy for its indicated uses. Patients should be advised of the conditional nature of the authorization; Product Monographs – Nabilone, Mar. 2009; Δ9-THC and CBD buccal spray, Dec. 2008

.

THC - tetrahydrocannabinol

CBD - cannabidiol

Conclusions: Limited evidence suggests that cannabis may

alleviate neuropathic pain in some patients, but insufficient

evidence exists for other types of chronic pain. Among

general populations, limited evidence suggests that

cannabis is associated with an increased risk for adverse

mental health effects.

GUIDANCE ON CANNABINOID PRESCRIBING

Your College’s guidelines/policies

CMPA (revised August 2016)▪ https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2014/medical-

marijuana-new-regulations-new-college-guidance-for-canadian-doctors

CFPC (preliminary guidance, September 2014)▪ http://www.cfpc.ca/uploadedFiles/Resources/_PDFs/Authorizing%20Dried%20Cannabis

%20for%20Chronic%20Pain%20or%20Anxiety.pdf

PRESCRIBING CANNABINOIDS

Many Colleges state that:

▪ More information is required on the medical risks and therapeutic benefits of marijuana

▪ Suggest that clinicians should only sign the medical document when they have the necessary clinical knowledge to engage in a meaningful consent discussion with patients

Some Colleges suggest:

▪ Trial Nabilone first

▪ Treat MJ/monitor MJ as you would an opioid

Risks:

▪ Mood, cognitive impairment, COPD, CVS, hepatic, hyperemesis, pregnancy/adolescents, cannabis use disorder …

▪ One joint =0.5 g 95% of patients use <3 g/day

▪ The scientific evidence for cannabis oils is lacking


CASE 6. THE TRAVELLING PATIENT

2014o CR OC 80 mg i q8h on provincial drug plan

o Jun pharmacy request for vacation supply M:660o Sep going to be away in US for 6/12 M:665

2015o Jan away until June M:665o May tic bite M:665o July incr CR OC 80 mg ii q8h + going away M:120 + 120

o Oct 16 will be away 3-4 month M:480

60 y.o. woman CNCP = arthritis both knees, marital issues, anxiety/depression

CASE 6. THE TRAVELLING PATIENT

2014o CR OC 80 mg i q8h on provincial drug plan

o Jun pharmacy request for vacation supply M:660o Sep going to be away in US for 6/12 M:665

2015o Jan away until June M:665o May tic bite M:665o July incr CR OC 80 mg ii q8h + going away M:120 + 120

o Oct 16 will be away 3-4 month M:480

60 y.o. woman CNCP = arthritis both knees, marital issues, anxiety/depressio2n

▪ Prescriptions should be provided by the primary treating physician only for no more than 28 days at a time

▪ Intervals may be shorter when initiating therapy, in cases of suspected diversion or during dose escalation

SOME GUIDING PRINCIPLES FOR INITIATION OF OPIOIDS

Experts feel that it is reasonable to limit the amount of opioids prescribed at one time, but

also recognize that such policies may inconvenience patients who are travelling for

extended periods of time. Flexibility in such situations may be desirable

Expert Guidance Statement 1: Restriction in amounts of opioids prescribed


MY ADVICE FOR THE “TRAVELLING” PATIENT ON OPIOIDS

When going

How getting there

Where staying

To see plane/bus/train tickets

If on a provincial drug plan = ensure patient clears with appropriate authorities

Call contacts with patient sitting in front of you in the office


CASE 7. A YOUNG BOY

NMS record for hydrocodone liquid 200 cc:o Feb, Apr, Jun

Corresponding paper chart/EMR records for above dates:o Feb = URI; nothing about cougho Apr = diarrheao Jun = no visit

9 y.o. male = autism spectrum disorder, global development delay

CASE 7. A YOUNG BOY

Codeine is already not recommended for

children under age of 12, for any use.

Codeine should no longer be use

(contraindicated) in patients under 18 years of age to treat pain after

surgery to remove tonsils or adenoids, as

these patients are more susceptible to the risk of

serious breathing problems.

Hydrocodone is no longer recommended for children under six

years of age. This recommendation is

based on rare cases of serious breathing

problems including deaths in children in

this age group, usually involving higher-than recommended doses.


Health Canada – July 2016

New safety measures for prescription codeine and hydrocodone to further restrict use in children and adolescents

CASE 7. A YOUNG BOY AND HIS FATHER

40 y.o male = Hx ACL repair; pain both shoulders and right knee





CR OC 80 mg M:200 Jun 2, 16, 26 Jul 9, 23 Aug 7, 21 Sep 4, 18 Oct 2, 15, 30 Nov 13, 27 Dec 10

CR OC 80 mg M:400 Dec 30

Aceta/oxy M:180 same dates as CR OC

SR M 60 mg M:60 Jun 2, 16, 26 Jul 9, 23 Aug 7, 21 Sep 4

SR M 10 mg M:60 Oct 2, 15, 30

Hydrocodone 300 cc Jun 2 Jul 9, 23 Aug 7, 21 Sept 4 Oct 2, 15 Nov 13, 27 Dec 30





CR OC 80 mg M:200 Jun 2, 16, 26 Jul 9, 23 Aug 7, 21 Sep 4, 18 Oct 2, 15, 30 Nov 13, 27 Dec 10

CR OC 80 mg M:400 Dec 30

Aceta/oxy M:180 same dates as CR OC

SR M 60 mg M:60 Jun 2, 16, 26 Jul 9, 23 Aug 7, 21 Sep 4

SR M 10 mg M:60 Oct 2, 15, 30

Hydrocodone 300 cc Jun 2 Jul 9, 23 Aug 7, 21 Sept 4 Oct 2, 15 Nov 13, 27 Dec 30


Office visits:

Jan = all meds renewed early; froze,

then tried to melt them

Apr = 1-month supply; was at

grandmother’s and meds given to

drug store to destroy

Oct = All meds released early

CMAJ June 2017; https://www.ncbi.nlm.nih.gov/pubmed/28346310

Benzodiazepines, stimulants, testosterone, MJ …

Loperamide abuse:

o Recreational use of loperamide for its euphoric properties or to lessen symptoms of opioid withdrawal involves large oral dosages (>70 mg/day)

Gabapentanoid abuse:

o Gabapentin and pregabalin are abused for its euphoric/disassociation properties, particularly in the substance misuse population, especially as large quantities in a single dose

OTHER PRESCRIPTION DRUGS OF ABUSE TO THINK ABOUT


CASE 8: NEW PATIENT

Moved from BC 6 wks prior

o DM (insulin-dependent)

o Crohns (prednisone 15 mg); off biologic therapy x2 months

o Ca transverse colon – 2 surgeries

o Lost 20 lbs in last 6 wks; night sweats 2/52

o On B12 inj, antidepressant

C/o increasing severe upper abdominal pain

Using IR oxycodone 10 mg iv q4h

30 y.o. female = new patient; referred by ER

CASE 8: NEW PATIENT

1st visit

o Blood sugar measured …

o B12 injection done

o No abdominal exam done


Oxycodone IR 10 mg iv q4h

M:240

CASE 8: NEW PATIENT

2nd visit = 1 week later

o “lost previous script”



M:240

CASE 8: NEW PATIENT

3rd visit = 10 days later



M:720 D:240 q10d

CASE 8: NEW PATIENT

NMS/PMP data




Visit Oxycodone 10 mg

1st D:240

2nd lost previous script [7 days later] D:240

3rd [10 days later] D:240

CASE 8: NEW PATIENT

Doctors and pharmacies still doling out opioids to addicted patients, study finds man receives 26

prescriptions for opioids and other addictive drugs from 10 doctors in 4 months

By Angela Sterritt, CBC New Posted: Feb 22, 2017 7:32 PM PT Last Updated: Feb 22, 2017

A new case study is reminding doctors of the dangers of opioid shopping — where addicted patients

jump from doctor to doctor in search of drugs.

The College of Physicians and Surgeons of B.C., which published the study, says a database called

PharmaNet that tracks a patient's prescription drug use could mitigate the problem.

The study describes a 39 y.o. man who goes shopping for opioids and other addictive

drugs and receives more than 26 prescriptions from 10 different physicians in four months.


40 y.o. CNCP = numerous MSK complaints (shoulder, knee, back, MVAs …)

Can’t find meds

Gave father some of his meds

Borrowing meds

Meds stolen

Lost meds

Poked by needle

Tel: issues from venipuncture

Rx: Keflex

Morgellons disease

ADD

CASE 9. ABERRANT DRUG-RELATED BEHAVIOURS / OUD

2004 2006 2008 2010 2012

note from specialist: 17 yrs substance

abuse = iv; cocaine, narcotics …

CASE 9. ABERRANT DRUG-RELATED BEHAVIOURS / OUD

40 y.o. CNCP = numerous MSK complaints (shoulder, knee, back, MVAs …)

2013

Dog bite

2014

Tel:

Cut self & infected

ER for same :

Hx of cocaine abuse; recent relapse … injecting self with

self-clean needles

Tel x 3 for:

Stolen pills, misplaced pills,

2 month vacation

Indicator Examples

*Altering the route of delivery •Injecting, biting or crushing oral formulations

*Accessing opioids from other sources •Taking the drug from friends or relatives

•Purchasing the drug from the “street”

•Double-doctoring

Unsanctioned use •Multiple unauthorized dose escalations

•Binge rather than scheduled use

Drug seeking •Recurrent prescription losses

•Aggressive complaining about the need for higher doses

•Harassing staff for faxed scripts or fit-in appointments

•Nothing else “works”

Repeated withdrawal symptoms •Marked dysphoria, myalgias, GI symptoms, craving

Accompanying conditions •Currently addicted to alcohol, cocaine, cannabis or other drugs

•Underlying mood or anxiety disorders not responsive to treatment

Social features •Deteriorating or poor social function

•Concern expressed by family members

Views on the opioid medication •Sometimes acknowledges being addicted

•Strong resistance to tapering or switching opioids

•May admit to mood-leveling effect

•May acknowledge distressing withdrawal symptoms

CASE 9. ABERRANT DRUG-RELATED BEHAVIOURS

Available at: http://nationalpaincentre.mcmaster.ca/opioid * = behaviours more indicative of addiction /OUD

For patients with CNCP who are addicted to opioids, three treatment

options should be considered: methadone or buprenorphine treatment,

structured opioid therapy, or abstinence-based treatment.


CASE 10. OLDER PERSON

92 y.o. Multiple medical problems


Geriatric Ambulatory Care Clinic

oRecommended to primary physician to reduce benzodiazepines (BNZ)

Pain Clinic

oSR opioid not helpful; refer for physiotherapy

oSuggest reducing opioids and stopping NSAID

oConcerns re 3 BNZ, especially with recurrent falls




SR oxycodone

TDS F

AcetaO prn

Temazepam

Lorazepam

Alprazolam

NSAID


Multiple falls

Left femur fracture - ORIF

Hand written note from family member

▪ “when left hospital they reduced her pain meds ; only on prn acetaO”


SR oxycodone 40 bid

AcetaO prn

Lorazepam

PGB

ORIF=open reduction internal fixation; PGB=pregabalin

AcetaO=acetaminophen/oxycodone (325 mg/5 mg/); O=oxycodone


Presents to local ER with 3-day Hx of increased confusion

and disorientation; dramatically improves with naloxone

1Ontario Drug Policy Research Network (2015); 2http://www.toronto.ca/legdocs/mmis/2015/hl/bgrd/backgroundfile-83429.pdf

Each year in Ontario, people aged 65 and older account

for over 40% of opioid-related hospital admissions1,2

“Decreased LOC, most likely from

narcotics and benzodiazepine toxicity”



CASE 11.

41 y.o. man with chronic back and leg pain

3 previous surgeries for CLBP

4th surgery = single level fusion

CASE 11.

Arrested on suspicion of driving under the influence

Stated that his condition was the result of a reaction to mixing several

prescription drugs


CASE 11.


https://www.google.ca/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwj6yeeOupvVAhVq5oMKHc3YAqkQjRwIBw&url=http://www.canstockphoto.com/illustration/abort.html&psig=AFQjCNGMrY9S9uOqVLrkfAOhe-N2CPkp7Q&ust=1500763558897090

CASE 11.


Agreed to enter ‘treatment program’ to deal with prescription drugs

“Recently, I had been trying on my own

to treat my back pain and a sleep

disorder … but I realize now it was a

mistake to do this without medical

assistance”

CASE 11.


Agreed to enter ‘treatment program’ to deal with prescription drugs

Globe and Mail August 15, 2017

“I am continuing to work with my

doctors, and they feel I’ve made

significant progress”

CASE 11.


Globe and Mail August 15, 2017

Hydrocodone

Hydromorphone

Alprazolam

Zolpidem

THC

Toxicology Report

OVERCOMING BARRIERS TO CHANGE

acceptance and beliefs outreach visits

NHS: How to change practice

1. There is no substitute for an excellent

history and physical exam

2. Become familiar with signs of aberrant

drug use and opioid abuse disorder

3. Ask about patients’ sleep patterns and

mental health

4. Try alternative therapies

5. Prior to prescribing an opioid, use a risk

assessment tool like the ORT

6. Use a narcotic contract as a guiding too

for you and your patient

7. Limit the number of people you start on

narcotics and provide small amounts

8. Take the time to review addiction as a very

real risk to patients to whom you prescribe

narcotics

9. Develop an excellent relationship with

local pharmacists

10. Regularly call patients on narcotics for pill

counts and random UDS

11. If you are going to prescribe narcotics, you

should consider obtaining the knowledge

and skill to discontinue them

12. Find out from your local health unit if

naloxone kits are available in your area

13. Addiction crosses all social spectrums and

is a serious health concern

13 WAYS TO COMBAT THE OPIOID CRISIS* – BY DR. SARAH GILES

*Medical Post; February 21, 2017

https://www.cmpa-acpm.ca/static-assets/pdf/about/annual-meeting/com_16_opioids_chronic_non-cancer_pain-e.pdf