Managing Patients on Opioids for Chronic Noncancer Pain

The Role of the Family Nurse Practitioner

Literature Review

Significance of the ProblemStatement of Purpose and Search StrategyCritique of the Literature and Identification of GapsRecommendations for PracticeConclusion

Significance of the Problem: Chronic Noncancer Pain

Pain is considered to be chronic noncancer pain if:

the duration is longer than 3 months,

it is intractable, and thus not responsive to conventional treatment, but not due to malignancy

Diagnoses include: musculoskeletal pain, including back pain; neuropathic pain, fibromyalgia, sickle cell disease, inflammatory pain, headache disorders

Reported by up to 1/3 of U. S. adults, approx. 100 million (AHRQ, 2014)

Associated with increased anxiety, depression, as well as PTSD

Prevalence of Chronic Pain Compared to other Conditions

Condition Number of Sufferers Source

Chronic Pain 100 million Americans Institute of Medicine of The National Academies (2)

Diabetes 25.8 million Americans(diagnosed and estimated undiagnosed)

American Diabetes Association (3)

Coronary Heart Disease(heart attack and chest pain)Stroke

16.3 million Americans

7.0 million Americans

American Heart Association (4)

Cancer 11.9 million Americans American Cancer Society (5)

Source: http://www.painmed.org/PatientCenter/Facts_on_Pain.aspx#incidence

Common Treatments for Chronic Pain

Medical

Medications such as:

neuropathics/ anticonvulsants,

opioids

NSAIDs

antidepressants

topical analgesics

Interventional procedures such as nerve blocks, epidural injections, electrical stimulation, surgery

Complementary/Alternative

Acupuncture

Psychotherapy

Biofeedback

Cognitive Behavioral Therapy

Meditation

Massage

Tai Chi

Yoga

Physical Therapy

Significance of the Problem: Opioid Use for Chronic Noncancer Pain

Opioid medications such as morphine, fentanyl (Actiq=lollipop), hydrocodone (Norco, Vicodin), and oxycodone (Percocet, Percodan, Roxicodone), just to name a few, have been increasingly prescribed for chronic pain

Long acting versions of these meds: morphine (Kadian, MS Contin), fentanyl (Duragesic patch), oxycodone (Oxycontin), tramadol (Ultram ER)

Opioid Prescribing Trends

In 2010 an estimated 20% of patients presenting to physician offices in the United States with pain symptoms or diagnoses were prescribed opioids (CDC, 2015)

The number of prescriptions for opioids have escalated from around 76 million in 1991 to nearly 207 million in 2013

The United States is the biggest consumer globally, accounting for almost 100 percent of the world total for hydrocodone (e.g., Vicodin) and 81 percent for oxycodone (e.g., Percocet) (National Institute on Drug Abuse, 2015).

Opioid Prescriptions Dispensed by Retail Pharmacies—United States, 1991–2011

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110

50

100

150

200

250

76 78 8086 91 96 100

109120

131139 144

151158

169180

192201 202

210219

Year

Num

ber

of

Pre

scr

ipti

ons (

in m

illions)

From “Prescription Drug Abuse: It’s Not what the doctor ordered.” Nora Volkow National Prescription Drug Abuse Summit, April 2012.

Widely used, but little evidence to support…

Little solid evidence which supports the long-term use of opioids for this purpose (AHRQ, 2014)

in workers’ compensation populations, use of only a modest amount of opioid soon after injury is associated with at least double the odds of long-term disability, even after adjusting for other risk factors (Franklin, et al, 2011)

increasing doses of opioids over time, both in workers’ compensation patients with back injury/pain, as well as veterans with CNCP, did not improve pain and function in clinically meaningful ways (Franklin, et al, 2011)

Side Effects and Serious Consequences

Nausea

Chronic constipation and serious fecal impaction

Chronic dry mouth which can lead to tooth decay

Sedation and respiratory depression

Hypogonadism and other endocrine effects, including sexual dysfunction

Sleep-disordered breathing

Increased pain sensitivity or hyperalgesia

Diversion

Addiction

Accidents involving injuries (such as falls and motor vehicle accidents)

Overdose (fatal and nonfatal)

(Kolodny, et al, Physicians for Responsible Opioid Prescribing, 2015)

Opioid Misuse and Abuse

In 2011 alone, there were 16,917 fatal overdoses involving prescription opioids (AHRQ, 2014)

Resulted in nearly 660,000 emergency department visits in 2010, over twice as many as in 2004 (AHRQ, 2014)

since 2002, the US prevalence of high school seniors reporting past-year nonmedical use of opioids has been 8% to 10% for hydrocodone and 4% to 5% for oxycodone (CDC, 2014)

Opioid overdose is now the second leading cause of unintentional death in the United States, second only to motor vehicle crashes, which prompted the CDC to label pharmaceutical opioid overdose as a national epidemic (CDC, 2014)

Economic Consequences

opioid abuse costs insurers $72.5 billion dollars every year (CDC, 2011)

people who abuse opioids generate over 8 times the annual direct health care costs compared with people who do not (CDC, 2011)

substance abuse treatment admissions for opiates other than heroin increased more than six-fold from 1999 to 2009 (AHRQ, 2014)

Lost productive time from common painful conditions was estimated to be $61.2 billion per year, while 76.6% of lost productive time was explained by reduced work performance, not absenteeism (AAPM, 2015).

Statement of Purpose and Search Strategy

To review current literature on opioid management and best practices, as well as to consider the patient’s perspective in this endeavor

Improving the way opioids are prescribed through clinical practice guidelines can ensure that patients have access to safe, effective treatment while reducing the number of people who misuse, abuse, or overdose from these powerful drugs (CDC, 2015).

PubMed & CINAHL search, peer-reviewed, primary research studies published within the last 5 years. Literature review articles were not included in the literature table as part of this review, but are referenced

Critique in the Literature and Identification of Gaps

MANY articles on opioid management, particularly review articles, but very few directed to nurse practitioners

In regards to the efficacy of opioids for the long-term treatment of chronic pain, a dearth of research exists as noted by the recent AHRQ review in 2014

Areas of focus for review:

• Opioid dose

• REMS (Risk Evaluation and Mitigation Strategies)

• Psychosocial Aspects

Opioid Dose Matters

Compared with patients receiving less than 20 mg/day, this Canadian study found that those prescribed opioids at daily doses of 200 mg or more of morphine (or equivalent) had a much higher risk of opioid-related mortality (Gomes, et al, 2011)

Compared with patients receiving 1-20mg/day of opioids (0.2% annual overdose rate), patients receiving 50-99mg/day had a 3.7-fold increase in OD risk and 0.7% annual OD rate. Patients receiving 100mg/day or more had 8.9-fold increase in overdose risk and a 1.8% annual OD rate(Dunn, et al, 2010).

Franklin, et al, (Franklin, et al, 2011) wanted to assess changes in opioid dosing patterns and opioid-related mortality in their workers’ compensation system following a 2007 implementation of a specific Washington State opioid dosing guideline created in response to the escalating number of deaths related to prescription opioids in that state (Franklin, et al, 2011

compared to prior to 2007, there had been a substantial decline in both MED/day of long-acting schedule II opioids (by 27%), the percentage of workers on doses >120 mg/MED /day declined by 35%, and that there was a 50% decrease from 2009-2010 in number of deaths (Franklin, et al, 2011).

REMS (Risk Evaluation and Mitigation Strategies)

retrospective cohort study (Starrels, et al, 2011) of University of Pennsylvania primary care patients on long-term opioid therapy for CNCP, researchers discovered that monitoring of patients with CNCP on long-term opioids was quite limited: Only 8% of the study patients had had at least one urine drug test; 49.8% had attended regular office visits, and 23% received more than one early opioid refill (Starrels, et al, 2011)

skills and competencies considered most critical for primary care physicians to effectively manage opioid risk in patients treated for chronic pain, rated highest were: how to monitor opioids, and how to assess for risk factors ,and how to manage patients with comorbid conditions(Chiauzzi, et al, 2011)

EMR-based protocol for opioid prescribing increased UDS ordering by 145%, documentation of CNCP diagnosis in problem list by 424% and increased provider knowledge, job satisfiaction when managing these patients

Psychosocial Aspects

Outcalt, et al, study the nature of the relationships among chronic pain, PTSD, and depression and found that PTSD is strongly associated with multiple domains of pain, psychological status, quality of life, and disability and that these associations remain robust even after controlling for major depression (Outcalt, et al, 2015)

stressed the importance of screening for PTSD and depression among patients with chronic pain using simple measures

Adjunctive Therapy: CBT

6-week group cognitive behavioral therapy (CBT) program implemented for CNCP patients being treated with opioids to assess if CBT could enhance outcomes for this cohort

What is CBT?? CBT is a form of talk therapy that says that individuals -- not outside situations and events -- create their own experiences, pain included. And by changing their negative thoughts and behaviors, people can change their awareness of pain and develop better coping skills, even if the actual level of pain stays the same

Mood (including negative attitude, performance difficulty, and physical complaints), depressive symptoms, and patient impression of treatment benefit improved significantly after CBT; there was no significant improvement in physical function, however

PCPs were both pleased with the program and felt it was of benefit to their patients

(Whitten & Stanik-Hutt, 2012)

Life Before & After Opioid Therapy: Patient Perspectives

BEFORE

Desperation

Inability to function (emotional and physical)

Inability to perform role functions

Thoughts of suicide

(Vallerand & Nowak, 2009, 2010)

AFTER

Balancing act between pain management and level of function

Living a secret life from those who might not understand the COT regimen

Fear of losing pain management regimen

“Pain Trading” : exchange physical pain for emotional consequences of COT

Thankfulness for a life regained

Change in focus

Barriers to Care: Patient Perspectives

being stigmatized as “addicted and/or morally weak”

stigmatized by pharmacies as well as physicians

felt “disdain and negativity from family”

fear of losing their job

treated as though they were having acute pain, not chronic pain, in terms of prescribing

(Vallerand & Nowak, 2009, 2010)

Recommendations for Practice

Chronic noncancer pain is a complex clinical problem, and should be handled as such

the goal of treatment is to reduce pain and improve function, so the person can resume day-to-day activities.

Practitioners must be educated on risk, dosing, & alternatives

Less is MORE: risk of harm increases with doses over 100 mg morphine equivalent/day (some say 120 mg)

Best Practices: CDC guidelines

Conducting a physical exam, pain history, past medical history, and family/social history

Conducting urine drug testing, when appropriateConsidering all treatment options, weighing benefits and risks of

opioid therapy, and using opioids when alternative treatments are ineffective

Starting patients on the lowest effective dose

Best Practices: CDC guidelines

Implementing pain treatment agreements Monitoring pain and treatment progress with documentation; using greater

vigilance at high doses Using safe and effective methods for discontinuing opioids (e.g., tapering,

making appropriate referrals to medication-assisted treatment, substance use specialists, or other services)

Using data from Prescription Drug Monitoring Programs (PDMPs) to identify past and present opioid prescriptions at initial assessment and during the monitoring phase

CDC & National Center for Injury Prevention and Control Division of Unintentional Injury Prevention

Recommendations for Practice = Balanced Approach

Use measurement tools as a means of understanding the scope of the problem:

BPI (Brief Pain Inventory)

Patient Health Questionnaire (PHQ-9) (depression)

Generalized anxiety disorder (GAD) (anxiety)

Opioid Risk Tool (ORT)

Educate patients on safe opioid use, side effects, storage & disposal

Resources

http://www.supportprop.org/educational/PROP_OpioidPrescribing.pdf

Source: University of Washington Medicine, Anesthesiology and Pain Medicine

Balancing Pain Management and Prescription Opioid AbuseRecommend on FacebookTweet          

Educational Module (Released October 24, 2012)

                                                

Residency educators may download and use the following slides for their own teaching purposes.Prescription Drug Abuse and Overdose: Public Health Perspective (PDF[1.6MB], PPT[14.9MB])Managing Pain with and without Opioids in the Primary Care Setting (PDF[1.30MB])New NIDAMED Tools and Resources for Addressing Prescription Drug Abuse (PDF[940KB], PPT[5.4MB])Pain Management Discussion Questions[PDF 106KB]

Resources•CDC Vital Signs—Prescription Painkiller Overdoses: Use and Abuse of Methadone as a Painkiller

Conclusion

Robust topic! Much more data available on drug specifics, long vs. short acting formulations, beyond the scope of this presentation

Many excellent resources widely availableTry other options first, judicious use of opioids is keyCONSISTENCY is key