THE HIGHS AND LOWS OF OPIATES

A REVIEW OF THE CPSO GUIDELINES

Leon Rivlin MD, CCFP (EM)

OBJECTIVES

Evaluate opioids in the management of chronic pain

Define an approach to the recognition of opioid misuse in the chronic pain patient

Evaluate protocols for safe and effective prescribing of opioids in chronic pain

Discuss the pitfalls of opiate management

WHY IS OPIATE MANAGEMENT SUCH A GREAT CONCERN ?

WHY IS CHRONIC PAIN IMPORTANT?

Canadian National Pain Study 2002

Chronic pain is present in 22 – 39% adults #1 reason for chronic pain: arthritic

conditions Prevalence of pain increases with aging Only 36% of patients felt that their pain

was effectively Rx 68% of MD’s believed that chronic pain

could be treated more effectively

Moulin D., PR&M, 2002,2003

ECONOMIC IMPACT

13% of workers lose a mean of 4.6 hours /wk of productive work time due to common pain conditions

Costs to industry $6.2 B/yr (US) 76 % due to reduced performance at work

Costs of depression to industry $31 B/yr

Equal to impact of CV disease, or Cancer

Stewart et al. JAMA 2003

BARRIERS for PHYSICIANSto TREATING CHRONIC PAIN

Limited training in medical schools Insufficient knowledge and

understanding Disease centred model of care does not

prioritize the management of pain Biopsychosocial model of pain

underutilized Fears about regulatory bodies Biases and fears about opioid use &

addiction

BIASIS & FEARS ABOUT OPIOID ANALGESICS 2004 DATA

Study of Wisconsin physicians' knowledge and attitudes about opioid analgesic regulations David E. Weissman, MD; David E. Joranson, MSSW; and Margaret B. Hopwood, MA, RN, Milwaukee and Madison Wisconsin Medical Journal 1991

200 Wisconsin physicians were polled 54% of the respondents indicated that,

due to concern of regulatory scrutiny, they will do one of the following: reduce drug dose or quantity, reduce the number of refills, or choose a drug in a lower schedule

EFFICACY OF OPIOID USE IN THE MANAGEMENT OF CHRONIC PAIN

Some but not all trials show functional improvement (Arkinstall et al., Pain 1995)

Subjective pain ratings show a 20 – 50 % decrease with a wide variation of individual response (Watson & Babul, Neurology 1998, Moulin et al, Lancet 1996)

• Opioids are better than NSAIDS or TCA’s for pain relief but not for improved functional outcomes (Sandoval, Furlan, Fonseca, Tunks, Mailis, submitted for pub)

Quality of life may improve with optimal dosing

ADVERSE EFFECTS of OPIOIDS:GENERAL

Constipation, nausea, narcotic bowel syndrome

Sweating Sleep apnea, COPD,

reduced resp. drive Rebound head aches Fatigue, confusion Cognitive

impairment

Endocrine & Reproductive effects (suppression of testosterone, menstrual irregularities)

Lowered pain threshold (long term hyperalgesia due to altered pain receptors)

Neurotoxicity (Demerol)

ADVERSE EFFECTS: OVERDOSE

Decreased LOC RR < 12/min Bradycardia Speech slow &

drawling “Nodding off” appear

to fall asleep momentarily during conversationPatients may appear to be relatively alert when surrounded by others in a stimulating environment, only to drift into coma and die when going for a nap

Pinpoint pupils Ataxia and falling Emotional lability Disinhibition Profuse sweating

ADDICTION

ADDICTION

Addiction occurs when a patient finds a drug effect so reinforcing that he has difficulty controlling its use

Characterized by the four C’s: Loss off over use Control Use despite knowledge of harmful Consequences

Compulsion to use the drug Craving

ADDICTION & OPIOIDS

50% chronic pain patients are addicted to opioids

More formal studies found addiction rates to be 3 – 19%

54% of injection users inject morphine and hydromorphone, 42% inject heroin

7-31% prevalence for opioid misuse behaviors (running out, double doctoring)

CLINICAL FEATURES of ADDICTION

Use of higher doses than needed for pain control

Run out early Reluctant to try alternatives to drug of choice Acquire opioids from friends or other doctors Tendency to binge on opioids Deterioration in functional status Daily cycle of intoxication and withdrawal Experimenting with opioids (routes of

administration)

OPIOID OVERDOSE:RISK FACTORS

Dose, potency, underlying tolerance Age (extremes), renal insufficiency,

respiratory disease Restarting opioids

When a patient has been off of an opioid for 3 days or longer, restarting at the same dose may produce an overdose due to rapid decline in tolerance.

Restarting the medication should be at 50% of the previous dose with gradual titration up.

OVERDOSING

17% opioid users had an overdose in past 6 months

Risk for overdosing: injecting high potency opioid useconcurrent use of prescription opioids &

benzos tolerancedepression participation in abstinence based programs

GUIDELINES TO OPIOID PRESCRIBING

PREPARE A TREATMENT PLAN

Collect information and formulate a diagnosis

Define and priorize treatment targets Devise a COMPREHENSIVE treatment plan

Lifestyle changes Social changes Consider Psychological/Psychiatric

intervention Integrate paramedical care providers Pharmacotherapy Interventional medical therapy

START WITH NON-OPIOIDS

Opioids should only be initiated after an adequate trial of non-opioid analgesics and other modalities have failed

Treatment success is measured by 25 – 50 % diminished pain, improved mood, and improved function

Abstinence of pain is an unrealistic goal General reluctance to use opioids for

headaches (opioids 2nd/3rd line at best)

INITIATING OPIOIDS

Obtain informed consent (adverse effects, risk of dependence)

Set expectations (25 – 50 % relief of pain)

Identify one prescribing physician Sign a Treatment Agreement

Evidence supports improved complianceSandoval et al., 2005

MAXIMUM OPIATE DOSE IS 200 MG MORPHINE /DAYCPSO TASK FORCE CONCLUSIONS

COMPONENTS OF THE TREATMENT AGREEMENT

Patient will not receive opiates from other sources

Detail the amount of medication, and usage schedule

Will not refill if the patient runs out early

Will not replace if meds or script lost

Patient will attend to regular visits

Urine drug screen will be provided on request

Physician can cease opiate script if agreement broken

A copy of the agreement should be sent to other physicians involved in care

Consequences of breaking the agreement should be specified and adhered to

DOCUMENTATION

Keep an opiate flow sheet (record the amount dispensed and reasons for changes)

Keep copies of scripts on chart Orange paper scripts are hard to photocopy See patient frequently on initiation of

treatment At each visit, document: compliance,

adverse effects, changes in mood and functional status, and analgesic effectiveness (VAS)

OPIATE SELECTION, DOSAGE & TITRATION

There is no evidence that one opiate is superior to another, recommendations are based on specific patient populations

Codeine is usually the initial choice because it is the least potent Be cautious of the acetaminophen

component 4 g/d if healthy, 3.2 g/d if elderly, 2g/d if

EtOH

OPIOID SELECTION

10% of Caucasians can’t convert codeine

Fentanyl patch, oxicodone, & hydromorphone are less likely to cause sedation in elderly

Active metabolites of morphine can accumulate in renal dysfunction

Avoid oxycodone & hydromorphone in patients with addiction history

Methadone is first choice in chronic pain among addicts

Parenteral opioids should not be use in long-term pain due to risk of overdose, addiction, and other problems

Titration

Start low and go slow! Opiates have a graded analgesic

response with greatest benefit at lower doses and plateau at higher dosages

Confirm that with each dosage increase there is a decline in the VAS pain score

Avoid withdrawal especially in pregnancy

Titrate slowly in the elderly, co-sedating med users, renal, resp, hepatic disease

SWITCHING OPIOIDS

Switch if lack of effectiveness or intolerable side effects

Initial dose of new opioid should be 50% of the original opioid used

Discontinue if pain remains unresponsive after 3 or 4 different opioids

SAFE PRESCRIBING

Avoid prescriptions for large amounts Caution with high dependence opiates in

those at risk Use rescue doses sparingly

Should be time dependent rather than pain contingent

Max of 4 – 6 doses per month Reduce next days dose by equal amount

Tamper proof the prescription Keep track of the medications

Running out early is common in addiction

TAMPER PROOFING PRESCRIPTIONS

Use words and numbersUse lines in blank spacesNo repeatsKeep pad in safe placeNumbered, non reproducible pads

(orange is hard to photocopy)Do not allow phone repeats

FEATURES OF OPIOID MISUSEPatients are reluctant to acknowledge their addiction for fear their opioid will be discontinued and they will experience withdrawal & pain

Past history of recreational drug & EtOH use

Patient or family have concerns about use

Patterns of use (binge, running out early)

Overstating effectiveness, dramatic and unlikely analgesic effect of pain

Psychological dependence; mood levelling effect, relief of anxiety, sense of calm

Withdrawal symptoms

Withdrawal mediated pain

Psychiatric history Psychosocial Status

(family conflict, deterioration at work)

Double doctoring Physical findings Lab findings (CBC,

AST,ALT, HepB,C, GGT, MCV)

IN SUMMARY

Formulate a comprehensive treatment plan Include the patient & family in the decision

making Consider opioids late in treatment of pain

& use sparingly Monitor use of opioids closely Dispense small quantities of medication on

any one visit Frequently evaluate effectiveness of

treatment models & guidelines

THE END