opioids and pain management...
TRANSCRIPT
PrinciplesofPreventioninPrimaryCarePractice:PearlsandPitfalls
May17,2020
DanielP.Alford,MD,MPHProfessorofMedicine
AssociateDean,ContinuingMedicalEducation
Director,ClinicalAddictionResearchandEducation(CARE)Unit
Director,SafeandCompetent OpioidPrescribingEducation (SCOPEofPain)Program
BostonUniversitySchoolofMedicine|BostonMedicalCenter
OpioidsandPainManagementPreventingHarmandMaximizingBenefit
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DanielAlford,MD,MPH
Disclosures
• IserveascoursedirectorforsaferopioidprescribingCMEfundedbyan
unrestrictededucationalgrantawardedtoBostonUniversitybytheREMS
ProgramCompaniesaspartoftheFDA'sOpioidAnalgesicREMSprogram
• Ididnotreceiveanydirectpaymentfromindustryfortheseactivities
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Roadmap
• Background:Pain,Opioids,Trends
• ProviderandPatientMistrust
• SaferOpioidPrescribing
• Resources
• Q&A
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Background
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ChronicPainisComplex
Dzau VJ,Pizzo PA.JAMA.2014
WalkD,Poliak-TunisM.MedClinNAm.2016
Argoff CE,etal.PainMed.2009
• Adaptive byelicitingmotivationtominimizeharmandallowhealing
AcutePainLifesustainingsymptom
• Maladaptive,pathologic, disorderofthe
somatosensory painsignaling pathways
influenced bygenetic andepigenetic
factors
ChronicPainCanbeadiseaseinitself
Petrosky E,etal.AnnInternMed.2018
Ilgen MA,etal.JAMAPsychiatry.2013
TangNKetal.PsycholMed.2006
*
• Associated withhigherriskoffatalandnonfatalsuicide attempts*
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• Chronicpain iscommon
• Painissubjective tothepatient andtheclinician
• Paincan’talwaysbevisualized
• Psychiatricco-morbidities arecommon
Significantbarrierstoadequatepaincare
• Negative attitudes anddisparities inpaincare
• Lackofdecision supportforchronicpainmanagement
• Financialmisalignment favoringuseofmedications
• Poorsupportforteam-based careandspecialty clinics
• Manycompeting priorities inprimarycare
ChronicPaininPerspective
InstituteofMedicine.2011RelievingPaininAmerica.WashingtonDC
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OpioidAnalgesics
• Analgesia
• Turnondescendinginhibitorysystems
• Preventascendingtransmissionofpainsignal
• InhibitterminalsofC-fibersinthespinalcord
• Inhibitactivationofperipheralnociceptors
• Variableresponse(notallpatients respondtothe
sameopioid inthesameway)
• >1000polymorphisms inthehumanMORgene
• Differencesinpharmacokinetics(opioidmetabolism)
• Activetherewardpathway
McCleane G,SmithHS.MedClin NAm2007
SmithHS.PainPhysician.2008
Somatosensory
cortex
Thalamus
Ascending
pathways
DorsalHorn
Peripheral
nerves
Descending
pathway
Periaqueductal
grayarea
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www.fda.gov,ONDCP2019
Since2011MME
declineby43%
2018largestMME
declineat17%
OpioidPrescribingTrends
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TrendsinOpioidOverdoseDeaths
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OpioidRisks
• Allergies arerare
• Sideeffectsarecommon
• Nausea,sedation,constipation,urinaryretention,sweating
• Respiratorydepression– sleepapnea
• Organtoxicities arerare
• Suppressionofhypothalamic-pituitary-gonadalaxis
• Immunosuppression
• Increasedriskofinvasivepneumococcaldz andcommunityacquiredpneumonia
• Worseningpain (hyperalgesia insomepatients)
• Addiction(OpioidUseDisorder)
• Overdose
• whencombinedw/othersedativesandathigherdoses
DunnKMetal.AnnInternMed2010
LiXetal.BrainRes2001
Doverty Metal.Pain 2001
AngstMS,ClarkJD.Anesthesiology2006
WieseAD,etal.AnnInternMed.2018
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ProblematicOpioidUse
• Systematicreviewfrom38studies(26%primarycaresettings, 53%painclinics)
Misuse rates:21%- 29%
Misuse:Opioidusecontrarytothedirectedorprescribedpatternofuse,regardlessofthepresenceor
absenceofharmoradverseeffects.
Addiction rates:8%- 12%
Addiction: Patternofcontinued usewithexperienceof,ordemonstrated potential for,harm(eg,
impairedcontroloverdruguse,compulsiveuse,continued usedespiteharm,andcraving ).
Vowles KEetal.Pain.2015
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• Aclinicalsyndromepresentingas…
– LossofControl
– Compulsiveuse
– Continuedusedespiteharm
Aberrant
Medication
Taking
Behaviors
SavageSRetal.JPainSymptomManage2003
AddictionisDifficulttoDiagnose
• Addictionisa behavioralmaladaptation
• PhysicalDependenceisa physiologicadaptation
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AberrantMedicationTakingBehaviors
TheSpectrumofSeverity
o Requestsforincreaseopioiddose
o Requestsforspecificopioidbyname,“brandnameonly”
o Non-adherencew/otherrecommendedtherapies(e.g.,PT)
o Runningoutearly(i.e.,unsanctioneddoseescalation)
o ResistancetochangetherapydespiteAE(e.g.over-sedation)
o Deteriorationinfunctionathomeandwork
o Non-adherencew/monitoring(e.g.pillcounts,urinedrugtests)
o Multiple“lost”or“stolen”opioidprescriptions
o Illegalactivities– forgingscripts,sellingopioidprescription
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Volkow NDetal.NEngl JMed2016
Medication-relatedFactors Risk
Dailydose>100MME overdose addiction
Long-termopioiduse(>3mo) overdose addiction
ER/LAopioidformulation overdose
Combinationopioids+benzodiazepines overdose
<2weeksafterstartingER/LAopioid overdose
OpioidRiskFactors
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Patient-relatedFactors Risk
Mentalhealthdisorder(e.g.depression,anxiety) overdose addiction
Substanceusedisorder(e.g.,alcohol,nicotine, illicit&prescriptiondrug) overdose addiction
Familyhistoryofsubstanceusedisorder misuse
Adolescent addiction
Age<45 misuse
Age>65 overdose
Sleep-disorderedbreathing overdose
Legalhistory(e.g.,DUI,incarceration) misuse
Historyofsexualabuse misuse
Historyofoverdose overdose
OpioidRiskFactors
Akbik H,etal.JPainSymptomManage.2006IvesJ,etal.BMCHealthServ Res.2006
LiebschutzJM,etal.JPain.2010
Michna E,etal.JPainSymptomManage.2004ReidMC,etal.JGenInternMed.2002
Volkow NDetal.NEngl JMed2016
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OpioidsandChronicPain
“Theproblemis,there’snoevidence
thatopioidsworkforchronicpain,
accordingtoguidelinesreleasedin
2016bytheCDC”
JuliaLurie– reporter,MotherJones,
April27,2018
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Meta-analyses(3-6mfollow-up)
• Opioidsvsplacebo
Opioidswithstatistically
significantbutsmall
improvementsinpain1,2
andphysicalfunctioning.2
(highqualitystudies)
• Opioidsvsnonopioids
Bothwithsimilarbenefits2
(low-modqualitystudies)
RCT3 foundopioids
notsuperiorto
nonopioids for
improving
musculoskeletal pain-
relatedfunctionover12
months
Studylimitations:
• Patientsalreadyonlong-termopioidswereexcluded
• 89%ofpatientsdeclinedtobeenrolled
Twolongerterm
follow-upstudies
found44.3%on
chronicopioidsfor
chronicpainhad
atleast50%
painrelief4
1.Meske DS,etal.JPainRes.20182.Busse JW,etal.JAMA.20183.KrebsEE,etal.JAMA.20184.NobleM,etal.CochraneSystematicReviews.2010
OpioidEfficacyforChronicPain
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OpioidsinPerspective
• Theefficacyandsafetyofchronicopioidtherapyforchronicpainhasbeen inadequately
studied*
• Opioidprescribing needs tobemoreselective andconservative
• Opioidsforchronicpain…
§ helpsome patients
§ harmsome patients
§ areonlyonetool formanagingseverechronicpain
§ areindicated onlywhenalternative safertreatment optionsareinadequate
ChouRetal.AnnInternMed2015
DowellDetal.JAMA 2016
Manchikanti Letal.PainPhysician2011
ReubenDBetal.AnnInternMed2015
Volkow ND,McLellanT.NEngl JMed2016
*
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Over-PrescribingOpioids
•Societalmedicationmania
•Patients(families)overlyfocusedonopioids(“painkillers”)
•Clinicians’confrontationphobia
• Lackoftraininginpainandaddictionatalllevelsofhealthprofessional
education
• Lackofaccess/coveragetocomprehensivepainmanagementservices
Mezei Letal.JPain2011
Watt-WatsonJetal.PainResManage2009
Morely-ForsterPKetal.JPainRes2013
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Mistrust
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• Qualitativestudy
• Adultswithlowbackpain
• Patientandproviderthemes
BuchmanDZetal.PainMed.2016
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Patient Theme1:
ThreatstoTrustworthiness
andIatrogenicSuffering
• Perceptionsthattheirclinicianshavedemonstratedalackofcare,empathy,
andrespect…affectingpatients’assessmentsofclinician
trustworthiness…negative interactionswithclinicianscausedthemfurther
suffering.
SUSAN:“Youcouldjusttellthathejustdidn’tbelievemethatIwasinas
muchpainasIwas.Hewasjustveryunsympathetic.Hewouldliterallywalk
awaywhileIwasinthemiddleofasentence.”
BuchmanDZetal.PainMed.2016
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Patient Theme2:
Motive,Honesty,andTestimony
• Patients’doubtsthattheircliniciansbelievedthattheywerebeinghonest
abouttheirmotivesforseekingtreatment(e.g.,drugmisuseordrug
diversion).Patientsdescribedbeingperceivedasuntrustworthybyclinicians
LUDWIG:“WhenIwasin[hospital]justacoupleofweeksago…the
ambulancedriversjusttookonelookatmeanditwas,like—thelookintheir
eyeswaslike,‘Oh,he’sjustajunkielookingtogetstoned.’Theydidn’t
believethatIwasactuallysufferingandinpain.TheythoughtIwasfakingit
completely…”
BuchmanDZetal.PainMed.2016
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Clinician Theme1:
ChallengesofthePracticeContext
• Physicianshighlightedthechallengingcontextinwhichchronicpain
managementisdelivered.Theyrecalledseveraldifficultinteractions
andtheimpacttheseinteractionshadontheirapproachtocare
DR.JOHN:“Thethingsthatwerememberarethetimesthatwegot
burned,right...Youmaygetburnedonein100,butthatonein100is
enoughtoburnanimpressioninyourmindthatmakesyouwaryofall
patientspotentially.”
BuchmanDZetal.PainMed.2016
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Clinician Theme2:
ComplicatedClinicalRelationships
• Chronicpainmanagementinvolvingopioidanalgesicscanprohibitor
destabilizethedevelopmentoftrustingclinicalrelationships.Physicians…did
notnecessarilyseetheirroleasacollaborativepartner…[they] saw
themselvesinadefensiveroleofinterrogator
DR.HENRY:“Inmostdoctor–patientrelationshipswelearntolistentothe
patientandaccepttheirtestimony…insomeinstances, tobequitehonest,we
areinterviewingthepatientasifweareapoliceofficeroralawyerandwe’re
tryingtofindflawsintheirstory…Sothereisadifferentrelationshiphere.”
BuchmanDZetal.PainMed.2016
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BuildingTrust:ProviderIssues
Afteryoucompleteathoroughpainhistory,focusedphysicalexam,andappropriatediagnostictesting…
Showempathyforpatientexperience
Validatethatyoubelievepain isreal
Believingtheseverityofapatient’spaincomplaint
doesnotmeanopioidsareindicated
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SaferOpioidPrescribing
forChronicPainCOPYRIGHT
Physical
Exercise
Manualtherapies
OrthoticsTENS
Othermodalities(heat,cold,stretch)
MedicationNSAIDs
Anticonvulsants
AntidepressantsTopicalagents
Opioids
Others
ProceduralAcupuncture
Nerveblocks
SteroidinjectionsTriggerpointinjections
Stimulators
Pumps
Psycho-behavioral
CBT/ACT
Txmood/traumaissues
AddresssubstancesMeditation
MultidimensionalCareforChronicPain
CultivateWell-being
ReducePain
ImproveQualityofLife
RestoreFunction
SELFCARE
Studiesonallpharmacologicandnonpharmacologictreatmentsforchronicpainare< 12m,majorityare< 12w
Tayeb BO,etal.PainMed.2016
Multimodalapproachesaremorecost-effectivethansinglemodalityoptions
FlorH,etal.Pain1992RobertsAH,etal.ClinJPain.1993PatrickLE,etal.Spine.2004Kamper SJ,etal.CochraneReview.2014
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• Misuseriskassessment– ORT- OpioidRiskTool
– SOAPP- ScreenerandOpioidAssessment forPatientswithPain
– DIRE- Diagnosis,Intractability,Risk,Efficacy
• PatientProviderAgreements(PPA)– Informedconsent(risksandbenefits)
– Planofcareincludingmedicationmanagement
• Frequentface-to-facevisits– Assessanddocumentrisksandbenefits
• Monitorforadherence,addictionanddiversion– Urinedrugmonitoringandpillcounts
– PrescriptionDrugMonitoringProgram(PDMP)data
GourlayDLetal.PainMed2005
Using UniversalPrecautions
whenPrescribingOpioids(notevidence-based buthasbecome standard ofcare)
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PrescribingOpioidsDuringCOVID-19
• DEAadoptedpolicies effectiveMarch31st to
allowcontrolled substances prescribing
withouthavingtointeract in-personwith
patients
www.deadiversion.usdoj.gov/coronavirus.html
• Evaluatingthepatient
– Itisacceptabletousetelemedicineevenifneverevaluatedpatientinperson
• DeliveringtheRxtothepharmacy
– IfnecessaryprescribercancallinRxtothepharmacywithconfirmationwithin15daysby
written,electronic,scannedorphotograph
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CDCGuideline DowellDetal.MMWR 2016
Whentoinitiate/
continueopioidsOpioidmanagement
Assessrisks/
addressharms1.Donotuseopioidsas1st-line
therapy.Ifused,combinew/
othertherapies
4.Whenstartinguse immediate-
releaseopioids
8.Usestrategiestomitigaterisk
(eg,naloxone)
2.Beforestartingopioids establish
realisticgoals.Continueopioids
only ifmeaningfulimprovements
outweighsrisks
5.Prescribethe lowesteffective
opioiddose.Usecautionwithany
dose, ifpossibleavoiddoses >90
mgmorphinemgequivalents
9.ReviewPDMP data
3.Beforestartingandthen
periodicallydiscussrisksand
benefitsofopioids
6.Prescribeshortdurationsfor
acutepain.<3daysoften
sufficient;>7daysrarelyneeded
10.Useurinedrugtesting
7.Evaluatebenefitsandharms
within4weeksofstartingandat
leastevery3months thereafter
11.Avoidconcurrent
benzodiazepines
12.Offer/arrangetreatmentfor
patientswithanOUD
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OpioidsforChronicPainWhatistheclinician’srole?
VS.
NicolaidisC.PainMedicine2011
• Usearisk-benefitframework
• Judgetheopioidtreatment,not thepatient
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Patient-CenteredSaferOpioidPrescribing
• Whileimplementingsafeopioidprescribingguideline-based
practicesdon’tforgetaboutthepatientexperience…
– Howdoyourpatientsperceivethesaferopioidprescribing
procedures…agreements,urinedrugtesting,pillcounts?
– Howdoyourclinicalstaffperceivethepatientswithchronicpainon
chronicopioidtherapy?
• Requirestrainingandre-trainingyourclinicalstaff…
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DiscontinuingOpioids
• Donothavetoproveaddictionordiversion,onlyassessandreassess the
risk-benefitratio
• Ifpatientisunabletotakeopioidssafelyorisnon-adherentwith
monitoring,thendiscontinuingopioidsisappropriate,eveninsettingof
benefits
YouareNOT
abandoning
thepatient,
youare
ABANDONING
THEOPIOID
• Needtodeterminehowurgentthediscontinuation
shouldbebasedontheseverityoftherisksandharms
• Documentrationalefordiscontinuingopioids
• Determineiftheopioidneedstobetapered
duetophysicaldependence
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TaperingOpioids
• Novalidated protocols inpatients onopioids forchronicpain
• Systematic review1 foundverylowqualityevidencesuggesting
severaltypesofopioidtapersmaybeeffective andthatpain,
function,andqualityoflifemayimproveforsomepatientswith
decrease opioiddose
• Cohortstudy2 ofover100,000patients onlong-term opioids
– Annualtaperingincreasedfrom11%(2008)to22%(2017)
– Tapermorelikelyinwomenandthoseonhigheropioiddoses
– 19%haddosereductionrateexceeding10%perweek
1FrankJW,etal.AnnInternMed.20172FentonJJetal.JAMANetworkOpen.2019
CDCRecommendation:
Decreaseof10%permonthifpatientonopioidsforyears
Decreaseof10%perweekifpatientonopioidsforweekstomonths
DowellD,etal.MMWR.2016.
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www.scopeofpain.org
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www.scopeofpain.org
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