reuben strayer on opioids - pain, compassion, addiction, malingering

Pain, Compassion, Addiction, Malingering: How To Use Opioids

reuben j. strayer @emupdates

and how to not use opioids

slideset and references emupdates.com/help

no disclosures / conflicts

responsibilities of the emergency physician

resuscitation

symptom relief

resource stewardshipcustomer service

public health

identification of dangerous conditions

determination of disposition / level of caremanaging ED flow

The unprecedented increase in opioid pain reliever consumption has led to the worst drug overdose epidemic in US history.

Kolodny 2015

CDC:

Volkow 2014 Baumblatt 2014 MMWR 2015 Reuben 2015

opioids are responsible for 1 in 8 deaths in americans aged 25-34

Fischer 2013 Boyer 2012

Prescriptions for opioid analgesics in the United States increased by 700% between 1997 and 2007

IMS 2013 Meier 2013 Kolodny 2015

900% increase in prescription opioid addiction treatment between 1997 and 2011

Dea

th ra

te p

er 1

00,0

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0

2.5

5

7.5

10

'70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06

HeroinCocaine

43,982 drug overdose deaths in 2013

Unintentional Drug Overdose Deaths United States, 1970–2007

National Vital Statistics System, http://wonder.cdc.gov

Year

c/o A. Kolodny, MD

c/o L Paulozzi, MD

Burghardt 2013

Turner 2015 Tolia 2015

CDC - Prescription Painkiller Overdoses Policy Impact Brief

morphine equivalence milligrams per person, 2010

japan united states

26.38 663.45

Mehendale 2013

INCB 2013 Statistics on Narcotic Drugs

The Epidemic of Untreated Pain

“Studies indicate that the de novo development of addiction when opioids are used for the relief of pain is low.”

"I gave innumerable lectures in the late 1980s and '90s about addiction that weren't true.”

"Clearly, if I had an inkling of what I know now then, I wouldn't have spoken in the way that I spoke. It was clearly the wrong thing to do.”

the epidemic of untreated pain opiophobia pain is a vital sign pseudoaddiction pain score zero opioids are effective in chronic non-cancer pain addiction cannot come from treating pain it is better to over treat than to under treat pain safety of high dose opioids always assume a patient claiming pain is in pain oral opioids don’t cause respiratory depression

When I was in medical school, I was told, if you give opiates to a patient who's in pain, they will not get addicted. Completely wrong. Completely wrong. But a generation of doctors, a generation of us grew up being trained that these drugs aren't risky. In fact, they are risky.

Thomas Frieden Director of the U.S. Centers for Disease Control and Prevention

prevent addiction

protect addicts and promote recovery

control supply

recreation

self limited

careful ongoing use no escalation

few addiction features

escalation misuse

addiction

opioid prescription

opioid use trajectories

morbidity, mortality

recreation

self limited



escalation misuse

addiction

opioid prescription

prescribe to fewer patients


Lindenhovious 2009


acetaminophen 1 g q6 +

ibuprofen 400 mg q6

Fathi 2015 P Moore 2013

Derry 2013 Teater 2014 Poonai 2014

R Moore 2013

chasing zero pain

function

pain10 0

chance of harm

My job is to manage your pain at the same time that I manage the potential for some pain medications to harm you.

recreation

self limited



escalation misuse

addiction

opioid prescription


prescribe fewer pills

Brands 2010

prescribe fewer pills

3 days and flush

recreation

self limited



escalation misuse

addiction

opioid prescription

opioid use trajectories


acute pain

opioids

chronic pain

benefit:harm

in chronic pain and addiction opioids provide temporary relief of symptoms

but make the problem worse

misplaced focus on deception

opioid misuse spectrum

opioid naive diversionrecreationchronic pain addiction

opioid naive diversionrecreation

opioid misuse spectrum

term

inal

illn

ess

chronic pain addiction

pain at the end of lifeaggressive multimodal analgesia including escalating doses of IV opioids as necessary

PO opioids as necessary

verify outpatient care

everyone else benefit:harmrisk factorsjudgment

red flags for opioid misuse

yellow flags for opioid misuse

poly-provider, poly-hospital patient, relation, or provider reports addiction or diversion injects oral opioid preparations obtains drugs through dubious means (e.g on the street) uses others’ meds, steals Rx pads/syringes, forges Rx, false ID

many visits, refill requests, dose escalation requesting specific meds, requesting med IV, declines non-opioids from out of town, primary provider unavailable, pt passed by closer institutions allergies to analgesics and other relevant non-opioids opioid/Rx is lost, stolen uninterested in diagnosis or alternative treatments, refuses tests repeatedly misses followup appointments, has been terminated by providers history of substance abuse or incarceration absence of objective findings of acute pain symptom magnification, inconsistency, distractibility rehearsed, textbook presentations deterioration of work/social function, disability

low risk acute pain no chronic pain no flags for opioid misuse

in the ED: aggressive multimodal analgesia including escalating doses of IV opioids prn

discharge: optimal outpatient analgesia, +/- breakthrough opioids and guidance

acetaminophen 1g + ibuprofen 400 mg q6 ice, heat, elevation, immobilization, mobilization set expectations: zero pain is not the goal

optimal outpatient analgesia

breakthrough opioids if necessary, considering harm

prescribe smartly small number - 3 days and flush avoid euphorics avoid combinations

ditch percocet and vicodin

IR Morphine 15 mg tabs 1 tab q3-4h prn pain disp #12

take them off your formulary - if you can

Wightman 2012 Cicero 2013 Zacny 2008

acetaminophen 1g + ibuprofen 400 mg q6 ice, heat, elevation, immobilization, mobilization set expectations: zero pain is not the goal

optimal outpatient analgesia

breakthrough opioids if necessary

prescribe smartly small number - 3 days and flush avoid euphorics - oxycodone is the most abuse prone avoid combinations - to maximize scheduled APAPnever ER/LA preparations

Bon 2012 Galinkin 2014 Miller 2015 Meier 2012

be especially cautious in 10-30, sedative use and social/psych/substance history

high risk + chronic pain + flags for misuse

avoid opioids in the ED and by prescription

use alternate modalities to manage pain

express concern that opioids are causing harm and refer

I know you are in pain and I want to improve your pain, but I believe that opioids are not only the wrong treatment for your pain, but that opioids are the cause of your pain. I think pain medications are harming you, and if you could stop taking them, your pain and your life would improve. Can I offer you resources that will help you stop taking pain medications?

HelpCardemupdates.com/help

discharge

alternatives to opioids in the ED

regional and local anesthesia“trigger point injection”


droperidolor, sadly, haloperidol

Richards 2011


ketamine

Richards 2011 Hocking 2003 Patil 2012 Bell 2009 Visser 2006

alternatives to opioids in the EDlow back pain

chronic pancreatitis fibromyalgia myofascial pain syndrome complex regional pain syndrome sickle cell opioid withdrawal neuropathic pain cyclic vomiting gastroparesis abdominal migraine chronic ischemic pain atypical odontalgia phantom pain postherpetic neuralgia post-stroke pain spinal injury pain TMJ joint arthralgia intractable headache

intravenous lidocaine dexmedetomidine propofol

de Pinto 2012 Belgrade 2010 Canavero 1995


alternatives to opioids for discharge

acetaminophen 1 g q6 +

ibuprofen 400 mg q6

nonanalgesics


topicals

nonpharmacologicsthermotherapy (heat), cryotherapy (ice), exercise, weight loss, yoga, tai chi, meditation

lidocaine capsaicin diclofenac

anticonvulsants TCAs gabapentanoids


weed

alaska arizona california colorado connecticut DC delaware hawaii illinois maine maryland massachusetts michigan minnesota montana nevada new hampshire new jersey new mexico new york oregon rhode island vermont washington

Bachhuber 2014

maybe risk no history of chronic pain +yellow flags I’m not sureprescription drug monitoring programno opioids challenge

no opioids challengeMy most important job as an emergency doctor is to make sure there’s no emergency, so I would like to do some tests to make sure there’s nothing dangerous happening to you, and also I want to relieve your pain. But you will not receive any opioids while you are here, because I think opioids could be harmful to you.

opioid naive diversionrecreationchronic pain addiction

less interested in opioid alternatives

electroanalgesia (TENS), counter-irritative therapy, spinal cord and deep brain stimulators, neuroablation, biofeedback, hypnosis, rehab medicine, OT, chiropractor, meditation, acupuncture, shaman

there are options for chronic pain patients

house of health

medical

socialsu

bsta

nce

psychiatric

house of health

medical

socialsu

bsta

nce

psychiatric

resuscitation

symptom relief

resource stewardshipcustomer service

public health

identification of dangerous conditions

determination of disposition / level of caremanaging ED flow

want to know more?emupdates.com/help

@LNelsonMD @JMPerroneMD @DavidJuurlink @andrewkolodny

moderate or severe painpatient may benefit from opioids

how likely is the patient to be harmed by opioids?*

risk stratify using red/yellow flags

low risk high risk maybe risk acute pain

no chronic pain no red/yellow flags

chronic pain +red/yellow flags

acute pain +yellow flags

in ED: aggressive multimodal analgesia

Rx: 1 g acetaminophen + 400 mg ibuprofen q6h

+nonpharmacologics (e.g. ice) +/- breakthrough opioid tabs

avoid euphorics (e.g. oxycodone) avoid ER/LA preparations

avoid combination pills 3 days supply, flush unused pills

goal is not zero pain

avoid opioids in ED and by prescription

use alternate modalities to manage pain

express concern that patient is being harmed by opioids and nudge toward recovery

prescription drug monitoring program

no opioids challenge: I’m going to try to manage your

pain without opioids because I’m concerned that pain

medications might harm you

*pain at the end of life: opioid harms less important, escalate opioids as needed

emupdates.com/help

I can’t deal with this today

give the patient what he wants and move on

I feel threatened

“Here is your prescription. I am not entirely comfortable giving you this prescription because I am concerned that you are being harmed by these pain killers. When you decide that you want to stop using these drugs, and I hope you do, we can help you. Here is a list of resources available to help you stop.”

HelpCard

Prescription pain medications, even when used as directed, can cause patients to become dependent, and I’m concerned that the pills we prescribed for you in the past, even though you were using them appropriately, you may now be dependent on them. We can help you break free of that dependence.

allergy challengeI understand you’ve had an allergic reaction in the past to nitroglycerine. Sometimes what people think are allergic reactions aren’t, and sometimes these reactions go away. I’m comfortable giving you nitroglycerine - if you have an allergic reaction, we are prepared to manage it, that’s what we do in the ER.

Brady 2015

Chang 2014 Mazer 2014


Gomes 2013

Volkow 2011 Beaudoin 2014 Straube 2013 Hansen 2005 Logan 2013

Volkow 2011 Beaudoin 2014 Straube 2013 Hansen 2005 Logan 2013

more than one third misuse

misusers target EDs

a big problem for EMand a big opportunity

1 out of 8 ED patients with headache, back pain, or toothache received prescriptions from ≥8 providers in the preceding 12 months.

250 patients: 4,639 unused tabletsRodgers 2012

Patient perception of postoperative pain has evolved from an expected consequence of surgery to a “measurable” vital sign

requiring treatment. Rodgers 2012

Bates 2011

“the doctors meant well.”

Tao 2012

Hasegawa 2014

Deyo 2015

Simon 2015

Harvard Chan School / Boston Globe April 2015 Survey

4 out of 10 americans know someone who has abused opioids

in the past five years.

in those cases, 20% reported that abuse led to the user’s death.

“Unlike the other drugs in the other epidemics that we have faced, heroin in the 70s and crack cocaine in the 80s, prescription drugs come from a legal source –

they are manufactured by pharmaceutical companies and are prescribed by doctors. Overprescribing is the root cause of this problem.”

Beaudoin

Hoppe 2014

misuse

abuse

addiction

chronic pain

Ashworth 2013 Chou 2014

misuse

abuse

addiction

chronic pain

Ashworth 2013 Chou 2014

opioids more likely to harm than benefit

seconds of exposure to

heated surface prior to paw withdrawal

analgesia hyperalgesia

infusion

infusion discontinued

Brush 2012 Angst 2006

opioid hyperalgesiatolerance

when subject starts to feel pain

when subject can no longer stand the pain and removes

hand from water

seconds

arm in icewater

Doverty 2001

opioid hyperalgesia

“Morphine isn't that great at all.. as in euphoric anyway.” “Morphine is a waste unless you shoot it. And i don't recommend ever shooting anything. So fuck it. Stick with oxy.” “Morphine is best for controlling pain, for a high you are better off using beer or wine or booze than taking morphine for fun.”

MMWR July 2014

reuben strayer on opioids - pain, compassion, addiction, malingering

Health & Medicine