safe and effective tapering of opioids · arrange for treatment of opioid use disorder, and offer...
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Safe and Effective Tapering of Opioids
OPIOIDEDUCATION
SDDEPT.OFHEALTHGRANT
• Protectagainstopioidabuse• Evaluationforopiatedependence/abuse• Opiateinitiation,monitoringandreview• Useofalternativestoopioids
SDDEPT.OFHEALTHGRANT
• Incorporatingpainassessmenttools• ProperDocumentationinpatientrecords• UseofthePDMPaspracticetool– (PrescriptionDrugMonitoringProgram)
Education
• Livepresentations• Webbasedcurriculum• “Toolkit”foropioidprescribing
SDDEPT.OFHEALTHGRANT
• Incorporatingpainassessmenttools• ProperDocumentationinpatientrecords• UseofthePDMPaspracticetool– (PrescriptionDrugMonitoringProgram)
Goals/Objectives
• Areviewofresourcesavailabletohelpthosewithaddiction
• Understandinghowtocreateaplanforsafelytaperingpatientsoffopioids
• Theutilizationofalternativestoopioids• Adiscussionofpatientmonitoringandreview
• World wide: Up to 36 million abuse opioids• USA: 2.1 million abuse opioids• USA: 467,000 heroin addicts• 80% of opioid users reported that their first regular
opioid was a Rx pain reliever• 85% of heroin users first used an opioidwww.drugabuse.gov
How Many People Are Addicted?
• Assess risk of addiction using risk stratification tool• Assess pain, function, behavioral health and drug-related
behaviors• Obtain informed consent for therapy• Monitor pain and function, opioid risk and progress toward
treatment goals• Use treatment agreements for long-term opioid therapy• Document
MMIC Brink, Summer 2017
What can you do?
Statistics
Education/Resources
AddictionServicesAddictionServices
AssessmentTools
AssessmentTools
AssessmentTools
Tapering Opiates
Considertaperingtoareducedopioiddosageortaperinganddiscontinuingopioidtherapywhenyourpatient:1. requestsdosagereduction2. doesnothaveclinicallymeaningfulimprovementinpain
andfunction(e.g.,atleast30%improvementonthe3-itemPEGscale)
3. isondosages≥50MME*/daywithoutbenefitoropioidsarecombinedwithbenzodiazepines
*morphinemilligramequivalents4. showssignsofsubstanceusedisorder(e.g.workor
familyproblemsrelatedtoopioiduse,difficultycontrollinguse)
5. experiencesoverdoseorotherseriousadverseevent6. showsearlywarningsignsforoverdoserisksuchas
confusion,sedation,orslurredspeech
Tapering OpiatesHOWTOTAPERTaperingplansshouldbeindividualizedandshouldminimizesymptomsofopioidwithdrawalwhilemaximizingpaintreatmentwithnonpharmacologic therapiesandnonopioid medications.Ingeneral:
GoSlowAdecreaseof10%oftheoriginaldoseperweekisareasonablestartingpoint.Somepatientswhohavetakenopioidsforalongtimemightfindevenslowertapers(e.g.,10%permonth)easier.Discusstheincreasedriskforoverdoseifpatientsquicklyreturntoapreviouslyprescribedhigherdose.
ConsultCoordinatewithspecialistsandtreatmentexpertsasneeded—especiallyforpatientsathighriskofharmsuchaspregnantwomenorpatientswithanopioidusedisorder.Useextracautionduringpregnancyduetopossiblerisktothepregnantpatientandtothefetusifthepatientgoesintowithdrawal.
SupportMakesurepatientsreceiveappropriatepsychosocialsupport.Ifneeded,workwithmentalhealthproviders,arrangefortreatmentofopioidusedisorder,andoffernaloxoneforoverdoseprevention.Watchforsignsofanxiety,depression,andopioidusedisorderduringthetaperandoffersupportorreferralasneeded.
EncourageLetpatientsknowthatmostpeoplehaveimprovedfunctionwithoutworsepainaftertaperingopioids.Somepatientsevenhaveimprovedpainafterataper,eventhoughpainmightbrieflygetworseatfirst
Tapering Opiates
Considerations:1.Adjusttherateanddurationofthetaperaccordingtothepatient’sresponse.2Don’treversethetaper;however,theratemaybeslowedorpausedwhilemonitoringandmanagingwithdrawalsymptoms.3Oncethesmallestavailabledoseisreached,theintervalbetweendosescanbeextendedandopioidsmaybestoppedwhentakenlessthanonceaday.
MME Calculator
MorphineEquivalentDose(MED)MaximumPriorAuthorization
• Medicaidpatientsrequiringaneworrenewalprescriptionformorphineequivalentdosinggreaterthan300MEDsperdaywillrequirepriorauthorization.Claimswithoutpriorauthorizationwillbedenied.
• ImplementationistargetedforOctober1,2018.• ForbothneworrenewalprescriptionsandthoseinplacepriortoOctober1,2018,theMEDthresholdwill
decreasebyapproximately10%eachmonthuntilthetargetMEDisreached.SouthDakotaMedicaidwillutilizethefollowingtaperingschedule:
• October1,2018:300MEDs• November1,2018:270MEDs• December1,2018:240MEDs• January1,2019:220MEDs• February1,2019:200MEDs• March1,2019:180MEDs• April1,2019:160MEDs• May1,2019:140MEDs• June1,2019:130MEDs• July1,2019:120MEDs• August1,2019:110MEDs• September1,2019:100MEDs• October1,2019:90MEDs• ThetargetisinalignmentwithCDCrecommendedmaximumMEDlevelsandthetaperingschedule
approximatesa10%MEDreductioneachmonthinlinewiththeCDCrecommendationsfortapering.
MME Calculator
SD Addiction Services
MME Calculator
AddictionServices
Medication“ladder”
Alternatives to opiates
MedicationAssistedTherapy
Buprenorphine
• WhatexactlyisBuprenorphine?•
Buprenorphine(BYOO-pre-NOR-feen) ('bu-pre-'nor-feen) isanopioidmedicationusedtotreatopioidaddictionintheprivacyofaphysician’soffice.Buprenorphinecanbedispensedfortakehomeuse,byprescription.Thisinadditiontobuprenorphine’spharmacologicalandsafetyprofilemakesitanattractivetreatmentforpatientsaddictedtoopioids.
• Buprenorphineisdifferentfromotheropioidsinthatitisa partialopioidagonist.Thispropertyofbuprenorphinemayallowfor;– lesseuphoriaandphysicaldependence– lowerpotentialformisuse– aceilingonopioideffects– relativelymildwithdrawalprofile
• Attheappropriatedosebuprenorphinetreatmentmay:– Suppresssymptomsofopioidwithdrawal– Decreasecravingsforopioids– Reduceillicitopioiduse– Blocktheeffectsofotheropioids– Helppatientsstayintreatment
Patient Monitoring
• SDPDMP• UrineDrugScreen• Followup• “FunctionalAssessment”
SD Prescription Drug Monitoring, 2016
SD Prescription Drug Monitoring, 2017
Prescriptions:259,700v234,367
Hydrocodonedoses:17.4millionv14.9million
MME’s Prescribed Per Capita, 2015
MME’s Prescribed Per Capita, South Dakota, 2015
Socio-EconomicProblem
• Increaseaccesstomentalhealthandaddictionservices
• Psychosocialsupport• Opioidmaintenance:buprenorphine• Availabilityofnaltrexone