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Addressing the Barriers to Effective Pain Management and Issues of Opioid Misuse and Abuse. Earl Quijada, MD Assistant Professor, Physical Medicine and Rehab Linda Loma University Linda Loma, California.

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Addressing the barriers to effective pain management and issues of opioid misuse and abuse

Addressing the Barriers to Effective Pain Management andIssues of Opioid Misuse and Abuse

Earl Quijada, MDAssistant Professor, Physical Medicine and RehabLinda Loma UniversityLinda Loma, California

Sponsored by The France FoundationSupported by an educational grant from King Pharmaceuticals


Faculty disclosure
Faculty Disclosure

It is the policy of The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity. The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The France Foundation has identified and resolved any and all conflicts of interest prior to the release of this activity.

The following faculty have indicated they have no relationships with industry to disclose relative to the content of this CME activity:

  • Dr. Earl Quijada has nothing to disclose.


Educational learning objectives
Educational Learning Objectives

  • Identify the negative impact of persistent pain on health and quality of life, methods to assess pain levels, appropriate use of opioid medications, and documentation required for compliance with regulatory policies

  • Integrate appropriate risk assessment strategies for patient abuse, misuse, and diversion of opioids into an overall management approach for acute and chronic pain

  • Describe the specific elements of new abuse deterrent technologies associated with opioid therapy, and assess their implications for clinical practice


Prevalence of Recurrent

and Persistent Pain in the US

  • 1 in 4 Americans suffer from recurrent pain (day-long bout of pain/month)

  • 1 in 10 Americans report having persistent pain of at least one year’s duration

  • 1 in 5 individuals over the age of 65 report pain persisting for more than 24 hours in the preceding month

    • – 6 in 10 report pain persisting > 1 year

  • 2 out of 3 US armed forces veterans report having persistent pain attributable to military service

    • – 1 in 10 take prescription medicine to manage pain

American Pain Foundation. http://www.painfoundation.org. Accessed March 2010.


Multiple types of pain
Multiple Types of Pain

  • A. Nociceptive

  • B. Inflammatory

  • Neuropathic

  • Noninflammatory/

  • Nonneuropathic

Noxious

Peripheral

Stimuli

Inflammation

Multiple Mechanisms

Peripheral Nerve Damage

No Known Tissue or Nerve Damage

Abnormal Central Processing

  • Patients may experience multiple pain states simultaneously1

Adapted from Woolf CJ. Ann Intern Med. 2004;140:441-451.

1. Chong MS, Bajwa ZH. J Pain Symptom Manage. 2003;25:S4-S11.


Long term consequences of acute pain potential for progression to chronic pain
Long-Term Consequences of Acute Pain: Potential for Progression to Chronic Pain

Structural Remodeling

Sensitization

CNS

Neuroplasticity

Hyperactivity

Peripheral

Nociceptive

Fibers

Peripheral

Nociceptive

Fibers

Sustained

currents

Transient Activation

Sustained

Activation

Surgeryorinjurycausesinflammation

CHRONIC

PAIN

ACUTE

PAIN

Woolf CJ, et al. Ann Intern Med. 2004;140:441-451; Petersen-Felix S, et al. Swiss Med Weekly. 2002;132:273-278; Woolf CJ. Nature.1983;306:686-688; Woolf CJ, et al. Nature. 1992;355:75-78.


Neuroplasticity in pain processing
Neuroplasticity in Pain Processing

100

Hyperalgesia3

heightened sense of pain to noxious stimuli

80

60

Injury

Normal Response

To Painful Stimulus

Pain Sensation

Allodynia

pain resulting from normally painless stimuli

40

20

0

innocuous

noxious

Stimulus Intensity

  • Woolf CJ, Salter MW. Science. 2000;288:1765-1768.

  • Basbaum AI, Jessell TM. The perception of pain. In: Kandel ER, Schwartz JH, et al. eds. Principles of Neural Science. 4th ed. New York, NY: McGraw-Hill; 2000:479.

  • Cervero F, Laird JMA. Pain. 1996;68:13-23.


Vicious cycle of uncontrolled pain
Vicious Cycle of Uncontrolled Pain

Avoidance

Behaviors

Decreased

Mobility

Pain

Social

Limitations

Altered

Functional

Status

Diminished

Self-

Efficacy


Breaking the chain of pain transmission
Breaking the Chain of Pain Transmission

5-HT = serotonin; NE = norepinephrine; TCA = tricyclic antidepressant

1. Gottschalk A, Smith DS. Am Fam Physician. 2001;63:1979-1984; 2. Iyengar S, et al. J Pharmacol Exp Ther. 2004;311:576-584; 3. Morgan V, et al. Gut. 2005;54:601-607; 4. Reimann W, et al. Anesth Analg. 1999;88:141-145. Vanegas H, Schaible HG. Prog Neurobiol. 2001;64:327-363; 6. Malmberg AB, Yaksh TL. JPharmacol Exp Ther. 1992;263:136-146; 7. Stein C, et al. J Pharmacol Exp Ther. 1989;248:1269-1275.


Multimodal treatment
Multimodal Treatment

Pharmacotherapy

Opioids, nonopioids, adjuvant analgesics

Physical Medicine and Rehabilitation

Assistive devices, electrotherapy

Interventional Approaches

Injections, neurostimulation

Strategies for Pain and Associated Disability

Complementary and Alternative Medicine

Massage, supplements

Psychological Support

Psychotherapy, group support

Lifestyle Change

Exercise, weight loss

Fine PG, et al. J Support Oncol. 2004;2(suppl 4):5-22. Portenoy RK, et al. In: Lowinson JH, et al, eds. Substance Abuse: A Comprehensive Textbook. 4th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2005:863-903.


Components of chronic pain
Components of Chronic Pain

BTP

10

8

6

Pain Level

4

Baseline Pain

2

0

7

8

9

1

2

3

4

5

7

8

9

1

2

3

4

10

11

10

11

6 PM

5 AM

6 AM

12 PM

12 AM

Time, h

  • Chronic pain

    • Baseline persistent pain

    • Breakthrough pain (BTP)

  • Each component of chronic pain needs to be independently assessed and managed

Portenoy RK, et al. Pain. 1999;81:129-134; Svendsen K, et al. Eur J Pain. 2005;9:195-206.


Positioning opioid therapy for chronic pain
Positioning Opioid Therapyfor Chronic Pain

Chronic non-cancer pain: evolving perspective

Consider for all patients with severe chronic pain, but weigh the influences

What is conventional practice?

Are there reasonable alternatives?

What is the risk of adverse events?

Is the patient likely to be a responsible drug-taker?

Fine PG, Portenoy RK. Clinical Guide to Opioid Analgesia, 2nd edition, 2007.

Jovey RD, et al. Pain Res Manag. 2003;8(Suppl A):3A-28A.

Eisenberg E, et al. JAMA. 2005;293:3043-3052.

Gilron I, et al. N Engl J Med. 2005;352:1324-1334.


Chronic opioid therapy guidelines and treatment principles
Chronic Opioid Therapy Guidelines and Treatment Principles

Patient Selection

Patient Selection and Risk Stratification (1.1-1.3)

Alternatives to Opioid Therapy

Use of Psycho-therapeutic Cointerventions (9.1)

Initial Patient Assessment

Informed Consent and Opioid Management Plans (2.1-2.2)

High-Risk Patients (6.1-6.2)

Comprehensive Pain Management Plan

Driving and Work Safety (10.1)

Identifying a Medical Home* and When to Obtain Consultation (11.1-11.2)

Chou R, et al. J Pain. 2009;10:113-130. *Clinician accepting primary responsibility for a patient’s overall medical care.


Chronic opioid therapy guidelines and treatment principles cont
Chronic Opioid Therapy Guidelines and Treatment Principles (cont)

Trial of Opioid Therapy

Initiation and Titration of Chronic Opioid Therapy (3.1-3.2)

Methadone (4.1)

Opioids and Pregnancy (13.1)

Patient Reassessment

Monitoring (5.1-5.3)

Dose Escalations, High-Dose Opioid Therapy, Opioid Rotation, Indications for Discontinuation of Therapy (7.1-7.4)

Opioid Policies (14.1)

Continue Opioid Therapy

Monitoring (5.1-5.3)

Breakthrough Pain (12.1)

Implement Exit Strategy

Opioid-Related Adverse Effects (8.1)

Chou R, et al. J Pain. 2009;10:113-130. *Clinician accepting primary responsibility for a patient’s overall medical care.



Formulation points to consider
Formulation Points to Consider (cont)

  • Dose-limiting issues and toxicity with co-analgesics

    • 4 g/day acetaminophen limit

  • Importance of titration

    • Risk of overdose, challenges of dose conversion during rotation

  • Pharmacokinetics versus temporal patterns of pain

  • Adherence

  • Cost

  • Convenience

  • Caregiving issues


Domains for pain management outcome the 4 a s
Domains for Pain Management Outcome: (cont)The 4 A’s

Analgesia

Activitiesof Daily Living

AdverseEvents

AberrantDrug-Taking Behaviors

Passik SD, Weinreb HJ. Adv Ther. 2000;17:70-83.

Passik SD, et al. Clin Ther. 2004;26:552-561.


Model policy for the use of controlled substances for the treatment of pain

Model Policy for the Use of Controlled Substances for the Treatment of Pain

Federation of State Medical Boards House of Delegates, May 2004. http://fsmb.org. Accessed March 2010.

Federation of State Medical Boards

of the United States, Inc


Fsmb model policy basic tenets
FSMB Model Policy Treatment of PainBasic Tenets

  • Pain management is important and integral to the practice of medicine

  • Use of opioids may be necessary for pain relief

  • Use of opioids for other than a legitimate medical purpose poses a threat to the individual and society

  • Physicians have a responsibility to minimize the potential for abuse and diversion

  • Physicians may deviate from the recommended treatment steps based on good cause

  • Not meant to constrain or dictate medical decision-making

FSMB, Federation of State Medical Boards


New illicit drug use united states 2006
New Illicit Drug Use United States, 2006 Treatment of Pain

2,500

2,150

2,063

2,000

1,500

1,112

New Users (thousands)

977

1,000

860

845

783

500

267

264

91

69

0

Marijuana

Cocaine

Stimulants

Sedatives

Heroin

Pain Relievers*

Tranquilizers

Ecstasy

Inhalants

LSD†

PCP†

*533,000 new nonmedical users of oxycodone aged ≥ 12 years. Past year initiates for specific illicit drugs among people aged ≥ 12 years.†LSD, lysergic acid diethylamide; PCP, phencyclidine.

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 2006 National Survey on Drug Use and Health. Department of Health and Human Services Publication No. SMA 07-4293; 2007.


Definition of terms
Definition of Terms Treatment of Pain

  • Use of a medication (for a medical purpose) other than as directed or as indicated, whether willful or unintentional, and whether harm results or not

Misuse

  • Any use of an illegal drug

  • The intentional self administration of a medication for a nonmedical purpose such as altering one’s state of consciousness, eg, getting high

Abuse

Diversion

  • The intentional removal of a medication from legitimate and dispensing channels

  • A primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations

  • Behavioral characteristics include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, craving

Addiction

  • Syndrome of abnormal behavior resulting from undertreatment of pain that is misidentified by the clinician as inappropriate drug-seeking behavior

  • Behavior ceases when adequate pain relief is provided

  • Not a diagnosis; rather, a description of the clinical intention

Pseudoaddiction

Katz NP, et al. Clin J Pain. 2007;23:648-660.


Prevalence of misuse abuse and addiction
Prevalence of Misuse, Abuse, Treatment of Painand Addiction

Misuse 40%

Abuse: 20%

Total PainPopulation

Addiction: 2% to 5%

Webster LR, Webster RM. Pain Med. 2005;6(6):432-442.


Who misuses abuses opioids and why
Who Misuses/Abuses Opioids and Why? Treatment of Pain

  • Nonmedical

  • Use

  • Recreational abusers

  • Patients with disease of addiction

  • Medical Use

  • Pain patients seeking more pain relief

  • Pain patients escaping emotional pain


Rx opioid users are heterogeneous
Rx Opioid Users Are Heterogeneous Treatment of Pain

“Self-Treaters”

“Recreational users”

“Adherent”

“Chemical copers”

“Substance abusers”

“Substance abusers”

“Addicted” (SUD)

“Addicted” (SUD)

Nonmedical Users

Pain Patients

Passik SD, Kirsch KL. Exp Clin Psychopharmacol. 2008;16(5):400-404.


Risk factors for aberrant behaviors harm
Risk Factors for Treatment of PainAberrant Behaviors/Harm

Biological

Psychiatric

Social

  • Age ≤ 45 years

  • Gender

  • Family history of prescription drug or alcohol abuse

  • Cigarette smoking

  • Substance use disorder

  • Preadolescent sexual abuse (in women)

  • Major psychiatric disorder (eg, personality disorder, anxiety or depressive disorder, bipolar disorder)

  • Prior legal problems

  • History of motor vehicle accidents

  • Poor family support

  • Involvement in a problematic subculture

Katz NP, et al. Clin J Pain. 2007;23:103-118; Manchikanti L, et al. J Opioid Manag. 2007;3:89-100.

Webster LR, Webster RM. Pain Med. 2005;6:432-442.


Stratify risk
Stratify Risk Treatment of Pain

Low Risk

Moderate Risk

High Risk

  • No past/current history of substance abuse

  • Noncontributory family history of substance abuse

  • No major or untreated psychological disorder

  • History of treated substance abuse

  • Significant family history of substance abuse

  • Past/comorbid psychological disorder

  • Active substance abuse

  • Active addiction

  • Major untreated psychological disorder

  • Significant risk to self and practitioner

Webster LR, Webster RM. Pain Med. 2005;6:432-442.


10 principles of universal precautions
10 Principles of Universal Precautions Treatment of Pain

  • Diagnosis with appropriate differential

  • Psychological assessment including risk of addictive disorders

  • Informed consent (verbal or written/signed)

  • Treatment agreement (verbal or written/signed)

  • Pre-/post-intervention assessment of pain level and function

  • Appropriate trial of opioid therapy adjunctive medication

  • Reassessment of pain score and level of function

  • Regularly assess the “Four A’s” of pain medicine: Analgesia, Activity, Adverse Reactions, and Aberrant Behavior

  • Periodically review pain and comorbidity diagnoses, including addictive disorders

  • Documentation

Gourlay DL, Heit HA. Pain Med. 2009;10 Suppl 2:S115-123.

Gourlay DL, et al. Pain Med. 2005;6(2):107-112.


Initial visits
Initial Visits Treatment of Pain

  • Initial comprehensive evaluation

  • Risk assessment

  • Prescription monitoring assessment

  • Urine drug test

  • Opioid treatment agreement

  • Opioid consent form

  • Patient education


Mcgill short form pain questionnaire
McGill Short Form Pain Questionnaire Treatment of Pain

Results of Short and Long Form tests correlate well for postsurgical pain

r = 0.67 - 0.86, P 0.002

Melzack R. Pain. 1987;30:191-197.


Principles of responsible opioid prescribing
Principles of Responsible Opioid Prescribing Treatment of Pain

  • Patient Evaluation

    • Pain assessment and history

    • Directed physical exam

    • Review of diagnostic studies

    • Analgesic and other medication history

    • Personal history of illicit drug use or substance abuse

    • Personal history of psychiatric issues

    • Family history of substance abuse/psychiatric problems

    • Assessment of comorbidities

    • Accurate record keeping

Fine PG, Portenoy RK. Clinical Guide to Opioid Analgesia, 2nd edition, 2007.


Principles of responsible opioid prescribing1
Principles of Responsible Opioid Prescribing Treatment of Pain

Treatment Plan

  • I have resolved key points before initiating opioid therapy

    • Diagnosis established and opioid treatment plan developed

    • Established level of risk

    • I can treat this patient alone/I need to enlist other consultants to co-manage this patient (pain or addiction specialists)

  • I have considered nonopioid modalities

    • Pain rehabilitation program

    • Behavioral strategies

    • Non-invasive and interventional techniques


Principles of responsible opioid prescribing2
Principles of Responsible Opioid Prescribing Treatment of Pain

Treatment Plan (cont)

  • Drug selection, route of administration, dosing/dose titration

  • Managing adverse effects of opioid therapy

  • Assessing outcomes

  • Written agreements in place outlining patient expectations/responsibilities

  • Consultation as needed

  • Periodic review of treatment efficacy, side effects, aberrant drug-taking behaviors


Algorithm for the management of chronic pain
Algorithm for the Treatment of PainManagement of Chronic Pain

Pain frequency

Frequency flares of constant disturbing pain

Infrequent flares < 4 days per week

Occupational therapy

Physical therapy

Analgesics

Additional features

Physical therapy

Psychology

Psychology

Ineffective or require excessive doses

Relaxation Stress management

Cognitive restructuring Relaxation Stress management

Flare management: oscillatory movements, distraction techniques, trigger point massage

Neuropathic pain, burning quality, nerve injury, neuralgia

Structural pathology with disability and or overuse of analgesics

Reconditioning Stretching exercises

Body mechanics Work simplification Pacing skills

Short-acting opioids

First line

Adjunctive

Antidepressants: TCA, SSRI Antiepileptics: gabapentin, lamotrigine

Capsaicin cream Mexiletine Long-acting opioids

Long-acting opioids

TCA = tricyclic antidepressants: SSRI = selective serotonin reuptake inhibitors

Marcus DA. Am Fam Physician. 2000;61(5):1331-1338.


Medical records
Medical Records Treatment of Pain

  • Maintain accurate, complete, and current records

    • Medical Hx & PE

    • Diagnostic, therapeutic, lab results

    • Evaluations/consultations

    • Treatment objectives

    • Discussion of risks/benefits

    • Tx and medications

    • Instructions/agreements

    • Periodic reviews

    • Discussions with and about patients

Fishman SM. Pain Med. 2006;7:360-362. Federation of State Medical Boards of the United States, Inc. Model Policy for the Use of Controlled Substances for the Treatment of Pain. 2004.


Considerations
Considerations Treatment of Pain

  • What is conventional practice for this type of pain or pain patient?

  • Is there an alternative therapy that is likely to have an equivalent or better therapeutic index for pain control, functional restoration, and improvement in quality of life?

  • Does the patient have medical problems that may increase the risk of opioid-related adverse effects?

  • Is the patient likely to manage the opioid therapy responsibly?

  • Who can I treat without help?

  • Who would I be able to treat with the assistance of a specialist?

  • Who should I not treat, but rather refer, if opioid therapy is a consideration?

Fine PG, Portenoy RK. Clinical Guide to Opioid Analgesia. Vendome Group, New York, 2007.


Initiation of Therapy for Chronic Pain Treatment of Pain

Marcus DA. Am Fam Physician. 2000;61(5):1331-1338.


Monitoring chronic pain review of efficacy of therapy
Monitoring Chronic Pain Treatment of PainReview of Efficacy of Therapy

Marcus DA. Am Fam Physician. 2000;61(5):1331-1338.


Opioid treatment agreement
Opioid Treatment Agreement Treatment of Pain

http://www.lni.wa.gov/ClaimsIns/Files/OMD/agreement.pdf. Accessed March 2010.


Differential diagnosis of aberrant drug taking attitudes and behavior
Differential Diagnosis of Aberrant Treatment of PainDrug-Taking Attitudes and Behavior

  • Addiction (out-of-control, compulsive drug use)

  • Pseudoaddiction (inadequate analgesia)

  • Other psychiatric diagnosis

    • Organic mental syndrome (confused, stereotyped drug-taking)

    • Personality disorder (impulsive, entitled, chemical-coping behavior)

    • Chemical coping (drug overly central)

    • Depression/anxiety/situational stressors (self-medication)

  • Criminal intent (diversion)

Passik SD, Kirsh KL. Curr Pain Headache Rep. 2004;8:289-294.


Identifying who is at risk for opioid abuse and diversion
Identifying Who Is at Risk Treatment of Pain for Opioid Abuse and Diversion

Predictive tools

Aberrant behaviors

Urine drug testing

Prescription monitoring

programs

Severity and duration of pain

Pharmacist communication

Family and friends

Patients


Signs of potential abuse and diversion
Signs of Potential Abuse and Diversion Treatment of Pain

However, emergencies happen: not every person in a hurry is an abuser/diverter

Request appointment toward end-of-office hours

Arrive without appointment

Telephone/arrive after office hours when staff are anxious to leave

Reluctant to have thorough physical exam, diagnostic tests, or referrals

Fail to keep appointments

Unwilling to provide past medical records or names of HCPs

Unusual stories

Drug Enforcement Administration. Don't be Scammed by a Drug Abuser. 1999. Cole BE. Fam Pract Manage. 2001;8:37-41.


Risk assessment tools
Risk Assessment Tools Treatment of Pain

  • Addiction Behaviors Checklist (ABC)

    • Evaluate and monitor behaviors indicative of

      addiction related to prescription opioids in patients

      with chronic pain

  • Addiction Severity Index (ASI)

    • Assess current and lifetime substance-use

      problems and prior treatment

  • Current Opioid Misuse Measure (COMM)

    • Periodically monitor aberrant medication-related

      behaviors in patients with chronic pain currently on

      opioid therapy

Passik SD, Squire P. Pain Med. 2009;10 Suppl 2:S101-14.


Risk assessment tools cont
Risk Assessment Tools (cont) Treatment of Pain

  • Drug Abuse Screening Test (DAST-10)

    • Screen for probably drug abuse or dependence

  • Pain Medication Questionnaire (PMQ)

    • Assess risk for opioid medication misuse in patients with chronic pain

  • Screening Instrument for Substance Abuse Potential (SISAP)

    • Identify individuals with possible substance-abuse history

  • Opioid Risk Tool (ORT)

    • Predict which patients might develop aberrant behavior when prescribed opioids for chronic pain

Passik SD, Squire P. Pain Med. 2009;10 Suppl 2:S101-14.


Risk assessment tools cont1
Risk Assessment Tools (cont) Treatment of Pain

  • Diagnosis, Intractability, Risk, Efficacy (DIRE)

    • Predict the analgesic efficacy of, and patient compliance to, long-term opioid treatment in the primary care setting

  • Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R)

    • Predict aberrant medication-related behaviors in patients with chronic pain considered for long-term opioid therapy

      • Empirically-derived, 24-item self-report questionnaire

      • Reliable and valid

      • Less susceptible to overt deception than past version

      • Scoring:  18 identifies 90% of high-risk patients

Passik SD, Squire P. Pain Med. 2009;10 Suppl 2:S101-14.

Butler SF, et al. J Pain. 2008;9:360-372.


Ort validation
ORT Validation Treatment of Pain

  • Exhibits high degree of sensitivity and specificity

  • 94% of low-risk patients did not display an aberrant behavior

  • 91% of high-risk patients did display an aberrant behavior

N = 185

ADD, attention deficit disorder; OCD, obsessive-compulsive disorder.

Webster LR, Webster RM. Pain Med. 2005;6:432-442.


Soapp
SOAPP Treatment of Pain

Name:_________________ Date:___________

The following survey is given to all patients who are on or being considered for opioids for their pain. Please answer each question as honestly as possible. This information is for our records and will remain confidential. Your answers will not determine your treatment. Thank you.

Please answer the questions below using the following scale:

0 = Never, 1 = Seldom, 2 = Sometimes, 3 = Often, 4 = Very Often

1. How often do you have mood swings?

2. How often do you smoke a cigarette within an hour after you wake up?

3. How often have you taken medication other than the way that it was prescribed?

4. How often have you used illegal drugs (for example, marijuana, cocaine, etc.) in the past five years?

5. How often in your lifetime have you had legal problems or been arrested?

Please include any additional information you wish about the above answers. Thank you

Chris Jackson

9/16/09

Mr. Jackson’s Score = 3

To score the SOAPP, add ratings of all questions.

A score of 4 or higher is considered positive

О

0 1 2 3 4

0 1 2 3 4

О

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4


Risk assessment tools highlights
Risk Assessment Tools Highlights Treatment of Pain

  • ORT, SOAPP & DIRE

    • Best assess abuse potential among those being considered for long-term opioid therapy

  • COMM & PMQ

    • Characterize degree of medication misuse or aberrant behavior once opioids are started

  • DAST-10 & PMQ

    • More suitable for assessing current alcohol and/or drug abuse than potential for such abuse

Passik SD, et al. Pain Med. 2008;10 Suppl 2:S145-166.


Urine drug testing
Urine Drug Testing Treatment of Pain

  • When to test?

    • Randomly, annually, PRN

  • What type of testing?

    • POC, GS/MS

  • How to interpret

    • Metabolism of opioids

    • False positive and negative results

  • What to do about the results

    • Consult, refer, change therapy, discharge


The role of udt
The Role of UDT Treatment of Pain

UDT in clinical practice may

Provide objective documentation of compliance with treatment plan by detecting presence of a particular drug or its metabolites

Assist in recognition of addiction or drug misuse if results abnormal

Results are only as reliable as testing laboratory’s ability to detect substance in question

Heit HA, Gourlay DL. J Pain Symptom Manage. 2004;27:260-267.Dove B, Webster LR. Avoiding Opioid Abuse while Managing Pain: a Guide for Practitioners.

North Branch, MN: Sunrise River Press; 2007.


Positive and negative urine toxicology results
Positive and Negative Treatment of PainUrine Toxicology Results

  • Positive forensic testing

    • Legally prescribed medications

    • Over-the-counter medications

    • Illicit drugs or unprescribed medications

    • Substances that produce the same metabolite as that of a prescribed or illegal substance

    • Errors in laboratory analysis

  • Negative compliance testing

    • Medication bingeing

    • Diversion

    • Insufficient test sensitivity

    • Failure of laboratory to test for desired substances

Heit HA, Gourlay DL. J Pain Symptom Manage. 2004;27:260-267.


Urine drug testing1
Urine Drug Testing Treatment of Pain

Initial testing done with class-specific immunoassay drug panels

Typically do not identify individual drugs within a class

  • Followed by a technique such as GC/MS

    • To identify or confirm the presence or absence of a specific drug and/or its metabolites

Heit HA, Gourlay D. J Pain Sympt Manage. 2004:27:260-267.


Udt immunoassay screening
UDT Immunoassay Screening Treatment of Pain

Lab Testing or POCT

Drug class

High sensitivity, low specificity

Rapid results

Not quantitative

POCT, point-of-care testing

Hammett-Stabler CA, Webster LR. A Clinical Guide to Urine Drug Testing. Stamford, CT: PharmaCom Group Inc; 2008.


Detection of opioids
Detection of Opioids Treatment of Pain

Opiate immunoassays detect morphine and codeine

Do not detect synthetic opioids

Methadone

Fentanyl

Do not reliably detect semisynthetic opioids

Oxycodone

Hydrocodone

Buprenorphine

Hydromorphone

GC/MS will identify these medications

Heit HA, Gourlay D. J Pain Sympt Manage. 2004:27:260-267.


Udt laboratory based tests
UDT Laboratory-Based Tests Treatment of Pain

GC/MS, LC/ MS, ELISA

High sensitivity, high specificity

Expensive

Quantitative

1-3 days for results

RESULTS OF CONTROLLED SUBSTANCE UDT: WORKPLACE

Donor Name: Jack Donor ID #: 1897221 Specimen ID #: 1897221-112 Accession #: None assigned Reason for test: Random Date collected: 04/11/2008 Time collected: 1648Date received: 04/15/2008 Date reported: 04/15/2008

Class or AnalyteResultScreen Cut-OffAMPHETAMINES NEGATIVE 1,000 ng/mlBARBITUATES NEGATIVE 200 ng/mlBENZODIAZEPINES NEGATIVE 200 ng/mlCANNABINOIDS NEGATIVE 50 ng/mlCOCAINE NEGATIVE 300 ng/mlMETHADONE NEGATIVE 150 ng/mlOPIATES POSITIVE 100 ng/ml

Validity TestResultNormal RangeCREATININE NORMAL at 33.4 mg/dL≥ 20 mg/dLSPECIFIC GRAVITY NORMAL ≥ 1.003pH NORMAL 4.6-8.0

ELISA, enzyme-linked immunosorbent assay; GC, gas chromatography; LC, liquid chromatography;

MS, mass spectrometry.

Hammett-Stabler CA, Webster LR. A Clinical Guide to Urine Drug Testing. Stamford, CT:

PharmaCom Group Inc; 2008.


Opioid metabolism
Opioid Metabolism Treatment of Pain

Not comprehensive pathways, but may explain presence of apparently unprescribed drugs

Dihydrocodeine

Dihydromorphone

Minor

Minor

Gourlay D, et al. http://www.familydocs.org/assets/171_UDT%202006.pdf. Accessed March 2010;

Cone EJ, et al. J Anal Toxicol. 2006;30:1-5; Heit HA, Gourlay D. Personal Communication. 2008.


Detection times of common drugs of misuse
Detection Times of Common Drugs of Misuse Treatment of Pain

Gourlay DL, Heit HA. Pain Med. 2009;10 Suppl 2:S115-123.


Risk evaluation and mitigation strategies
Risk Evaluation and Mitigation Strategies Treatment of Pain

Position of the FDA

  • The current strategies for intervening with [the problem of prescription opioid addiction, misuse, abuse, overdose and death] are inadequate

  • New authorities granted under FDAAA: [FDA] will now be implementing Risk Evaluation and Mitigation Strategies (REMS) for a number of opioid products

  • [FDA expects] all companies marketing these products to [cooperate] to get this done expeditiously

  • If not, [FDA] cannot guarantee that these products will remain on the market

Rappaport BA. REMS for Opioid Analgesics: How Did We Get Here? Where are We Going? FDA meeting of manufacturers of ER opioids, FDA White Oak Campus, Silver Spring, MD. March 3, 2009.


States with pmps
States with PMPs Treatment of Pain

Operational PMP:32

Start-up phase: 6

In legislative process: 11

No action: 1

Office of Diversion Control. http://www.deadiversion.usdoj.gov/faq/rx_monitor.htm#1. Accessed March 2010.


Identifying and managing abuse and diversion
Identifying and Managing Abuse Treatment of Painand Diversion

Assessing risk and aberrant behaviors

Performing scheduled and random UDTs

Utilization of PMPs

Assessing stress and adequacy of pain control

Developing good communication with pharmacists

Receiving input from family, friends, and other patients


Case study opioid renewal clinic what is the impact of a structured opioid renewal program
Case Study: Opioid Renewal Clinic Treatment of PainWhat is the impact of a structured opioid renewal program?

  • Primary goal: reduce oxycodone SA use to 3% of opioids

  • Setting

    • Primary care

    • Managed by nurse practitioner and clinical pharmacist

    • Philadelphia VA pain clinic

  • Structured program

    • Electronic referral by PCP

      • Signed Opioid Treatment Agreement

      • UDT

    • Support from multidisciplinary pain team: addiction psychiatrist, rheumatologist, orthopedist, neurologist, and physiatrist

    • Multimodal management

      • Opioids

      • NSAIDs and acetaminophen for osteoarthritis

      • Transcutaneous electrical stimulation (TENS) units

      • Antidepressants and anticonvulsants for neuropathic pain

      • Reconditioning exercises

Wiedemer NL, et al. Pain Med. 2007;8(7):573-584.


Opioid renewal clinic results
Opioid Renewal Clinic: Results Treatment of Pain

  • OTAs increased: 63  214

  • Monthly UDTs increased: 80  200

  • Oxycodone SA use decreased

    • Quarterly costs: $130,000 $5,000

    • Percent of opioids: 22.5% 0.4%

  • ER visits reduced 73%

  • Unscheduled PCP visits reduced 60%

  • PCPs satisfied (questionnaire)

  • 171/335 patients referred had aberrant drug-taking behaviors

    • 45% adhered to OTA (resolved aberrant behaviors)

    • 38% self-discharged from ORC

    • 13% referred for addiction treatment

    • 4% consistently negative UDT

Wiedemer NL, et al. Pain Med. 2007;8(7):573-584.


Opioid Abuse-Deterrent Treatment of Pain

Strategies Hierarchy

Combination Mechanisms

Pharmacologic

  • Sequestered antagonist

  • Bio-available antagonist

  • Pro-drug

Aversive Component

  • Capsaicin – burning sensation

  • Ipecac – emetic

  • Denatonium– bitter taste

Increasing Direct Abuse Deterrence

Physical

  • Difficult to crush

  • Difficult to extract

Deterrent Packaging

  • RFID – Protection

  • Tamper-proof bottles

Prescription Monitoring


Electronic track and trace rfid
Electronic Track and Trace RFID Treatment of Pain

Secures integrity of drug supply chain by providing accurate drug "pedigree"

A record documenting that the drug was manufactured and distributed under secure conditions. We particularly advocated for the implementation of and noted that radio-frequency identification (RFID) is the most promising

RFID technology

Tiny radio frequency chip containing essential data in the form of an electronic product code (EPC)

Each discrete product unit has a unique electronic serial number

Product can be tracked electronically through every step of the supply chain

RFID, radiofrequency identification


Physical deterrent viscous gel base
Physical Deterrent: Viscous Gel Base Treatment of Pain

SR oxycodone formulation: Remoxy™

Deters dose dumping

Accessing entire 12-h dose of CR medication at 1 time

Difficult to crush, break, freeze, heat, dissolve

The viscous gel-cap base of PTI-821 cannot be injected

Resists crushing and dissolution in alcohol or water


Aversive component
Aversive Component Treatment of Pain

  • Capsaicin

    – Burning sensation

  • Ipecac

    – Emetic

  • Denatonium

    – Bitter taste

  • Niacin

    – Flushing, irritation


Pharmacologic deterrent antagonist
Pharmacologic Deterrent: Antagonist Treatment of Pain

Sequestered antagonist

Bioavailable antagonist

Antagonists are released only when agent is crushed for extraction

Oral-formulation sequestered antagonist becomes bioavailable only when sequestering technology is disrupted; targeted to prevent intravenous abuse

Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. 1st ed. North Branch, MN: Sunrise River Press; 2007.


Remaining questions
Remaining Questions Treatment of Pain

How much does the barrier approach deter the determined abuser?

How much do agonist/antagonist compounds retain efficacy?

How much do agonist/antagonist compounds pose serious adversity?


Patient case studies
Patient Case Studies Treatment of Pain


Case study 1
Case Study 1 Treatment of Pain

A 56-year-old healthy male with acute back pain

Conservative therapy ineffective

Dx with acute thoracic compression fractures

Persistent pain 6/10 and activity related pain 10/10

ORT 5

UDT consistent therapy

PMP: no opioids

Rx started with hydrocodone 10 mg/APAP q 4 hours

Titrated to 50 mg CR morphine/naltrexone BID


Case Study 1 (cont) Treatment of Pain

  • Monitoring

    • Weekly visits until stable

    • Prescribe only enough medication until next visit

  • RX

    • Short acting for BTP

    • CR formulation (with less street attractiveness)

    • Vertebroplasty partially effective

  • Six month follow-up

    • Much improved; pain 2/10, => tapered of opioids by 70%

    • No aberrant behaviors

    • PMP showed no aberrant behavior

    • Monthly UDT consistent with therapy


Case study 2
Case Study 2 Treatment of Pain

38-year-old female actress with ovarian cancer and peripheral neuropathy from therapy

ORT score was 9

Urine drug test: THC, amphetamines

History of oxycodone addiction, ADD, sexual abuse

Smokes 1 pack per day since the age of 12

Consumes 20 drinks per week

PMP: several opioid prescriptions from different providers


Case Study 2 (cont) Treatment of Pain

  • RX

    • Instructed to D/C THC

    • OTA

    • Pregabalin 600 mg/day

    • Methadone was slowly titrated to 10 mg qid, Education for Safe Use

  • Two weeks later

    • Patient said she couldn’t tolerate methadone

    • Asked for oxycodone

    • Pregabalin is causing confusion and severe memory impairment, can’t remember her lines in performance


Case Study 2 (cont) Treatment of Pain

  • High risk determines what type of monitoring/therapy

    • Can oxycodone be safely prescribed?

  • Abnormal PMP suggest substance abuse or diversion

    • UDT and PMP role in monitoring? Frequency?

  • What to do about THC?

    • What if it is medical marijuana?

  • Positive UDT amphetamine due to ADD treatment?

    • Can UDTs differentiate methamphetamine from Adderall?

  • What multi-therapeutic approaches should be taken?

  • Should opioids be prescribed?


Conclusion
Conclusion Treatment of Pain

  • Use of opioids may be necessary for pain relief

  • Balanced multimodal care

    • Use of opioids as part of complete pain care

    • Anticipation and management of side effects

    • Judicious use of short and long acting agents

    • Focus on persistent and breakthrough pain

    • Maintain standard of care

      • H&P, F/U, PRN referral, functional outcomes, documentation

  • Treatment goals

    • Improved level of independent function

    • Increase in activities of daily living

    • Decreased pain


Pharmacovigilance Treatment of Pain

Functional outcomes

Standard medical practice

FSMB policy

Certain

It is required

Uncertain

What is meant by pain management?

Who needs what treatment?

Do universal approaches work?

Does it improve outcomes?

For patients

For regulators

Conclusion (cont)


Online resources
Online Resources Treatment of Pain


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