2017 Opioid Guideline Update

Transcription

1 2017 Opioid Guideline Update The 2017 Canadian Guideline for Opioid Therapy and Chronic Non-Cancer Pain (CNCP) Dr. Lydia Hatcher, MD, CCFP, FCFP, CHE, D-CAPM Associate Clinical Professor of Family Medicine, McMaster Chief of Family Medicine, St Josephs Healthcare, Hamilton FMF 2017 S

2 Disclosure Dr. Lydia Hatcher Advisory board or similar committee Nonprofits Purdue Pharma, Lilly, Astra Zeneca, Tilray, Paladin Alliance for Best Practice in Health Education Clinical trials or studies Honoraria/speaker fees Nonprofits Research grants Non Financial Starting CHOIR (Nov 2017) and cannabis registries (2018) at McMaster Purdue Pharma, Lilly, Mettrum, Tilray, Knight Pharmaceuticals, MdBriefcase, CME Solutions, CME Away, MD Analytics College of Physicians and Surgeons of Ontario, Alliance for Best Practice in Health Education, Touchstone Institute, Essex County Medical Society, Joule-CMA None National Opioid Use Guideline Group expert panel, College of Family Physicians of Canada Community of Practice Committee in Chronic Pain

3 Disclosure of Commercial Support S This program has received no financial support in its development S The speaker will receive no honorarium for this talk

4 Mitigating Potential Bias Potential sources of bias identified in the preceding 2 slides have been mitigated as follows: S Information/recommendations provided in the following program will be evidence- and/or guideline-based and opinions of the speaker will be identified as such. S The Speaker completed the CPFC Mainpro Declaration of Conflict of Interest form evidencing compliance with Mainpro requirements, a requisite for this program to be given accredited status.

5 S Utilize the 2017 Canadian guidelines based on updated evidence for opioid use to inform: S Recommendations for the prescribing of opioids in adult chronic non cancer pain patients. S Adoption of Best Practice statements for use of opioids into your practice S Use of Guidance statements for safe use and tapering of opioids

6 Panel Composition and Conflict of Interest Management S 4-member Steering Committee S 15-member Guideline Panel (only ones to vote on recommendations) S S S 13 clinicians, most of whom had extensive methodological training 1 medical regulator two patient representatives S 13-member multi-disciplinary Clinical Expert Committee with expertise in the management of chronic pain and the prescribing of opioids S 16-member Patient Advisory Committee

7 This Guideline Does Not Address The use of opioids to manage the following: S Cancer-related pain S Opioid addiction or opioid use disorder S Acute or sub-acute pain (pain lasting less than 3 months) S Pain or suffering associated with end-of-life care

8 The Target Audience S Primary care physicians S Specialists who manage patients with chronic non-cancer pain S Nurse practitioners S Regulatory agencies and other policy makers

9 Development of Recommendations S Good practice statements: S Actionable guidance with compelling indirect evidence of large net benefits S Input from medical regulators guided our selection S Guidance statements: S Expert perspectives on questions that cannot be adequately answered by clinical evidence through a systematic GRADE* approach. S Recommendations *Grading of Recommendations, Assessment, Development and Evaluation

10 Understanding strength of recommendations S Recommendations are, according to standards for trustworthy guidelines and the GRADE system, categorized as strong or weak recommendations. S Strong recommendations: appropriate for all or almost all individuals. S represent candidates for quality of care criteria or performance indicators. S Weak recommendations: recognize that different choices will be appropriate for individual patients, consistent with their values and preferences. S Weak recommendations should not be used as a basis for Standards of Practice.

11 Patient with Chronic Pain SMarie, a 62-year-old female SChronic neck, shoulder, and back pain SRecent flare of lower back can t move or sleep

12 Section 1: Initiation and Dosing of Opioids in Patients with CNCP Recommendation #1: S When considering therapy for patients with CNCP S Recommend optimization of non-opioid pharmacotherapy and non-pharmacological therapy, rather than a trial of opioids S (Strong recommendation, Low quality evidence)

13 Patient with Chronic Pain SMarie has S No current or past substance use disorder S No current serious psychiatric disorders S She is experiencing persistent pain despite optimizing her non-opioid therapy S NOW WHAT???

14 Section 1: Initiation and Dosing of Opioids in Patients with CNCP Recommendation #2: S Without current or past substance use disorder(sud) S Without other active psychiatric disorders S Who experience persistent problematic pain despite optimized non-opioid therapy S Suggest adding a trial of opioids rather than continued therapy without opioids. S (Weak recommendation, Moderate quality evidence).

15 Recommendation 2: Remark By a trial of opioids, S we mean initiation, titration, and monitoring of response, with discontinuation of opioids if important improvement in pain or function is not achieved. S The studies included -alcohol abuse and dependence, and narcotic abuse and dependence, and sometimes referred to ICD-9 diagnoses. S The mental illnesses identified were generally anxiety and depression, including ICD-9 definitions, as well as psychiatric diagnosis, mood disorder, and post-traumatic stress disorder.

16 Patient with Chronic Pain S What if your patient has an active SUD??

17 Section 1: Initiation and Dosing of Opioids in Patients with CNCP Recommendation #3: S For patients with CNCP with an active SUD (DSM V) S Recommend against the use of opioids S (Strong recommendation, Low quality evidence). AGAINST

18 Section 1: Initiation and Dosing of Opioids in Patients with CNCP Recommendation #3: Remark S Clinicians should facilitate treatment of the underlying substance use disorders, if not yet addressed. S The studies identified alcohol abuse and dependence, and narcotic abuse and dependence, and sometimes referred to ICD-9 diagnoses.

19 Patient with Chronic Pain SWhat if your patient has a serious mental health problem?

20 Section 1: Initiation and Dosing of Opioids in Patients with CNCP Recommendation #4: S With an active psychiatric disorder whose non-opioid therapy has been optimized S Who experience persistent problematic pain S Stabilize the psychiatric disorder before considering a trial of opioids S Weak recommendation, Low quality evidence

21 Patient with Chronic Pain SWhat if your patient has a history of SUD??

22 Section 1: Initiation and Dosing of Opioids in Patients with CNCP Recommendation #5: S With a history of SUD, whose non-opioid therapy has been optimized S Who experience persistent problematic pain S Continue non-opioid therapy rather than a trial of opioids S Weak recommendation, Low quality evidence

23 Opioid Dosing S What are the limits of Morphine Equivalents (MEQ) I should prescribe??

24 Section 1: Initiation and Dosing of Opioids in Patients with CNCP Recommendation #6 S For patients with CNCP beginning opioid therapy S Restrict the prescribed dose to under 90mg MEQ daily rather than no upper, or a higher limit on dosing S Strong recommendation, Moderate quality evidence

25 Section 1: Initiation and Dosing of Opioids in Patients with CNCP S Recommendation #7: S For patients with CNCP beginning opioid therapy S Restrict the prescribed dose to under 50mg MEQ daily S Weak recommendation, Moderate quality evidence

26 Rotating and Tapering S Doc, my pain pills aren't working S I want to get off these patches S Can we try something else?

27 Section 2: Rotation and tapering of opioids in patients with CNCP Recommendation #8: S For patients with CNCP currently using opioids, with persistent problematic pain and/or problematic side-effects S Rotation to other opioids rather than keeping the opioid the same S Weak recommendation, Low quality evidence

28 Section 2: Rotation and tapering of opioids in patients with CNCP Recommendation #9: S For patients with chronic non-cancer pain currently using 90mg MEQ of opioids per day or more S Taper opioids to the lowest effective dose, potentially including discontinuation, rather than no change in opioid therapy S Weak recommendation, Low quality evidence

29 Section 2: Rotation and tapering of opioids in patients with CNCP Recommendation #10: S For patients with CNCP using opioids and experiencing serious challenges in tapering S We recommend a formal multidisciplinary program S Strong recommendation, Moderate quality evidence

30 Best Practice Statements S 1. Acquire informed consent prior to initiating opioid use for CNCP. S A discussion about potential benefits, adverse effects, and complications will facilitate sharedcare decision making regarding whether to proceed with opioid therapy. S 2. Clinicians should monitor their CNCP patients using opioid therapy for their response to treatment, and adjust treatment accordingly. S 3. Clinicians with CNCP patients prescribed opioids should address any potential contraindications and exchange relevant information with the patient s GP (if they are not the GP) and/or pharmacists.

31 Guidance Statements S 1: Restriction in amount of Opioids Prescribed S ON: 650MEQ, 20,000MEQ, BC: 3 months/250tabs S 2: Immediate vs Controlled Release Opioids S Depends on circumstances S 3: Co-prescribing (sedatives) with opioids S Prescribe Benzodiazepines rarely

32 Guidance Statements S 4: Sleep apnea S Option 1: Reduce opioid dose without specific treatment for sleep apnea. S Option 2: Provide specific treatment for sleep apnea without reducing opioid dose. S Option 3: Reduce opioid dose and provide specific treatment for apnea. S 5: Hypogonadism S Taper and/or trial of testosterone therapy

33 Guidance Statements Risk Mitigation S 6: Urine drug screening S Ask first, point of care better S?annually, 30% aberrant results S 7: Treatment agreements S Written may be useful

34 Guidance Statements Risk Mitigation S 8: Tamper-resistant formulations S Less favoured for misuse, costly S 9: Fentanyl patch exchange S P4P, law in ON S 10: Naloxone S May mitigate risk, yes for addicts

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