Industry Support. Opioid Guidelines from Around the World (for Long-Term Pain Therapy) (not end-of-life) None

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1 Opioid Guidelines from Around the World (for Long-Term Pain Therapy) (not end-of-life) Paul A. Sloan, M.D. Professor and Vice Chair for Research Associate Program Director, Pain Medicine Fellowship Department of Anesthesiology University of Kentucky Editor-in-Chief, Journal of Opioid Management International Conference on Opioids. June, 2018 Industry Support None 1

2 Outline Guideline origins Guideline limitations Guidelines for long-term opioid therapy from around the world I. Guideline Origins Australia 2

3 First USA Guidelines Eichhorn JH. JAMA 1986; 256:1017 II. Guideline Limitations We are only human, and limited by our interpretation of the data American Civil War, versus War of Northern Aggression 3

4 Therapeutic Interventions in Chronic Pain James Rathmell, MGH, Harvard Epidural Steroids: A Comprehensive, Evidence-Based Review Cohen S. Reg Anesth Pain Med 2013;38:175 Modest effect size lasting more than 3 months in well-selected patients For selected patients, ESI may prevent surgery We are of the firm belief that ESIs should continue to be part of a multimodal treatment strategy Armon C. Neurology 2007; 68:723 In general, epidural steroids for radicular lumbosacral pain is not recommended 4

5 Effect of Author Specialty on Results/Conclusions Cohen SP. Reg Anesth Pain Med 2013; 38;175 III. Opioid Guidelines from Around the World: A Comparison with 2016 USA CDC Opioid Guidelines Methods: Search the world for opioid guidelines for CNMP National groups (associations) only reviewed No local, hospital or state guidelines Compare directly with USA CDC guideline Part A: introduction remarks, special populations and medical conditions addressed Part B: compare with 12 CDC definitive recommendations Interesting comments from world guidelines International Conference on Opioids. June,

6 CDC Guidelines for Prescribing Opioids for Chronic Pain (Sloan paraphrase) Intro: Patients within the scope of this guideline include cancer survivors with chronic pain who have completed cancer treatment, are in clinical remission, and are under surveillance only Patients with active cancer, palliative care or end-of-life care are excluded. 12 recommendations CDC Morbidity and Mortality Weekly Report March 18, 2016; 65:1-49 CDC Guidelines for Prescribing Opioids: Introduction Adults only Patients with active cancer, palliative care or end-of-life care are excluded. Cancer survivors included Elderly included Pregnant women included History of SUD included Active SUD addressed Sleep-disordered breathing addressed Patients with renal or hepatic insufficiency addressed Patients with mental health conditions addressed History of prior overdose attempt addressed 6

7 CDC Long-Term Opioid Guidelines 1. Non opioid therapies for chronic pain are preferred 2. Establish treatment goals before starting COT A. Continue opioid therapy only if there is clinically meaningful improvement in pain and function 3. Educate patients/families on risks and benefits, etc 4. Start with IR opioids only 5. Keep the daily dose low if possible. Avoid doses >90/d OME 6. When treating AP, use lowest opioid dose and for shortest period of time 7. After initiation of COT, evaluate patient within 1-4 weeks for benefits/harms. Evaluate at a minimum of q3months. A. -document analgesia, activity, adverse side effects CDC Morbidity and Mortality Weekly Report March 18, 2016; 65:1-49 CDC Long-Term Opioid Guidelines 8. Prior to initiation, evaluate patient for risk factors -addiction history, family hx, psychological issues, legal issues, social issues, for all patients 9. Review the Prescription Drug Monitoring data 10. Utilize UDS prior to initiation and a minimum of yearly 11. Avoid prescribing benzodiazepines with opioids 12. Offer or arrange treatment for patients that demonstrate opioid use disorder -do not dismiss from practice -do not abandon patient -continue with nonopioid analgesic treatment -assist patient in finding qualified addiction treatment CDC Morbidity and Mortality Weekly Report March 18, 2016; 65:1-49 Guidelines of Long-Term Opioid Therapy for patients with chronic nonmalignant pain 7

8 18 national guidelines; 16 enough detail for comparison; 12 from USA III. Opioid Guidelines from Around the World: A Comparison with 2016 USA CDC Opioid Guidelines Results Part A Introduction: 16 useable national guidelines Majority (75%) in the USA; all in countries of high opioid consumption No guideline addressed children CDC was only guideline to specifically include cancer survivors Most guidelines designated for CNMP Only 4/16 guidelines addressed multiple issues compared with the CDC guideline Results Part A Introduction: Only 3/16 specifically addressed the elderly Only 4/16 specifically addressed pregnant women 6/16 addressed sleep-disordered breathing issues 6/16 addressed patients with active SUD Only 4/16 addressed patients with mental health conditions 8

9 USA CDC Guideline March, 2016 Recommendations with majority agreement: USA CDC Guideline March, 2016 Recommendations with least agreement: Start with IR opioid only: split 50:50 Avoid benzodiazepines: 10/16 in agreement For noncompliant patient-continue to treat with nonopioids and arrange addiction specialist: 10/16 9

10 Guidelines almost exactly with CDC: American College of Cardiology USA VA Guideline ASIPP USA Federation of State Medical Boards ACOEM Royal College of Australia GPs Unique Differences versus CDC Guideline: American College of Rheumatology 2012 For osteoarthritis pain only conditionally recommend tramadol ; but, have no recommendations of opioids European Pain Federation 2016 ER opioids preferred Opioid rotation addressed Do NOT address any maximum high opioid dose American Academy of Pain Medicine 2016 Opioids must remain an important option as part of a multidisciplinary treatment We have concerns that the CDC guideline makes disproportionately strong recommendations based upon a narrowly selected portion of the available clinical evidence Unique Differences versus CDC Guideline: Canadian Guideline 2017 ER opioids acceptable Evidence to avoid benzodiazepines is weak For history of SUD, or active SUD, do NOT use opioids Royal College of Anesthetists 2018 Excellent web site No mention of urine drug monitoring Pain Association of Singapore 2013 ER opioids preferred over IR High opioid dose defined as 200 mg OME/day 10

11 Unique Differences versus CDC Guideline: USA VA Guideline 2017 Strongly avoid benzodiazepines There is no absolute safe opioid dose Not supportive of ER opioids, but recognize that the evidence is weak Patient with active SUD- do not use opioids American Society of Interventional Pain Physicians 2017 ER opioids only in specific circumstances Unique Differences versus CDC Guideline: German Pain Society 2015 No recommendation or preference for a particular opioid or route of administration ER opioids very acceptable After 6 months of long-term opioids; consider a drug holiday No mention of benzodiazepines No mention of IR opioids to initiate an opioid trial Very good section on special patient groups 11

12 R Portenoy Guidelines (1996) Portenoy R. J Law, Med & Ethics 1996; 24:296 Summary Most USA CDC recommendations are agreed upon by national guidelines of developed western nations Guidelines have disagreement regarding a preference for IR versus ER opioids 37% of national opioid guidelines reviewed did not discuss concomitant use of benzodiazepines Know at least one opioid guideline well Know your state opioid law/guideline very well Keep most patients within guidelines Keep all patients within your state law 12