Opioids in 2017: their evolving clinical role

Transcription

1 Opioids in 2017: their evolving clinical role Dr. Lori Montgomery MD CCFP Medical Director, AHS Chronic Pain Centre, Calgary Zone Clinical Lecturer, Department of Family Medicine Clinical Lecturer, Department of Anesthesia, Perioperative and Pain Medicine Cumming School of Medicine, University of Calgary

2 Disclosures Faculty: Lori Montgomery Some slides created by Dr Nick Etches, medical officer of health, Calgary Zone Relationships with commercial interests: Grants/Research Support: none Speakers Bureau/Honoraria: none Consulting Fees: none

3 Objectives explain to a patient how new opioid guidelines may affect their pain treatment answer patient questions about best evidence in pain management use cognitive strategies to support a patient s pain treatment plan

4 Simone Fibromyalgia for 18 years Opioid treatment for 12 years Dose stable for some time, but recently escalating to 400mg MEDD Admitted to hospital with pneumonia Hospitalist asked her to think about tapering Why??

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6 Overdose deaths fentanyl OD deaths by Opioid type

7 Overdose deaths fentanyl OD deaths by Opioid type

8 Overdose deaths by Opioid type fentanyl OD deaths

9 All opioid overdose deaths in Alberta are increasing Deaths due to an acute drug toxicity with One or more opioids listed on the ME s certificate of death OR A review of the toxicology database showed one or more opioids present Year Edmonton Calgary Rural (4) Total * *this is an estimate, pending data: In 2015 Q1-Q3 fentanyl OD deaths represented 57% of opioid OD deaths 343/0.57 = 600

10 Prescribed Opioids CPSA and AH data ,000 patients prescribed opioids 10,687 patients prescribed methadone and buprenorphine (some for pain) 929,000 opioid prescriptions per quarter 13,044 people taking >100mg MEDD

11 967mg/capita 700mg/capita

12 Why

13 Opioid Prescribing versus Harms

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15 The down side: long term/high dose GERD symptoms Myoclonus Opioid-induced hyperalgesia Hormonal effects Direct pituitary and hypothalamic effects Direct hormone effects Elevated prolactin, ACTH, ADH Decreased TSH, FSH, LH, GH, cortisol (Immune dysfunction) (mood problems) Addiction and Diversion

16 Do they work for chronic pain? Ballantyne JC, and Mao J, N Engl J Med 2003 Kalso et al, Pain 2004 (all dx) Eisenberg et al, JAMA 2005 (neuropathic pain) Furlan et al, CMAJ 2006 (all dx) Martell et al, Ann Intern Med 2007 (back pain) Noble M et al. The Cochrane database of systematic reviews 2010 Agency for Healthcare Research and Quality 2011 Ivers, Dhalla, Allan, TFP ACFP 2012 (OA) Deyo RA, Von Korff M, Duhrkoop D, BMJ 2015 (back pain)

17 Efficacy N= 789 patients with mixed neuropathic pain 7 Canadian tertiary pain centres Prospective observational cohort Follow-up q3months for 2 years Moulin DE et al The Journal of Pain, Vol 16, No 9 (September), 2015

18 Efficacy 51.7% tried opioids during the study another 30% had been on opioids previously 17% (<10% overall) saw improvement with opioids Average dose >100mg MEDD (40mg MEDD if it worked) Moulin DE et al The Journal of Pain, Vol 16, No 9 (September), 2015

19 Smith, HS. Pain Physician, 2012;15:ES1-ES7

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22 CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016 Recommendations and Reports / March 18, 2016 / 65(1);1 49

23 CDC recommendations Apply to opioid naïve patients only No recommendations on patients taking high doses of opioids already Canadian guideline is expected to comment specifically on this group

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25 Inpatient non-surgical opioid prescribing

26 CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016 Recommendations and Reports / March 18, 2016 / 65(1);1 49

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33 Action Efforts underway nationally/provincially to look at regulatory/policy changes A number of groups looking at possible QI studies in acute care Complex problem Needs multifaceted solutions Aiming for culture change re: opioids

34 Self-monitoring Pacing Relaxa3on Self-talk Communica3on Damush TM et al, Pain self-management training increases self-efficacy, self-management behaviours and pain and depression outcomes, Eur J Pain 20(7): , August 2016

35 Self Monitoring?

36 Headache Diary Adapted from: Headache Network Canada Name: Month: Year: HEADACHE SEVERITY Record your greatest headache severity each day Rate pain level on a scale of No pain = 0 Pain as bad as it could be = 10 Morning Afternoon Evening/Night DATE TRIGGERS* Record the trigger(s) on each day when you feel a headache was triggered by the following: Stress Caffeine withdrawal Sleeping in Too little sleep Meals (irregular/skipping) Over or under activity Weather change Food Food Other Other DATE *Triggers are things that you experience which seem to bring on a headache at least some of the time Foods that patients commonly report can trigger a migraine include alcohol, citrus fruits, nuts, onions, monosodium glutamate (MSG), nitrites, dairy products, smoked fish, pickled herring, chocolate, eggs; beans; fatty foods; yeast extracts; aspartame; caffeine. Caffeine may be found in coffee, tea, cola beverages, chocolate, and energy drinks. The amount of caffeine in coffee has a large range. Decaffeinated coffee may still have an effect on some people s headaches. MENSTRUAL PERIODS Place an X on each day that you experience menstrual bleeding DATE

37 Pacing

38 Do It No Matter What and Function Activity Level Tolerance Do It No Matter What Time

39 Wait Until and Function Activity Level Tolerance Do it no matter what Wait Until Time

40 Pacing Approach Pacing Activity Level Tolerance Do it no matter what Time Wait Until

41 Positive Self Talk

42 Relaxation/ Breathing

43 Grand Hyatt Kauai, photo by L. Montgomery

44 Options: n PCN based pain programs n Alberta Healthy Living n Chronic Pain Centre n (UK site) n n 1:1 --- one day at a time

45 Mindfulness

46 Mindfulness Paying attention (being aware) In a particular way On purpose In the moment Non-judgmentally (Kabat Zinn) Brain Push-Up

47 MBSR Evidence Base Grossman, Niemann, Schmidt, Walach (2004). Mindfulness-based stress reduction and health benefits: A metaanalysis. Journal of Psychosomatic Research, 57, Improvements in standardized measures of pain such as medical symptoms, sensory pain, physical impairment, and functional quality-of-life estimates

48 MBSR Evidence Base Baer, R. A. (2003). Mindfulness Training as a Clinical Intervention:A Conceptual and Empirical Review. Clinical Psychology: Science and Practice (10)2. In general, findings for chronic pain patients show statistically significant improvements in ratings of pain, other medical symptoms, and general psychological symptoms. Many of these changes maintained at follow-up evaluations.

49 Mindfulness Resources

50 Mindfulness Resources

51 Summary new opioid guidelines have been developed to help keep patients safe in light of new evidence Our best evidence suggests that nonpharmacologic strategies are best anyway We can use brief cognitive interventions to support a patient s pain treatment plan

52 Simone Fibromyalgia for 18 years Opioid treatment for 12 years Dose stable for some time, but recently escalating to 200mg MEDD Admitted to hospital with pneumonia Hospitalist asked her to think about tapering Why??

53 ???!