Opioid Use: Current Challenges & Clinical Advancements

Transcription

1 Opioid Use: Current Challenges & Clinical Advancements Whitney Bergquist, PharmD, MBA, BCPS Acute Care NPPA Conference February 8, MFMER slide-1

2 No Disclosures 2017 MFMER slide-2

3 Objectives Summarize the current state of the opioid use and misuse in the United States Discuss challenges with opioid use and prescribing faced by providers Introduce pharmacogenomics and possible applications in pain medicine 2017 MFMER slide-3

4 Opioid Use Why the attention? Highest consuming nation of opioids By 2010, 5.1 million individuals had used opioids for nonmedical purposes 78 deaths per day in the U.S. Opioid Rx s increased 7.3% per capita from 2007 to 2012 Geographic variation in prescribing patterns Daubresse, M et al. Med Care (10): National Vital Statistics System mortality data.cdc Website. cdc.gov/nchs/deaths.htm Levy B et al. Am J Prev Med 2015;49(3): MFMER slide-4

5 Prescribing rates by state Paulozzi LJ. MMWR 2014;63(26): MFMER slide-5

6 Opioid Use Why the attention? Relationship between opioid dose and death Dasgupta N. Pain Med 2016;17(1): MFMER slide-6

7 Opioid Use Why the attention? Relationship between concurrent opioid and benzodiazepine use and death Dasgupta N. Pain Med 2016;17(1): MFMER slide-7

8 Opioid Use How did we get here? Pain is subjective, unverifiable Pain as the 5 th vital sign Lack of consensus on appropriate opioid use American College of Emergency Physicians American Society of Anesthesiologists Washington Agency Medical Directors Group American Academy of Pain Medicine U.S. Department of Veterans Affairs/Department of Defense Emphasis on patient satisfaction 2017 MFMER slide-8

9 Recent Developments CDC Guidelines 2017 MFMER slide-9

10 Education Screen and treat opioid use disorder Re-shape public perception of addiction 2017 MFMER slide-10

11 2016 CDC Guideline for Prescribing Opioids for Chronic Pain Adults with Chronic, non-cancer pain Primary Care Providers 3 areas of of consideration: When to initiate or continue Selection, dose, duration, follow-up & discontinuation Assessing risk and addressing harms Dowell, D et al. MMWR (1): MFMER slide-11

12 Initiation & Continuation of Opioids 1. Nonpharmacologic/nonopioid options preferred. Opioids only if benefits > risks. 2. Establish treatment goals for opioids and discontinuation plan if benefits < risks. 3. Before initiation and periodically during therapy, discuss risks and benefits of opioids MFMER slide-12

13 Selection, Duration, Dosage, Follow-Up & Discontinuation 4. Start with immediate-release, not extendedrelease or long-acting 5. Use lowest effective dose: 50 MME/day - reassess benefit 90 MME/day - avoid increasing unless carefully justified 6. Acute pain: lowest dose for shortest duration needed for expected duration of pain 7. Reassess benefit every 3 months or 1-4 weeks after initiation or dose escalation 2017 MFMER slide-13

14 Assessing Risk and Addressing Harm 8. Before initiation and periodically during therapy, assess risk factors for opioid-related harms 9. Use state prescription drug monitoring programs (PDMP) to assess if dosages or combinations increase risk for overdose 10.Use urine drug screening to assess for other prescribed opioids or illicit drugs 11.Avoid concurrent opioids and benzodiazepines 12.Offer and arrange treatment for patients with opioid use disorder 2017 MFMER slide-14

15 ICSI Comprehensive Pain Management Guideline September 2016 Hooten M et al. Institute for Clinical Systems Improvement. Sep MFMER slide-15

16 2017 MFMER slide-16

17 Acute Opioid Treatment Algorithm (cont.) 2017 MFMER slide-17

18 Consideration for Continuing Opioid Treatment Algorithm 2017 MFMER slide-18

19 Consideration for Continuing Opioid Treatment Algorithm (cont.) 2017 MFMER slide-19

20 Overdose or Abuse Legislation for availability of naloxone Abuse and addiction resources Increased focus on use of buprenorphine 2017 MFMER slide-20

21 Pharmacogenomics An Introduction and Review Related to Pain Medicine 2017 MFMER slide-21

22 Pharmacogenomics 101 Definition: the influence of genetics variation on an individual s drug response Growth of knowledge and clinical evidence with the 2003 Human Genome Project FDA incorporation of pharmacogenomics testing into drug labels 2017 MFMER slide-22

23 Pharmacogenomics 101 From genetic testing we can determine the genotype of certain cytochrome P450 enzymes Genotypes correspond to Phenotypes: Ultra-rapid metabolizer Extensive metabolizer Intermediate metabolizer Poor metabolizer The degree of metabolism can affect the success of treatment or the dose needed 2017 MFMER slide-23

24 Pharmacogenomics & Pain Medicine Targeted metabolic pathways: CYP2D6 CYP2C9 ABCB1 COMT Others? 2017 MFMER slide-24

25 Pharmacogenomics: CYP2D6 Accounts for 5% of liver CYP450 enzymes Accounts for 25% of liver enzyme activity Codeine and tramadol metabolized by CYP2D6 to active metabolite Concern for Ultra rapid metabolizers d/t increased efficacy Concern for intermediate to poor metabolizers d/t decreased efficacy Minor impact on oxycodone metabolism 2017 MFMER slide-25

26 Pharmacogenomics: CYP2C9 Poor metabolizers most frequently are caucasian Can result in reduced clearance of NSAIDs Increased drug levels for longer periods of time Increased risk of adverse events (i.e. GI bleeding) Naproxen as an alternate treatment. Senagore AJ et al. AM J Surg epub MFMER slide-26

27 Pharmacogenomics: ABCB1 Certain mutation in this gene requires higher morphine doses and systemic levels for analgesia Affects all opioids that interact with the mu opioid receptor Mu opioid receptor has greatest affect for pain relief Substitution of tapentadol d/t dual action Mu opioid receptor interaction Norepinephrine uptake inhibition 2017 MFMER slide-27

28 Pharmacogenomics: COMT Catechol-O-methyltransferase moderates transmission of pain by removing catechols Reduced activity is related to increased pain sensitivity and pro-inflammatory cytokine production Implications for targeted drug therapy in the future? 2017 MFMER slide-28

29 Limitations in Application Cost Limited Availability No National Laboratory Standards Education and Awareness No guidelines for standard use 2017 MFMER slide-29

30 Assessment Question AB is concerned about postoperative pain as he was unsatisfied with pain management during his last surgery. What would be the most impactful genomic testing to perform? A. CYP2C9 B. ABCB1 C. COMT D. CYP2D MFMER slide-30

31 Assessment Question AB s genetic testing reveals he is an ultra high metabolizer of the aforementioned enzyme. What is the greatest impact on his postoperative pain regimen that could be made based on this genetic information? A. Avoid tramadol B. Use naproxen C. Use morphine instead of oxycodone D. Trial tapentadol 2017 MFMER slide-31