Opioids: The Cause of, and Solution

Transcription

1 Opioids: The Cause of, and Solution to, All Things Pain Tina Korownyk & Jessica Kirkwood Faculty/Presenter Disclosure Presenter: Tina Korownyk Relationships that may introduce potential bias and/or conflict of interest: Grants/Research Support: Program/project funding received from non profit sources Alberta College of Family Physicians, other provincial chapters of the CFPC, Toward Optimized Practice Speakers Bureau/Honoraria: Tina Korownyk has received a speaker fee and expense support from the Alberta College of Family Physicians. Consulting Fees: N/A Other: Paid by University of Alberta, Alberta Health 1

2 Faculty/Presenter Disclosure Presenter: Jessica Kirkwood Relationships that may introduce potential bias and/or conflict of interest: Grants/Research Support: N/A Speakers Bureau/Honoraria: Jessica Kirkwood has received a speaker fee and expense support from the Alberta College of Family Physicians. Consulting Fees: N/A Other: N/A Disclosure of Commercial Support This program is presented by the Alberta College of Family Physicians (ACFP) without any commercial or in kind support. The ACFP provides a speaker fee and expense support for presenting at the Practical Evidence for Informed Practice. 2

3 Objectives Discuss evidence for opioids in Acute pain Do they work? For what? How long? Chronic pain Long term risks and benefits Tapering Practical Suggestions Troubleshooting 2017 Chronic Non Cancer Pain Guidelines Average Jo Psychiatric Concerns Substance Abuse ABO Ok, opioids Aim < 50mg/d Treat psych Treat substance abuse Ok, no more than 90mg/d Rotate Opioids Refer to Formal Multidisciplinary Program Titrate down 3

4 2017 Chronic Non Cancer Pain Guidelines Average Jo Psychiatric Concerns Substance Abuse ABO Ok, opioids Aim < 50mg/d Treat psych Treat substance abuse Ok, no more than 90mg/d Rotate Opioids Refer to Formal Multidisciplinary Program Titrate down X X 4

5 CMAJ Oct 2016 Pediatric Acute Pain Management MSK Injuries 1 : 3 RCTs, 740 children, ibuprofen vs aceta, codeine, or both Ibuprofen > either alone for pain, ibuprofen = combination Ibuprofen improved function, fewer AEs RCT 134 kids, ibuprofen (10mg/kg) vs morphine (0.5mg/kg) No difference pain scores 24 hrs Morphine AE 56% vs 31%, NNH = 4 Outpatient Post Operative Pain RCT 154 children, orthopedic surgery (ORIF, cysts, hardward removal) Ibuprofen vs Morphine 2 No difference pain scores up to 48 hrs Morphine NNH = 4 Similar for post tonsillectomy pain 3 1) TFP #14, updated July , CMAJ DOI: ) CMAJ 2017 October 10;189:E ) Pediatrics 2015;135:

6 Legitimate opioid use before high school was independently associated with a 33% risk future opioid misuse after high school. Pediatrics Nov;136(5):e Acute Pain in Adults Adult Back Pain < 2 weeks 2 : RCT, Naprosyn 500 BID: + cyclobenzaprine 5mg, oxycodone/acetaminophen 5/325mg, or placebo (1 2 TID) No difference frequent/always back pain day 6: 29%, 28%, 35% Return to normal activities: 4d, 4d and 5d. Soft Tissue Injury 3 : Cochrane (4 RCTs, 958 pts): No difference opioid vs NSAID for pain outcomes Improved function at 7d with NSAIDs. MVC Pain 4 : ER Cohort: NSAID vs Opioid no difference in pain at 6 weeks Those prescribed opioids 20% more likely to report opioid use at 6 weeks Labour 5 : Insufficient evidence that parenteral opioids are more effective than placebo or other interventions 2) JAMA. 2015;314(15): ) Ann Intern Med Feb 16;164(4):JC19.. 3) Cochrane Database Syst Rev Jul 1;(7):CD ) Pain Feb;158(2): ) Cochrane Database Syst Rev Mar 14;(3):CD

7 How Many Opioids Do We Need? Ann Surg Apr;265(4): How Many Opioids Do We Need? Post op: 80% of patient requirements met by 5 15 pills Ann Surg Apr;265(4):

8 Unused Opioids After Surgery Up to 71% of opioid tablets prescribed were unused 1 Among persons who were abusing analgesics, 53% reported receiving them from a friend or relative 2 JAMA Surg Aug 2. doi: /jamasurg ) Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. NSDUH series H 48. HHS publication no. (SMA) Rockville, MD Opioid Sparing Effects of NSAIDs 1 Pediatric Sys Rev 1 : 27 RCTs Perioperative NSAID consumption opioid requirement in first 24 hrs SMD = 0.83 (Large effect) 1 Adult Sys Rev + Network Meta Analysis 2 : Post op NSAID + Acetaminophen morphine requirement by 23mg/24hr (CI 14 32) 1) Anesth Analg 2012;114: ) Br J Anaesth Jan;118(1):

9 Bottom Line Acute Pain Ambulatory care: no strong evidence that opioids are superior 1 If opioids prescribed, most will not require more than 5 15 tablets Consider addition of NSAIDs/Acetaminophen to reduce opioid consumption 1) Ann Emerg Med Oct;60(4): ) 3) mdacep org/md%20acep%20pamphlet%20final April% pdf Are Long Acting Opioids Better? Study Pain Time Pts Findings Oxycodone Systematic Review: 7 RCTs, 568 pts, short vs Caldwell 1999 OA 30d 107 Equal for pain and sleep long acting opioids Hale 1999 Back 6d 47 Equal for pain No difference pain or functional outcomes Salzman 1999 Back 10d 57 Equal for pain Codeine Hale 1997 Back 5d 83 LA better pain (but higher doses)* 200mg vs 71mg / day Dihydrocodeine Gostick 1989 Back 14d 61 Equal for pain Lloyd 1992 OA 14d 86 Equal for pain Morphine Jamison 1998 Back 112d 36 LA better pain (but higher doses) * Carson S, Thakurta S, Low A, Smith B, Chou R. Drug Class Review: LA group Long Acting titrated Opioid up Analgesics: as needed Final Update 6 Report. Portland, OR: Oregon Health and Science University; July Accessed Oct

10 CMAJ Dec 8;181(12): Long Vs Short Acting Opioids Cohort, 319 Unintentional Overdoses, veterans admin healthcare system 1 Risk Overdose with long acting: HR 2.33 Highest in 1 st 2 weeks: HR 5.25 Mortality with Long acting compared to other pain medications 2 Because of the greater risks of overdose and death with extended release opioid formulations, reserve [these medications] for use in patients for whom alternative treatment options (e.g. non opioid analgesics or immediate release opioids) are ineffective (FDA 2013) 1) JAMA Intern Med. 2015;175(4): ) JAMA. 2016;315:

11 Benefits and Risks of a long term commitment 11

12 Opioids for Chronic Pain Abuse or dependence 1 : 0.7% with 36 MME/d, 6.1% with 120 MME/d Overdose 1 : risk with dose: MME/d HR MME/d HR 3.79 >100 MME/d HR 8.87 Road trauma: ~ 20% odds with 20MME/d 2 Mortality: (LA Opioid vs TCA or anticonvulsant) 3 <30 d: 260/10,000 vs 63/10,000 (HR = 4.16) Overall: 167/10,000 vs 108/10,000 (HR = 1.64) Mixed evidence for fractures, MI, & sexual dysfunction 1) Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain United States, MMWR Recomm Rep 2016;65(No. RR 1): ) JAMA Intern Med 2013;173: ) JAMA. 2016;315: Opioids for Chronic Pain Cochrane systematic reviews Chronic back pain 1 : Majority < 4weeks, opioids better than placebo, no better than NSAIDs or antidepressants Neurologic pain 2 : half the studies <24hrs. Opioids > placebo for pain but not function. No diff with gabapentin or TCAs OA pain 3 : small benefit vs placebo, trials <4 weeks demonstrated significantly greater pain benefit (p=0.001) Sys Rev, opioids >3 mo 4 No placebo controlled RCTs > 3 months No study opioids vs no opioids evaluated >1 yr outcomes of pain, function or quality of life. 2) Cochrane 2013; 8: CD ) Cochrane Database of Systematic Reviews 2013, CD ) Cochrane 2014; 9: CD ) Ann Intern Med Feb 17;162(4):

13 Opioids for Chronic Pain As highlighted by an on the National Institutes of Health Pathways to Prevention panel: Particularly striking was the realization that evidence is insufficient for every clinical decision that a provider needs to make about the use of opioids for chronic pain. Bottom Line: Evidence of long term benefit on pain, function and QOL with opioids is lacking. Ann Intern Med 2015;162: Is Tapering Actually Helpful? Sys Rev 67 studies, opioid d/c or Voluntary: Multidisciplinary Pain Clinic, Buprenorphine, Behavorial interventions, Detox, Ketamine, Accupuncture, or Other Patient Outcomes (fair quality studies): 8/8 reported Pain severity 5/5 reported Function 3/3 reported QOL Limitations: Observational, absolute benefit unclear, a/es poorly reported, heterogeneous interventions, applicability to forced tapering? CDC: Evidence on tapering strategy or benefit too limited to make recommendations Ann Intern Med Aug 1;167(3): ) Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain United States, MMWR Recomm Rep 2016;65(No. RR 1):1 49. DOI: 13

14 Whoooo are you? Ready Set Go! 14

15 STOP! BEFORE you sign that Rx: Discuss alternatives Discuss side effects Review goals (focus on fxn!) Opioid Contract UTT? (Urine Drug Screen) Opioid Contract Who pt, sole prescriber/clinic What med, dose, route Where single pharmacy When dispensing interval Why what are we treating, goals Won t divert, store unsafely, combine with harmful substances (etoh, benzos, other opiates, etc) come begging for more when I drop them down a storm drain, etc. Wee Routine UTTs 15

16 Acute Pain Specific end date (sunrise, sunset) Reconsider length of Rx is 2 weeks or 30 tabs really necessary? Review dispensing interval, storage, disposal How you doin? How to tell when it s going well Function function function!! Attending appts, not breaching opioid contract Decrease? 16

17 How you doin? How to tell when it s going well Function function function!! Attending appts, not breaching opioid contract Decrease? How you doin? How to tell when things are going poorly Listen to your gut Escalating doses with no perceived benefit Concerns re: misuse Early releases Missed appts Reports from colleagues Evidence of dependence A problematic pattern of opioid use leading to significant impairment or distress 17

18 Now what? If no evidence of OUD Rotate Taper Discuss benefits of tapering (improved energy, decreased side effects, improved pain control) Optimize non opiate pain management Set realistic function goals Optimize psychosocial supports Create a schedule (5 10% every 2 4 weeks) Frequent follow up Now what? If no evidence of OUD Rotate Taper Discuss benefits of tapering (improved energy, decreased side effects, improved pain control) Optimize non opiate pain management Set realistic function goals Optimize psychosocial supports Create a schedule (5 10% every 2 4 weeks) Frequent follow up 18

19 Now what? If you suspect OUD Discuss concerns and suggest voluntary taper with psychosocial supports Discuss Methadone or Suboxone Physician or self referral Phone a friend! Consult a colleague Opioid Dependency Telephone Consultation RAAPID North RAAPID South Thank you! 19