Safe Opioid Prescribing Practices in the Elderly

Transcription

1 Safe Opioid Prescribing Practices in the Elderly Masil George, MD Director, Geriatric Palliative Care Program Medical Director, Baptist Hospice This program has been funded under grant #U1QHP28723

2 No financial interests Disclosure

3 Objectives Provide framework for understanding and assessing chronic pain Describe the good, the bad and the ugly aspects of prescription opioid pain medications Define role of opioids in managing chronic non-malignant pain in the geriatric outpatient setting Tips to ensure prescriber responsibility and patient safety

4 The opioid epidemic

5 Facts and Figures Roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them. Between 8 and 12 percent develop an opioid use disorder. An estimated 4 to 6 percent who misuse prescription opioids transition to heroin. In 2013, enough opioids prescriptions for all adults in USA About 80 percent of people who use heroin first misused prescription opioids. Source: National Institute on Drug Abuse (NIDA)

6 Facts and Figures The annual number of overdose deaths involving prescription and illicit opioids has nearly quadrupled since In addition, more than 2 million people in the United States are addicted to prescription opioids More than 12 million report having misused these medications in Prescription opioid addiction and misuse are also contributing to a resurgence in heroin use and the spread of HIV and hepatitis C Vivek Murthy, Ending the Opioid Epidemic NEJM Dec 2016

7 A brief history of opioids 3400 BC to 300 AD Hippocrates, Alexander 1500s- Laudanum 1800s- Morphine isolated from opium and heroin synthesized from morphine Opioid schedules War on drugs

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9 Recent history 1990s- Several new opioid options, extensive marketing Pain the fifth vital sign More people die of opioid overdose than any other year on record, Hydrocodone to schedule II CDC released guidelines for prescribing opioids for chronic pain

10 Ms. KM Ms. KM is a 65 y/o WF presented to clinic to get established, and for pain management PMH of essential Hypertension, Major depression with anxiety, Fibromyalgia, morbid obesity with BMI of 52.1, Lymphedema, admission to psychiatric inpatient unit in 2013 SH- Widow since 2010, Highly educated, moved from out of state Oxycontin 80 mg po bid, and hydrocodone 7.5/325 every 4 hours/ PRN

11 DEFINITION OF PAIN Unpleasant sensory and emotional experience associated with actual or potential tissue damage

12 Types Nociceptive: pains are complication of infiltration of tissue by tumor or tissue injury Somatic: deep aches Visceral: cramping, colicky Neuropathic: complication of injury to the peripheral or central nervous systems Poorly tolerated and difficult to control

13 Acute and chronic pain Acute pain- Comes on quickly, can be severe, lasts short time Chronic pain- Pain that persists longer than course of natural healing

14 Pain physiology

15 Elements of pain assessment Location Intensity or severity Quality (description) Duration Pattern Current treatment/response What has worked in the past?

16 How to assess pain? Verbal pain intensity scale Numeric pain intensity scale Visual analog scale Faces

17 Assessment of Pain Intensity Verbal Pain Intensity Scale Visual Analog Scale No Mild Moderate Severe Very Worst pain pain pain pain severe possible pain pain No pai n Worst possible pain 0 10 Numeric Pain Intensity Scale Faces Scale No Moderate Worst pain pain possible pain Sources: Portenoy RK, Kanner RM, eds. Pain Management: Theory and Practice. FA Davis; 1996:8-1 Wong DL. Waley and Wong sessentials of Pediatric Nursing. 5th ed. Mosby, Inc.; 1997: McCaffery M, Pasero C. Pain: Clinical Manual. Mosby, Inc. 1999:16. 17

18 Multimodal pain assessment tools Brief pain inventory (short form) McGill pain questionnaire Graded chronic pain scale 3 question PEG scale - Pain on average? - Pain interfered with enjoyment of life? - Pain interfered with general activity?

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20 Pathophysiology of chronic pain Acute pain- Strong relationship between peripheral stimulation and pain perception Chronic pain- created by nervous system secondary to nociceptor activation

21 Chronic pain- It is all in their head Sensitization of pain transmission fibers Death of inhibitory cells Loss of tonic inhibition Structural neuroplastic changes

22 Psychology of pain Psychological factors can dramatically modulate pain related suffering and dysfunction. Expectation of pain, and reinforcement of pain behavior increase pain behavior, and it has now been demonstrated that these factors increase cortical activation associated with experimental pains. Conversely, distraction reduces pain.

23 Tip of the iceberg Chronic Pain Acute Pain Depression Anxiety Addiction Somatoform disorders Personality disorders

24 Pain ladder

25 Non pharmacological pain management CBT- mindful meditation Exercise Acupuncture, Yoga, hypnotherapy, massage TENS Interventional approaches

26 Non opioid pharmacological pain Antidepressants Anticonvulsants Alpha-2 adrenergic agonists Local anesthetics Corticosteroids Baclofen N-methyl-D-aspartate receptor agonists Muscle relaxants Topical creams and gel Neuroleptics Antihistamines Psychostimulants Calcitonin management Pain Management in the Elderly Population: A Review Alan D. Kaye, Amir Baluch, Jared T Scott

27 Opioids- The good Works really well Usually well tolerated Works for pretty much for any type of pain No ceiling effect (only dose limiting side effects) Opioids and the management of chronic severe pain in the elderly Pergolizzi J, Boger RH et al

28 Opioids- the bad Common side effects: Nausea/vomiting (resolved in 3-5 days), sedation, nausea, delayed gastric emptying, sexual dysfunction, sleep disturbance, multiple drug interactions, constipation (never resolves), pruritus, myoclonus, especially for the elderly: delirium, hallucinations, cognitive impairment Other side effects: Opioids induced neruotoxcity, hyperalgesia/allodynia, urinary retention, noncardiogenic edema, seizure, endocrine/immune effects? Respiratory Depression: occurs with excess doses of medication esp in opioid naïve patients; or when opioids requiring reduction Somnolence precedes respiratory depression Opioids and the management of chronic severe pain in the elderly Pergolizzi J, Boger RH et al

29 Opioids- the ugly Pseudo-Addiction Physical dependence confused with psychological dependence Pain-relief seeking, not drug-seeking When right dose used, patient functions better in life, whereas opposite true with the true addict Physical Dependence Tolerance (20-40%) up-regulate opioid receptors to need higher dose for sustained effect Withdrawal (20-40%) after 2 wks, withdrawing drug leads to adrenaline response (sweating, tachycardia, tachypnea, cramps, diarrhea, hypertension); avoid by decreasing drug 25% a day. Psychological Dependence Addiction (0.1% in CA pain) a need to get high where drug controls your life, compulsive uncontrolled behavior to get the drug; lie, cheat, steal. Risk factors for addiction: male, family history, personal history, criminal record, mental health issues

30 CDC guidelines for prescribing opioids for chronic pain 1. Non pharmacological and non opioid pharmacologic therapy is preferred for chronic pain. Only consider opioids if benefits anticipated to outweigh risks 2. Establish realistic treatment goals for pain and function before starting opioids and consider how opioids will be discontinued if benefits do not outweigh risks 3. Discuss known risks and realistic benefits before starting and periodically during therapy 4. When starting opioids for chronic pain, prescribe IR opioids instead of ER/LA 5. Prescribe lowest effective dose, try to keep below 90 MME per day 6. When treating acute pain, try to prescribe for 3 days or less

31 CDC guidelines for prescribing opioids for chronic pain 7. Evaluate within 1 to 4 weeks of starting opioids or dose escalation and every 3 months 8. Mitigate risk- consider naloxone if risk of opioid overdose such as previous history, higher dose (> 50 MMEs) or concurrent benzodiazepines 9. Review state prescription monitoring program when starting opioids and periodically 10. Consider urine drug testing at least annually 11. Avoid prescribing opioids and benzodiazepines concurrently 12. For patients with opioid use disorder, offer or arrange evidencebased medication assisted treatment programs

32 Realistic goals for pain management S- specific M- measureable A- action-oriented R- realistic T- time-sensitive Source: Scope of pain: safe and competent opioid prescribing education

33 Challenges to choosing right opioid Baby Zoomers Comorbidities Polypharmacy Physiological changes Cognitive and communication challenges Opioids and the management of chronic severe pain in the elderly Pergolizzi J, Boger RH et al

34 Special considerations Renal Failure Fentanyl and Methadone are safest, use morphine and oxycodone cautiously, avoid codeine and meperidine Liver Failure- Fentanyl is the safest, Use morphine, oxycodone and dilaudid cautiously and avoid methadone and Codeine Allergy- Find out what patient actually means Source: Pain treatment topics. Opioid safety in patients with hepatic or renal dysfunction, Sarah J Johnson, Pharm D

35 All dollars are not equal 1 US $ = 35,000,000,000,000,000 Z $ Quadrillion Zimbabwean dollars

36 Equianalgesic dosing 1 mg iv Morphine = 3 mg of oral Morphine 5 mg oral Morphine = 1 mg oral Dilaudid 5 mg of iv Morphine = 1 mg iv Dilaudid 1mg iv Dilaudid = 5 mg oral Dilaudid 25mcg/ hr Fentanyl patch= 1mg of iv morphine per hour= 50 to 75 mg of oral morphine over 24 hours 10 mg of oral Morphine = 1 mg of oral Methadone

37 Starting/ titrating/ rotating Tramadol 50 mg, Hydrocodone 5/325, Oxycodone 5 mg Reassure that addiction risk minimal if uses appropriately Advise on side effects and duration of action and dose appropriately (every 4 hours/ PRN oral) Bowel program- Miralax and Senna Titrate to goal every 3 to 5 days, follow up every 3 monthspill counts, PMP Use opioid conversion table and reduce dose by 33 to 50% when rotating from one opioid to another

38 6 A s for follow up Analgesia Activities Adverse effects Aberrant behaviors Affect Adherence

39 Pain management agreement One prescriber, one pharmacy Medications to be taken only as prescribed Refill schedule- call several days prior to running out of medication Lost medications/ prescriptions will be replaced at prescriber discretion Be willing to do urine drug testing, memory testing, driving evaluation, psychiatric evaluation as advised by prescriber Renew yearly

40 Screening for opioid misuse ORT- opioid risk tool PDMP- Prescription drug monitoring program SOAPP- Screener and opioid assessment for patients with pain DIRE- Diagnosis, intractability, risk, efficiency instrument UDT- Urine drug test PPA- Patient/ prescriber agreement

41 Arkansas PDMP Statistics 2015 Data: Controlled substance prescription records in the database Prescriber queries Dispenser queries >28 Million 68,000/mo 30,000/mo Law Enforcement queries 254 Regulatory Board queries 311

42 Opioid induced hyperalgesia State of nociceptive sensitization caused by exposure to opioids It is a distinct, definable, and characteristic phenomenon that could explain loss of opioid efficacy in some patients. Paradoxical response whereby a patient receiving opioids for the treatment of pain could actually be worse due to opioids. A comprehensive review of opioid-induced hyperalgesia. Lee M, Silverman SM et al

43 Discontinuing chronic opioid therapy Opioid withdrawal is associated with physical pain, this does not represent progression of underlying disease. Decrease dose by 5 to 10% each visit that patient is ready for dose reductionindividualize plan Taper opioid over several months A. Lembke, Weighing the risks and benefits of chronic opioid therapy; American Family Physician June 15, 2016

44 Substance Use Disorder in the Elderly On an average day in 2011, there were 2,056 drug-related ED visits by older adults, of which 290 involved illegal drug use, alcohol in combination with other drugs, or nonmedical use of pharmaceuticals -118 involved prescription or nonprescription pain relievers, 80 of which involved narcotic pain relievers specified by name (e.g., hydrocodone, oxycodone); -48 involved benzodiazepines -25 involved alcohol in combination with other drugs -23 involved antidepressants or antipsychotics -13 involved cocaine -7 involved heroin -5 involved marijuana -2 involved illicit amphetamines or methamphetamine Source: SAMSHA- Substance Abuse and Mental Health Services Administration

45 Ending the Opioid Epidemic August US Attorney General Dr. Vivek Murthy send 2.3 million letters to US clinicians. October President Trump declared opioid a public health emergency.

46 Who Treats Addiction? Addiction is defined as a disease by most medical associations, including the American Medical Association and the American Society of Addiction Medicine. Addiction and substance abuse should be managed and treated by a team of trained health care professionals, including physicians, psychologists, licensed counselors, social workers, physician assistants, nurses and nurse practitioners who specialize in addiction care. Source: The National Center on Addiction and Substance Abuse

47 Case Conclusion Ms. KM After detailed discussion with Ms. KM, we decided upon goals which included Physical therapy, weight reduction, sleep hygiene, and increased participation in social activities at the assisted living Facility. Opioids were reduced gradually- 10 mg every 3 to 4 months, and she is currently on 30 mg oxycontin bid (started out at 80 mg bid). She is also on Hydrocodone 5/325 tid, Cymbalta 60 mg po daily, and Neurontin 300 mg po tid.

48 Questions?