WHY GOOD PAIN MANAGEMENT IS GOOD DRUG ABUSE PREVENTION

Transcription

1 WHY GOOD PAIN MANAGEMENT IS GOOD DRUG ABUSE PREVENTION Bob Twillman, Ph.D., FAPM Executive Director Academy of Integrative Pain Management Walking the Tightrope of Pain Management Adverse Events Misuse Death Addiction Diversion Abuse Two Major Public Health Problems Prescription opioid abuse: 12.5 million non-medical users per year $ billion cost per year 16,000-19,000 overdose deaths per year (maybe) Chronic pain: >100 million with chronic pain, ~25-39 million with daily chronic pain, ~10 million disabled $ billion cost per year Suicide risk doubled 42,800 suicide deaths in 2014 ~28,000 were people with chronic pain 1

2 More Commonalities than Differences Prescription drug abuse and chronic pain are more alike than different: Both are highly prevalent Both are very costly, in economic and human terms Both highly stigmatized--patients are blamed Both are poorly understood by the medical profession Both are under-resourced vis-à-vis treatment Both are complex problems, with many moving parts Both best addressed with a biopsychosocial approach Most importantly: Both involve tremendous suffering Not A Zero-Sum Game Often, it feels like any attempt to prevent prescription opioid abuse must be accomplished by reining in prescribing, potentially increasing pain and decreasing function Similarly, it often seems as though any effort to improve pain management must involve increased prescribing, which could, in turn, lead to more adverse outcomes I believe this misstates the case, and that it is possible to address both problems without adversely affecting either by providing balanced pain management A Thought For every complex problem, there is a solution that is neat, simple, and wrong H.L. Mencken I believe that implementing overly simplistic policy solutions for these two very complex problems leads to the zero-sum game that we so often perceive Perhaps the solutions we should be seeking are as complex as the problems we are trying to solve 2

3 Overdose Deaths Involving Prescription Opioids Statistics are somewhat squishy due to Coding, and counting, multiple causes of death for one decedent Difficulty distinguishing between parent drug and metabolites Difficulty distinguishing between licit and illicit forms of the same drug, especially fentanyl Overdose Deaths Involving Prescription Opioids Overdose Deaths Involving Opioids 3

4 Overdose Deaths Involving Prescription Opioids Most are poly-substance overdoses: Previous CDC research suggests that about 75-80% of decedents used multiple drugs, not including alcohol Among drug overdose decedents in Florida in the first half of 2013, the state medical examiners network reported that 93.5% had multiple drugs on board Most decedents don t have active prescriptions: Two studies (one from CDC) show that as many as 55-60% did not have an active prescription for the drugs involved Recent research in Massachusetts revealed that only 8% of decedents had active prescriptions We need much better understanding of what these numbers mean, so we can craft better solutions Filtering the Noise to Find the Signal One key task in statistics is reducing or eliminating the noise to detect the true signal Drug overdose data have always been pretty noisy, but the static is increasing Detecting the true signal is very challenging What s happening to prescription drug abuse rates? Increasing? Stable? Decreasing? 4

5 How Do We Explain This? Rx Opioid OD Deaths Rx Opioid OD Deaths NSDUH data: Non-medical use, opioid use disorder rates (%) in people > 12 years old Past Yr NMU Past Year OUD Asking the Right Questions To get the right answers, we have to ask the right questions The Right Question about Opioids for Chronic Pain The wrong question is, Should we use opioids to treat chronic pain? The right question is, In which patients should we use opioids, at what doses, for how long, with which adjunctive treatments, and with what precautions? 5

6 Pathways to Prevention Findings In September 2014, NIH sponsored a two-day Pathways to Prevention workshop on The Role of Opioids in the Treatment of Chronic Pain Extensive evidence review was carried out prior to the meeting After the meeting, an unbiased panel developed a report regarding the risks and benefits of using opioids to treat chronic pain The key conclusion: What was particularly striking to the panel was the realization that there is insufficient evidence for every clinical decision that a provider needs to make regarding the use of opioids for chronic pain, leaving the provider to rely on his or her own clinical experience. Question: If that s the case, then how do we find our way out of the mess we re in? Revisiting the Role of Opioids for Chronic Pain Careful, judicious use of opioids with both pain relief and patient safety in mind is appropriate in pain management. Opioids are necessary, but we need other tools as well: Within the context of an integrative model of care, the Academy recognizes the effectiveness of opioids as part of a comprehensive treatment plan for some people who experience chronic pain. When prescribed judiciously by clinicians who are well educated about prescribing these medications, and taken as directed by patients who are well informed about these medications, opioids may be useful in reducing pain and restoring function. Appropriate Treatment for Chronic Pain Appropriate treatment for chronic pain is multimodal, including interventions like exercise, nutrition, integrative medicine treatments, medications not just opioids, because there may be others that work better This kind of treatment focuses primarily on improving function, rather than focusing totally on pain intensity Use of multiple types of treatment should reduce reliance on opioid analgesics as a primary means of treating pain Multiple barriers exist to providing this type of care for chronic pain 6

7 Appropriate Treatment for Chronic Pain (cont.) If all you have is a hammer, every problem looks like a nail. Abraham Maslow The biopsychosocial model recognizes the need to use multiple tools to fix the broken system that results in chronic pain Unfortunately, the system that provides those tools also is broken. We need more tools, and better access to the tools we have. This requires: More basic medical education content for traditional students Extensive continuing education for licensed providers Available providers of non-medication treatments Access to referral networks for those providers Adequate reimbursement for those providers Guidelines for Treating Chronic Pain Increasingly, we are seeing governmental agencies issue guidelines for the treatment of chronic pain The focus of these guidelines tends to be heavily on appropriate use of opioids in this setting ALL of these guidelines are based, almost entirely, on expert opinion Guideline issued on March 15, 2016 by the CDC is a prime example Good Evidence is Lacking Remember the Pathways to Prevention expert panel statement: What was particularly striking to the panel was the realization that there is insufficient evidence for every clinical decision that a provider needs to make regarding the use of opioids for chronic pain, leaving the provider to rely on his or her own clinical experience. 7

8 Good Evidence is Lacking Lack of evidence rarely inhibits policymakers who see an opportunity Legislating the CDC Guideline: Dose Limits Rhode Island H 8224: Limits opioids for acute pain to no more than 30 MME/day for a maximum of 20 doses Maine: 300 MME/day maximum dose initially; as of 7/1/17, 100 MME/day maximum dose; no more than a 30- day supply in a 30-day period for chronic pain; no more than a 7-day supply in a 7-day period for acute pain Exceptions: Active and aftercare cancer treatment, palliative care, end-of-life and hospice care, MAT for SUD, or other circumstances by rule Similar legislation introduced in Pennsylvania and Michigan Legislating the CDC Guideline s Acute Pain Recommendation: DC 15-Day Limit 10-Day Limit 7-Day Limit 5-Day Limit 3-Day Limit 8

9 ACUTE PAIN Excess Supplies of Opioids in Acute Pain Prescriptions for acute pain have also been noted by some as the source of excess opioid doses One case example will illustrate this point; many people have similar stories Acute Pain Management Case 53 y/o female has arthroscopic knee surgery for partial medial meniscectomy. Patient has a history of adverse reaction to hydrocodone/ APAP (full body rash). The surgeon prescribed oxycodone/apap, along with an NSAID and an ice machine. 9

10 Acute Pain Management Case Here is how much oxycodone/apap was actually used by the patient: Acute Pain Management Case Here is how much oxycodone/apap was left over: Why Does This Happen??!? Surgeons are doing what they learned to do in their training They are motivated to ensure that their patients have adequate pain relief They have a hard time accommodating patients who run out of medication, so they prescribe as if every patient uses as much as the patient at the 99 th percentile Note that hydrocodone rescheduling may be exacerbating this Partial fill legislation may alleviate this They may not know the 50 th percentile, or median, dose 10

11 The Right Question about Prescription Opioid Supplies How can we reduce the supply of prescription opioids? is the wrong question The right question is, How can we reduce the EXCESS supply of prescription opioids? How do we define excess? Data on Prescribing for Surgical Pain Hill et al., 2017, Annals of Surgery Studied opioids prescribed for five common outpatient surgeries Surveyed patients to determine how much of prescribed medication was used Calculated the number of pills needed to supply the needs of 80% of patients Calculated potential pill savings if this number was prescribed Data on Prescribing for Surgical Pain Surgery Median Rx d Range Rx d Percent Taken 80th %ile Partial Mastectomy Partial Mastectomy + Sentinel LN Biopsy Laparoscopic Cholecystectomy Lap Inguinal Hernia Repair Open Inguinal Hernia Repair N = 642; if 80 th percentile amount was prescribed, would save 9,787 pills 11

12 Data on Prescribing for Surgical Pain In a follow-up study, authors educated surgeons about their findings, and encouraged use of NSAID/ acetaminophen Mean number of pills prescribed decreased: PM: from 19.8 to 5.1 PM+SLNB: from 23.7 to 9.6 Lap Chole: from 35.2 to 19.4 Lap Ing Hernia: from 33.8 to 19.3 Open Ing Hernia: from 33.2 to 18.3 Overall, 53% decrease in pills prescribed Only 1 of 246 patients in study needed a refill Other Possible Solutions Conduct a PDMP check prior to discharge, so that patients with medications already at home are taught how to use them appropriately, rather than dispensing a new excess supply Allow partial fills of prescriptions, with remainder still available if needed CARA bill allows this at the federal level DEA is writing regulations to enact this law Some state laws will need to be changed to allow this Patient Safety Best Practices Pursue a balanced, multi-disciplinary approach to providing pain care Individualize treatment plans for each person with pain there is no cookbook, and one size doesn t even fit most Decrease opioid prescribing by incorporating multimodal analgesia Emphasize proper use, storage, and disposal; educate people with pain, family members, other loved ones and caregivers 12

13 A Final Word Medical professionals, especially those specializing in pain management, want to be part of the solution that enables us to provide pain care that is both safe and effective In part, we need to better use some tools we already have In part, we need some additional tools to effectively treat both acute and chronic pain in ways that don t exacerbate prescription drug abuse and other adverse outcomes We need to assert our appropriate role in developing solutions that promote balanced pain management, on behalf of ourselves and the people with pain for whom we care Thank you for your attention 13