1/30/2017 SEISMIC UPGRADE FOR THE OPIOID PARADIGM SHIFT ACPE PRE-TEST QUESTIONS. I have no declarations.

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1 SEISMIC UPGRADE FOR THE OPIOID PARADIGM SHIFT Traci Hamer, PharmD, MAT Kaiser Permanente Northwest Pain Management Pharmacy Services I have no declarations. ACPE PRE-TEST QUESTIONS True/False: Opioids may be appropriate for some patients with chronic nonmalignant pain in the context of a comprehensive pain management plan including non-pharmacologic therapies. Select which situations may be appropriate to taper: (a) patient consistently with slurred speech; (b) patient found obtunded; (c) patient stable on 400 MME; (d) all of the above Which symptom is consistent with opioid withdrawal? (a) constipation; (b) slow heart rate; (c) sweating; (d) nasal congestion. True/False: Managing diabetes, mental health, and sleep may improve pain control. Which of the following may assist in patient discussion about tapering (select all that apply)? (a) Drawing out the patient perspective; (b) consulting about what to expect; (c) shared decision making; (d) Motivational Interviewing. 1

2 OBJECTIVES Discuss where opioids fit in the management of chronic pain in the context of the CDC Guidelines of Prescribing Opioids for Chronic Pain Describe when and how opioids should be tapered or discontinued Describe potential side effects and management options for opioid withdrawal List non-opioid alternatives for the management of chronic pain Discuss approaches to patient conversations about safe opioid use and opioid taper THE OPIOID PROBLEM THE OPIOID PROBLEM ml 2

3 THE OPIOID PROBLEM drugoverdose/media / index.html THE OPIOID PROBLEM drugoverdose/media / index.html THE OPIOID PROBLEM Interagency Guideline on Prescribing Opioids for Pain. From the Washington State Agency Medical Directors Group. 3

4 THE OPIOID PROBLEM US DOJ DEA 2016 National Drug Threat Assessment Summary, November THE OPIOID PROBLEM *THE SUBDUCTION ZONE* CDC GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN 4

5 CDC GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN WHEN TO INITIATE OR CONTINUE OPIOIDS Nonpharmacologic and nonopioid pharmacologic therapy is preferred Establish realistic treatment goals Assess and reassess risks and benefits CDC GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN OPIOID SELECTION, DOSE, DURATION, FOLLOW UP, DISCONTINUATION If need to start opioid therapy, use shortacting opioids, NOT long-acting. Lowest effective dose. Prefer <50 morphine equivalent (MME). Not >90 MME. For acute pain, limit to 3 to 7 days supply Evaluate within 1 to 4 weeks of start, then every 3 months CDC GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN ASSESSING RISK & ADDRESSING HARMS Risk mitigation part of plan Review PDMP baseline, every 3 months, as needed. Urine Drug Screen at baseline, annually, as needed. Avoid concurrent benzodiazepines and opioids. Evidence-based treatment for opioid use disorder. 5

6 EARTHSHAKING CONCERNS Patient Why are you doing this to me? The government has no business... I am not an addict, I have real pain. Both education and discussion are crucial. EARTHSHAKING CONCERNS Clinician I don t have time to do this in an office visit. I m not sure how to taper or manage withdrawal. My patient satisfaction scores will decrease. HOW TO SEISMICALLY UPGRADE FOR THIS PARADIGM SHIFT Practical Tips How Pharmacists Can Help 6

7 REBUILDING WITH OUR NEW FRAME OF REFERENCE: EFFICACY & HARM REDUCTION Neurology 2014; 83: REBUILDING WITH OUR NEW FRAME OF REFERENCE: EFFICACY Better understanding of chronic pain and effective treatments Pain is a complex experience Opioids have limited success Many more options available now 7

8 REBUILDING WITH OUR NEW FRAME OF REFERENCE: HARM REDUCTION Pharmacist-patient engagement and education Opioids for acute vs chronic pain Overdose & naloxone Drug disposal Tapering & withdrawal Safety monitoring OPIOIDS FOR ACUTE PAIN CONSULTATION Temporary use in lowest dose for shortest duration needed NOTE: Should NOT use long-acting for the opioid naïve or acute pain Part of multi-modal plan: rest, ice, physical therapy, other pharmacotherapy Adverse effects: sedation, constipation, nausea/vomiting, itching Overdose & drug disposal OPIOIDS FOR CHRONIC PAIN CONSULTATIONS Lack of long-term effectiveness trial & consider taper Part of multi-modal plan: PT, CBT, CAM, nonopioid meds, procedures Long-term adverse effects: Increased sensitivity to pain opioid-induced hyperalgesia Constipation Decreased sex hormones, sexual dysfunction Decreased bone density Drug Interactions Overdose & drug disposal 8

9 How to avoid OPIOID OVERDOSE CONSULTATION Only take as prescribed. Follow up with your clinician if worse pain. Never mix with alcohol, sleeping pills, illicit substances. Safeguard medications away from children, pets, others. Dispose of unused medication. Teach support person what to do. SAMHSA Opioid Overdose Prevention Toolkit Signs Sleepiness, confusion, slurred speech Slow or shallow breathing Slow heartbeat or low blood pressure Pinpoint pupils Turning pale, blue Vomiting Unresponsive OPIOID OVERDOSE CONSULTATION SAMHSA Opioid Overdose Prevention Toolkit Teach support person what to watch for and do Check for responsiveness (sternal rub, breathing) Call 911. Note: Good Samaritan Law protects caller and patient. Rescue breathing OPIOID OVERDOSE CONSULTATION Administer naloxone; repeat after 3 minutes if needed. SAMHSA Opioid Overdose Prevention Toolkit 9

10 NALOXONE Pure opioid antagonist Reverses respiratory depression, but rapid withdrawal No effect for person NOT exposed to opioids Consider for populations at risk Pharmacists authorized to prescribe Community members who complete approved Oregon Health Authority training Few mins to onset, wears off ~30-45mins. Dispense 2 doses. Always call INTRANASAL NALOXONE 4 MG PER DOSE INTRANASAL NALOXONE 4 MG PER DOSE

11 INTRAMUSCULAR NALOXONE 0.4 MG PER DOSE Make-Your-Own Kit (per dose) Naloxone 0.4 (1 ml) vial Syringe for at least 1 ml 25 gauge inch needle for IM inj Alcohol swabs Naloxone 0.4 /0.4 ml (Evzio Injectable Device) Use similar to epinephrine pen Resources: Opioid 911 SAMHSA Opioid Overdose Prevention Toolkit Oregon Health Authority OPIOID OVERDOSE CONSULTATION Opioids: What You Should Know Opiate Overdose Treatment: Naloxone Training Protocol SAMHSA Opioid Overdose Prevention Toolkit DRUG DISPOSAL Many options: DEA Drug Take Back Days Local law enforcement Controlled Substance Disposal Location Mail Back programs FDA recommendations Remove identifying label Mix with kitty litter, dirt, coffee grounds Mixture in sealable vessel Flush rs/ ConsumerUpdates/UCM pdf 11

12 DRUG DISPOSAL TAPERING Portray confidence this is a good thing! CALCULATING MORPHINE MILLIGRAM EQUIVALENT (MME) Type of Opioid CDC (CMS) Conversion Factor () Example Type of Opioid CDC (CMS) Conversion Factor () Example Codeine Fentanyl mcg/hr Hydrocodone 1 30 Hydromorphon e Methadone 3 10 Morphine 1 30 Opium 1 30 Oxycodone Oxymorphone 3 10 Tramadol Does NOT account for incomplete cross-tolerance when converting. ONLY for estimating morphine equivalency pdf 12

13 CDC GUIDELINE: WHEN TO TAPER OPIOIDS FOR CHRONIC PAIN Patient requests to reduce No clinically meaningful improvement of pain and function o (>30% improvement on 3 item PEG scale) >50 MME without benefit Opioids and benzodiazepines CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016 Recommendations and Reports / March 18, 2016 / 65(1); CDC GUIDELINE: WHEN TO TAPER OPIOIDS FOR CHRONIC PAIN Signs of substance use disorder o Frequent early refill requests o Multiple prescribers Overdose or other serious adverse event Early warning signs for overdose risk (confusion, sedation, slurred speech) TAPERING TIPS Taper by 10-20% every 7 to 28 days Simple and specific directions Work with available strengths Consult about what to expect Tapering is FOR you not AGAINST you Temporary side effects & self-care Take only as prescribed--do NOT adjust dose 13

14 EXAMPLE 1: MORPHINE SR 30 MG EVERY 12 HOURS (MME 60) Step 1: morphine SR15 am and 30 pm. Separate doses every 12 hours. Step 2: morphine SR15 every 12 hours Step 3: morphine SR15 at bedtime Step 4: discontinue morphine SR. Keep it simple. Work with available strengths. EXAMPLE 2: OXYCODONE ER 60 MG EVERY 8 HOURS OXYCODONE 180 MG = 270 MG MME 10-20% = MG OF OXYCODONE Step 1: 60 /40 /60 Step 2: 40 /40 /60 Step 3: 40 /40 /40 Step 4: 40 /20 /40 Step 5: 20 /20 /40 Step 7: 20 /10 /20 Step 8: 10 /10 /20 Step 9: 10 /10 /10 Step 10: 10 /0 /10 Step 11: 0 /0 /10 EXAMPLE 3: METHADONE 20 MG EVERY 8 HOURS METHADONE 60 MG = 180 MG MME (OR MORE) 10-20% = 6-12 MG OF METHADONE Step 1: 20 /10 /20 Step 2: 10 /10 /20 Step 3: 10 /10 /10 Step 4: 10 /5 /10 Step 5: 5 /5 /10 TWO OPTIONS MOVING FORWARD Continue 5 dose reductions until off. If patient is struggling, reasonable to suggest 2.5 dose reductions until off. 14

15 OPIOID WITHDRAWAL Onset: 8 to 48 hours, depending Duration: 4 to 20 days or longer, depending Symptoms: Withdrawal hyperalgesia Anxiety Nausea/vomiting Restless Insomnia Rapid heartbeat Stomach cramps/diarrhea Muscle twitching Sweating Hot flashes Watery eyes Runny nose Avoid adding medications Optimize self-care MANAGING OPIOID WITHDRAWAL Self-reassurance this is temporary Hydrate Stretch, move, walk, exercise Distraction Ice/heat TENS unit Calm environment Relaxation techniques MONITORING TOOLS Opioid Treatment Agreements and Informed Consent Pain Intensity Scales Urine Drug Screen (UDS) Pill/Patch Counts Prescription Drug Monitoring Programs 15

16 PATCH/PILL COUNTS Suggest completed within 24 to 48 hours of when requested Count quantity and verify imprint code Notify prescriber of results put in context Patient is 15 tablets short, or approximately 5 days out of a 28 day supply. Patient presented with the wrong pills. Patient has an extra 12 patches, or 36 day supply. Just the facts - avoid jumping to conclusions. Suggest next steps. PRESCRIPTION DRUG MONITORING PROGRAMS Use routinely for safety screening Unexpected results found? Not obligated to dispense Inform prescriber(s) orlogappl/bdorpdmqlog/pmqhome.htm l NAVIGATING OPIOID CHANGES PATIENT CASE #1 16

17 MEET OUR PATIENT - VIRGINIA 51 yo female with fibromyalgia, migraine, and osteoarthritis referred to taper to lowest possible dose of fentanyl. Comorbid Diagnoses: Obesity (BMI 35.5), Insomnia, and Depression. Current Medications: Fentanyl 75 mcg/h, 1 patch every 2 days for chronic pain (#14 patches/28 days) Clonazepam 1, 1 tablet at bedtime as needed for sleep (#30 tablets/30 days) A CHANGE IN PLAN IS INDICATED Concern for polypharmacy with various centrally-acting medications. Recommend tapering fentanyl, with plan to taper benzodiazepine in the future Recommend self-care pain management techniques and addressing comorbidities VIRGINIA S FENTANYL TAPER PLAN Starting point: Fentanyl 75 mcg/h (MME = 180 ) Step 1: Decrease to fentanyl mcg/h every 2 days Step 2: Decrease to fentanyl 50 mcg/h every 2 days Step 3: Decrease to fentanyl mcg/h every 2 days Step 4: Decrease to fentanyl 25 mcg/h every 2 days Step 5: Decrease to fentanyl 12.5 mcg/h every 2 days Step 6: Discontinue fentanyl 17

18 VIRGINIA, 10 MONTHS LATER Successfully tapered off of fentanyl (and clonazepam!) Also of note: Obesity: now resolved; BMI = 26 Insomnia: evaluated by sleep clinic; diagnosis of OSA, using CPAP Depression: stable, seeing therapist NAVIGATING OPIOID CHANGES PATIENT CASE #2 MEET OUR PATIENT - DAVE 39 yo male with low back pain, lumbosacral disc degeneration, sciatica Comorbid Diagnoses: anxiety, insomnia Current Medications: Oxycodone SR 80 qid Diazepam 5 hs Trazodone 100 hs Cyclobenzaprine 10 tid 18

19 Concerns: A CHANGE IN PLAN IS INDICATED Poor pain relief despite high dose opioids Concern for polypharmacy Concern oxycodone may be contributing to comorbidities Recommend: Converting to lower dose of alternate opioid, with plan to reduce polypharmacy in future Self-care pain management techniques and addressing comorbidities DAVE S OXYCODONE SR CONVERSION PLAN Starting point: Oxycodone SR 80 qid (MME = 480 ) Step 1: oxycodone SR 80 /40 /80 /40 morphine SR 15 q12h Step 2: oxycodone SR 60 q8h morphine SR 15 q8h Step 3: Change of course pt self-dc d morphine SR oxycodone SR 40 q8h Step 4: oxycodone SR 40 /20 /40 DAVE S OXYCODONE SR TAPER PLAN Step 4: oxycodone SR 20 /20 /40 Step 5: oxycodone SR 20 q8h Step 6: oxycodone SR 20 /10 /20 Step 7: oxycodone SR 10 /10 /20 Step 8: oxycodone SR 10 q8h Step 9: oxycodone SR 10 q12h Step 10: oxycodone SR 10 hs Step 11: Discontinue oxycodone SR. 19

20 DAVE, 4 MONTHS LATER As oxycodone dose decreased, pain, sleep, restlessness, and anxiety improved. Tapered/discontinued diazepam, cyclobenzaprine, and trazodone. Initially less energy with oxycodone taper, replaced by feeling more alert and able to engage better with family. Walking on lunch hour. I have my life back. IN SUMMARY New frame of reference for opioid use: efficacy + harm reduction. Listen to patient s perspective. Normalize fears but focus on benefits of tapering. Consult what to expect during an opioid taper and self-care for managing withdrawal Bastions of safety Safety consultation: overdose, naloxone, drug disposal Safety monitoring: signs of misuse, PDMP, patch/pill counts Given the option, work together to individualize plan including nonpharmacologic and non-opioid treatment options. ACPE POST-TEST QUESTIONS True/False: Opioids may be appropriate for some patients with chronic nonmalignant pain in the context of a comprehensive pain management plan including non-pharmacologic therapies. Select which situations may be appropriate to taper: (a) patient consistently with slurred speech; (b) patient found obtunded; (c) patient stable on 400 MME; (d) all of the above Which symptom is consistent with opioid withdrawal? (a) constipation; (b) slow heart rate; (c) sweating; (d) nasal congestion. True/False: Managing diabetes, mental health, and sleep may improve pain control. Which of the following may assist in patient discussion about tapering (select all that apply)? (a) Drawing out the patient perspective; (b) consulting about what to expect; (c) shared decision making; (d) Motivational Interviewing. 20

21 RESOURCES AND REFERENCES CDC Guideline for Prescribing Opioids for Chronic Pain United States, Guideline: Pocket guide, fact sheet, nonopioid txs, calculating dose, PDMPs, etc: Oregon Opioid Prescribing Guidelines: Recommendations for the Safe Use of Opioid Medications, Oregon Health Authority. Available online: ments/ taskforce/oregon-opioid-prescribing-guidelines.pdf National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain. Health and Human Services RESOURCES AND REFERENCES Oregon Pain Guidance. Patients and professionals. Southern Oregon and Portland. Tips about chronic pain, opioid tapering, naloxone, marijuana, drug disposal, etc. Oregon Health Authority: Reducing Opioid Overdose and Misuse s/index. aspx Overdose and Naloxone RESOURCES AND REFERENCES SAMHSA Opioid Overdose Prevention Toolkit. Opioid 911: State of Oregon: Drug Disposal FDA: Oregon Pain Guidance: State of Oregon: Pages/ takeback.aspx State of Washington: 21

22 QUESTIONS? 22