Chronic Pain Pharmacist role in the clinic

Transcription

1 Chronic Pain Pharmacist role in the clinic WSPA Annual Meeting 2015 Alvin Goo, PharmD Clinical Associate Professor University of Washington Schools of Pharmacy and Family Medicine Speakers Declaration Dr. Goo declares that neither he, nor any member of his family, has had a financial interest, arrangement or affiliation with an organization providing support for this continuing medical education activity. Objectives Discuss the evidence supporting the benefits of opioid analgesics for chronic nonmalignant pain Describe a role of the pharmacist in the management of chronic opioid analgesics Identify alternative methods of managing and coping with chronic nonmalignant pain Apply your knowledge in providing your patient and provider with thoughtful recommendations 1

2 Acute versus Chronic Pain Characteristic Acute Pain Chronic Pain Relief Desirable Desirable Dependence / Not common Common Tolerance Psychological component Usually not present Present Organic cause Common Difficult to determine, vague Environmental Small Significant contribution Insomnia Unusual Common Treatment goal Cure Function 2012 opioid prescribing 2

3 Rates of opioid prescriptions and deaths King County

4 How do opioids affect the brain Opioids and chronic low back pain Cochrane review There is some evidence (very low to moderate quality) for short-term efficacy (for both pain and function) of opioids to treat CLBP compared to placebo. The very few trials that compared opioids to non-steroidal anti-inflammatory drugs (NSAIDs) or antidepressants did not show any differences regarding pain and function. The initiation of a trial of opioids for long-term management should be done with extreme caution, especially after a comprehensive assessment of potential risks. There are no placebo-rcts supporting the effectiveness and safety of long-term opioid therapy for treatment of CLBP. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD DOI: 4

5 Effectiveness of opioids Systematic review of 4209 articles resulted with 40 acceptable publications No studies assessed function or quality of life No studies were greater then 1 year Chou R, et al. Ann Intern Med 2015;162:276 Harms Cohort data Annual rate of overdose 256/100,000 people prescribed opioids 36/100,000 people not prescribed opioids Risk of factures 6% opioid users 4% non users Cardiovascular events Current opioid therapy versus nonuse was associated with increased odds of myocardial infarction (adjusted OR, 1.28 [CI, 1.19 to 1.37]) Chou R, et al. Ann Intern Med 2015;162:276 Limited evidence Chronic low back pain Chronic non-malignant pain Outcomes of quality of life or functional activity are lacking Weak evidence of benefit with opioids 20-30% reduction in pain scales (studies < 24 week) 5

6 Controversial issues with chronic use of opioid analgesics National trend of increasing rate of opioid prescriptions and related deaths Cardiac shock, Respiratory depression Increased depression, mood disorders, hormonal imbalance, reduced libido / testosterone associated with chronic opioid analgesics Tolerance (results to increase dosage) Dependence Addiction (rare) Hyperalgesia (controversial but occurs) Case 56 yo male presents with increasing joint, back, shoulder and neck pain. In the past his current pain regimen has managed his pain and allowed him to perform daily activities, walk about and catch the bus. He presents with prescriptions of his opioid analgesic medications and upset that his provider is reducing the doses. States how unfair the new restrictions are and how his provider does not understand how to treat pain. Hx: Train vs pedestrian accident 1998, past hx ETOH abuse Medications: Methadone 10mg 7 times daily Oxycodone 5mg #210/month Baclofen 10mg tid Omeprazole 20mg daily Discussion Describe your initial thoughts about patients utilizing chronic opioid analgesics Should the patient receive the opioids Is the patient utilizing excessive opioids? Is the provider not listening to the patient? 6

7 The patient s story Chronic nonmalignant pain Assess Depression Insomnia Anxiety Irritability Reduced activity Work problems Family stability Social withdrawal Alcohol / Drug use Patient s expectations What are your goals for treatment? Beliefs about pain management Pain Intensity Daily Activities :What activities are limited by the pain Quality of Life Functional Goals 7

8 Evaluate Activities Ability to perform daily activities Assess activities in which chronic pain seems to be more bearable Assess activities the patients are able to refocus attention away from pain Reflect and describe times when the pain is not as intense? What activities are you typically engaged with during the good days? Psychosocial history Evaluate stressors in life Enjoyment Enjoyment of employment Personal relationships History of ETOH, substance abuse 8

9 Opioid analgesic agents for nonmalignant pain Controversial treatment Harm reduction No opioid tolerance and no limit in opioid dose Provide sufficient dose and quantity of opioid analgesic Versus Questions the benefit of chronic opioid analgesics Limited benefit of opioids Risk of death associated with opioids Pharmacist role in clinic Initially started treating pain with the philosophy of harm reduction in 1998 Provided patients with liberal amounts of opioid analgesics After 6 months opioid doses escalated to high doses Addressed concerns: Efficacy, Safety Family medicine clinic 2000 reviewed literature Open discussion with providers Developed collaborative approach and philosophy regarding the treatment of chronic pain Pain agreement between patient and provider Establish opioid analgesic maximum Reduce emphasis on opioid analgesic agents 9

10 Clinic maximum gradually reduced daily maximum daily dose from 80 to 20mg/day Currently Methadone 20mg /day or morphine 120mg/day Avoid short acting opioids If prescribed limit to #60/month Chronic pain agreement Discuss limitations of pain medications De-emphasize opioids Focus on developing coping skills and functional goals Discuss safety concerns Agreed responsibility and behavior Chronic pain agreement Informed consent Provide limitations / side effects / risks of chronic opioid analgesics One prescriber, one pharmacy No selling or sharing controlled substance No early refills Random urine tox screen Therapy contingent on functional improvement Therapy contingent on participation in all aspects of treatment plan 10

11 Behavior Multiple providers, multiple pharmacies (review WA PMP) Self-escalation of dose Demanding early refills Frequent ER visits for opioids Frequently losing opioid analgesics Focused exclusively on opioids Presence does not mean patient is abusing or criminal Presence does not exclude from opioids Documentation Complete work-up and treatment plan Track function goal levels Restate or adjust goals at each visit Document drug-seeking behaviors and clinic agreement infractions as they occur Document the presence and absence of opioid side effects Document follow-up arrangements for each visit Record all Rx s prescribed accurately Factors that increase risk of toxicity Age Renal insufficiency Hypokalemia/Hypomagnesemia Hypo/Hyperthyroidism Combination Benzodiazepines, ETOH, Illicit substances, other opioids Combination with drugs that also prolong QTc interval Drug interactions that increase levels of opioid analgesic agents Sleep apnea 11

12 Opioid prescribing at family medicine clinic 2000 > 80 pts receiving chronic opioids Majority received > 120mg ME Received Long and Short acting opioids Today < 60 pts on pain agreement Majority receives long acting opioids < 120mg ME 20mg Methadone /day Case HC is a 65 yo woman presenting to clinic today to establish care (due to her old PCP no longer taking her Medicare insurance). Her most pressing issue is refilling her chronic pain medications which she has received for the past 5-6 years. Her chronic pain stems from osteoarthritis from janitorial work and MVA in Her pain limits her daily activities, and she is hoping to continue with her current regimen to manage the pain. PMH: Osteoarthritis (bilateral hip, back, bilateral shoulder), depression, anxiety, emphysema SH: Current smoker, 1 PPD; has attempted cessation 5 times. Denies illicit drug use. Denies ETOH. She has custody of and cares for her 4 grandchildren which is physically/mentally exhausting. She is retired from her job as a housekeeper in a hotel. Current medications: Albuterol MDI 1-2 puffs Q6h prn Oxycontin 60mg Bid Ipratropium 2 puffs 3 times daily Percocet 5/325 4 times daily Tylenol Arthritis Citalopram 40mg daily Naproxen 500 mg twice daily Case The provider requests your: Assessment Describe the pain agreement Recommendation for conversion to morphine or methadone Final recommendation 12

13 References Agency for Medical Directors Opioid dosing guidelines Opioid dose calculator Washington State Prescription Monitoring Program t/ bing/guideline.html Methadone and Morphine Equivalence 13

14 Fundin Washington State Methadone Overdose deaths associated with methadone % of all overdose deaths % of all overdose deaths Key Principles George S, et al. Physical Therapy 2004;84(6):538 14

15 Non Judgmental Be Mindful Depersonalize Coping behavior Manage stress Positive thinking (focus on improvements, you are not powerless) Be active and engaged (distraction away from pain) Support system Promote coping behavior 15

16 Emphasize reassurance Acknowledge complex nature of chronic pain Acknowledge patient s pain Empathy Assure movement will not worsen condition Chronic pain is not a condition that requires limited activity Requires reconditioning and quota based exercise physical therapy Cognitive Behavioral health counseling and development of coping skills Emphasize the ability of the patient to refocus thoughts away from pain Re engage in enjoyable activities Focus on Functional Goals rather than pain scale or pain relief Skills that may improve coping Change negative statements to positives Stay in the present moment Practice gratitude Enjoy the enjoyable Practice affirmations Practice acceptance instead of resistance Practice mindfulness Regular stretching/exercise will improve your functional goals 16

17 Treatment of Chronic Nonmalignant Pain Patient selection and risk stratification at the beginning of opioid therapy complex Clinicians should discuss realistic expectations from therapy and on the precautions necessary to avoid diversion or other misuse. Doses need to be carefully titrated. Frequent monitoring and re-evaluation are necessary. Additional therapies targeting psychosocial factors should be considered. Patients should have a medical home to ensure that treatment of pain, the underlying condition, and comorbidities is coordinated. Chronic Pain 17