Approach to Use of Opioids in Patients with Low Back Pain Follow-up Q & A Webinar with Case Discussions

Transcription

1 Approach to Use of Opioids in Patients with Low Back Pain Follow-up Q & A Webinar with Case Discussions Roger Chou, MD, FACP Professor of Medicine Oregon Health & Science University Director, the Pacific Northwest Evidence-based Practice Center 1

2 Conflict of Interest Disclosure Research funding from the American Pain Society and the Agency for Healthcare Research and Quality Consultant with Wellpoint Inc, Blue Cross Blue Shield, Palladian Health Author royalties from UpToDate 2

3 Planning Committee, Disclosures AAAP aims to provide educational information that is balanced, independent, objective and free of bias and based on evidence. In order to resolve any identified Conflicts of Interest, disclosure information from all planners, faculty and anyone in the position to control content is provided during the planning process to ensure resolution of any identified conflicts. This disclosure information is listed below: The following developers and planning committee members have reported that they have no commercial relationships relevant to the content of this webinar to disclose: AAAP CME/CPD Committee Members Dean Krahn, MD, Kevin Sevarino, MD, PhD, Tim Fong, MD, Tom Kosten, MD, Joji Suzuki, MD; and AAAP Staff Kathryn Cates-Wessel, Miriam Giles, Sharon Joubert Frezza, and Justina Andonian. All faculty have been advised that any recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported, or used in the presentation must conform to the generally accepted standards of experimental design, data collection, and analysis. Speakers must inform the learners if their presentation will include discussion of unlabeled/investigational use of commercial products. 3

4 Target Audience The overarching goal of PCSS-O is to offer evidence-based trainings on the safe and effective prescribing of opioid medications in the treatment of pain and/or opioid addiction. Our focus is to reach providers and/or providers-intraining from diverse healthcare professions including physicians, nurses, dentists, physician assistants, pharmacists, and program administrators. 4

5 Educational Objectives At the conclusion of this activity participants should be able to: List the benefits and harms of opioids in patients with low back pain. Apply an evidence-based approach in the use of opioids for low back pain. 5

6 Background Low back pain is very common and associated with large patient and societal burdens Despite more aggressive management and treatment of LBP, prevalence is on the rise Low back pain is one of the most common conditions that opioids are prescribed for: o Higher doses, more use of schedule II opioids o Patients more likely to be prescribed opioids who have risk factors for misuse/abuse/addiction Koes BW et al. BMJ 2006;332:1430;Katz JN. J Bone Joint Surg Am 2006;88 (suppl 2):21;Martin BI et al. JAMA 2008;299:656 6

7 Increasing Rates of Opioid Use 7 Deyo RA et al. J Am Board Fam Med 2009;22:62-8

8 Benefits and Harms of Opioid Therapy for LBP Benefits for chronic LBP appear moderate at best for shortterm pain relief Estimates of abuse/misuse vary from 4% to 26%, or higher ~15,000 deaths related to prescription opioids annually Other adverse effects: GI, neurological, endocrinological Chapparo A et al. Cochrane Database System Rev 2013:CD004959;Martell BA et al. Ann Intern Med 2007;146:116; Franklin GM et al. Clin J Pain 2009;25:743; Furlan AD et al. CMAJ 2006;174:

9 Opioid Pain Reliever (OPR) Overdose Deaths, Treatment Admissions, and Kilograms Sold 9

10 Risk Factors for Overdose Higher-dose opioid therapy Concomitant use of CNS depressants (especially benzodiazepines) Recent initiation of opioids Multiple opioid prescribers Significant mental health disorders Aberrant drug related behaviors Use of methadone Presence of significant medical comorbidities Active or history of substance abuse Dunn KM et al. Ann Intern Med 2010;152:85; Bohnert AS. JAMA 2011;305:1315; Gomes T et al. Arch Intern Med 2011;171:686; Braden JB et al. Arch Intern Med 2010;170:1425; Hall AJ et al. JAMA 2008;3000:

11 Use Opioids Only in the Context of an Overall LBP Management Plan Understand chronic LBP as a complex biopsychosocial condition o Opioids alone do not address psychosocial contributors to pain o Benefits of opioids unlikely to exceed an average 20-30% reduction in pain (may be smaller) o Be clear with patients that opioids generally do not eliminate pain, and are just part of a comprehensive management plan o Use opioids in conjunction with therapies that address psychosocial factors For acute LBP, the natural history is very favorable o ~85% of patients improve substantially in the first month o Opioid use in acute LBP associated with poorer functional outcomes and subsequent long-term use o Selective opioid use for acute severe pain on a time-limited basis, for shortterm symptomatic relief Gatchel RJ et al. Psychological Bulletin 2007;133:581;Franklin GM et al. Spine 2008;33:199; Webster BS et al. Spine 2007;32:

12 Management Approach to LBP First-line medications: acetaminophen and NSAIDs o Recent RCT showed no benefits of acetaminophen for acute LBP o Second-line options: skeletal muscle relaxants (acute LBP) and antidepressants (chronic LBP) Emphasis on self-care and improving function o Advise patients to remain active o Exercise therapy, interdisciplinary rehabilitation Identify and address psychosocial contributors to pain o Depression, anxiety, maladaptive coping behaviors (fear avoidance, catastrophizing) o Cognitive behavioral therapy, functional restoration, interdisciplinary rehabilitation Consider other non-pharmacological therapies o Spinal manipulation, acupuncture, massage Reserve opioids for patients who don t respond to first-line therapies, or selected cases with very severe symptoms Chou R et al. Ann Intern Med 2007;147:478; Williams CM et al. Lancet (e-published 23 July 2014) 12

13 Prescribing Opioids Initial course of treatment should be viewed as a short-term, therapeutic trial Start at low doses and titrate cautiously, to reduce risk of accidental overdose Define achievable functional goals in order to assess benefits Do not continue opioids in patients who are not benefitting Have an exit strategy for discontinuation of opioids and be prepared to restructure therapy 13 Chou R et al. J Pain 2009;10:113; Chou R et al. J Pain 2009;10:131

14 Opioids and Low Back Pain Consider opioids only in the context of an overall pain management plan o Opioids do not address the psychosocial contributors to pain Not recommended as first-line treatment o Evidence on effectiveness for LBP limited Average 20-30% improvement in pain at best, limited o o o data on improvement in function Potential harms include addiction, abuse potential, overdose Consider only after performing risk assessment and with appropriate monitoring Duration-limited trial of therapy Dose-dependent overdose risks Unclear benefits of higher doses Caution with doses > mg morphine equivalents/day 14

15 Case 1 Mr. S. is a 57 year old with LBP x 2 years, no specific inciting event No associated leg pain or other neurological symptoms Pain slowly worsening, to the point of not being able to walk more than 2 to 3 blocks, rated 7/10 most days Continues to golf most weekends, but riding cart now Working as an engineer X-rays show lumbar disc degeneration and facet joint arthropathy Tried acetaminophen and NSAIDs and has undergone PT What do you think about trying an opioid doc? 15

16 16

17 Scoring the STarT Back Screening Tool Note: Psych score based on items 5-9 of STarT Back Screening Tool 17

18 Opioid Risk Tool (ORT) Administration On initial visit Prior to opioid therapy Scoring 0-3: low risk (6%) 4-7: moderate risk (28%) > 8: high risk (> 90%) 18 Webster LR et al. Pain Med. 2005;6:432.

19 Case 1 Risk Assessment Mr. S. has no personal or family history of substance abuse No history of depression or other psychological disorders No serious comorbid conditions that are contraindications to opioid therapy STarT Back Score: 1 (only able to walk short distances) Opioid Risk Tool score: 0 Urine drug test negative Assessed risk for misuse/abuse: Low 19

20 Case 1 Management Plan and Initial Follow-up Set goal of walking 30 minutes 4 times a week Longer term goal walking 9 holes of golf Low-dose opioid therapy (oxycodone 5 mg twice daily) initiated At 4 week follow-up, pain decreased from 7/10 to 4/10 Able to walk minutes 4 times a week No signs of aberrant behaviors Plan: Continue opioid therapy at the same, low dose, follow-up in 2 months 20

21 Case 1 Follow-up 2 Months Walking 20 minutes once or twice a week. I can t walk more because it makes things worse. Still not able to walk 9 holes of golf Has taken an extra oxycodone on several days with increased pain and has run out of prescription one or two days early I feel like I m never going to improve No signs of aberrant behaviors UDS: No oxycodone or other opioids, no illicit drugs PDMP: No controlled substances from other providers 21

22 Case 1 Management Plan Counsel on need to stick with prescribed doses Counsel on importance of activity and exercise Increase oxycodone to 10 mg twice daily Add duloxetine 10 mg po qd Refer back to physical therapy Follow-up in 1 month 22

23 Case 1 Follow-up 3 Months Still having pain and not walking Started PT but stopped it because it hurt too much States taking oxycodone as directed, but UDS shows no oxycodone Duloxetine made him feel funny and he stopped it PDMP: OK Requesting more opioids 23

24 Case 1 Management Plan Refer for cognitive-behavioral therapy Continue oxycodone at current dose but plan to taper off if continues to shown signs of aberrant behaviors or does not engage in non-opioid therapies (CBT and PT) Trial of pregabalin instead of duloxetine 1 month follow-up 24

25 Case 1 Follow-up 5 Months No improvement in pain or function Has attended some CBT and PT sessions, says they are not helping Taking pregabalin but doesn t think it s helping States taking oxycodone as prescribed UDS shows oxycodone, but also shows oxymorphone and morphine PDMP: OK 25

26 Chart of common opiate metabolites

27 Expected results via urine drug testing Codeine Morphine Agent taken by patient Codeine + + +/ Morphine ^ Hydrocodone * ** - - Hydromorphone - * * + - ** - Oxycodone - - ** Oxymorphone ** * + - Methadone Heroin * Fentanyl /- = possible with high doses of parent drug; * = highly unlikely but reverse metabolism possible; * * = theoretically possible, but does not normally occur; ^ = has been described and thought due to contamination Hydrocodone Hydromorphone Oxycodone Oxymorphone Methadone

28 Case 1 Management Plan Taper off oxycodone Offered treatment for substance abuse, but patient declined Referred for intensive interdisciplinary rehabilitation Titrated up pregabalin 28

29 Case 2 Patient on fentanyl patch 50 mcg/hr every 3 days for 10 years Clinically doing well, assessed as low risk of abuse, no signs of aberrant drug-related behaviors Urine drug screen: No opioid 29

30 Unexpected Urine Drug Test Results What is the differential diagnosis for the results? What are the likely explanations for the results? How do you address these results with the patient? Do you continue to prescribe opioids for this patient? Do you make changes to the opioid regimen? Do you make any changes to the monitoring regimen? 30

31 Differential for Urine Drug Test Results Urine drug test is positive Urine drug test is negative Expected result Prescribed medication, appropriate use Metabolite of prescribed medication Prescribed medication, inappropriate use Drug screen doesn t pick up the drug in question Patient appropriately not taking opioid Test performed prior to initiation of opioids Unexpected result Use of non-prescribed medications Use of illicit substance Use of previously prescribed medications (hoarding) Cross-reaction (food, OTC, herbal products) Contamination Laboratory error Uncommon metabolite Diversion Tampering Outside time frame for positive test Fast metabolizer Laboratory processing error Extreme dilution of urine Malabsorption? Hoarding/binging 31

32 Case 2 Expected metabolites for fentanyl: fentanyl Observed metabolites: None Unexpected findings: Absence of fentanyl Make sure lab is testing for fentanyl; if it is, consider running sample with no threshold testing or obtaining a quantitative level 32

33 Case 3 Patient on morphine SR 60 mg bid and hydrocodone/acetaminophen 10/650 3 tabs/day Assessed as being at moderate risk for abuse, no signs of aberrant behaviors Urine drug screen: Positive for morphine, hydrocodone, hydromorphone, and oxymorphone 33

34 Case 3 Expected metabolites with morphine: Morphine, hydromorphone Expected metabolites with hydrocodone: Hydrocodone, hydromorphone Observed metabolites: Morphine, hydrocone, hydromorphone, oxymorphone Unexpected findings: Oxymorphone 34

35 Case 4 Patient on morphine SR 100 mg tid for many years No signs of aberrant behaviors Had been doing well but pain has been slowly increasing Plan: Do not want to increase dose further. o Discuss trial of opioid rotation to oxycodone, may be able to use lower dose due to incomplete crosstolerance 35

36 Case 4 Patient on morphine SR 100 mg tid for many years No signs of aberrant behaviors Had been doing well but pain has been slowly increasing Plan: Do not want to increase dose further. o Discuss trial of opioid rotation, may be able to use lower dose due to incomplete cross-tolerance 36

37 Dose Conversion Table 37

38 Morphine to Methadone Conversion Ratios 24 hour total oral morphine Oral morphine to methadone conversion ratio <30 mg 2: mg 4: mg 8: mg 12: mg 15:1 >1000 mg 20:1 Managing Cancer Pain in Skeel ed. Handbook of Cancer Chemotherapy. 6th ed., Phil, Lippincott, 2003, p

39 Opioid Conversion Tables are only a rough guide In general, aim to undershoot equivalent dose by about 25% and titrate up Caution with methadone, as morphine:methadone dose ratio increases with higher doses, recommend starting at maximum of mg/day when switching patients even on high doses 39

40 Case 4 Switch to oxycodone, assume morphine:oxycodone ratio of 2:1 Calculated equianalgesic dose is 150 mg/day Reduced by ~25%, initial target dose ~110 mg/day Plan switch to oxycodone SR 45 mg bid + IR 5-10 mg po q 6 hrs prn 40

41 References Bohnert et al. JAMA 2011; 305: Braden JB et al. Arch Intern Med 2010; 170: Chapparo A et al. Cochrane Database System Rev 2013: CD Chou R and Shekelle P. JAMA 2010; 303: Chou R et al. Ann Intern Med 2007; 147: 478. Chou R et al. J Pain 2009; 10: 113. Cifuentes M et al. JOEM 2012; 54: 491. Deyo RA et al. J Am Board Fam Med 2009; 22:

42 References Deyo RA et al. J Am Board Fam Med 2011; 24: Dormuth CR et al. CMAJ 2012; 184: E852. Dunn et al. Ann Intern Med 2010; 152: 85. Dunn KM et al. Ann Intern Med 2010; 152: 85. Fleming MF et al. J Pain 2007; 7: 573. Franklin GM et al, Am J Industrial Med 2012; 55: 325. Franklin GM et al. Clin J Pain 2009; 25: Franklin GM et al. Spine 2008; 33:

43 References Freburger JK. Arch Intern Med 2009; 169: 251. Furlan AD et al. CMAJ 2006; 174: Gatchel RJ et al. Psychological Bulletin 2007; 133: 581. Gomes et al. Arch Intern Med 2011; 171: 686. Gourlay DL et al. J Addict Dis 2008; 27: 23. Gugelman HM. JAMA 2011; 306: Hall AJ et al. JAMA 2008; 3000: Hill JC et al. Lancet 2011; 378:

44 References Katz JN. J Bone Joint Surg Am 2006; 88(suppl 2): 21. Kobus AM et al. J Pain 2012; 13: Koes BW et al. BMJ 2006; 332: Luo X et al. Spine 2004; 29: Martell BA et al. Ann Intern Med 2007; 146: 116. Martin BI et al. JAMA 2008; 299:

45 References Webster BS et al. Am J Ind Med 52; Webster BS et al. Spine 2007; 32: Webster L. J Opioid Manage 2011; 7: 235. Webster LR et al. Pain Med. 2005; 6: 432. Williams CM et al. Lancet (e-published 23 July 2014) 45

46 PCSS-O Colleague Support Program and Listserv PCSS-O Colleague Support Program is designed to offer general information to health professionals seeking guidance in their clinical practice in prescribing opioid medications. PCSS-O Mentors comprise a national network of trained providers with expertise in addiction medicine/psychiatry and pain management. Our mentoring approach allows every mentor/mentee relationship to be unique and catered to the specific needs of both parties. The mentoring program is available at no cost to providers. For more information on requesting or becoming a mentor visit: Listserv: A resource that provides an Expert of the Month who will answer questions about educational content that has been presented through PCSS-O project. To join pcss-o@aaap.org. 46

47 PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership with: American Dental Association (ADA), American Medical Association (AMA), American Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American Society for Pain Management Nursing (ASPMN),and International Nurses Society on Addictions (IntNSA). For more information visit: For questions pcss-o@aaap.org Funding for this initiative was made possible (in part) by Providers Clinical Support System for Opioid Therapies (grant no. 5H79TI023439) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and 47 Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.