AOMA 2017 Fall Seminar Drug Tapering, Modification, or Discontinuation: Establishing the Lowest Effective Dose. AOMA 2017 Fall Seminar Drug Tapering

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1 AOMA 2017 Fall Seminar Drug Tapering, Modification, or Discontinuation: Establishing the Lowest Effective Dose Steven C. Boles, DO, FASM AOMA 2017 Fall Seminar Drug Tapering Dr. Boles has no conflicts to disclose

2 Addiction Medicine Steven C. Boles, D.O., FASAM Board Certified FP & ADM CAQ in ADM from AOBFP Fellow of ASAM (American Society of Addiction Medicine) Boards American Osteopathic Board of Family Physicians American Board of Addiction Medicine Addiction Medicine (ADM) Steven C. Boles, D.O., FASAM Adjunct Assistant Professor, Division of Clinical Education : Midwestern University Arizona College of Osteopathic Medicine (AZCOM); , ongoing President : Arizona Society of Addiction Medicine, Inc. (AzSAM) ;

3 ADM I was trained at St. Luke s Behavioral Health Center, in Phoenix, Arizona, from April 1999 to August 2000 by C.J. Shaw, M.D. (and the nursing staff). I will be forever grateful to Dr. Shaw - for that experience, - for being my mentor, - for being my friend, to this day. AA was founded in 1935 When 2 alcoholics began to talk to each other about their struggles with alcohol And found that they both stayed sober. When nothing else had worked. Bill Wilson was a stock broker Dr Robert Smith was a colorectal surgeon

4 AA was founded in 1935 What does the very famous founder of AA Bill Wilson And Osteopathic Medicine have in common? Bill Wilson s mother was a D.O.??!! Emily Griffith Wilson Bill and Dorothy s mother, Emily decided that she did not want to become a leftbehind single mother, so she obtained a divorce and made plans to go to school in Boston where she earned a degree in osteopathy leaving her children with her parents. She later trained as a psychoanalyst with Dr. Alfred Adler. She was remarried to Dr. Charles Strobel. Describing their relationship with their mother, Bill wrote neither Dorothy nor I have ever stood in quite the right relation to mother in spite of our efforts to do so. Text and picture from Bill Wilson My Name is Bill (S. Cheever p. 149)

5 Animals and Humans use addictive drugs to get high Although Chemical Abstracts lists over 15 million compounds, only a FEW score (~ 130 if one counts all the variations within each class) of these are addictive Representing 8 classes of drugs The 8 classes of addictive drugs These 8 known classes can be grouped into an Organizational Paradigm represented by 7 unrelated European working class males 1 female ringleader and their individual drugs of choice

6 Sneezy : Cocaine Dopey : Marijuana

7 Sleepy : BZD and Barbiturates (or other non-barb sedatives) Bashful : PCP & Ketamine (dissociative anesthetics)

8 Happy : Amphetamines Grumpy : Alcohol

9 Doc : Opioids Snow White: Marlboro Lights (Nicotine)

10 Mismanaged Pain Behavior can be distinguished from Addiction : When the pt seeking pain relief Receives adequate analgesia or treatment they demonstrate IMPROVED FUNCTIONING in daily living. Addicts DO NOT. Mismanaged Pain Behavior can be distinguished from Addiction : Legitimate pain pts use their medication as prescribed. Addicts DO NOT. Pain pts do not use their medications, or ANY other drugs, INCLUDING ALCOHOL, in a manner that persistently causes sedation or euphoria. ADDICTS DO THIS ALL THE TIME.

11 Problems suggesting addiction during opioid Rx : PREOCCUPATION WITH OPIOIDS - failure to comply with non-drug therapies - failure to keep appointments - shows interest only in relief of symptoms, not rehabilitation - reports no effect from non-opioid Rx s - seeks meds from multiple physicians The 5 C s suggesting addiction during opioid Rx : Continued Use Despite Adverse Consequences from Medications : - decreasing functionality - observed intoxication - increasing complaints of pain, despite titration of medications - negative affective (emotional) states

12 The 5 C s suggesting addiction during opioid Rx : Loss of CONTROL Over Medication Use - failure to bring unused medications to appointments - requests for early renewals / refills - reports lost, or stolen, prescriptions - appearance at clinic without appointment, and IN DISTRESS The 5 C s suggesting addiction during opioid Rx : Compulsive Use of Medication - frequent visits to ED, requesting drugs - family reports overuse, or intoxication

13 The 5 C s suggesting addiction during opioid Rx : Craving & PREOCCUPATION WITH OPIOIDS - failure to comply with non-drug therapies - failure to keep appointments - shows interest only in relief of symptoms, not rehabilitation - reports no effect from non-opioid Rx s - seeks meds from multiple physicians The 5 C s suggesting addiction during opioid Rx Concurrent use of mood altering drugs such as alcohol, marijuana, methamphetamine, or nonprescribed benzodiazepines by report, or UDS

14 We taper opioid using pain pts We detox opioid addicts since it is illegal to write an opioid Rx to treat opioid addiction, unless waivered to use Buprenorphine containing medication There are no such laws or provisions in CFR for BZD s, sedatives, or stimulants BZD

15 BZD WDS : Host factors Concurrent Medical Dx s Avoid BZD WDS during acute medical or surgical conditions, because of physiologic / adrenergic stress Risks of exacerbating the following conditions may outweigh the long-term benefits of BZD discontinuation : Principles of Addiction Medicine, 5th Ed., p. 658 BZD WDS : Host factors Concurrent Medical Dx s CAD / cardiac dysrhythmias / CV disease Asthma SLE Inflammatory bowel disease Severe NIDDM/IDDM Severe arthritis Severe thyroid disease Principles of Addiction Medicine, 5th Ed., p. 658

16 W I T H D R A W A L I N T E N S I T Y ACUTE WDS HIGH DOSE, ANY LOW DOSE SHORT ACTING LOW DOSE LONG ACTING PROLONGED POST ACUTE WDS (PAWS) DAYS MONTHS DURATION OF SEDATIVE HYPNOTIC / BZD WDS BZD & Other Sedative- Hypnotics : #1 = Taper method : - wean pt down by 10% starting dose - per week - for final 20% of the taper, - 5% starting dose q 2 weeks This obviously takes 3 months GOOD LUCK. Principles of Addiction Medicine, 5th Ed., p. 731

17 BZD Detox : I was trained on a 2 nd method for BZD s Clonazepam (as long as Pt < 3mg/d of clonazepam): - 1mg BID x 2 doses, then - 0.5mg BID x 2 doses, then mg BID x 2 doses, then DC Simultaneously begin divalproex or valproic acid : - 250mg QID for men - 250mg TID for women Check valproic acid level day #4 Principles of Addiction Medicine, 5th Ed., p BZD Detox/taper over 6 weeks (may want to cont valproate as mood stabilizer or for common migraine) The divalproex or valproic acid is tapered over 5 wks. Men : 250mg QID x 2 wks, then 250mg TID x 1 wks, then 250mg BID x 1 wks, then 250mg per day x 1 wk, then DC Women : 250mg TID x 3 wks, etc. Principles of Addiction Medicine, 5th Ed., p

18 BZD Detox/taper over 6 weeks (may want to cont valproate as mood stabilizer or for common migraine) Extend the initial clonazepam taper While starting the valproate, for pts who use long term, or very high doses of BZD s : Clonazepam : - 1mg q 12 hr x 2 doses, then - 0.5mg q 12 hr x 4 doses, then mg q 12 hr x 4 doses, then DC Use simultaneous valproate as indicated. Principles of Addiction Medicine, 5th Ed., p Substitute and taper If pt on lorazepam 0.5mg QID 1 st Month Taper to 2 lorazepam per day plus 1 divalproex 250mg or 1 valproic acid 250mg 2 nd Month Taper to 1 lorazepam per day plus divalproex 250mg BID Principles of Addiction Medicine, 5th Ed., p , 655

19 Substitute and taper If pt on lorazepam 0.5mg QID or less 3 rd Month (off lorazepam) pt is now on divalproex 250mg TID, then cont at that dose as mood stabilizer (or taper by 1 dose q 2 weeks) Principles of Addiction Medicine, 5th Ed., p , 655 Carisoprodol 350mg taper If more than 4 per day, taper by 2 pills per week until at 4/day Then taper by 1 dose per day per week Down to 1-2 per day, then DC and begin baclofen 10mg BID- TID Principles of Addiction Medicine, 5th Ed., p ,

20 CDC 90 MME per day Goal Dose, conversion factor,mme MS 90 mg x 1 = 90 MME Hydrocodone 60 mg x 1 = 60 MME Hydromorphone 12 mg x 4 = 48 MME Oxycodone 40 mg x 1.5 = 60 MME Fentanyl patch 25mcg/hr = 60 MME MTD 20mg x 3 = 60 MME Bup film/tab/buccal 2mg (2,000mcg) x 30 = 60 MME Bup weekly patch 20mcg/hr = 36 MME Motivation for Change: Discuss and Educate: CDC Guidelines and Consider Taper The previous basis of our treatment plan was that stable doses with reasonable pain control without loss of control (at nearly any dose) or harm is acceptable, but now they're telling us that anything above 90 MME is unacceptable.

21 Motivation for Change: Discuss and Educate: CDC Guidelines and Consider Taper Pt is educated about recent Pain Medication regulation changes that are being proposed AZ DHS Opioid Prescribing Guidelines contemplate that each pt should be on less than or equal to 90 MME per CDC 10/2016 Guidelines Motivation for Change: Discuss and Educate: CDC Guidelines and Consider Taper Pt can be educated that many people can have the same pain and less meds or no meds and less pain (due to hyperalgesia resolution). As of late 2017 we are anticipating changes and the need to approach the 10/2016 CDC Guidelines, even though it is retroactive in its application to many of our current Pts

22 Motivation to Change: Prescription may not be paid for by your insurance company insurance may interpret these guidelines as a reason to not pay for doses that are higher than 90 MME s First Opioid taper options: Taper by 1 ER/LA opioid Or Taper by 1 short acting opioid per day, over the next month until seen again continue the above Until 90 MME goal is reached.

23 First Opioid taper options: In the same manner as you would to increase by a small incremental dose Down taper just as would up-taper for someone asking for a higher analgesic dose First Opioid taper options: (each dose change lasts a month) If on MS ER 60mg BID, then MS ER 30mg TID, Then by 30mg BID Then 15mg BID

24 First Opioid taper options: (each dose change lasts a month) MS ER or IR doses over 180mg per day can usually per tapered to 180 quickly in mg downtaper monthly adjustments Then by 30mg per month average change Use symptomatic adjunctive meds, esp Buspirone or Tizanidine First Opioid taper options: (each dose change lasts a month) If on Oxycodone ER 40mg BID, then Oxycodone ER 30mg BID, then Oxycodone ER 20mg BID (60 MME) Oxycodone ER 10mg BID (30 MME)

25 First Opioid taper options: (each dose change lasts a month) If on Fentanyl patch 100 mcg/hr, then Fentanyl patch 75 mcg/hr, then Fentanyl patch 50 mcg/hr, then Fentanyl patch 25 mcg/hr, (60 MME) First Opioid taper options: (each dose change lasts a month) If on Oxymorphone ER 40mg BID, (240 MME) first convert to oxycodone mg for mg Oxycodone ER 40mg BID (120 MME) Oxycodone ER 30mg BID, then Oxycodone ER 20mg BID Oxycodone ER 10mg BID (30 MME)

26 First Opioid taper options: (each dose change lasts a month) If on Methadone for chronic pain Reduce dose by 5mg per day for the month If on MTD 10mg 6 per day (180 MME) Then 2 PO in AM, 2 PO noon, 1 & ½ in PM Then 2 PO in AM, 2 PO noon, 1 in PM, etc. down to MTD 10 mg 1 PO BID (60 MME) Or MTD 10 mg 1 PO TID (90 MME) Second option: 20 day Opioid taper off all opioids using 2 Rx s: Buprenorphine 2mg SL tab : first Rx, uses #20 tabs Bup 2mg SL tab 2 SL BID x 2 days (8mg/day..8,000mcg) Bup 2mg SL tab 1 SL TID x 2 days (6mg /day) Bup 2mg SL tab 1 SL BID x 2 days (4mg /day) Bup 2mg SL tab 1/2 SL BID x 2 days (2mg /day) Principles of Addiction Medicine, 5th Ed., p

27 Second part of 20 day Opioid taper Bup Transbuccal Film : Rx #2, uses #14 films Transbuccal Bup 450 mcg TID x 2 days (1.35mg/day) Transbuccal Bup 450mcg BID x 2 days Transbuccal Bup 450mcg ½ BID x 2 days Transbuccal Bup 450mcg ½ per day x 2 days Transbuccal Bup 450mcg ½ QOD x 2 doses (112 mcg) Then DC Principles of Addiction Medicine, 5th Ed., p Additional symptomatic Rx meds during opioid tapering 1. Quetiapine 50mg 1 PO HS for sleep 2. Trazodone 50mg 1 PO HS for sleep 3. Ibuprofen 600mg TID for arthralgias 4. Chlorzoxazone 500mg QID for myalgias 5. Ranitidine 150mg PO BID for dyspepsia

28 Additional symptomatic Rx meds during opioid tapering 5. Clonidine 0.1mg PO BID-TID for anxiety (Bp?) 6. Buspirone 5mg-10mg PO BID for anxiety 7. Immodium A-D 2 PO after loose BM (max 8/d) 8. Tizanidine 4mg PO TID for myalgias/cramps We ll end here, I m sure there s lots of questions Thanks so much! You ve been a great audience! Let s give the AOMA a big hand for this wonderful event!!

29 References: 1. In Principles of Addiction Medicine, 5th ed., (Ries, R.K., Fiellin, D.A., Miller, S.C., Saitz, R. Eds.) pp American Society of Addiction Medicine; Chevy Chase, Maryland