Managing pain without overusing opioids

Transcription

1 Balanced information for better care Managing pain without overusing opioids Implementing safe, effective, and less risky analgesic strategies

2 Opioids in America: increasing use, increasing complications Pain is the most common reason for physician visits. 1 Over 100 million Americans suffer from some form of chronic pain. 2 In the 1990s, concern about under-treatment of pain and the introduction of new opioid products were followed by a surge in the use of prescribed opioids. FIGURE 1. Opioid pain medication use increased sharply, as did deaths caused by prescription pain medications and admissions for the treatment or abuse of these products Rate Prescribed opioid sales kg/10,000 Prescribed opioid deaths/100,000 Treatment admissions/10, Year * Age-adjusted rates per 100,000 population for prescribed opioid deaths, crude rates per 10,000 population for treatment admissions related to prescribed opioid abuse, and crude rates per 10,000 population for kilograms of prescribed opioid sold. The increase in dependence, morbidity, and mortality caused by opioid analgesics has prompted a reassessment of the appropriate role of these medications in managing both acute and chronic pain. 2 Managing pain without overusing opioids

3 Limit the quantity and duration of opioids in acute pain Most acute pain is self-limited. Initial management of acute pain should include: non-pharmacologic options (R.I.C.E. Rest, Ice, Compression, Elevation) pharmacologic options (acetaminophen or non-steroidal anti-inflammatory (NSAIDs)) Only the small minority of patients with severe pain will require an opioid. Principles for prescribing opioids for acute pain: Use a low dose. Use an immediate release formulation. For those who need opioids, 2-3 days of treatment will usually suffice. FIGURE 2. In a recent study of patients prescribed opioids after outpatient orthopedic surgery, almost half of patients used less than 5 pills from the average of 30 dispensed % Subjects On average, 19 pills per patient were unused Number of pills used Leftover opioids become an opportunity for diversion or other misuse. In one state study, 20.8% of the population received an opioid prescription in a year. Over half the patients with unused medications kept them. 5 Over half of people using prescription opioids for non-medical purposes got the drug from friends or family. 6 Alosa Foundation Balanced information for better care 3

4 Higher doses = higher risk Risks of opioid use include:! misuse, abuse, addiction 7 chronic constipation 8 intentional or accidental overdose 9 falls and fractures (especially in the elderly) at initiation and dose increase 10 low testosterone % 40-50% 1.8% 4.7% 19.3% Increases noted above are for patients taking >100mg morphine-equivalent dose per day (see below). The risk of complications from opioids rises with doses over 100 mg morphine-equivalent dose daily. 100 mg morphine-equivalent dose = hydrocodone 100 mg hydromorphone 25 mg oxycodone 65 mg fentanyl (mcg/hr) >37 Or use dose calculator online: 4 Managing pain without overusing opioids

5 Opioids for chronic pain: Little evidence of efficacy, considerable evidence for harm FIGURE 3. Weighing the risks and benefits of chronic opioid use High rate of adverse effects Little evidence of long-term benefit All randomized trials of opioids in chronic pain lasted for only 16 weeks or less; average trial lasted for 5 weeks. 12 TABLE 1. Among studies that do exist, opioids, especially strong opioids, can reduce pain scores, but a reduction in pain does not translate to functional gain. 12 AVERAGE EFFECT Pain (95% CI) Function (95% CI) Opioids v placebo -0.6 (-0.69, -0.50) (-0.41, -0.22) Opioids v NSAIDs or TCAs (-0.32, 0.21) 0.16 (0.03, 0.30) Strong opioids v NSAIDs or TCAs (e.g. morphine, oxycodone) (-0.67, -0.01) 0.0 (-0.35, 0.35) 1. Negative results favor opioids; positive results favor the comparator. 2. Over 30% of patients dropped out of the studies, due to side effects and/or inadequate pain relief in the opioid group. Alosa Foundation Balanced information for better care 5

6 Initial management of chronic pain Orient treatment around functional goals. For example: participation in physical therapy sleeping in a bed, instead of a chair Select one or more treatment options. Non-Pharmacologic exercise weight training yoga massage Tai Chi relaxation cognitive behavior therapy Pharmacologic Match to cause of pain: SNRIs antiepileptics tricyclic antidepressants (TCAs) lidocaine patches REASSESS REGULARLY Is the patient meeting functional goals? Y N REASSESS REGULARLY Continue or taper therapy. Increase, add, or change therapy. 6 Managing pain without overusing opioids

7 Does pain still impede functional improvement despite optimizing therapy? Evaluate whether opioid therapy may be required. Complete ABCDPQRS opioid risk assessment: 13 Alcohol use Benzodiazepines and other drug use Clearance and metabolism of the drug Delirium, dementia, and falls risk Psychiatric comorbidities Query the prescription monitoring program Respiratory insufficiency and sleep apnea Safe driving, work, storage, and disposal Y Is the patient at high risk of opioid-induced problems? N Are opioids an option, with increased monitoring? N Explore or revisit previous treatments. Consider other non-opioid treatment options. Refer to pain specialist. Y Start opioid therapy: Start low and go slow. No opioid is more effective than another. No benefit from using a long-acting or extended release product. 14 Continue to reassess progress towards functional goals. Alosa Foundation Balanced information for better care 7

8 Implement a system for opioid monitoring If patients require ongoing use of opioid medications, a monitoring system can help guide progress and identify problems. FIGURE 4. Example of a monitoring approach A ctivity Determine if patient is progressing toward functional goals. A nalgesia Evaluate the patient to determine response to treatment. A dverse effects constipation nausea or vomiting sedation pruritus hallucination or dysphoria sexual dysfunction A buse If you suspect abuse: 1. Use a screening tool like the Opioid Risk Tool (ORT). 2. Discuss concern with the patient. 3. Review expectations from pain management plan. 4. Increase monitoring: urine screens, pill counts, reviewing the patient s profile in the prescription monitoring program. Resources for patients with substance abuse: Substance abuse treatment in your office: Screening, Brief Intervention, and Referral to Treatment (SBIRT) Materials and training available at: integration.samhsa.gov/clinical-practice/sbirt SAMHSA s Behavioral Health Treatment Locator findtreatment.samhsa.gov Helpline at HELP ( ) 8 Managing pain without overusing opioids

9 Improving the safety of opioid use Use prescription monitoring programs to enhance safety and improve communication. Prescribers can review a patient s prescription opioid-use history: provides a platform for discussion with patient about pain medication use enhances coordination of care between providers identifies combinations of medications that may be problematic or put patient at risk of overdose Challenges: Federal programs do not report to state prescription monitoring programs (Veterans Affairs, Department of Defense, Indian Health Services). Data is not yet real time. Identify and reduce risk of opioid overdose. Educate patient and family on signs of opioid overdose. 1. Emphasize the need to take as prescribed. 2. Keep track of how frequently as needed medications are taken. Consider prescribing the opioid antagonist naloxone (Narcan) for: anyone on >50mg morphine equivalents daily patients on opioids with: renal dysfunction or hepatic disease concurrent benzodiazepine or antidepressant use patients or caregivers, upon request Be sure to instruct patients on how to administer naloxone (Narcan). Alosa Foundation Balanced information for better care 9

10 Tapering patients off chronic opioids Do not suddenly discontinue an opioid in a patient who has been taking high doses (e.g. >200 mg MED) for many months. Develop a collaborative plan with the patient. FIGURE 5. Algorithm for tapering opioids Calculate patient s total daily opioid dose. Include PRN and scheduled doses. Taper dose by 25-50% a week, use slower tapers based on patient factors if needed. 15 Is the patient having symptoms of withdrawal? sweating, tearing, runny nose anxiety muscle aches diarrhea increased blood pressure agitation insomnia nausea/vomiting tachycardia N Continue with scheduled taper. Y Can symptoms be managed with supportive therapy? Y Continue with scheduled taper. N Pause taper; resume when symptoms improve. If patients exhibit problematic or abusive behaviors during a taper, refer to an addiction or pain specialist. 10 Managing pain without overusing opioids

11 Summary Acute pain: Acute pain usually responds well to non-pharmacologic approaches, NSAIDs, and acetaminophen. Use opioids only when acute pain is severe, and prescribe limited amounts of opioids, for short durations. Chronic non-cancer pain: First, optimize pharmacologic and non-pharmacologic alternatives to opioids; resort to chronic opioid therapy only for severe pain when other alternatives are inadequate. Screen patients for risk of abuse or misuse before writing an opioid prescription. Periodically re-screen during treatment. Counsel patients about opioid side effects, safe storage, and disposal. If opioids are prescribed, set clear functional goals and realistic expectations as part of a comprehensive pain management plan. Opioids will generally not return the patient to normal function, and may even reduce functional status. Taper and discontinue opioids whenever possible, and particularly in patients who have significant side effects or exhibit problematic behavior. Refer patients to a chronic pain or addiction specialist for advice if the patient does not achieve functional goals or shows signs of problematic behavior. References: (1) Fox CD, Berger D, Fine P, et al. Pain assessment and treatment in the managed care environment: a position statement from the American Pain Society. Glenview, IL: American Pain Society; (2) Institute of Medicine. Relieving pain in American: a blueprint for transforming prevention, care, education, and research. June (3) Centers for Disease Control & Prevention. Vital signs: overdoses of prescription opioid pain relievers United States, MMWR. Morbidity and mortality weekly report. 2011;60(43): (4) Rodgers J, Cunningham K, Fitzgerald K, Finnerty E. Opioid consumption following outpatient upper extremity surgery. The Journal of hand surgery. 2012;37(4): (5) Centers for Disease Control & Prevention. Adult use of prescription opioid pain medications Utah, MMWR. Morbidity and mortality weekly report. 2010;59(6): (6) McCabe SE, West BT, Boyd CJ. Leftover prescription opioids and nonmedical use among high school seniors: a multi-cohort national study. The Journal of adolescent health: official publication of the Society for Adolescent Medicine. 2013;52(4): (7) Edlund MJ, Martin BC, Russo JE, DeVries A, Braden JB, Sullivan MD. The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription. The Clinical Journal of Pain. 2014;30(7): (8) Coyne KS, LoCasale RJ, Datto CJ, Sexton CC, Yeomans K, Tack J. Opioid-induced constipation in patients with chronic noncancer pain in the USA, Canada, Germany, and the UK: descriptive analysis of baseline patient-reported outcomes and retrospective chart review. ClinicoEconomics and outcomes research: CEOR. 2014;6: (9) Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Annals of internal medicine. 2010;152(2): (10) Miller M, Sturmer T, Azrael D, Levin R, Solomon DH. Opioid analgesics and the risk of fractures in older adults with arthritis. Journal of the American Geriatrics Society. 2011;59(3): (11) Deyo RA, Smith DH, Johnson ES, et al. Prescription opioids for back pain and use of medications for erectile dysfunction. Spine. 2013;38(11): (12) Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ. 2006;174(11): (13) Thorson D, Biewen P, Bonte B, Epstein H, Haake B, Hansen C, Hooten M, Hora J, Johnson C, Keeling F, Kokayeff A, Krebs E, Myers C, Nelson B, Noonan MP, Reznikoff C, Thiel M, Trujillo A, Van Pelt S, Wainio J. Institute for Clinical Systems Improvement. Acute Pain Assessment and Opioid Prescribing Protocol. Published January (14) Pedersen L, et al. A randomized, double-blind, double-dummy comparison of short- and long-acting dihydrocodeine in chronic non-malignant pain. Pain. 2014;155(5): (15) Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2): Alosa Foundation Balanced information for better care 11

12 About this publication These are general recommendations only; specific clinical decisions should be made by the treating physician based on an individual patient s clinical condition. More detailed information on this topic is provided in a longer evidence document at alosafoundation.org. The Independent Drug Information Service (IDIS) is supported by the Massachusetts Department of Public Health and the PACE Program of the Department of Aging of the Commonwealth of Pennsylvania. This material is provided by the Alosa Foundation, a nonprofit organization which is not affiliated with any pharmaceutical company. IDIS is a program of the Alosa Foundation. This material was produced by Brian Bateman, M.D., M.Sc., Assistant Professor of Anesthesia, Jerry Avorn, M.D., Professor of Medicine, Michael A. Fischer, M.D., M.S., Associate Professor of Medicine, Niteesh K. Choudhry, M.D., Ph.D., Associate Professor of Medicine, all at Harvard Medical School; Eimir Hurley, BSc (Pharm), MBiostat, Program Director, Ellen Dancel, PharmD, MPH, Director of Clinical Material Development, both at the Alosa Foundation. Drs. Avorn, Bateman, Choudhry, and Fischer are all physicians at the Brigham and Women s Hospital in Boston. None of the authors accepts any personal compensation from any drug company. Medical writer: Stephen Braun. Copyright 2015 by the Alosa Foundation. All rights reserved.