Scope of the Opiate Problem 6/5/18. Chronic Pain Management and the Use of Opioid Medications: The CDC Guideline and Beyond. Overview.

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1 Chronic Pain Management and the Use of Opioid Medications: The CDC Guideline and Beyond David Anisman, MD Medical Director, Farmington Health Center (Primary Care) Associate Medical Director, Community Physicians Group None Disclosures Overview Scope of the opioid problem Brief history of pain and opioid prescribing CDC Guideline review CPG Guideline and policy highlights Barriers to safe and effective practice Call to action Scope of the Opiate Problem Nationally : >165,000 deaths from prescription opioids alone 1 Deaths from all opioids now > HIV + MVA (+CAD) 1999: ~8, : 33, : 42,249 1.CDC. Multiple cause of death data on CDC WONDER. Atlanta, GA: US Dept of Health and Human Services, CDC; 2016 Scope of the Opiate Problem Utah 1 Rank in US for prescription opioid deaths 2013: #8 2014: #7 2016: #20 (but no change in death rate) Death Rate (per 100K population) 2014 = 22.4, 2015 = 23.4, 2016 = Utahns die every month from prescription opioids Prescribing Rates (per 100K population) /100K (255M) : 66.5M (214M) - 18% 1. Utah Department of Health website 1

2 6/5/18 Prescribing Rates (per 100K population) Scope of the Opiate Problem Death Rate (per 100K population) 2014 = 22.4, 2015 = 23.4, 2016 = 22.4 (no change) UT Prescribing rates: 2014 = 78.9/100, 2015 = 74.5/100, 2016 = 70.4/100 (10.7% ) Why no correlation? Need to address other risks: High dosages High-risk combinations Inappropriate diagnoses (missing SUD?) 1. CDC. Multiple cause of death data on CDC WONDER. Atlanta, GA: US Dept of Health and Human Services, CDC; 2016 Utah rates: : /100K % increase 2

3 1. State Legislatures Scope of the Problem: The Key Actors Washington State 1st; UT HB 50 & 90 (2017) Focus: limiting amount prescribed 2.Federation of State Medical Boards (recommendations, CME requirements) 3. Payers (Regence BCBS in Massachusetts) Scope of the Problem: The Key Actors Medical Community Largely silent Professional Societies: CME requirements for MOC CDC Guideline Primary Care Providers Inadequate training 1 Account for nearly 50% of opiates dispensed 2 1. Jamison et al. Beliefs and attitudes about opioid prescribing and chronic pain management: survey of primary care providers. J Opioid Management 2014; 10: Levy B et al. Trends in opioid analgesic prescribing rates by specialty, US, AM J Prev Med, 2015: 49:409. Prescribing trends follow several developments Development of meds and delivery systems Rise of Pharma as driver of prescribing practices Progress of neuroscience Early 19th Century: pain is good Improved healing via stimulation of CV and immune function 1850s: pain should be eliminated Development of new meds Development of hollow bore needle Today: Pain is bad for health Directly responsible for increases in opioid prescribing Acute pain pathways: peripheral NS (fact) Chronic Pain: Development of central pathways that sustains pain perception without input from the peripheral NS (theory) 1980s: State regulations prevented Pharma from incentivizing providers directly Ex: Purdue Pharma and JCAHO JCAHO used Purdue s videos as training materials Tied pain control to Quality measures Created analog pain scale ( 5th VS ) 3

4 3 Opioid Myths 1. Effective for long-term pain control 2. No dose is too high 3. Not addictive if given for pain Data Good data on opioid effectiveness for acute pain 1 and cancer pain Few studies on long term benefits of opioid for chronic pain What evidence there is suggests serious harms that appear to be dose-dependent 2 1.Chou R, et al. The effectiveness and risks of long-term opioid treatment of chronic pain. AHRQ Pub #14-E005-EF, CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016, p9. Data Odds Ratio of Overdose by Opiate Dosage (relative to 1-19 MME/day) Opiate Dosage OR of Any OD Event OR of OD Death Ranges (MME/day) When to Initiate or Continue Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain > Dunn DM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010; 152;85 Gomes T, et al. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med 2011; 171:686 Consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. When to Initiate or Continue Establish treatment goals (including function) Continue opioid therapy only if there is clinically meaningful improvement (and function) When to Initiate or Continue Discuss known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy 4

5 Opioid Selection, Dosage, Duration, etc. Prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids Opioid Selection, Dosage, Duration, etc. Prescribe the lowest effective dosage Reassess benefits & risks when considering increasing dosage to 50 morphine milligram equivalents (MME)/day Avoid increasing dosage to 90 MME/day Opioid Selection, Dosage, Duration, etc. Long-term opioid use often begins with treatment of acute pain. Three days or less will often be sufficient; more than seven days will rarely be needed Opioid Selection, Dosage, Duration, etc. Evaluate benefits & harms within 1 to 4 weeks of starting/escalating Re-evaluate every 3 months or more frequently. If benefits do not outweigh harms, work to taper or discontinue opioids Evaluate risk factors for opioid-related harms. Review PDMP ( = CSD in UT) Consider naloxone if increased risk for OD, to include dosages ( 50 MME/day) 5

6 Use urine drug testing before starting opioid therapy and at least annually Avoid prescribing opioids & benzodiazepines concurrently whenever possible Offer/arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder Rationale PCPs can no more be excused from addressing their patients chronic pain than they can be expected to prescribe opioids in every case or in an unlimited manner. Assist PCPs in deciding when to treat with opioids and when not to Rationale Provide institutionally-endorsed limits for opioid dosages Provide workflow options to facilitate safe and appropriate opioid management Reduce both the risk to the provider as well as conflict with patients Proper assessment: thorough Hx (pain and PMH) Effective and ineffective treatments Impact on function (2 Item Graded or PEG) Screen for mood disorders (PHQ-9 & GAD) Opiate Risk Tool (ORT) CAGE-AID UDS CSDB review No opioids at the first visit! 6

7 2 Item Graded Pain Scale PEG : Who to Treat, Who Not to Treat Reasonable Cancer pain Moderate-severe arthritis & DDD Spinal stenosis Some neuropathic pain RLS : Who to Treat, Who Not to Treat Caution Advised Psychiatric co-morbidities Renal & hepatic disease Pulmonary disease Lack of engagement in full treatment plan Unclear Diagnosis History of treatment by multiple providers : Who to Treat, Who Not to Treat Discouraged Migraine (and most headache) Fibromyalgia (and most myofascial conditions) Mechanical low back pain Sciatica History of substance abuse (tobacco?) Medication Specifics Dosage limits Re-evaluate annually 90 MME/day: bi-annual review/referral (clinrx, BH, pain specialist) Sleep testing for >90 MME/day (lower if pulm dis) Start with short-acting Avoid dangerous combos (benzos strongly discouraged; SOMA prohibited) 7

8 Medication Specifics Methadone only if provider experienced No meperidine (Demerol) Naloxone > 50 MME/day Tapering protocol Workflow Expectations 1. Controlled Substance Agreements 2. No refills without a clinic appointment 3. One provider, one pharmacy 4. UDS at least annually 5. Schedule follow-up at each refill appointment 5As Workflow Expectations 6. Continually monitor function, not just pain 7. Document treatment goals and progress 8. 5As 9. Patient Education Mandatory use of formatted pain note in EMR Mandatory documentation of treatment goals, ineffective treatments Must have a specific, legitimate diagnosis Barriers to Policy Implementation Provider discomfort with opiate prescribing & managing chronic pain Unethical to refuse to address & manage pain No obligation to treat unsafely (think: antibiotics) Takes time Patient expectations & impact on satisfaction Learning to say no and set boundaries with kindness and empathy 8

9 A Call To Action! Create Your Own Policy Recommendations vs Mandatory Limits Dosage limits (# pills vs MME/d) Documentation requirements No refills without an appointment Dedicated refill appointments Use of CSDB every time UDS Medication specifics Provide support resources as much as possible Visit the CDC Website! search by alphabet: O; pick Opioids Guideline Resources: Clinical Tools Questions? Within the UofU: SmartWeb 9