Canadian Guideline for Opioids for Chronic Non-Cancer Pain. Speaker Disclosure. Objectives. Canadian Guideline for Opioids for Chronic Non-Cancer Pain

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1 Canadian Guideline for Opioids for Chronic Non-Cancer Pain John Fraser Community Hospital Program New Glasgow November 1, 2017 This speaker has been asked to disclose to the audience any involvement with industry or other organizations that may potentially influence the presentation of any educational material. Receiving evaluations is critical to the accreditation process. After the program, please provide feedback at Speaker Disclosure College of Physicians and Surgeons of Nova Scotia College of Physicians and Surgeons of Newfoundland Labrador Atlantic Mentorship Network No commercial interests Objectives 1. Describe the recommendations of the Canadian Guideline for Opioids for CNCP. 2. Apply the Guideline recommendations in the clinical setting. 3. Identify patients requiring review of their opioid management. 4. Conduct patient-centred opioid tapering. Canadian Guideline for Opioids for Chronic Non-Cancer Pain Strong recommendations (4) Weak recommendations (6) Best practice statements (3) Expert guidance statements (10) Strong Recommendations All or almost all fully informed patients would choose the recommended course of action Recommendation is appropriate for all or almost all individuals 1

2 Weak Recommendations Majority of informed patients would choose the suggested course of action, but an appreciable minority would not Different choices will be appropriate for individual patients Clinicians should help patients arrive at a decision consistent with their values and preferences Best Practice Statements Common sense practice Supported by indirect evidence Associated with large net benefit Expert Guidance Statements Provides direction in areas for which there is either: no published evidence insufficient evidence to justify a formal recommendation Canadian Guidelines 2010 Process of opioid prescribing 24 recommendations Tools and practice information 2017 Do s and Don ts 10 recommendations 13 guidance statements Case #1 34 year old woman 9 years low back pain (9/10) Radiation down back of left leg (electric, numb) 2 year old and 4 year old at home Physiotherapy for 1 month: no benefit Nortriptyline 25 mg od: stopped after 4 days due to side effects Requesting opioid therapy for pain relief to be able to care for children 1. Optimize Non-Opioid Therapy Benefits of opioids roughly equivalent to other pharmacotherapies Risks of opioids greater Addiction 5.5% Overdose 0.1% Risk increases with higher doses (0.23% > 100 OME) Diversion 2

3 Optimize Non-Opioid Therapy Physical therapies Physiotherapy Chiropractic Massage Psychologic Pain self management Relaxation Mindfullness Optimize Non-Opioid Therapy Pharmacotherapy TCA Gabapentinoids SNRI Interventional Opioids for Chronic Pain Little evidence for the use of opioids in many common chronic pain problems: fibromyalgia headaches mechanical back pain osteoarthritis irritable bowel syndrome chronic pelvic pain Opioids for Chronic Pain Almost all RCT s less than 12 weeks Reserved for patients with severe pain that is refractory to other treatments Krashin et al, 2013, Curr Rheumatol Rep Ballantyne, 2015, Phys Med Rehabil Clin N Am Case #2 32 year old man Chronic neuropathic leg pain following inguinal hernia repair Binge drinker 12 beers a day, about one month out of three Plans to stop Failed trials of non-drug therapy Failed trials of TCA, SNRI, pregabalin, gabapentin Requesting opioid therapy 3. No Opioid with Active Addiction 8.9% risk of developing opioid addiction Increased risk fatal overdose (from 0.1% to 0.46%) Rate of overdose increases with higher doses Continue non-opioid pain management Refer to addiction services 3

4 Case #3 54 year old man Chronic HIV-related neuropathic pain Failed non-opioid trials Cocaine addiction 10 years daily inhaled use In full remission for 6 months 5. No opioid with a history of addiction Increased risk of fatal overdose (from 0.1% to 0.38%) Risk of overdose increases at higher doses Case #4 54 year old man Chronic HIV-related neuropathic pain Failed non-opioid trials Alcohol addiction 5 years daily use 10 beers In full remission for 30 years CP with History of Addiction Majority no opioid therapy Minority Benefits may outweigh risks Get second opinion Addiction and Chronic Pain 5.5% risk overall 8.9% risk with active addiction Addiction and Chronic Pain 5.5% risk overall 8.9% risk with active addiction Risk with No history History, in remission Active 4

5 Abuse and Addiction in CNCP Addiction in CNCP 24 studies CNCP on opioid therapy n=2,507 average 26 months exposure 0.2% develop opioid abuse or addiction in the absence of a past history of addiction Meta-analysis Opioid therapy over 6 months for CNCP oral, transdermal and intrathecal 17 studies, n=3,079 Signs of addiction in 0.05% Fishbain et al, 2008, Pain Med Noble et al, 2008, J Pain Symptom Manage Addiction in CNCP Systematic review CNCP on opioid therapy > 6 months 26 studies (25 case series, 1 RCT) n=4,893 Signs of opioid addiction 0.27% Addiction risk in CNCP Systematic review 17 studies Available evidence suggests that opioid analgesics for chronic pain conditions are not associated with a major risk for developing addiction Noble et al, 2010, Cochrane Review Minozzi et al, 2013, Addiction Opioid Addiction in CP Active addiction 8.9% History, in remission 4.4% No history 0.17% Total 5.5% Case #5 37 year old woman Chronic phantom limb pain Failed trials of TCA, gabapentin, pregabalin, SNRI Active schizophrenia Requesting morphine 5

6 4. Stabilize Active Mental Illness before Opioid Therapy 8.0% risk of developing addiction Increased risk of fatal overdose (from 0.1% to 0.15%) risk of overdose increases at higher doses Case #6 37 year old woman Chronic phantom limb pain Failed trials of TCA, gabapentin, pregabalin, SNRI Chronic depression due to constant severe pain Requesting morphine Stabilize Active Mental Illness before Opioid Therapy If considering opioid therapy, screen for mental illness Anxiety Post-traumatic stress disorder: Depression 2. Opioid Trial Persistent problematic pain despite optimized non-opioid therapy, start trial of opioid therapy Reduction in pain (11%) Improvement in function (10%) Opioid Trial Screening (risk assessment) Addiction history Mental illness screening Urine drug screen Prescription Monitoring Program (PMP) or Drug Information System (DIS) Opioid Risk Tool 10 item self administered Family history substance abuse Personal history substance abuse Age Preadolescent sexual abuse Psychological disease 6

7 Substance Use History Urine Drug Screening Each drug class (alcohol, benzodiazepines amphetamines, cocaine, opioids, marijuana, hallucinogens, solvents) Have you ever used? first use regular use (duration, frequency, amount, route) current use (last use) Consequences of drug use (harms) Treatment Before initiation After initiation according to risk and aberrant behaviours Be aware of test used and its limitations Interpret carefully Informed Consent Treatment agreement Risks Benefits Expectations Terms of prescribing Goals functional Opioid Trial Only one prescriber Avoid driving when titrating dose Avoid benzodiazepines very rarely Opioid Trial Initial opioid Not methadone, fentanyl Not meperidine, pentazocin Initiate with lowest dose available Dispense at a frequency depending on risk Daily or weekly if necessary No more than 1 month at a time Opioid Trial SR vs IR unclear Tamper-resistant products May reduce risk of altering route Patch returns May reduce diversion Naloxone Benefits with chronic pain unclear May be useful with high risk or high dose 7

8 7. Restrict Opioid Dose to 50 mg Oral Morphine Equivalent When beginning opioid therapy, limit dose to below 50 mg OME Increased risk of fatal overdose 0.1% < 20 mg OME 0.14% 20 to 49 mg OME 0.18% 50 to 99 mg OME Some patients willing to accept the increased risk above 50 mg OME 6. Restrict Opioid Dose to 90 mg Oral Morphine Equivalent Dose-dependent increase in the risk of fatal opioid overdose: 0.1% <20 mg OME 0.14% 20 to 49 mg OME 0.18% mg OME 0.23% 100 mg OME No benefit pain or function No increased risk of addiction Restrict Opioid Dose to 90 mg Oral Morphine Equivalent Some patients may gain important benefit over 90 mg OME Refer for second opinion Monitoring Outcomes Function ADL s Sleep Patient-defined functional goals Pain Monitoring Adverse effects Falls Cognitive dysfunction Sedation Sleep apnea Hyperalgesia Depression Hypogonadism Monitoring UDS Aberrant behaviours Less serious More serious 8

9 Aberrant Behaviours Aberrant Behaviours Less Serious Requests dose increases Requests early refills Unsanctioned dose increases Requests specific opioids Misses appointments Requests Rx for travel Requests faxed Rx Using for other symptoms Non-adherence to other treatment More Serious Selling opioids Stealing opioids Forging prescription Injecting/snorting Non-medical sources Illicit drug use Presents intoxicated Lost prescriptions Drug-related crime Less Serious Pseudo-addiction Tolerance Pseudo-tolerance Hyperalgesia Failed Opioid Trial Opioid withdrawal Chemical coping More Serious Addiction Diversion Opioid Trial Adequate trial 3 to 6 months Discontinue opioid with failed trial: No significant reduction in pain or improvement in function (50 to 90 OME) Presence of significant complications 8. Opioid Rotation with Persistent Pain or Side Effects May be useful with some patients May be part of tapering process idmanager/documents/opioid_manager_s witching_opioids.pdf Opioid Rotation 1. Calculate equivalent dose 2. Divide by 2 to get target dose 3. Rotate in one or more steps 4. Titrate Hydromorphone 18 mg bid to morphine 1. Calculate OME 18 x 2 = x 5 = 180 OME 9

10 Hydromorphone 18 mg bid to morphine 2. Divide by 2 to get target = 90 OME Equivalency tables not exact Most patients can reduce total OME by 25 to 50% through rotation Hydromorphone 18 mg bid to morphine 3. Rotate in one or more steps If OME < 50, rotate in one step If OME > 50, rotate in 2 or 3 steps Target OME = 90 2 steps Reduce HM by 1/2, add 1/2 morphine HM 18 mg am, morphine 45 mg pm Discontinue HM, morphine 45 mg bid Hydromorphone 18 mg bid to morphine 3. Rotate in one or more steps If OME < 50, rotate in one step If OME > 50, rotate in 2 or 3 steps Target OME = 90 3 steps Reduce HM by 1/3, add 1/3 morphine HM 12 mg bid, morphine 15 mg bid HM 6 mg bid, morphine 30 mg bid Discontinue HM, morphine 45 mg bid Hydromorphone 18 mg bid to morphine 4. Titrate Some patients will be stable at 50% reduction Most patients will require up-titration to stabilize Usually titrate to 25% reduction Don t titrate above original dose Case #7 54 year old man Moderately severe lumbar spinal stenosis Non-surgical Nortriptyline 25 mg qhs Gabapentin 800 mg tid Hydromorphone SR 24 mg q8h IR 4 mg qid Function Not working Walks 20 minutes 3 times a week Helps occasionally housework 9. Current Patient > 90 OME Taper to Lowest Effective Dose High dose opioid therapy associated with: Overdose Falls Sedation Cognitive dysfunction Sleep apnea Hyperalgesia Depression 10

11 Case #8 54 year old man Moderately severe lumbar spinal stenosis Non-surgical Nortriptyline 25 mg qhs Gabapentin 800 mg tid Hydromorphone SR 12 mg q8h Function Working full time as accountant Exercises 30 minutes a day Active social life Helps with all housework Current Patient > 90 OME Taper to Lowest Effective Dose Benefits of tapering Clearer thinking More energy More alert More functional Improved QoL Indications for Tapering Failed trial 50 to 90 OME with insignificant reduction in pain or improvement in function Failed titration One or two dose increases do not result in reduced pain or increased function Complications Intolerable side effects Non-adherence to treatment plan that results in increased risk of serious complication Pain condition resolved Dose > 90 OME Patient request Process of Tapering Engage patient in process Discuss risks of high doses and benefits of taper Give some control to patient Decision to taper not negotiable Process of taper is negotiable which medication first rate of taper Principles of Tapering Client centred Rate of taper Outcome of taper Short term opioid therapy: days to weeks Long term opioid therapy: months to years no longer than ¼ time on opioids Goal is the lowest effective dose Maximum function without adverse effects Sometimes this means tapering to zero Process of Tapering Start at 5% a week Monitor closely for withdrawal and pain Adjust rate of taper as needed decrease amount and/or frequency of dose reduction Provide alternative strategies for pain management Consider opioid rotation 11

12 Process of Tapering Process of Tapering If tapering causes significant increase in pain decrease in function opioid withdrawal 1. Stabilize maintain dose for a period increase dose sometimes 2. Resume taper If significant increase in pain or decrease in function persists > 1 month Consider abandoning taper Do not destabilize Goal is maximum function, minimum risk Goal is NOT a number If considering abandoning taper with dose > 200 mg OME, get second opinion Refer to Multidisciplinary Program if Challenging Taper alternative is a coordinated multidisciplinary collaboration that includes several health professionals (primary care physician, nurse, pharmacist, physical therapist, chiropractor, kinesiologist, occupational therapist, addiction specialist, psychiatrist, psychologist) Summary 1. Opioids only with severe pain refractory to non-opioid therapy 2. No opioids with active mental illness Be aware of interrelationship between chronic pain and mental illness 3. No opioids with a history of addiction Active addiction: no opioid, provide addiction treatment Addiction in remission: in some patients benefits may outweigh risks (get second opinion) No history of addiction, risk low (<0.17%) 4. Monitor regularly Function Pain Adverse effects Aberrant behaviors UDS Summary Summary mg OME: trial dose Many patients will have adequate outcome mg OME: maximum dose Some patients may benefit from higher dose (get second opinion) 7. Discontinue opioid therapy or consider opioid rotation if: No significant positive outcome Significant complications 12

13 Summary Resources 8. Taper opioids (sometimes to zero) when: Failed trial (or failed dose titration) Complications Pain condition has resolved Dose > 90 mg OME Pause or abandon taper if significant and persistent increase in pain or decrease in function Do not destabilize patients 9. Refer challenging tapers Nova Scotia Prescription Monitoring Program Medical Consultant Atlantic Mentorship Network Pain & Addiction National Pain Centre John Fraser