What do they have in common?

What do they have in common?

Opioid use in USA Approximately 9 million people on long term opioids Approximated 5 million people reporting non-medical use of opioids 1997: 96mg/person morphine eq dispensed 2007, 700mg/person morphine eq dispensed NMWR2012:61(1):10-13

Opioid use in Australia Opioid base supply: Australia, 1991-2009 base Kg 1600 1400 1200 1000 morphine oxycodone 800 pethidine 600 methadone 400 200 codeine 0 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

Harm from Opioid prescription

Cost to the community 5 months 3 States 173 doctors 287 visits 425 prescriptions for narcotics, morphine 425 x 20 = 8,500 tabs 8,500 x $20 = $170,000 Western NSW 2008, in 1 year: 10,400 tabs, 2,500 oxycodone tabs Selling at: $50 a tablet $114 million per year

Aberrant drug related behaviour Selling prescription drugs Prescription forgery Stealing or borrowing drugs Injecting oral formulations Obtaining prescription drugs from non-medical sources Concurrent abuse of alcohol or illicit substances Multiple non-sanctioned dose escalations Repeated episodes of prescription loss Repeatedly seeking prescriptions from other clinicians or A&E without informing prescriber or after warning to desist Evidence of deterioration in ability to function (work, family, socially) that appear to be drug related Repeated resistance to therapy change despite clear evidence of adverse physical or psychological drug effect 1. Højsted J and Sjøgren P. Eur J Pain. 2007;11:490-518

Opioid misuse in Australia Opioid scripts obtained by doctor shoppers Morphine inj:1 in 5 Ms contin 100mg: 1 in 9 Oxycontin 80mg : 1 in 7 Police detainees positive for drugs 55% Cannabis 23% Methamph 20% Benzodiazepine 9% Heroin 30% Other opiates Hospitalization due to opioid poisoning 1998-99: 32.6% 2007-08: 80.3% Aust Ins Criminol. Drug use monitoring in Australia.2006 no.75

Opioid misuse Negative urine toxicology screen Inconsistent urine toxicology screen Multiple prescribers Diversion Prescription forgery Lack of tolerance to opioids Ives et al 2006

Misuse predictors Incidence is 32% in USA Male Previous convictions Previous alcohol addiction Previous opioid addiction Previous cocaine addiction Ives et al 2006

Therapeutic Guidelines, 2007. 2. Ballantyne & LaForge, 2007. Addiction Addiction is a complex neurobiopsychosocial disorder Characterized by aberrant drug-seeking and drug-taking behaviors despite the risk of harmful consequences Psychological dependence The psychological component of withdrawal comprises unpleasant emotional effects (withdrawal, anhedonia and dysphoria) and motivational effects (craving during withdrawal)

Incidence of addiction True addiction/abuse of opioids occurred in: 3.3% of all patients treated with opioids for chronic pain 0.2% of patients preselected for no previous or current history of abuse/addiction Aberrant drug-related behaviours occurred in: 11.5% of all patients treated with opioids for chronic pain 0.6% of patients preselected for no previous or current history of abuse/addiction Studies of chronic pain populations over the last two decades reveal problematic opioid use ranging from 2.8 50% depending on definition Fishbain et al. 2008. Ballantyne & LaForge, 2007.

Fine line between pleasure and pain VTA (ventral tegmental area) Receive information on how well fundamental and human needs are being satisfied Nucleus accumbens Reinforces the behaviours by which we satisfy our fundamental needs Hypothalamus Amygdala Septum Prefrontal cortex Canadian Institute of Neuroscience, Mental Health and Addiction, 2008

Pain or pleasure Interconnection between pleasure centres Reward circuit is a part of the MFB (medial forebrain bundle) Reticular formation VTA lateral hypothalamus Nu acc., amygdala, septum, PFC Monoamines as neurotransmitter Canadian Institute of Neuroscience, Mental Health and Addiction, 2008

What opioids to use? 1. Fentanyl: Parenteral, Lozenges, Patch 2. Oxycodone: Parenteral, Oxycontin, Targin, Elixir 3. Morphine: Parenteral, Ms Contin, Kapanol, Elixir 4. Hydromorphone: Parenteral, Elixir, Jurnista 5. Methadone: Parenteral, Physeptone, Elixir 6. Pethidine: Parenteral 7. Buprenorphine: Parenteral, Patch, Suboxone, Temgesic 8. Codeine Oral, Paracetamol mix,ibuprofen mix

Useful rules for prescribing 1. Opioid therapy part of a wider pain management approach 2. Avoid using opioids in isolation 3. Inform patients about the limits of opioid therapy 4. Arrange for a trial of opioid with clear review point 5. One doctor responsible for prescribing opioids 6. Refer to another GP or pain specialist if concerned about the prescription or if opioid therapy is not achieving desirable results Therapeutic Guidelines, 2007. Graziotti & Goucke, 1997

The 4 A s Analgesia Activity Adverse effects Aberrant behaviors Gourlay & Heit, 2005.

Useful tips for Perioperative care 1. A quick addiction risk assessment 1. Previous addiction 2. Previous criminal history 3. Psychiatric history including personality disorder 4. High level of anxiety 2. Pain diagnosis 3. What opioids they are on?; how long?; who is prescribing? (Doses greater than 120mg Morphine equivalent per day) 4. Previous opioid use history 5. Verification of the prescription and last prescription pick up 6. Who is at home with them; other opioid users; employment status 7. Limited supply of opioids to go home with; avoid more potent opioids with high misuse potential 8. There is no obligation to prescribe high potency, high dose opioids. Get the original prescriber involved when possible. If concerned, question the the appropriateness

Informed Consent Dependence, tolerance and addiction Safety issues Responsibilities Consequences of aberrant behavior Side effects Treatment goals Risk of sudden opioid cessation Exit strategy and dose reduction Graziotti & Goucke, 1997. Tedeschi, 2006.

Patient awareness Burwaiss & Majedi: 2012 yet to be published

Focus on Safety Opioids vary in dynamics and kinetics dramatically There is vast pharmacogenetics variation The opioid therapy has to be tailored to the individuals No such thing as safe drugs Least abused and least likely to cause accidental overdose: Tramadol, Buprenorphine, and Codeine

Burephorphine Norspan/ Temgesic / Subutex Not reliant on renal function or dialysis Has Kappa, delta and Mu activity Mixed agonist /antagonist activity Ideal for situations of misuse and accidental overdose potential. Andrea et al: Pain Physician 2008

Tramadol Immediate release/ Slow release/ Durotram XR/ IM/IV Poorly tolerated by some patients Renal clearance Potential for seizures and serotonergic syndrome Concerns of interaction with TCA /SSRI/SNRI Andrea et al: Pain Physician 2008

The pink elephant in the room approach Nothing beats blatant honesty Patients need to know the issues with opioids and how to use them carefully Patients need to be aware of issues of responsibility and obligations of the prescriber and that not escalating opioid dosage is in their interest Patients need to know that despite pain, increasing opioid dosage is actually more harmful Patients need to know that no law can enforce a practitioners to prescribe opioids or any other drug for that matter if the medical practitioners feels that the drug will cause harm. Patients need to be aware of their obligation and responsibility when prescribed any medication including opioids

Future Real time electronic prescribing Electronic health records Better education and raising awareness Better support for prescribers Peri-operative clinics Better analgesics. Gradual move away from opioids

Summary All opioids are subject to side effects All opioids are subject to misuse and abuse All opioids are powerful tools to help patients achieve pain management and assist in rehabilitation We have a humane and physiological obligation to treat pain Newer opioids and formulations such Jurnista, Targin and Norspan are designed to deliver a better opioid based pain control with more predictable pharmacokinetics and pharmacodynamics Sadly opioid misuse and abuse will always be an issue despite newer opioids and formulations Current recommendations, encourage practitioners not to exceed 120mg morphine equivalent per unless reviewed by specialist Long term all opioids at high dose result in morbidity Opioids used in long term basis should be considered as a Compromise therapy. Ie used as a last resort once all other thearpy and attempts of have failed ( need careful risk, benefit analysis and a firm diagnosis) They are not a cure for pain, but a management tool and have to be considered in risk-benefit terms