OPIOIDS AND PAIN An In-Depth Guide Know your risks Understand the side effects Learn where opioids fit into a comprehensive pain management plan Advanced Pain Management (APM) is a caring organization that is committed to providing patients with innovative pain management services. 1 To learn more or to schedule a consult, call (888) 901-PAIN (7246).
INDEX Quiz: Are you in danger of side effects?...3 Opioid Conversion Tool...4 Common Side Effects...5-6 Opioids Place in Pain Management...7 Conditions and Treatment Options...8 ABOUT ADVANCED PAIN MANAGEMENT Advanced Pain Management (APM) is one of the largest pain management groups in the country, with locations in Wisconsin, Minnesota and Indiana. We offer a broad array of comprehensive pain management treatments administered by fellowship trained, board certified physicians. Our physicians work on an individual level to find the source of your pain and recommend the best treatment options, whether that s minimally invasive procedures, physical therapy, behavioral health care or a combination of these treatments. Our priority is exceptional patient care and we re dedicated to getting you back to the things you love. 2
OPIOID RISK QUIZ Are you in danger of serious opioid-related side effects? Take our simple 6-question quiz to find out now. 1 2 3 4 Have you been taking opioids for three months or more? Has your dose been increasing? Has your pain stayed the same (or increased) despite an increasing dose? N/A Are you currently on a dose above 90 morphine milligram equivalents (MME) a day? (See chart on the next page to calculate your MME.) ANSWER KEY If you answered yes to 3 or more of these questions, you may be at an increased risk for opioid-related side effects, including addiction or overdose. (For a list of common opioid-related side effects, please see page 6.) Although no dose of opioids is completely safe, the higher the dosage and the longer the course of treatment, the riskier opioids become. 5 Do you have a personal or family history of alcohol or drug abuse? Have you been diagnosed with any type of mood or anxiety disorder? 6 3
Calculating Your Total Morphine Milligram Equivalents (MME) A Day Many clinicians, including those at Advanced Pain Management, are now using the CDC Guideline for Prescribing Opioids for Chronic Pain 1 to guide their plan of care for patients on long-term opioid therapy. These guidelines recommend: When a patient s dose meets or exceeds 50 MME/day, it s time to take a step back and weigh the benefits and risks of continuing with opioid therapy. Exceeding 90 MME/day should be avoided, if at all possible, because the risk of overdose increases at higher dosages. Drug Example Trade Names Dose Multiplier MME Hydrocodone (1 mg) Vicodin, Lortab, Lorcet HD, rco, Hycodan, Vicoprofen, Max Daily Dose Morphine = 50 mg Max Daily Dose Morphine = 90 mg x 1 50 mg 90 mg Oxycodone (1 mg) Tylox, Percocet, OxyContin x 1.5 33 mg 60 mg Tramadol 2 (1 mg) Ultram, Ultracet x 0.1 500 mg 900 mg Fentanyl (1 mcg/hr TTS) Actiq, Fentora, Duragesic x 2.4 21 mcg/hr TTS 37.5 mcg/hr TTS Hydromorphone (1 mg) Dilaudid x 4 12.5 mg 22.5 mg Oxymorphone (1 mg) Opana, Opana ER x 3 16.7 mg 30 mg Codeine (1 mg) Tylenol 3, Tylenol 4, Fioricet x 0.15 333 mg 600 mg Tapentadol (1 mg) Nucynta x 0.4 125 mg 225 mg Buprenorphine 2 (1 mcg/hr TTS) Butrans x 1.8 27.8 mcg/hr TTS 50 mcg/hr TTS Methadone (1-20 mg/day) Methadone (21-40 mg/day) x 8 Methadone (41-60 mg/day) Dolophine, Methadose x 10 Methadone ( 61-80 mg/day) x 12 Total Morphine Milligram Equivalents = x 4 12.5 mg 20* mg *Conversion of methadone to MME is nonlinear. Doses exceeding 20 mg methadone thus exceed the 90 mg max MME. 1 Dowell, Deborah, Tamara M. Haegerich, and Roger Chou. CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. Morbidity and Mortality Weekly Report (MMWR) 65, no. 1 (March 18, 2016): 1-49.
COMMON OPIOID-RELATED SIDE EFFECTS While opioids can be a useful component in the treatment of pain, they can also cause many serious side effects. If you re experiencing side effects from long-term opioid treatment or would like to find pain relief without the use of opioids talk to your provider or a pain management specialist, who may be able to recommend other treatment options. OVERDOSE AND DEATH Every day in this country, 44 people die from prescription opioid overdose. 1 Opioids have the ability to depress respiration. When they are taken in too large a dose, they can dangerously slow a person s heart rate and breathing to a point where they will die without medical attention. ADDICTION In the U.S., roughly 1.9 million people live with a substance use disorder involving prescription opioids. 2 Signs of addiction may include continued use despite negative consequences and going to extreme lengths to obtain the drug (like stealing from family or friends or obtaining illegally). GASTROINTESTINAL ISSUES One of the most prevalent side effects of opioid usage is constipation. In fact, studies have shown that 40%-45% of those on opiate therapy suffer from it. 3 But it s not the only gastrointestinal trouble caused by opioids; it s only one of the symptoms categorized under the title opioid-induced bowel dysfunction, which also includes abdominal cramping, spasm and bloating, among others. 4 BREATHING PROBLEMS Abnormal breathing while asleep is a concerning issue for those on opioids, especially those on high doses. In fact, in a small study, 92% of patients on a dose of more than 200 morphine milligram equivalents (MME) a day experienced ataxic or irregular breathing, compared to 61% of people taking less than 200 mg and 5% of people not taking opioids. 5 CARDIOVASCULAR ISSUES Long-term opioid use, when compared with NSAIDs, has been shown in some studies to pose an increased risk for events such as myocardial infarction and heart failure. 3,6 This is especially true for those taking codeine for more than 180 days. Continued on the following page. -> 1 Prescription Drug Overdose Data. Centers for Disease Control and Prevention. October 16, 2015. Accessed March 07, 2016. http://www.cdc.gov/drugoverdose/data/ overdose.html. 2 Hedde, Sarra, Joel Kennet, Rachel Lipari, Grace Medley, Peter Tice, Elizabeth A. P. Copello, Larry A. Kroutil. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration (2014). 3 Baldini, Angee, Michael Von Korff, and Elizabeth H. B. Lin. A Review of Potential Adverse Effects of Long-Term Opioid Therapy. The Primary Care Companion For CNS Disorders 14, no. 3 (June 14, 2012). 4 Panchal, S. J., P. Müller-Schwefe, and J. I. Wurzelmann. Opioid-induced Bowel Dysfunction: Prevalence, Pathophysiology and Burden. International Journal of Clinical Practice 61, no. 7 (2007): 1181-187. 5 Walker, James M., Robert J. Farney, Steven M. Rhondeau, Kathleen M. Boyle, Karen S. Valentine, Tom V. Cloward, and Kevin C. Shilling. "Chronic Opioid Use Is a Risk Factor for the Development of Central Sleep Apnea and Ataxic Breathing." Journal of Clinical Sleep Medicine 3, no. 5 (August 2007): 455-61. 5 6 Dowell, Deborah, Tamara M. Haegerich, and Roger Chou. "CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016." Morbidity and Mortality Weekly Report (MMWR) 65, no. 1 (March 18, 2016): 1-49.
COMMON OPIOID-RELATED SIDE EFFECTS (CONTINUED) HYPERALGESIA HORMONE PROBLEMS Opioid-induced hyperalgesia (OIH) is another possible outcome for patients on long-term opioid therapy. In cases of OIH, the patient actually becomes increasingly sensitive to pain. Although it s not clear how prevalent OIH is, it can certainly cause some unwanted effects, including extreme acute pain after surgery and escalating opioid dosages. 7 INCREASED RISK OF FRACTURES Opioid use is associated with an increased risk of fractures, especially among the elderly population. The theory behind this is that opioids affect the central nervous system, causing such symptoms as dizziness and reduced alertness. 3,8 This, in turn, can result in falls. Elderly patients taking more than 50 MME a day have recently been found to be at double the risk of fracture among the elderly population, with a yearly fracture rate of 9.95%. 3 Chronic opioid therapy can also have an impact on the endocrine system, causing hormone changes in both men and women. For men, this manifests as hypogonadism, which causes a decrease in the production of sex hormones, particularly testosterone, as well as erectile dysfunction, reduced libido, fatigue and even hot flashes. 9 In women, opioids can cause a decrease in the levels of estrogen in the body, in addition to low follicle-stimulating hormone and increased prolactin. Combined, these changes can lead to osteoporosis, inappropriate milk production and light or infrequent periods. 3 DEPRESSION Patients on opioid therapy for long periods have an increased likelihood of developing depression. In one study, 38% of people on long-term opioids had at least moderate depression. 3,9 Furthermore, other opioid side effects, like intractable constipation, can lead to or worsen depression. 3 Enough opioids were prescribed in 2012 for every adult in the country to have their own bottle. That s roughly 259 million prescriptions a year. 10 7 Lee, Marion, Sanford Silverman, Hans Hansen, Vikram Patel, and Laxmaiah Manchikanti. "A Comprehensive Review of Opioid-Induced Hyperalgesia." Pain Physician 14 (2011): 145-61. 8 Smith, H. S., and J. A. Elliott. "Opioid-induced Androgen Deficiency (OPIAD)." Pain Physician 15, no. 3 (July 2012): ES145-156. 9 Sullivan, Mark D., Michael Von Korff, Caleb Banta-Green, Joseph O. Merrill, and Kathleen Saunders. "Problems and Concerns of Patients Receiving Chronic Opioid Therapy for Chronic n-cancer Pain." Pain 149, no. 2 (May 2010): 345-53. 6 10 Rosenblum, Andrew, Lisa A. Marsch, Herman Joseph, and Russell K. Portenoy. "Opioids and the Treatment of Chronic Pain: Controversies, Current Status, and Future Directions." Experimental and Clinical Psychopharmacology 16, no. 5 (October 2008): 405-16.
OPIOIDS' PLACE IN PAIN MANAGEMENT A GENERAL PLAN OF CARE When a patient enters treatment at APM, our fellowship trained, board certified physicians take a complete medical history, in addition to completing a comprehensive patient consultation. During these steps, the physician will ascertain which treatments a patient has used and how they worked, the patient s past and present usage of opioids and other medications, how their body uses pain medications and how they tolerate opioids. From this, they will determine a general plan of care tailored to the individual's needs and goals. OPIOIDS AS A TREATMENT COMPONENT If a decision is made that opioid therapy will be utilized as a component of care, the physician will work with the patient, as recommended by the CDC 1, to establish realistic goals regarding their pain and functional ability like being able to walk around the block or sleep through the night. Together, they will also discuss how and when the therapy will be discontinued if the benefits no longer outweigh the risks for instance, if there is no increase in pain levels or the ability to function. RISK-MITIGATING MEASURES If opioid therapy is warranted, every measure will be taken to reduce the risks. This includes prescribing opioids at the lowest possible dose necessary to achieve both pain relief and functional restoration. This may mean that patients currently on opioids will be tapered down to a more appropriate dose over time. Patients on opioids are required to sign a controlled substance agreement, which outlines their responsibilities, including taking their medication only as prescribed and avoiding alcohol and illegal drugs. The agreement also outlines other risk-mitigating measures that APM has in place, including urine drug testing and pill counts. APM'S COMMITMENT APM physicians are committed to decreasing patients need for opioids by reducing their overall pain levels. They do this by offering interventional procedures such as injections of pain-relieving medications, the administration of radio waves to ablate painful nerves and even implantable devices that can block pain signals from reaching the brain all to get patients back to a more normal lifestyle, with eliminated or reduced dependence on medication. 7 1 Dowell, Deborah, Tamara M. Haegerich, and Roger Chou. "CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016." Morbidity and Mortality Weekly Report (MMWR) 65, no. 1 (March 18, 2016): 1-49.
Conditions Treated Advanced Pain Management has more than 30 doctors in a variety of specialties dedicated to pinpointing the cause of your pain. We treat a number of painful conditions including: Back pain Herniated discs Carpal tunnel Hip pain Complex Regional Pain Syndrome (CRPS) Knee pain Diabetic neuropathic pain Fibromyalgia Neck pain Pelvic and abdominal pain Shingles (Postherpetic neuralgia) Shoulder pain Spinal stenosis Work and sports injuries Sacroiliac pain Headaches Sciatica Treatment Options Epidural steroid injections Lumbar sympathetic blocks Radiofrequency neuroablation Facet joint injections Medication management Sacroiliac joint injections Intradiscal electrothermal therapy Minimally invasive lumbar decompression (MILD) procedure Spinal cord stimulation Intrathecal pump implants Kyphoplasty Lumbar and cervical discograms Neurolytic blocks Percutaneous tenotomy Peripheral nerve blocks Stellate ganglion blocks Transcutaneous electrical nerve stimulation (TENS) Trigger point injections Vertebroplasty TO SCHEDULE AN APPOINTMENT PLEASE CALL: (888) 901-PAIN (7246) APMHEALTH.COM