Pain Management Where are we now? Nelson Aragon, Pharm.D. July 19, 2017 2016 Envolve. 1
Objectives Describe the prevalence, types, and typical treatment options for non cancer related pain Discuss recent concerns with opioid overutilization and the "opioid epidemic" in the United States Review the recent CDC guidelines and their application in the general practice setting Explore methods and techniques which may help in identifying patients with substance use disorder 2016 Envolve. 2
What is pain? An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. 2016 Envolve. Part III: Pain Terms, A Current List with Definitions and Notes on Usage" (pp 209 214) Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk, IASP Press, Seattle, 1994. 3
Prevalence of Pain 2012 NHIS/CDC study estimates 55.7 % of all Americans experienced pain within last 3 months. Representative of general practice patients 2016 Envolve. Nahin, RL. Estimates of Pain Prevalence and Severity in Adults: United States, 2012. The Journal of Pain. Vol 16, no 8. August 2015: 769 780 4
Prevalence of Pain (cont.) Condition Number of Sufferers Source Chronic Pain 100 million Americans Institute of Medicine of the National Academies Diabetes 25.8 million Americans American Diabetes Association Coronary Heart Disease 16.3 million Americans American Heart Association (heart attack/chest pain) Stroke 7 million Americans Cancer 11.9 million Americans American Cancer Society Pain a co complaint when patient s go in for other chronic conditions. 2016 Envolve. American Academy of Pain Medicine. AAPM Facts and Figures on Pain. 2017 5
Prevalence of Pain (cont.) Most common types of pain reported: Low back pain (LBP) Headache/migraine Neck pain Back pain leading cause of disability in adults < 45 Adults with LBP are likely already in worse physical/mental health 2016 Envolve. National Centers for Health Statistics, Chart book on Trends in the Health of Americans 2006, Special Feature: Pain. 6
Types of Pain Duration vs. Classification Duration Acute Typically comes on suddenly and has fairly obvious etiology Post op pain Broken bone Burns/Cuts Labor/Post partum pain Duration: 3 6 months Subsides after the initial injury is healed Considered part of the normal human experience 2016 Envolve. NIH. Pain Management: Acute and Chronic Accessed 1/26/2017 7
Types of Pain Duration vs. Classification Duration Chronic Continues past normal healing process Suggests some type of nerve damage/sensitization, but not always Osteoarthritis Cancer Fibromyalgia CRPS Duration: extends beyond normal healing period Usually coexists with depression, anxiety, selfcatastrophizing 2016 Envolve. NIH. Pain Management: Acute and Chronic Accessed 1/26/2017 8
Types of Pain Duration vs. Classification Classification Nociceptive Results from neural activity secondary to actual tissue damage or potentially tissue damaging stimuli Post op pain Low back pain Sports injuries Can be subdivided further Somatic described as deep, achy, difficult to pinpoint origin Visceral described as muscle pain, intense dullness Responds very well to traditional analgesics NSAIDs Opioids 2016 Envolve. Am J Manag Care. 2006;12:S256 S262 9
Types of Pain Duration vs. Classification Classification Neuropathic Typically categorized as: Burning Shooting Electrical like May be disproportionate to stimuli Peripheral (e.g. CRPS) or Centralized (Spinal Cord Injury Pain) Perhaps another name for chronic pain? Does not respond well to traditional analgesics NSAIDs Opioids 2016 Envolve. Am J Manag Care. 2006;12:S256 S262 10
Pain Assessment Tools Unfortunately, medical science has yet to develop a pain ometer to help us conclusively and objectively measure pain. 2016 Envolve. 11
Pain Assessment Tools Pain Questionnaires Short form McGill Oswestry low back disability Pain Scales Pain Diaries Pain Drawings 2016 Envolve. 12
Typical Pharmacological Treatment Options Anti inflammatory Agents ibuprofen naproxen diclofenac Opioids morphine oxycodone oxymorphone fentanyl hydromorphone Antidepressants TCA s SNRI s Anticonvulsants gabapentin pregabalin Topical Products NSAIDs lidocaine 2016 Envolve. 13
World Health Organization (WHO) Pain Ladder 2016 Envolve. World Health Organization. Strategies for Improving Quality of Life of Your Patients with Metastatic Breast Cancer. http://www.advanceweb.com/web/astrazeneca/metastatic_breast_cancer_issue3/metastatic_breast_cancer_issue3_strategies_for_improving_quality_ of_life.html 14
Opioid Timeline 1980 s mention of ME surfaces 1996 APS issues consensus statement regarding use of pain medications in non malignant pain Pain is the 5 th vital sign Purdue launches LA version of oxycodone OxyContin 2000 Congress proclaims decade commencing 1/1/2001 as Decade on Pain Control and Research 2007 Washington State releases preliminary guidelines (120 mg) 2016 Envolve. Brennan F. The US Congressional "Decade on Pain Control and Research" 2001 2011: A Review. J Pain Palliat Care Pharmacother. 2015 Sep;29(3):212 227 15
Opioid Timeline (cont.) 2011 IOM issues report titled, Moral Imperative to Treat Pain public health crisis of epidemic proportions 2012 US Senate recognizes there s a growing opioid abuse problem 2015 all states, except Missouri, have PDMPs 2016 AMA calls for removal of pain as 5 th vital sign 2016 Envolve. http://iom.edu/reports/2011/relieving Pain in America A Blueprint for TransformingPrevention Care Education Research.aspx 16
Opioid Timeline (cont.) May 2017 State of Ohio sues five opioid manufacturers Purdue, Endo, Teva (Cephalon), J&J (Janssen), Allergan June 2017 FDA calls for voluntary withdrawal of Opana ER July 2017 Endo agrees to pull Opana ER 2016 Envolve. 17
Opioid Consumption in the United States US (4.6% of global pop.) consumes 81% of global oxycodone supply > 259 million opioid rxs written in US in 2012 4.3 million adol/adults reported non medical use (2014) Leads to questions regarding how much opioid is too much? 2016 Envolve. http://www.painpolicy.wisc.edu/sites/www.painpolicy.wisc.edu/files/country_files/morphine_equivalence/unitedstatesofamerica_me_methadone.pdf 18
Morphine Equivalent Doses (MED) What s considered a high dose? APS: 200 mg CDC: > 90 mg (50 mg ideal) NEJM (2016): >180 mg? 2016 Envolve. 19
Morphine Equivalent Doses (MED) State Medicaid Dose limits FFY 2015 (reported December 2016): Colorado 300 mg Delaware/Idaho/Michigan/Oregon/Minnesota 120 mg Kansas 200 mg MA 240 mg Maine 30 mg North Carolina 750 mg! North Dakota 90 mg Wyoming 180 mg 2016 Envolve. Medicaid Drug Utilization Review State Comparison/Summary Report FFY 2015 Annual Report. CMS 2016 20
What does all this mean? 2016 Envolve. National Survey on Drug Use and Health (NSDUH), 2014. 21
CDC Guidelines CDC develops opioid guidelines for primary care clinicians treating adults with chronic, non cancer pain. Aims to provide national standard in a sea of guidelines with inconsistent recommendations. 2016 Envolve. 22
CDC Opioid Guidelines Opioids are not 1 st line therapy Evaluate benefit/harm frequently Establish goals for pain/function Mitigate risk Discuss risks/benefits Review PDMP data Use SA opioids before LA opioids Urine Drug Testing Use lowest effective dose Avoid opioid + benzos Short term use for acute pain Offer treatment for opioid use disorder 2016 Envolve. Dowell, D et al. CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. Centers for Disease Control & Prevention. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm 23
CDC Opioid Guidelines CDC recommends non pharmacologic and nonopioid pharmacologic therapy as the preferred methods to treat chronic pain Physical Therapy Exercise Cognitive Behavioral 2016 Envolve. 24
CDC Opioid Guidelines Three main principles to remember: Non opioid therapy is preferred for chronic pain outside of active cancer, palliative, and end of life care Use lowest opioid dose whenever possible IF opioids are necessary Exercise caution and monitor ALL patients closely 2016 Envolve. Dowell, D et al. CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. Centers for Disease Control & Prevention. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm 25
At the end of the day. Maybe we ve been asking the wrong question all along Maybe the wrong question is: How much higher of a dose can I give? Maybe the right question is: Are opioids the right option for my patient? 2016 Envolve. 26
Signs that your patient may be misusing opioids Use of multiple prescribers/pharmacies Inconsistent urine drug tests Always seem to lose their medications Higher risk when combined with benzos and other CNS depressants (e.g. carisoprodol) 2016 Envolve. 27
Vigilance is the key Use pain contracts/agreements Prescribe smaller quantities of opioids See patients more frequently Encourage use of a single pharmacy or chain Random pill counts Random urine drug screens Remember that opioids are not the only option for treating pain! 2016 Envolve. 28
Urine Drug Testing Use as part of a multi approach method to mitigate risk Be leery of office based dip sticks Pill scraping/shaving When in doubt, send for IA confirmation Don t schedule testing keep it random Know what should and shouldn t be present 2016 Envolve. 29
Urine Drug Testing (cont.) Deception is possible Urine dilution: check the specific gravity, ph, creatinine Urine substitution: do observed sampling Adulterated sample: know what should be present Use resources from your contracted laboratory 2016 Envolve. 30
Urine Drug Testing (cont.) 2016 Envolve. Reisfield, GM et al. Rational Use and Interpretation of Urine Drug Testing in Chronic Opioid Therapy. Annals of Clinical & Laboratory Science. 2007;37(4): 301 314 31
2016 Envolve. Ameritox Rx Guardian Sample Report 32
Pain Contracts/Agreements Many versions out there. Find one that works for your practice Make it specific! Takes the burden off of me and shifts it to we Our clinical policy in this practice is https://www.drugabuse.gov/sites/default/files/files/sam plepatientagreementforms.pdf 2016 Envolve. 33
Resources CDC Opioid Guidelines https://www.cdc.gov/drugoverdose/prescribing/guideline.html National Institute on Drug Abuse https://www.drugabuse.gov/nidamed medical health professionals/toolresources your practice/opioid prescribing resources PainEDU.org https://www.painedu.org/tools.asp?utm_source=painedu+newsletter+1%2f14%2 F2015&utm_campaign=PainEDUnewsletterVol131No2&utm_medium=email Medication Assisted Treatment (MAT) http://store.samhsa.gov/shin/content/sma09 4443/SMA09 4443.pdf 2016 Envolve. 34