Approaches to Responsible Opioid Prescribing The Opioid Naïve Patient
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Learning Objectives After attending this program, participants will be able to: Apply the 2017 Canadian Opioid Guidelines with respect to starting opioids in patients who have chronic non-cancer pain (CNCP) Use Strategies to monitor appropriateness of opioid therapy in patients with with CNCP
Question Once you start a patient on opioids A) They must take them forever or as long as they have pain B) Doses seem to increase over time C) Stopping opioids can be difficult due to severe withdrawal symptoms or other unexpected problems D) It can be hard to tell if you have created a patient with an addiction to the opioid Do you feel trapped when you start opioids?
INTRODUCING: RENEE Copyright: fotosmurf / 123RF Stock Photo
Patient Profile: Renee Female aged 55 years Bilateral knee pain with moderate osteoarthritic changes Orthopedic review conservative therapy Not a Surgical Candidate Obesity; onset 6 years ago after her daughter s suicide Current BMI 31 kg/m 2 Chronic anxiety and mild to moderate depression On disability for 1 year following a difficult cholecystectomy complicated by several episodes of Clostridium difficile BMI, body mass index.
Seeing a bariatric surgeon Current Treatments: Renee With an appropriate weight loss strategy, has lost 30 pounds in the last 6 months Escitalopram 30 mg once daily Clonazepam 1mg twice daily for anxiety Zopiclone 7.5mg at bedtime for insomnia Lyrica 75 mg BID Acetaminophen 1000 mg TID prn Has tried physiotherapy, chiropractic therapy, topical compound medication, CBT and mindfulness meditation Has had both cortisone and orthovisc injections No help with topical Pennsaid or Voltaren Gel
Renee s Visit Today She makes an appointment to see you because her function and enjoyment of life are deteriorating because of her bilateral knee pain.
Renee Average pain score is 8/10, increasing to 10/10 with prolonged walking, generally proportional to activity Brief Pain Inventory score: 55/70 indicating severe interference with daily life activities Mood: PHQ-9 score is 9 (mild depression), GAD-7 score is 15 (moderate anxiety) Sleep apnea screening: initial insomnia (anxious thoughts) and severe sleep apnea GAD-7, Generalized Anxiety Disorder 7-item scale. PHQ-9, Patient Health Questionnaire 9-item scale. TSH, thyroid-stimulating hormone. UDT, urine drug test.
Renee Physical examination: Both knees stable, no significant bony enlargement Pain-free hip range of motion Evidence of muscle tenderness with trigger points in vastus medialis and vastus lateralis Quadriceps weakness Patellofemoral pain with patellar compression and quads activation No abnormal sensitivity to light touch Radiographs: findings consistent with mild to moderate osteoarthritis no recent change
The Pain Management Challenge Benefit Risk
Opioid Trial Assuming you believe she might benefit from an Opioid Trial, How would you go about prescribing opioids for her? What would your medical record contain?
Prescribing Opioid for Opioid Naïve Patients AN OPIOID RX
Optimal Approach to Initiating Opioids for Chronic Non-Cancer Pain AN OPIOID RX Assessment biopsychosocial Non-opioid treatments Opioid risks vs. benefits Psychological assessment Informed consent (signed agreement) Order Urine Drug Testing (and other labs as required) Individualize opioid titration 50 mg and 90 mg MED Document outcomes of treatment Reassess and monitor regularly. exit strategy if goals not met or problematic behaviours
Assessment biopsychosocial Do a comprehensive assessment to ensure opioids are a reasonable choice and to identify risk/benefit balance for the patient Document results of history, physical exam and results of relevant investigations Formulate Differential and Working Diagnosis Document Pain Diagnosis (e.g. predominantly nociceptive or neuropathic) Assess Home Environment (e.g. co-inhabitants risk of misuse of Opioids) /. Involve family and/or caregiver in management (e.g. obtain consent from patients to communicate with family)
Non-Opioid treatments Maximize and Continue with Non-pharmacological therapies, including patient self-management and life style management (weight loss, exercise, nutrition, sleep hygiene) Non-Opioid analgesics and/or adjuvants, as appropriate Review Patient co-morbidities (e.g. renal function, /. cardiovascular risk, ) Concomitant medications with respect to potential drug interactions
Opioid risks vs. benefits Inform patient of their role in safe use and monitoring effectiveness Set Goals of Treatment (Improved Functions) and Realistic Expectations (e.g. 30 % decrease in pain scores) Inform patient of potential Nausea, constipation, drowsiness, dizziness, itching Adverse Effect on driving and operating machinery Medical complications such as sexual dysfunction, sleep apnea, opioid-induced hyperalgesia, and hormonal effects Overdose, diversion, addiction, withdrawal Potentiation of harm with alcohol.
Psychological assessment Consider a tool to diagnosis and monitor mental disorders (e.g. PHQ- 9 for depression) Assess both any past and present mental disorders Treat any present mental disorders before initiating Opioids Assess Suicide and/or Accidental overdose risk based on any mental disorders Taper or avoid benzodiazepines if Opioids are to be initiated Assess Sleep and Environmental Stressors (e.g. work environment)
Informed consent (signed agreement) Obtain Informed Consent about the prescribing of Opioids Discuss and have patient review/sign an Opioid Treatment Agreement Be explicit about characterizing opioid prescribing as a trial and that opioid therapy will be be discontinued if it is not effective or benefits are outweighed by harms
Order Urine Drug Testing (and other labs as required) Consider using urine drug screening (UDS) To set a baseline measure of substance use that may help assess risk for addiction For ongoing monitoring of the patient s compliance with Opioids prescribed Point of care testing, normal lab urine drug testing and gas chromatography can all be useful depending on the clinical situation
Individualize Opioid titration Initiate with a low dose; increase gradually; monitor Opioid effectiveness and recognize optimal dose. Watch for any emerging risks/complications to prevent unwanted outcomes including misuse and addiction Track daily dose in morphine equivalents (MED) per day Consult a colleague if daily morphine equivalent dose exceeds 90 mg Consider Immediate Release vs. Controlled Release Consider Abuse- Deterrent Formulation vs. Non Abuse-Deterrent Oral vs. Transdermal (Fentanyl must not be used in Opioid Naïve Patients)
Document outcomes of treatment Analgesic Effect and Score Adverse Effects Discussed and attempts to manage Affect (mood and cognitive function) Aberrant Behaviour (lost Rx s, requests for early refills) Activities of Daily Living (Effect of Treatment)
Reassess and monitor regularly Function and Pain Scores ( e.g. Brief Pain Inventory) Employment Recreational Activities Interpersonal Relationships Overall Quality of Life Any evidence of abuse, misuse or diversion
Exit Strategy A trial of opioid therapy implies an exit strategy is understood from the beginning Opioid Treatment Agreement indicates common reasons for either reduction of opioid dose (tapering to lower dose) or stopping opioids (tapering to Zero) o Misuse, Abuse or Diversion of Opioids o Opioid Tolerance o Opioid Induced Hyperalgesia o Development of Co-Morbid Medical Conditions (sleep apnea, endocrine issues) o Adverse Effects (constipation, other GI issues, cognitive issues,
Renee Options/Summary Start on low dose IR Opioid or Start on low dose CR Opioid Function and Adverse Effects Monitored Signs of misuse or abuse Monitored Other non-opioid Treatments continued