The Role of Opioid Medication in Chronic Pain

ManagementLorraine Widdall, MS APRN BC

Interventional Spine and Pain Center

Effective December 15, 2013

Emergency rule that temporarily adds provisions under P.L. 185-2013 (SEA246) regarding physicians prescribing opioids for chronic pain.

Under Title 844 Medical Licensing Board of Indiana

Indiana Prescribing Guidelines

Patients with chronic pain. Chronic Pain is defined in this document

as: A state in which pain persists beyond the

usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years.

Included:

Patients with a terminal condition Residents of a healthcare facility Patients enrolled in a hospice program Patients enrolled in an inpatient or

outpatient palliative care program of a hospital

Excluded:

Patient has been prescribed:

1. More than 60 opioid containing pills a month; or

2. A morphine equivalent dose of more than 15 mg per day;

for more than 3 consecutive months

Guidelines apply when:

Evaluation and Risk stratification Education of the patient as to risks and

benefits of opioid therapy as well as expectations related to prescription requests and proper medication use

Continual monitoring and evaluation of therapy

DOCUMENTATION

Also included

Indiana legislature passed a law, in compliance with a federal mandate for states, requiring the Indiana Medical Licensing Board to develop an emergency opioid prescribing rule.

Proliferation of “pill mills” Prescription drug abuse has become a

bigger problem than all other illicit street drugs

Pain has been treated as “5th Vital Sign”

Why?

The US comprises 4% of the world’s population yet consumes 85% of the opioid medication.

CDC

Is there a problem?

Detox in Lake County Jail exploding from prescription drugs (10:1 RX to heroin)

Sheriff has established the High Intensity Drug Trafficking Task Force (Seized over $7M in RX drugs in 2013, already over that for 2014)

New trend: heroin cut with BZA Wellbutrin and Gabapentin snorted together

mimic heroin.

Lake County, IN

17th in US for RX drug deaths

Porter county #1 in IN for heroin deaths

In 2013, the OAG filed disciplinary complaints against 15 physicians for overprescribing pain medication; so far in 2014 they have already surpassed that number

Indiana

Procedures Physical therapy/Aquatic therapy Lifestyle changes NSAID Adjuvant medications Psychological counseling Alternative treatments

Opioid Free Treatment

Epidural Steroid Injections Joint injections Steroid/Hyaluronate (Synvisc or Hyalgan) Trigger Point Injections Scar Neuroma Injections Nerve Blocks (Chemical/Thermal) Chemodenervation (Botox)

Procedures

Aquatic Therapy

Land Based

Home exercise program

Physical Therapy

Weight loss Smoking Cessation Activity pacing Back to work (work

hardening/conditioning/restrictions) Exercise

Lifestyle Changes

OTC ibuprofen and naproxen Prescription Mobic, Celebrex, Motrin, Diclofenac Tylenol Topical preparations Pennsaid, Voltaren Gel, Flector patches

NSAID’s

Antidepressants: Nortriptyline, Amitriptyline, Effexor, Cymbalta, Savella

Antiseizures: Gabapentin, Lyrica, Topamax, Lamitcal, Tegretol, Gralise

Muscle Relaxants: Baclofen, Tizanadine, Flexeril, Zanaflex, Robaxin, Skelaxin, (Exclude Soma)

Sedative/Antianxiety: Valium, Xanax, Klonopin

Topical: Lidoderm

Adjuvant Medications

Evaluation is ALWAYS appropriate Treat underlying issues that are closely

related to pain such as depression and sexual abuse

Biofeedback Relaxation/meditation Imagery Music therapy

Psychological Counseling

Acupuncture Acupressure Massage Hypnosis

Alternative Treatments

Evaluation and risk stratification History and physical

Obtain and review records from other providers

Objective pain assessment tool

Risk for substance abuse tool (SOAPP)

Establish working diagnosis and tailor a treatment plan

Managing Opioid Therapy

Risks/benefits and expectations Discuss alternative modalities to opioids

Simple and clear explanation to help patient understand the key elements of their treatment plan

Discuss with females ages 14-55 with childbearing potential possible risks to the fetus

Managing Opioid Therapy

Review and sign a treatment agreement which shall include at least the following:

1. Goals of treatment 2. Consent to drug testing*****(delayed

until 1/1/15 due to ACLU lawsuit filed 1/8) 3. Physician prescribing policies which

must include (at least) that the medication be taken as prescribed and not shared with anyone else.

Managing Opioid Therapy

4. A requirement that the patient inform the physician about any other controlled substances prescribed or taken.

5. Permission for random pill counts 6. Reasons that the opioid therapy may be

discontinued or changed by the physician.*A copy of this agreement is to be retained in

the patient’s chart.

Periodic scheduled face to face visits Stable medication regime: at least every 4

months Changed medication regime: at least every 2

months During the visit, evaluate progress and

compliance and set clear expectations along the way (such as participation in physical therapy)

Managing Opioid Therapy

INSPECT At the outset of an opioid treatment plan

and at least annually thereafter. Document in chart the consistency with

physician’s knowledge of patient’s controlled substance history

Managing Opioid Therapy

Drug Testing At the outset of opioid treatment plan and at

least annually thereafter. Doesn’t specify serum, urine or saliva Must include confirmatory test results Inconsistencies or presence of illicits require

review of treatment plan. Documentation of revised plan and

discussion with patient must be recorded in chart.

Managing Opioid Therapy

When a patient’s opioid dose reaches a morphine equivalent of 60 mg/day:

Face to face review of treatment plan Consideration of referral to specialist If continuing therapy, there must be a

revised assessment and plan for therapy Documented assessment of increased risk

for adverse outcomes, including death.

Managing Opioid Therapy

Short acting: Tylenol with codeine, Tramadol, hydrocodone, oxycodone, hydromorphone, Nucynta

Long acting: MS Contin, Fentanyl, Opana, Oxycontin, (Zohydro)

Methadone Demerol Intrathecal opioid therapy

Appropriate Use of Opioids

THE HOLY TRINITY

Hydrocodone Muscle Relaxant (Soma) Benzodiazepine

Red flag for DEA

Appropriate Use of Opioids

PRN vs. Scheduled Treat flares and return to baseline It’s OK to say “no.” Be aware of trends and fads (Adderall) Stay informed and aware www.opiophile.org

Appropriate Use of Opioids

Lake County Drug Task Force 219-755-3822 www.deadiversion.udsoj.gov Scott Nowland (219) 681-7000 x128 www.cdc.gov www.bitterpill.IN.gov (Indiana AG office) www.supportprop.org (Physicians for

Responsible Opioid Prescribing)

Resources