Opioids:Maximizing Patient Safety

Alberto Rivera Sanchez MDDiplomate of the American Board of Pain Medicine

Fellow of the American Academy of PM&RDiplomate of the American Board of Disability Analysts

DisclosureNo drug or medical device company has a

financial interest in this lecture. “I wish they did, but they don’t.”

CDC: Injury and Prevention Control: Prescription drug overdose. April 2015

16,235 deaths related to opioid use in 2013300% increase in opioid sales

Evidence Based Medicine for Opioids “Are they backed up by evidence?”

Furlan et al 2006:Meta analysis of 41 RCT’sOpioids are more effective than placebo for pain and

functional outcomes for nociceptive pain, neuropathic pain and fibromyalgia

No study was longer than 3 monthsMost were sponsored by drug companies

Cochrane Review 2010The authors concluded that the evidence supporting

opioids for chronic pain was weak

Screening for Opioid Use“There is a method to our madness”

Like in marriage subject selection is the keySelect the patient after thorough history and

physical

Risk of OpioidsShort Term:

Nausea Vomiting Constipation Drowsiness Respiratory depression

Long Term: Tolerance Dependence Addiction Hyperalgesia Hormonal imbalances Hypogonadism OP, Depression, Cognitive

Impairment

How to maximize safetyAssess non opioid Tx:

Delay opioid Tx Adequate W/U Trials of non-opioid

Manchikanti. Pain physician 2012

Opioid Risk Tool It is recommended that these

tools are used Limited evidence in predicting

addiction risk

J. Pain 2006Pain physician 2012

History and PE

UDT Urine drug testingMust be random1st do immunoassayTest for opioids, BDZ’s,

Barb’s, Cocaine, Amphetamines, and THC

Confirm with gas chromatography

Opioid agreements should talk aboutMedication and drug

prescribedGoals of therapyPotential adverse effectsRisk of addictionProvider may D/C

opioids if risk outweigh benefit

Someone stole my prescription

2 attempts with law enforcement report

PM&R Journal 2015

What opioid to use??? No opioid has proven to

be a superior option when starting opioid therapy

Most common 1st step: Hydrocodone Oxycodone Morphine

Kirpalani 2015

Tramadol MOR like effects Serotonin/NE like reuptake

inhibitor

Some guidelines: Most guidelines start short

acting at low doses Then convert to long acting

for higher doses Long acting and short acting

have similar efficacy

Manchikanti 2012, Chou 2009, VA 2010

According to the DEASchedule 2:Must be hand writtenSecure prescription

paperTamper proof

Schedule 3-5:May be submitted orally,

in writing or faxDEA has permitted e-

scripts but for Schedule 2 a written copy is still needed

Kirpalani 2015

Monitoring effectiveness of opioid Tx “Keep your enemies

closer”

• Monitor high risk patients closely

• Frequency of visits is not clearly defined (Chou 2009)

• 5 A’s of monitoring:• Analgesia• Adverse Effects• ADL’s• Aberrant behaviors• Affect

Aberrant Behaviors (PM&R 2015):

Self dose escalationFrequent visits for medication refillsPain medication form multiple providerAlcohol or illicit drug abuseUnexpected + or – resultsLost or stolen prescriptionsEvidence of diversion

Inheriting a patient

• Use the 5 A’s• Do risks outweigh the benefits?• Evaluate for aberrant behaviors• Unstable psychological disease?• If you do not agree, do “Tapering”

Tapering Off OpioidsHigh dose patients (>200MED morphine) may tolerate

taper rates until reaching 100 MED At 100 MED or less they will start having greater

symptoms of side effectsMost guidelines recommend a slow taper of 10% per

weekFast taper is 20-50% every few days

Manchikanti 2012

Kirpalani 2015

Withdrawal Symptom Treatment Clonidine .1-.2mg BID or .1 to .2mg patch/24hr Loperamide TCA’s (amitriptyline, nortriptilyne) for irritability, sleep

disturbance and neuropathic pain Gabapentin for neuropathic pain W/D symptoms may last up to 6 months

Manchikanti 2012

California Guidelines for Prescribing Controlled Substances for Pain Nov 2014

Washington Dc VA 2010

Conclusion for safe opioid prescribing Proper screening History and PE Addiction risk Psych Eval. UDT PDMP Have functional goals Measure risks Consider addiction medicine referral