Judith Martin, MD Medical Director, Substance Abuse Services, San Francisco DPH

Transcription

1 Western Occupational & Environmental Medical Association CME Webinar April 17, 2013 Judith Martin, MD Medical Director, Substance Abuse Services, San Francisco DPH PLEASE STAND BY - WEBINAR WILL BEGIN AT 12:00 PM PST FOR AUDIO: CALL /ACCESS CODE: #

2 No financial conflict of interest May discuss off-label use of buprenorphine.

3 Some statistics about opioids. Adjustments in clinical practice to reduce risk. Opioid addiction during chronic pain treatment; detecting and addressing concerning signs. Opioid agonist treatment for addiction: buprenorphine and methadone maintenance Some possible approaches integrating care for opioid-addicted patients who have pain.

4 47 year old woman with hip dysplasia has been your patient for a year, on chronic opioids for pain. At her regular visit she tells you she had to go to another physician for additional opioids because she ran out early, and could not wait for her refill. She shows you an empty bottle from another physician labeled oycodone. Her on-site toxicology test today is favorable.

5 This behavior indicates: A. addiction to opiates B. concerning behavior, but not addiction C. likely diversion of her prescribed medication D. lack of response to opioids

6 (NSDUH, 2002)

7 NSDUH,

8 NSDUH, 2010

9 Rates of prescription painkiller sales, deaths and substance abuse treatment admissions ( ) 9 ://wwhttpw.cdc.gov/vitalsigns/painkilleroverdoses/

10 Use of treatment agreements for everyone on chronic opioids for pain Screening for risk before starting opioids Addressing red and yellow flag behaviors Use of toxicology tests on everyone Team care approach, with psychoeducational approach to pain management Dose limits, hard or soft Routine check of PDMPs (prescription drug monitoring programs, statewide registries of opioid prescriptions)

11 Single prescriber and pharmacy Informed consent: who does well, who doesn t, addiction and overdose as part of informed consent. How to refill medication Monitoring: urine test, pill count, pain scale, function or disability index Higher level of care if not improving: psychosocial care, PT, addiction treatment, etc. Discontinuation plan.

12 Predict aberrant medication taking behaviors Examples: Screener and Opioid Assessment for Patients with Pain, Opioid Risk Tool, Pain Medication Questionnaire No gold standard Lack rigorous testing Require high literacy Webster et al. Pain Med Butler et al. J Pain. 2008; Adams et al. J Pain Symptom Manage, 2004

13 What is the Addiction Risk? Published rates of abuse and/or addiction in chronic pain populations are 3-19% Known risk factors for addiction to any substance are good predictors for problematic prescription opioid use Past cocaine use, h/o alcohol or cannabis use 1 Lifetime history of substance use disorder 2 Family history of substance abuse, a history of legal problems and drug and alcohol abuse 3 Tobacco dependence 4 History of severe depression or anxiety 4 1 Ives T et al. BMC Health Services Research Reid MC et al JGIM Michna E el al. JPSM Akbik H et al. JPSM 2006

14 Evaluate for relative risk for developing problems (e.g. aberrant medication taking behaviors) 86% sensitive, 67% specific 0=Never, 1=Seldom, 2=Sometimes, 3=Often, 4=Very often 1. How often do you have mood swings? 2. How often do you smoke a cigarette within an hour after you wake up? 3. How often have you taken medication other than the way it was prescribed? 4. How often have you used illegal drugs (for example, marijuana, cocaine, etc) in the past 5 years? 5. How often, in your lifetime, have you had legal problems or been arrested? > 4 is POSITIVE < 4 is NEGATIVE 2008 Inflexxion, Inc.

15 How concerning is behavior or agreement break? Is it addiction? Is it hyperalgesia? Does it mean opioids are not working?

16 Yellow Flags Complaints about need for more medication Drug hoarding Requesting specific pain medications Openly acquiring similar medications from other providers Occasional unsanctioned dose escalation Nonadherence to other recommendations for pain therapy Passik SD Mayo Clin Proc 2009

17 Red Flags Deterioration in functioning at work or socially Illegal activities-selling, forging, buying from nonmedical sources Injection or snorting medication Multiple episodes of lost or stolen scripts Resistance to change therapy despite adverse effects Refusal to comply with random drug screens Concurrent abuse of alcohol of illicit drugs Use of multiple physicians and pharmacies Passik SD Mayo Clin Proc 2009

18 Urine test is most common On-site dipstick very useful, timely Test positive for prescribed substances (marker for diversion) Test negative for illicit and non-prescribed substances Favorable or unfavorable, negative or positive Send unfavorable for confirmation if unclear.

19 Think of tox screen as a lab test Don t test if you can t help the patient Discuss in person (physician or nurse) Get patient s perspective Discuss effects of unfavorable tested substances on health (give information) Adjust patient-prescriber agreement Be prepared to set a hard limit if unsafe.

20 Say what you know: there is cocaine in your urine (not you used cocaine ) Ask for patient input: what does this mean to you? What do you know about effects of cocaine? Give information: let s talk about effects of cocaine on you and your body Discuss need for favorable urine tests: We need negative urine from you, without cocaine or other substances, to proceed with your prescription, lay out next steps.

21 Refer for psychosocial counseling Taper off opiates because of agreement break Make a new, enhanced agreement (pill counts, random testing, shorter prescription) Ask patient if they think they can give a negative test next time. If not, offer addiction referral. Other

22 Synergistic sedation and respiratory depression confer special risk with opioids. Benzodiazepines often present at opioid overdose events.

23 Larger amount and for longer period than intended Persistent desire or repeated unsuccessful attempt to quit Much time/activity to obtain, use, recover Important social, occupational, or recreational activities given up or reduced Use continues despite knowledge of adverse consequences (e.g., failure to fulfill role obligation, use when physically hazardous) 23

24 Hoffman BM, Papas RK, Chatkoff DK, et al. Meta-analysis of psychological interventions for chronic low back pain. Health Psychol 2007;26:1 9. Meta-analysis of 22 controlled studies: Positive effects of psychological interventions, contrasted with various control groups, were noted for pain intensity, painrelated interference, health-related quality of life, and depression.

25 Cognitive-behavioral and self-regulatory treatments were specifically found to be efficacious. Multidisciplinary approaches that included a psychological component, when compared with active control conditions, were also noted to have positive short-term effects on pain interference and positive long-term effects on return to work. (quoted from abstract)

26 Odds Ratio Do Anxiety, Depression, or Sleep Problems Predict the Development of Pain? Odds Ratio Odds Ratio score 0-4 score 5-7 score 8-21 Anxiety (HAD Anxiety sub-score) score 0-3 score 4-8 score 9-20 Sleep (Sleep Problem Scale) score 0-2 score 3-5 score 6-20 Depression (HAD Depression subscore) 15 month prospective study, 3171 followed, 324 developed chronic widespread pain Gupta A, et al. Rheumatology. 2007;46:

27 Morasco et al: Association between Substance Use Disorder Status and Pain- Related Function Following 12 Months of Treatment in Primary Care Patients with Musculoskeletal Pain. J Pain March ; 12(3): Prospective, randomized study showed patients with SUD benefit from collaborative care

28 patients randomized to collaborative care had significant improvements in pain-related function, pain intensity, and depression relative to those assigned to treatment as usual.

29 Several studies show increased risk of overdose associated with higher morphine equivalents. (cause-effect harder to find) Does this mean we should have a dose cap, or does it mark a sub-group of patients with more complex condition? Some pilots of dose-triggered reviews: Franklin, et al: Bending the prescription opioid dosing and mortality curves: impact of the Washington State opioid dosing guideline. Am J Ind Med Apr;55(4):

30 (CDC)

31 Office-based treatment with sublingual buprenorphine under DATA Clinic-based treatment with methadone maintenance at specially licensed facilities. How to coordinate pain and addiction treatment when patients need opioid agonist treatment for addiction.

32 Signed by President Clinton October 2000 Enables prescription of sublingual buprenorphine for treatment of addiction with certain restrictions: 32

33 Physician training requirement Notification requirement, obtain new DEA number ( X-number ) Medication use restricted to schedule 3 and above, and FDA labeled for addiction (sublingual buprenorphine only qualifies) Patient census: 30 first year, 100 thereafter 33

34 Sublingual buprenorphine prescribed for pain is off label. Anything other than sublingual buprenorphine is illegal if prescribed for addiction. (must meet the restrictions of DATA 2000)

35 Daitch, et al: Conversion of Chronic Pain Patients from Full-Opioid Agonists to Sublingual Buprenorphine. Pain Physician: Opioid Special Issue July 2012; 15:ES59-ES66, Retrospective review of 104 cases, looking at pain outcomes in patients who were transferred to buprenorphine, showed significant reduction in pain scale.

36 Usually done when patient is discharged due to concerning behaviors. Difficult to evaluate tolerance at transfer MMT first dose may be too low May take time to earn takehome for patients who need more than one dose daily. Structure and requirements may work well for some patients: daily nurse observation of dose, testing, counseling, etc.

37 Need 42-CFR-compliant consent to coordinate and communicate. Methadone dosing window might be a resource for closer monitoring. Drug counselor can be a pain coach, addressing psychosocial interventions to reduce pain. Ability to coordinate care varies widely by community.

38 47 year old woman with hip dysplasia has been your patient for a year, on chronic opioids for pain. At her regular visit she tells you she had to go to another physician for additional opioids because she ran out early, and could not wait for her refill. She shows you an empty bottle from another physician labeled oycodone. Her on-site toxicology test today is favorable.

39 This behavior indicates: A. addiction to opiates B. concerning behavior, but not addiction C. likely diversion of her prescribed medication D. lack of response to opioids

40 Chronic opioid use for pain has a significant pain/addiction overlap Certain patients are at higher risk Many clinicians have adopted risk reduction strategies, often tied to a patient-prescriber agreement and monitoring. Addictive behaviors can be addressed with integrating psychosocial interventions, and with proper use of opioid agonist treatments for opioid dependence.

41 Thank you for par-cipa-ng in today s webinar. At the conclusion of this call you will receive an with a link to a post- webinar ques-onnaire. You will need to complete this ques-onnaire in order to receive CME for this webinar. This webinar presenta-on can be downloaded at