Opioid Prescribing For Opioid Prescribing For Chronic Pain: Chronic Pain: The Case For Universal The Case For Universal Precauations & The Role of Precauations & The Role of Urine Toxicologic Testing Urine Toxicologic Testing Paul R. Chelminski, MD, MPH, Paul R. Chelminski, MD, MPH, FACP FACP Associate Professor of Associate Professor of Medicine Medicine Associate Residency Program Associate Residency Program Director Director
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Opioid Prescribing For Chronic Pain: The Case For Universal Precauations & The Role of Urine Toxicologic Testing Paul R. Chelminski, MD, MPH, FACP Associate.
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Opioid Prescribing For Opioid Prescribing For Chronic Pain:Chronic Pain:
The Case For Universal The Case For Universal Precauations & The Role of Precauations & The Role of Urine Toxicologic TestingUrine Toxicologic Testing
Paul R. Chelminski, MD, MPH, FACPPaul R. Chelminski, MD, MPH, FACPAssociate Professor of MedicineAssociate Professor of MedicineAssociate Residency Program Associate Residency Program DirectorDirectorUniversity of North Carolina at University of North Carolina at Chapel HIllChapel HIll
ObjectivesObjectives
Provide the epidemiologic & clinical Provide the epidemiologic & clinical context for rigorous substance context for rigorous substance misuse monitoring (i.e. universal misuse monitoring (i.e. universal precautions)precautions)
Briefly discuss the elements of Briefly discuss the elements of universal precautionsuniversal precautions
Focus on UTS testing as component Focus on UTS testing as component of universal precautionsof universal precautions
Chronic Pain ManagementChronic Pain Management
ObjectivesObjectives1.1. Decrease painDecrease pain2.2. Improve functional statusImprove functional status3.3. Identify & treat depressionIdentify & treat depression4.4. MONITOR FOR MONITOR FOR
Society of General Internal Society of General Internal Medicine, 2006 Annual Medicine, 2006 Annual MeetingMeeting
Chronic Pain Workshop, Part 2:Chronic Pain Workshop, Part 2:
The Dilemma Between The Dilemma Between Treating Pain and Treating Pain and Endangering Public Endangering Public HealthHealth
In our nation’s war on In our nation’s war on drugs, unscrupulous drugs, unscrupulous doctors who traffic in doctors who traffic in narcotics are prosecuted narcotics are prosecuted by the U.S. Attorney and by the U.S. Attorney and the federal Drug the federal Drug Enforcement Enforcement Administration.Administration.
These are their stories.
LAW & ORDERINTENT TO DISTRIBUTE
LAW & ORDERINTENT TO DISTRIBUTE
U.S. ATTORNEY
Paul Chelminski
LAW & ORDERINTENT TO DISTRIBUTE
Assistant U.S. ATTORNEY
Mark Pletcher
LAW & ORDERINTENT TO DISTRIBUTE
Medical EXPERT Dr. Edna Sorlot
Heidi Coplin
LAW & ORDERINTENT TO DISTRIBUTE
Defense COUNSEL
Matthew Bair
Also Starring:
LAW & ORDERINTENT TO DISTRIBUTE
Ian Chen as Dr. Ignatz Dolophin DEFENDANT
With:
LAW & ORDERINTENT TO DISTRIBUTE
Peter Friedmann as Reginald T. Pillholdyr
PHARMACIST
LAW & ORDERINTENT TO DISTRIBUTE
Dan Alford as Dr. M.D. Discipline, Member STATE MEDICAL BOARD
LAW & ORDERINTENT TO DISTRIBUTE
Stacey Mollis as the JUDGE and NARRATOR
And Introducing:
LAW & ORDERINTENT TO DISTRIBUTE
Producers
Paul Chelminski Michael Picchioni
LAW & ORDERINTENT TO DISTRIBUTE
Written By
Stefan KerteszMina Madani
LAW & ORDERINTENT TO DISTRIBUTE
Executive Producer Dick Wolf
LAW & ORDERINTENT TO DISTRIBUTE
The Patient, Mr. IgotnotoeThe Patient, Mr. Igotnotoe Multiple toe amputations, PVD, NeuropathyMultiple toe amputations, PVD, Neuropathy History of alcohol misuseHistory of alcohol misuse
– Currently in Alcoholics AnonymousCurrently in Alcoholics Anonymous Discharged from surgeon’s care after amputationDischarged from surgeon’s care after amputation Signed contract with Dr. Dolophin to receive pain Signed contract with Dr. Dolophin to receive pain
medsmeds– 50 mg of methadone 3x/day, 3 Lortab/day for 50 mg of methadone 3x/day, 3 Lortab/day for
breakthrough painbreakthrough pain Functional improvement - got a jobFunctional improvement - got a job Occasionally tried to fill Rx early /ran out of meds Occasionally tried to fill Rx early /ran out of meds
earlyearly Pt gave some pills to nephew for root canal painPt gave some pills to nephew for root canal pain
– Teenage nephew combined pills with alcohol and caused Teenage nephew combined pills with alcohol and caused the death of an elderly woman while drivingthe death of an elderly woman while driving
Small time drug dealer with bottle of patient’s Small time drug dealer with bottle of patient’s Lortab prescribed by Dr. DolophinLortab prescribed by Dr. Dolophin
U.S. DISTRICT COURTPart 13
Monday April 26
Opening Statement of the Federal Prosecutor
The ChargesThe Charges Over 86 felony countsOver 86 felony counts
– Drug traffickingDrug trafficking– Illegal distribution of Schedule II narcoticsIllegal distribution of Schedule II narcotics– Prescription of medicine without a legitimate Prescription of medicine without a legitimate
medical purposemedical purpose– ConspiracyConspiracy– Health care fraud by billing Medicaid for his Health care fraud by billing Medicaid for his
illegal activities illegal activities – Mail fraud by use of the postal service for Mail fraud by use of the postal service for
billingbilling– Repeated money laundering by depositing his Repeated money laundering by depositing his
ill-gotten gains into a U.S. bankill-gotten gains into a U.S. bank– ManslaughterManslaughter
CHRONIC PAIN
MENTAL ILLNESS
SUBSTANCE MISUSE
PRESCRIPTIONSUBSTANCE MISUSE
Substance Abuse Disorders•Addiction•Dependence
Non-Medical Misuse•Diversion for profit•Barter for drug of choice
Street Value of Street Value of Controlled SubstancesControlled Substances
Drug Value
Oxycontin $3-4/mg (40mg tab=$160)
Oxycodone/APAP $15/tab
Hydrocodone/APAP $6-12/tab
Codeine/APAP $2-4/tab
Propoxyphene/APAP $2-20/tab
Hyrdomorphone $15/mg
Morphine $1/mg
Methadone $1-2/mg
Alprazolam $3-4/tab
Prescription Opioids & Prescription Opioids & Misuse: The Evolution of Misuse: The Evolution of an Epidemican Epidemic
1990’s: Opioids endorsed as appropriate for 1990’s: Opioids endorsed as appropriate for chronic painchronic pain
Per capita Rx of methadone, hydrocodone, Per capita Rx of methadone, hydrocodone, oxycodone increase 13X, 4X, 9X (1997-2007)oxycodone increase 13X, 4X, 9X (1997-2007)
Non-medical use increases dramaticallyNon-medical use increases dramatically ER visits increaseER visits increase Unintentional drug OD’s increase 68% (1999-Unintentional drug OD’s increase 68% (1999-
2004)2004) Prescription opioid overdose deaths greater than Prescription opioid overdose deaths greater than
heroin and cocaine combinedheroin and cocaine combined West Virginia has most dramatic rise: 550% & West Virginia has most dramatic rise: 550% &
one of highest per capita death ratesone of highest per capita death rates
Physicians & Public Health Physicians & Public Health Responsibility:Responsibility:Minimizing Collateral Minimizing Collateral DamageDamage Traditional: Infectious disease reporting (e.g.TB, Traditional: Infectious disease reporting (e.g.TB,
syphilis, hepatitis A)syphilis, hepatitis A)– Not commonly criminalNot commonly criminal– Not inherently adversarialNot inherently adversarial– Statutory requirement for reportingStatutory requirement for reporting
Substance Misuse/DiversionSubstance Misuse/Diversion– Potentially adversarialPotentially adversarial– Empathy replaced by mistrust with therapeutic intent of Empathy replaced by mistrust with therapeutic intent of
physician subvertedphysician subverted– Criminal implicationsCriminal implications– No statutory requirement for reportingNo statutory requirement for reporting
Opioids, warfarin, insulin:Opioids, warfarin, insulin: Considered top 3 “high alert Considered top 3 “high alert medications” Only opioids mandate public health in addition medications” Only opioids mandate public health in addition to clinical vigilance to prevent harm to third partiesto clinical vigilance to prevent harm to third parties
The Specter of The Specter of RegulationRegulation
Can You Identify a Drug Can You Identify a Drug Abuser?Abuser?
Appearance Appearance
RealityReality
Chronic Pain & Chronic Pain & Substance Abuse Substance Abuse DisordersDisorders 23% of 414 patients hospitalized with chronic pain 23% of 414 patients hospitalized with chronic pain (Int J (Int J
Addictions 1995; 30: 919-927)Addictions 1995; 30: 919-927) 60 to 70% of patients with depression; >50% anxiety.60 to 70% of patients with depression; >50% anxiety. Comorbid psychiatric conditions predict substance misuse Comorbid psychiatric conditions predict substance misuse
disorders and negative outcomes disorders and negative outcomes [Am J Psychiatry 2003; 160:5][Am J Psychiatry 2003; 160:5]
Substance and alcohol dependence and psychiatric Substance and alcohol dependence and psychiatric disease (JAMA 1990;264:2511-18)disease (JAMA 1990;264:2511-18)
– Substance misuse behaviors common in Yale University Substance misuse behaviors common in Yale University study of VA and resident clinics (24% and 31% of study of VA and resident clinics (24% and 31% of patients receiving opioids) (JGIM 2002;17:173-179)patients receiving opioids) (JGIM 2002;17:173-179)
– 32% in work by Ives, Chelminski, et al in primary care 32% in work by Ives, Chelminski, et al in primary care setting.setting.
– 23% over 6 years [Chelminski and Ives]23% over 6 years [Chelminski and Ives]
Dilemma 1:Dilemma 1: History of drug, ETOH abuse, severe History of drug, ETOH abuse, severe psychiatric disease cited as contraindications to opioid usepsychiatric disease cited as contraindications to opioid use
Dilemma 2:Dilemma 2: Identifying pain patients at risk for substance Identifying pain patients at risk for substance misuse with opioids a challenge (little literature). misuse with opioids a challenge (little literature).
Opioid Misuse*Opioid Misuse*
*Ives, T. J.; Chelminski, P. R..et al. Predictors of Opioid Misuse in Patients with Chronic Pain A Prospective Cohort Study. BMC Health Serv Res. 2006 Apr 4; 6(1)46.
Multivariate Predictors of Multivariate Predictors of Substance MisuseSubstance Misuse
ModelModel Odds Ratio Odds Ratio (95% CI)(95% CI)
AgeAge
Drug or DUI Drug or DUI ConvictionConviction
H/O Cocaine UseH/O Cocaine Use
H/O ETOH AbuseH/O ETOH Abuse
0.95 (0.90-0.95 (0.90-0.99)0.99)
2.58 (1.01-2.58 (1.01-6.59)6.59)
4.30 (1.76-4.30 (1.76-10.4)10.4)
2.60 (1.12-2.60 (1.12-6.26)6.26)
Fraudulent PromotionFraudulent Promotion
Shilling unproven and unsafe medications (e.g. Shilling unproven and unsafe medications (e.g. Vioxx®, Oxycontin®)Vioxx®, Oxycontin®)
• Iatrogenic Addictions= 1 in 10,000 (sic)•Wrong clinical dilemma•Too good to be true: Opioids would protect against substance misuse