Salem Clinic Presentation

Harm Reduction Strategies for Chronic

Pain Patients

Paul C. Coelho, MD Board Certified PM&R

Subspecialty Certified Pain Medicine

Disclosures

Paul Coelho,MD: No industry financial relationships to disclose. I am a member of the OPG planning committee and on the OPG speakers bureau.

Table Of Contents

1. Opioid Overdose Deaths (ODD)

2. 2016 CDC Opioid Guidelines

3. Risk Factors for an ODD

4. Risk Factors for Opioid Use Disorder (Addiction)

5. Harm Reduction Strategies

6. Sample Cases

0

12500

25000

37500

50000

198019821984198619881990199219941996199820002002200420062008201020122014

US Opioid Overdose Deaths 1980-2014Peak Incidence of Prescription ODD Age 45-54*

Death Rates 2000- 2015

http://www.pnas.org/content/112/49/15078.full.pdf

0

12500

25000

37500

50000

1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

Injection Increases Vs Opioid ODD

0

100

200

300

Opioid Overdose Deaths Increased 250%

Spinal Injections Increased 375%

2016 CDC Guidelines

https://www.cdc.gov/drugoverdose/pdf/guidelines_at-a-glance-a.pdf

2016 CDC Guidelines

https://www.cdc.gov/drugoverdose/pdf/guidelines_at-a-glance-a.pdf

Mandatory PDMP Use

http://content.healthaffairs.org/content/35/10/1876.abstract

Risk Factors for Overdose Death

1. Opioid Dose 2. Methadone 3. Opioids + Benzodiazepines/Sedative

Dose as a Risk Factor For ODD

https://www.aan.com/uploadedFiles/Website_Library_Assets/Documents/3.Practice_Management/2.Quality_Improvement/2.Patient_Safety/2.Patient_Safety_Education/C171%20-%20Franklin.pdf

Methadone as a Risk Factor for ODD

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6126a5.htm

1/3rd of all ODD

Co-Rx’d Benzos as a Risk Factor for ODD

http://www.ncbi.nlm.nih.gov/pubmed/26890165

1/3rd of all ODD

Risk Factors for Opioid Use Disorder

1. Age 2. Length of Exposure 3. Dose 4. Psychosocial Factors: a. H/o drug/alcohol tobacco abuse b. Family hx of drug/alcohol abuse c. H/o childhood trauma/abuse d. Intercurrent mental health ds

Prescribed Opioid Addiction Tx By Age

http://www.samhsa.gov/data/sites/default/files/2013_Treatment_Episode_Data_Set_National/2003_2013_Treatment_Episode_Data_Set_National_Body.html

2013

Opioid Use Disorder Dx By Age

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4032801/

0

10

20

30

40

18-30 31-40 41-50 51-64 >65

N = 570K

OR Medicaid Opioid Rx’s By Age (86% 18-60yrs)

http://www.ncbi.nlm.nih.gov/pubmed/26766755

0

22.5

45

67.5

90

18-39 40-59 60-79 >80

Top 10% Prescribers Rx’d 80% All Opioids

Dose & Length of Exposure As Risk Factors For OUD

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4032801/

Low Dose 0-36MED Med Dose 37-120MED High Dose > 120MED

Harm Reduction Strategies

Identify At Risk Patients

1. Morphine Equivalent Dose > 120mg/day 2. Methadone 3. Opioid and co-prescribed benzodiazepine 4. H/o aberrant behavior or addiction

Prescription Drug Monitoring Program

http://www.orpdmp.com/health-care-provider/

Prescription Drug Monitoring Program

http://www.orpdmp.com/health-care-provider/

PDMP Dashboard

https://orpdmp-ph.hidinc.com/orlogappl/bdorpdmqlog/pmqhome.html

6mo Look Back

Coelho’s PDMP Dashboard

https://orpdmp-ph.hidinc.com/orlogappl/bdorpdmqlog/pmqhome.html

Patient Name Dose >120 MED

Methadone Benzodiazepine >90 Days Use > 4 Pharmacies/Prescribers

167 39 (23%) 4 (2%) 98 (59%) 79 (47%) 4 (2%)

Opioid Dose Calculator

http://www.agencymeddirectors.wa.gov/Calculator/DoseCalculator.htm

Examples of 120MED

Fentanyl 50ucg/hr

Buprenorphine 4mg

Methadone 30mg

Hydromorphone 30mg

Oxycodone 80mg

Oxymorphone 40mg

Morphine 120mg

Codeine 800mg

MED > 90 Prescribe Nasal Naloxone

1. SB 384 legalized for lay administration in 2013.

2. Stock in your pharmacies. 3. Some patients must pay out of

pocket ($35.00 -$75.00)

http://www.amphastar.com/assets/naloxone.pdf

Consider a Data 2000 Waiver: Buprenorphine

http://projects.huffingtonpost.com/dying-to-be-free-heroin-treatment/opioid-abuse-outpace-treatment-capacity

17K MD/DO in OR, 400 with Waiver [2%]

Buprenorphine

1. Schedule III drug, partial mu agonist 2. FDA approved for both pain - Butrans/Belbuca - and addiction - Suboxone/Subutex. 3. Ceiling effect for respiratory suppression (RS).

Buprenorphine’s Ceiling Effect for R.S.

Buprenorphine & ODD

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6126a5.htm

Buprenorphine Substitution for High Dose Opioids

http://www.ncbi.nlm.nih.gov/pubmed/25220043

Buprenorphine Is A Powerful Analgesic

http://www.compoundchem.com/2014/09/25/painkillers/

Random Urine Or Saliva Drug Screening

https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

Sample Cases

Case 1: Teresa

75y/o retiree with diffuse OA. Lives alone in Prineville. Uses Oxycodone-APAP 10/325, five perday (MED 70). No h/o aberrant behavior or addiction.

Case 1: Teresa

Teresa reports that the medications give her comfort. She was started on her current dose years ago.

Recommendations: Continue as prescribed.

Case 2: Cleatus

68y/o retired logger with failed back surgery syndrome. Lives with spouse Rx’d Methadone 10mg po QID (MED 320). No h/o addiction or aberrant behaviors.

Case 2: Cleatus

Recommendations: Call Cleatus & his spouse in. Explain that his dose and medication are both unsafe and will need to change. a. Prescribe nasal naloxone & train spouse in assembly and use. b. Offer a conversion to Morphine Sulfate ER 75mg QD (30,15,30) at his next refill.

http://www.prescribetoprevent.org/wp-content/uploads/2012/11/naloxone-one-pager-in-nov-2012.pdf

Case 3: Jane

55y/o woman with FMS. Lives alone in Redmond. Uses OxyContin 30mg PO BID (MED 80), and alprazolam 0.5mg po QID. No h/o aberrant behavior or addiction.

Case 3: JaneRecommendations: Call Jane in to clinic. Explain that the combination of alprazolam and Oxycodone is unsafe. a. Offer a conversion to clonazapam 2mg BID. b. Taper clonazepam by .5 -1mg/mo over 4-8mo. c. Offer non-benzodiazepine alternatives for anxiety/sleep/panic attacks.

http://www.slideshare.net/101N/alternatives-to-benzodiazepines-60678319

Case 4: Luc

49y/o married restaurant owner with chronic migraine. Prescribed Oxycodone 5mg BID, 30/mo over many years. No h/o addiction or aberrant behavior. Recent review of the PDMP with at a f/u visit reveals visits to 6 other prescribers over the past 3mo for opioids. Patient acknowledges that he is overusing pain medication and wants your help in getting off opioids entirely.

Case 4: Luc

Recommendations: Use your data-2000 waiver to offer Luc treatment of opioid use disorder. Stop opioids. a. Offer conversion to buprenorphine

(Suboxone/Subutex) with a planned 6mo taper off. (8mg QD x 2mo, 4mgQD x 2mo, 4mg QOD x 2mo)

b. Offer an addiction counseling referral.

c. Continue to see frequently for followups with both urine or saliva drug screens and frequent checks of the PDMP to ensure adherence.

Help with Tough Cases

ResourcesAlternatives to Benzodiazepines: http://www.slideshare.net/101N/alternatives-to-benzodiazepines-60701295

Oregon Prescription Drug Monitoring Signup: http://www.orpdmp.com/health-care-provider/

Opioid Withdrawal Attenuation Cocktail: http://www.slideshare.net/101N/opioid-withdrawal-attenuation-coctail

Nasal Naloxone: http://www.amphastar.com/assets/naloxone.pdf http://www.narcannasalspray.com/nns-4-mg-dose/how-to-use-nns/

Oregon Drug & Alcohol Services by County: https://www.oregon.gov/oha/amh/publications/provider-directory.pdf

Thank You [email protected]