OPSC 2015 ANNUAL CONVENTION SYLLABUSUncov -Opat aat a atient | Presented by Lisa Pitino, DO Before...

2015 OPSC Annual Convention

syllabus

February 4-8, 2015 Hyatt Regency Mission BaySan Diego, California

SATURDAY, FEBRUARY 7, 2015: 3:00pm - 4:00pm

Uncovering theNon-Opiate Candidate Patient *

Presented by Lisa Pitino, DO

* California Pain / End-of-Life Care

OPSC’s 54th Annual Convention and Exposition Syllabus 772

PRESENTATIONLearning Objectives andSelf ASSESSMENT questions

LEARNING OBJECTIVES SELF ASSESSMENT QUESTIONS1. Define pain and different types of pain

2. Review California Medical Board Opioid Prescribing Guidelines 3. Review different types of patient opioid risk assessment tools

4. Discuss difference between addiction and pseudoaddiction

5. Discuss how to interpret a urine drug screen

1. A patient compressive pain history includes which of the following: a. What makes the pain better or worse? b. When and how did the pain start? c. Is the pain work related? d. Typical day pain rating? e. All of the above.

2. The CAGE questionnaire can be used as a patient opioid risk assessment tool. What number of positive responses indicates to use caution when prescribing opioids? a. 1 b. 2 c. 3 d. 4

3. A brief assessment used to help monitor a patient who is currently being prescribed opioid: a. Opioid Risk Tool b. Screener and Opioid Assessment for Patient with Pain c. Current Opioid Misuse Measure d. CAGE questionnaire

4. A patient on stable a dose of opioids for 2 years has noticed their pain medication is not helping as much. This is an example of: a. Addiction b. Pseudoaddiction c. Tolerance d. Dependence

5. A patient is taking hydrocodone for pain. Their urine drug screen should show: a. Hydrocodone b. Hydromorphone c. Morphine d. A and B e. A and C

6. California Medical Board guidelines suggest considering referral to a pain specialist if patient is taking above what amount of morphine equivalents? a. 50mg b. 80mg c. 100mg d. 120mg

7. A new patient sees you regarding their pain. They state they left their last doctor because they did not like how their pain was treated. This is an example of: a. Addiction b. Pseudoaddiction c. Tolerance d. Dependence


SATURDAY, FEBRUARY 7, 2015: 3:00pm - 4:00pm .................................................................... Uncovering the Non-Opiate Candidate Pain Patient | Presented by Lisa Pitino, DO

Uncovering the Non Opioid Candidate Patient

Lisa Pitino, DO Board Certified Physical Medicine & Rehabilitation Board Certified Pain Management St Joseph Heritage Medical Group Santa Ana, California



Objectives

1. Define pain and different types of pain 2. Review California Medical Board Opioid

Prescribing Guidelines 3. Review different types of patient opioid

risk assessment tools 4. Discuss difference between addiction

and pseudoaddiction 5. Discuss how to interpret a urine drug

screen



Pain

Pain: “An unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in such terms of damage.”

Acute Pain: lasting less than 3 months Chronic Pain: lasting more than 3 months



Types of Pain

Nociceptive Pain: Arises from actual or threatened damage to non neural tissue and is due to the activation of nocicepters

Neuropathic Pain: Caused by a lesion or disease to the somatosensory nervous system



Pain

The most common reason patients seek care

Between 1998 and 2008 the rate of opioid misuse increased 400%

More than 6 million Americans are abusing prescription drugs

100 million Americans suffer from chronic pain



Opioids do not work for all pain OR all patients

You must weigh the risks and benefits of prescribing opioids vs alternatives

Research supporting the long term use of opioids is limited and low quality



California Medical Board Opioid Regulations November 2014 90 pages http://www.mbc.ca.gov/Licensees/Prescrib

ing/Pain_Guidelines.pdf



Before You Prescribe Complete history and physical examination Establish a diagnosis and medical necessity Try non-opioid treatments Psychological Evaluation/Risk Assessment Evaluate potential risks/benefits of opioids Review state Prescription Drug Monitoring

Program (PDMP) Urine drug testing Be aware of drug seeking or aberrant

behaviors



Patient History

If you know in advance patient’s visit is for pain have them fill out a pain questionnaire while waiting ◦ Ex: Brief Pain Inventory (BPI)

Otherwise ask a comprehensive history



Comprehensive History When and how pain started Pain location and description of pain(burning,

shooting, stabbing, etc…) Typical day highest and lowest pain rating What makes the pain better & worse Effect of pain on sleep, mood, work, function, quality

of personal life, … Any pending legal action or work related What have they tried before (medications, therapy,

injections, or surgery) What can’t they do know, what would they like to be

able to do again History of or current mental illness



Inflexxion, Inc.® and http://www.painedu.org



Caution with these medical conditions: COPD CHF Sleep apnea Current or history of substance abuse Current or history of mental illness Age Pregnancy Renal or Liver dysfunction



Pain Assessment

VAS

Faces



Non Opioid Treatments Other medications Physical Therapy or Aquatic Therapy Osteopathic Manipulation or Chiropractor Acupuncture Cognitive Behavior Therapy Treat depression or other mental health illness Injections or interventional procedures Referral to a surgeon or other specialist



Patient Risk Assessment

CAGE modified for drugs Opioid Risk Tool (ORT) Screener and Opioid Assessment for

Patients with Pain-Revised (SOAPP-R)

Many more….



CAGE C: Wanted or needed to Cut down on alcohol

or drug use? A: Been Annoyed or Angered by others

complaining about your drinking or drug use? G: Felt Guilty about the consequences of the

patient’s drinking or drug use? E: Taken a drink/drug in the morning as an “Eye

Opener” to decrease hangover or withdrawal?

A single positive response suggests caution with prescribing opioids



Opioid Risk Tool

Brief Limit to patient’s knowledge of family

history and openness about past medical history



http://www.partnersagainstpain.com/hcp/



SOAPP-R Tool to help determine how much

monitoring a patient on long term opioids may require

22 questions Available in English and Spanish

Results: ◦ Low score: <9 ◦ Medium score: 10-21 ◦ High score: >21



Risk and Monitoring

Low: Less frequent visits, PDMP screening, and Urine drug screening.

Medium: More frequent.

High: Frequent visits, PDMP screening, and Urine testing. Consider referral to Pain Psychologist for counseling and treatment of any comorbid mental health disorders



PDMP Currently 49 states have an operating PDMP ◦ Missouri does not have legislation or program ◦ Washington DC has legislation only

California CURES: http://oag.ca.gov/cures-pdmp

Register online and mail in Dependent on pharmacy to enter information Pitfalls: ◦ Name change or nickname ◦ Pharmacies have until 18th of month to update prior

month prescription information



Medication Agreement Ensures you and the patient are under an

agreement and equal understanding of what is expected

Defines joint responsibilities of physician and patient

Can be short and simple or long and complex

Include: ◦ Risks of taking chronic pain medications ◦ Safe storage and disposal ◦ Policies and expectations



Opioid Risks Respiratory depression Sedation/cognitive impairment Constipation Endocrine dysfunction ◦ Hypogonadism with decreased bone density ◦ Decreased libido

Nausea/vomiting Tolerance Physical dependence



Opioid Naïve: Not taking opioids regularly, lacks adaptation to the drug

Tolerance: A state of adaptation in which exposure to a drug induces changes that result in a decrease of one or more of the drugs’ effects over time

Dependence: A state of adaptation that includes tolerance and is manifested by a drug-class specific withdrawal syndrome due to decrease or stopping of the drug

Addiction: Compulsive use of drugs for nonmedical reasons

Pseudoaddiction: Compulsive behavior due to inadequate pain relief

Opioid induced hyperalgesia: Nociceptive sensitization caused by exposure to opioids



Sample agreements: ◦ American Academy of Pain Medicine ◦ Pain EDU ◦ California Medical Board Guidelines

Per California Medical Board Guidelines: ◦ If on short acting, sign within 3 visits in 2

months ◦ Sooner if expected to require more than 3

months of opioids or if on long acting opioids



Before You Prescribe

Set goals Be willing to discontinue opioids if no

benefit Educate on safe storing and disposal of

medications



If High Risk for Overdose Educate on risk of overdose, signs/symptoms ◦ Starting 1-1-2015 California pharmacists will be

able to furnish an opioid reversal drug (ie Naloxone) in accordance with standardized procedures and protocols

Educational websites: ◦ Prescribe to Prevent http://prescribetoprevent.org/prescribers

SAMHSA Opioid Overdose Prevention Toolkit



Evaluating and Documenting Medication Response Pain, Enjoyment, and General Activity (PEG) ◦ Reduced level of pain ◦ Increased level of function ◦ Improved quality of life

5 A’s ◦ Analgesia ◦ Activity ◦ Adverse ◦ Aberrance ◦ Affect

Current Opioid Misuse Measure (COMM)



COMM

Brief patient self assessment to monitor patients on opioid therapy

17 questions Available in English and Spanish

Results: ◦ Sum ≥ 9, + result ◦ Sum <9, - result



Urine Drug Screening Do that day Do in office ◦ Check temperature (96-99˚)

Know what you are testing Dependent on patient, can cheat “white coat

compliance” Frequency depends on risk and if prior

aberrant results/behavior Can not detect how much medication

patient is taking, when it was taken, or source of the drug



Urine Drug Screen Results Drug Urine Metabolites Time Detected

Alcohol 7-12 hours

Amphetamines 1-3 days

Benzodiazepines Short up to 3 days Long/chronic use up to 30 days

Cocaine 2-3 days

Codeine Codeine, Morphine, and Hydrocodone 1-3 days

Fentanyl Norfentanyl 2-4 days

Hydrocodone Hydrocodone and Hydromorphone 1-3 days

Marijuana Single use 1-3 days Chronic use up to 30 days

Morphine Morphine, Codeine, and Hydromorphone

1-3 days

Oxycodone Oxycodone and Oxymorphone 1-3 days

Soma Carisoprodol and Meprobamate 1-4 days



Marijuana Federally Illegal California: ◦ Legal for patients to possess and cultivate

marijuana for their personal medical use given the recommendation or approval of a California-licensed physician ◦ Diagnosis covered: cancer, anorexia, AIDS, chronic

pain, spasticity, glaucoma, arthritis, migraine, or any other illness for which marijuana provides relief

No research proving it is effective in treating pain



While Prescribing Labs EKG Consider referral to specialist if prescribing

equivalent of >80mg Morphine per day (Per CA guidelines)

Avoid prescribing more than necessary, 30 days

Federal Law allows 90 day supply of prescriptions for schedule II medications

CII prescriptions are valid in California for 6 months



Opioid Use: Appropriate vs Misuse/Abuse Patient wishes to stop their opioid but

restarts when pain becomes worse Appropriate

The patient has little or no desire to try non opioid treatments Misuse/Abuse

The patient requests multiple changes/increases in medication due to not “feeling” the medication Misuse/Abuse



Addiction vs Pseudoaddiction Hoards medications ◦ Pseudoaddiction

Seen two doctors at once without them knowing ◦ Addiction

Asked for second opinion about pain medications ◦ Pseudoaddiction

Bought pain medications from the street ◦ Addiction



Patient Case 56 y/o man with history of prior back

surgery presents to your office with pain 9/10

Managed by another doctor in your group.

Currently taking OxyContin 200mg q12hrs and Dilaudid 8mg q3hrs prn

Ran out of Dilaudid Complaining of abdominal cramping,

anxiety, and tremors



What’s happening ?

A. Opioid addiction B. Pseudoaddiction C. Opiate tolerance D. Opioid withdrawal E. Opioid induced hyperalgesia

Answer: D



Opioid Withdrawal

Hours Since Last Dose Symptoms

8-12 Lacrimation, rhinorrhea, yawning, and sweating

18-20 Dilated pupils, anorexia, gooseflesh, tremors, restlessness, and anxiety

48-72 Irritability, insomnia, anorexia, sneezing, yawning, abdominal cramps, diarrhea, nausea/vomiting, tachycardia, hypertension, and body aches



Not Going Well

Re-evaluation of pain Frequent visits with pill counting Wean off opioids Consider referral to Pain Specialist and/or

Psychologist Consider referral to Comprehensive Pain

Treatment Program



Weaning Off

Wean off medications: ◦ Slow: 10% decrease per week ◦ Fast: 25-50% decrease every few days

Abstinence syndrome: nausea, vomiting, diarrhea, muscle pain and myoclonus ◦ Clonidine 0.1-0.2mg PO every 6 hours or

0.1mg/24hrs TD qweek



Special Considerations Acute Pain: ◦ Only prescribe for short periods, have an endpoint. ◦ Do not use ER/LA formulations

ER/UC: ◦ Try to use NSAIDs and other non opioids ◦ If necessary write for lowest amount possible, few days

until can see PCP/Specialist Elderly: ◦ Limit use of benzodiazepines with opioids

Pediatrics: ◦ Extreme caution, try other non-opioids first

Pregnancy: ◦ Best is none, if on taper slowly to lowest possible dosage



Patient Case #1 72 y/o Caucasian woman well known to your practice PMH: Rheumatoid arthritis, peripheral neuropathy,

severe right shoulder and bilateral knee arthritis, and cervical stenosis

Pain is getting worse. Unable to get out of house and go to church or to lunch with friends. Planning on going on a 2 week cruise with her husband in a couple months

Unable to take NSAIDs due to stage 3 kidney disease. Tried Tylenol 1000mg every 8 hours, no relief. Does not want to have surgery for her shoulder or

knees until after her trip.



What to do… Complete ◦ Physical examination ◦ Risk assessment: SOAPP-R score 9

Check PDMP Sign medication agreement Order lab if not done recently Then start pain medication, consider Norco

5/325 Follow up in one month and adjust as

needed



Follow up 6 months later…

Had shoulder replacement, went well Still having knee, neck, and foot pain Check UDS, no medications She admits being out early. Her grandson

visited her 3 weeks ago and took some of her medications. She did not say earlier because she was embarrassed.



New plan

Review with the patient the medication agreement, suggest how to keep medications safe

Have follow up frequently until stable again

Options if unable to keep medications from family…



Excuses I Have Heard… Left in hotel room Someone broke into my car I/my family member/my pet knocked

medications into sink/toilet Ex-husband/friend stole out of my house Soup dumped into my purse and the pill

bottle was open Patient’s husband/wife hurt their back and

needed pain medications Going on a trip and need early refill



Patient Case #2 55y/o African American with chronic low

back pain He just moved from New Jersey to

California. 3 prior back surgeries, last 2 years ago with

no relief. On chronic Morphine ER and Norco for

breakthrough. Brings all records and note from prior

physician



What to do…

Complete ◦ History and physical examination ◦ Risk assessment: SOAPP-R score 22

Check PDMP Sign medication agreement Labs if none recent If consistent, continue prior treatment

program.



What if no records?

No prior records, medication bottles, or documentation….

Get records and follow up in one week Do not have to prescribe if not

comfortable



Patient Case #3 45y/o woman with chronic back pain comes into UC

out of her pain medications No records Complete appropriate history and examination Risk assessment: CAGE 2+ Check PDMP or call pharmacy Prescribe as comfortable, if no opioids indicated then

do not prescribe If feel opioids indicated only give 1-3 days worth and

follow up with PCP. Don’t write rx just to get rid of patient If you do not feel comfortable then do not prescribe

but have compassion



Overall

Have empathy and compassion Be vigilant Develop a physician or practice protocol

and use with all patients



References Fishman, S. Responsible Opioid Prescribing: A

Clinician’s Guide. Washington, DC; Waterford Life Sciences, 2014.

https://www.painedu.org (Great website, free once make account, and has numerous forms for office use)

http://www.painmed.org/library/clinical-resources California Medical Board Opioid Prescribing

Guidelines: http://www.mbc.ca.gov/Licensees/Prescribing/Pain_Guidelines.pdf

Partners Against Pain: http://www.partnersagainstpain.com/hcp/



Questions…



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