Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer...
Transcript of Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer...
![Page 1: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/1.jpg)
Safe and Effective Tapering of Opioids
![Page 2: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/2.jpg)
OPIOIDEDUCATION
![Page 3: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/3.jpg)
SDDEPT.OFHEALTHGRANT
• Protectagainstopioidabuse• Evaluationforopiatedependence/abuse• Opiateinitiation,monitoringandreview• Useofalternativestoopioids
![Page 4: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/4.jpg)
SDDEPT.OFHEALTHGRANT
• Incorporatingpainassessmenttools• ProperDocumentationinpatientrecords• UseofthePDMPaspracticetool– (PrescriptionDrugMonitoringProgram)
![Page 5: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/5.jpg)
Education
• Livepresentations• Webbasedcurriculum• “Toolkit”foropioidprescribing
![Page 6: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/6.jpg)
SDDEPT.OFHEALTHGRANT
• Incorporatingpainassessmenttools• ProperDocumentationinpatientrecords• UseofthePDMPaspracticetool– (PrescriptionDrugMonitoringProgram)
![Page 7: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/7.jpg)
Goals/Objectives
• Areviewofresourcesavailabletohelpthosewithaddiction
• Understandinghowtocreateaplanforsafelytaperingpatientsoffopioids
• Theutilizationofalternativestoopioids• Adiscussionofpatientmonitoringandreview
![Page 8: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/8.jpg)
• World wide: Up to 36 million abuse opioids• USA: 2.1 million abuse opioids• USA: 467,000 heroin addicts• 80% of opioid users reported that their first regular
opioid was a Rx pain reliever• 85% of heroin users first used an opioidwww.drugabuse.gov
How Many People Are Addicted?
![Page 9: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/9.jpg)
• Assess risk of addiction using risk stratification tool• Assess pain, function, behavioral health and drug-related
behaviors• Obtain informed consent for therapy• Monitor pain and function, opioid risk and progress toward
treatment goals• Use treatment agreements for long-term opioid therapy• Document
MMIC Brink, Summer 2017
What can you do?
![Page 10: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/10.jpg)
![Page 11: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/11.jpg)
Statistics
![Page 12: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/12.jpg)
![Page 13: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/13.jpg)
Education/Resources
![Page 14: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/14.jpg)
![Page 15: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/15.jpg)
AddictionServicesAddictionServices
![Page 16: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/16.jpg)
AssessmentTools
![Page 17: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/17.jpg)
AssessmentTools
![Page 18: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/18.jpg)
AssessmentTools
![Page 19: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/19.jpg)
Tapering Opiates
Considertaperingtoareducedopioiddosageortaperinganddiscontinuingopioidtherapywhenyourpatient:1. requestsdosagereduction2. doesnothaveclinicallymeaningfulimprovementinpain
andfunction(e.g.,atleast30%improvementonthe3-itemPEGscale)
3. isondosages≥50MME*/daywithoutbenefitoropioidsarecombinedwithbenzodiazepines
*morphinemilligramequivalents4. showssignsofsubstanceusedisorder(e.g.workor
familyproblemsrelatedtoopioiduse,difficultycontrollinguse)
5. experiencesoverdoseorotherseriousadverseevent6. showsearlywarningsignsforoverdoserisksuchas
confusion,sedation,orslurredspeech
![Page 20: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/20.jpg)
Tapering OpiatesHOWTOTAPERTaperingplansshouldbeindividualizedandshouldminimizesymptomsofopioidwithdrawalwhilemaximizingpaintreatmentwithnonpharmacologic therapiesandnonopioid medications.Ingeneral:
GoSlowAdecreaseof10%oftheoriginaldoseperweekisareasonablestartingpoint.Somepatientswhohavetakenopioidsforalongtimemightfindevenslowertapers(e.g.,10%permonth)easier.Discusstheincreasedriskforoverdoseifpatientsquicklyreturntoapreviouslyprescribedhigherdose.
ConsultCoordinatewithspecialistsandtreatmentexpertsasneeded—especiallyforpatientsathighriskofharmsuchaspregnantwomenorpatientswithanopioidusedisorder.Useextracautionduringpregnancyduetopossiblerisktothepregnantpatientandtothefetusifthepatientgoesintowithdrawal.
SupportMakesurepatientsreceiveappropriatepsychosocialsupport.Ifneeded,workwithmentalhealthproviders,arrangefortreatmentofopioidusedisorder,andoffernaloxoneforoverdoseprevention.Watchforsignsofanxiety,depression,andopioidusedisorderduringthetaperandoffersupportorreferralasneeded.
EncourageLetpatientsknowthatmostpeoplehaveimprovedfunctionwithoutworsepainaftertaperingopioids.Somepatientsevenhaveimprovedpainafterataper,eventhoughpainmightbrieflygetworseatfirst
![Page 21: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/21.jpg)
Tapering Opiates
Considerations:1.Adjusttherateanddurationofthetaperaccordingtothepatient’sresponse.2Don’treversethetaper;however,theratemaybeslowedorpausedwhilemonitoringandmanagingwithdrawalsymptoms.3Oncethesmallestavailabledoseisreached,theintervalbetweendosescanbeextendedandopioidsmaybestoppedwhentakenlessthanonceaday.
![Page 22: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/22.jpg)
MME Calculator
![Page 23: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/23.jpg)
MorphineEquivalentDose(MED)MaximumPriorAuthorization
• Medicaidpatientsrequiringaneworrenewalprescriptionformorphineequivalentdosinggreaterthan300MEDsperdaywillrequirepriorauthorization.Claimswithoutpriorauthorizationwillbedenied.
• ImplementationistargetedforOctober1,2018.• ForbothneworrenewalprescriptionsandthoseinplacepriortoOctober1,2018,theMEDthresholdwill
decreasebyapproximately10%eachmonthuntilthetargetMEDisreached.SouthDakotaMedicaidwillutilizethefollowingtaperingschedule:
• October1,2018:300MEDs• November1,2018:270MEDs• December1,2018:240MEDs• January1,2019:220MEDs• February1,2019:200MEDs• March1,2019:180MEDs• April1,2019:160MEDs• May1,2019:140MEDs• June1,2019:130MEDs• July1,2019:120MEDs• August1,2019:110MEDs• September1,2019:100MEDs• October1,2019:90MEDs• ThetargetisinalignmentwithCDCrecommendedmaximumMEDlevelsandthetaperingschedule
approximatesa10%MEDreductioneachmonthinlinewiththeCDCrecommendationsfortapering.
![Page 24: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/24.jpg)
MME Calculator
![Page 25: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/25.jpg)
SD Addiction Services
![Page 26: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/26.jpg)
MME Calculator
![Page 27: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/27.jpg)
AddictionServices
![Page 28: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/28.jpg)
Medication“ladder”
![Page 29: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/29.jpg)
Alternatives to opiates
![Page 30: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/30.jpg)
MedicationAssistedTherapy
![Page 31: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/31.jpg)
Buprenorphine
• WhatexactlyisBuprenorphine?•
Buprenorphine(BYOO-pre-NOR-feen) ('bu-pre-'nor-feen) isanopioidmedicationusedtotreatopioidaddictionintheprivacyofaphysician’soffice.Buprenorphinecanbedispensedfortakehomeuse,byprescription.Thisinadditiontobuprenorphine’spharmacologicalandsafetyprofilemakesitanattractivetreatmentforpatientsaddictedtoopioids.
• Buprenorphineisdifferentfromotheropioidsinthatitisa partialopioidagonist.Thispropertyofbuprenorphinemayallowfor;– lesseuphoriaandphysicaldependence– lowerpotentialformisuse– aceilingonopioideffects– relativelymildwithdrawalprofile
• Attheappropriatedosebuprenorphinetreatmentmay:– Suppresssymptomsofopioidwithdrawal– Decreasecravingsforopioids– Reduceillicitopioiduse– Blocktheeffectsofotheropioids– Helppatientsstayintreatment
![Page 32: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/32.jpg)
Patient Monitoring
• SDPDMP• UrineDrugScreen• Followup• “FunctionalAssessment”
![Page 33: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/33.jpg)
SD Prescription Drug Monitoring, 2016
![Page 34: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/34.jpg)
SD Prescription Drug Monitoring, 2017
Prescriptions:259,700v234,367
Hydrocodonedoses:17.4millionv14.9million
![Page 35: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/35.jpg)
MME’s Prescribed Per Capita, 2015
![Page 36: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/36.jpg)
MME’s Prescribed Per Capita, South Dakota, 2015
![Page 37: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/37.jpg)
Socio-EconomicProblem
• Increaseaccesstomentalhealthandaddictionservices
• Psychosocialsupport• Opioidmaintenance:buprenorphine• Availabilityofnaltrexone
![Page 38: Safe and Effective Tapering of Opioids · arrange for treatment of opioid use disorder, and offer naloxone for overdose prevention. Watch for signs of anxiety, depression, and opioid](https://reader033.fdocuments.us/reader033/viewer/2022050218/5f64528d97a7957fb81e2482/html5/thumbnails/38.jpg)