Salem Clinic Presentation
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Transcript of 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
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
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
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 & ODD
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6126a5.htm
Buprenorphine Substitution for High Dose Opioids
http://www.ncbi.nlm.nih.gov/pubmed/25220043
Random Urine Or Saliva Drug Screening
https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
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.
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