We All Have One - Alberta College of Family Physicians19/10/2016 2 Disclosure of Commercial Support...
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19/10/2016 1 We All Have One: Evidence-based Review of Opioids for the Tx of CNMP & Strategies to Consider for Stopping Loren Regier Saskatoon, SK PEIP Conference – Oct 2016 Faculty/Presenter Disclosure Presenter: Loren Regier Relationships that may introduce potential bias and/or conflict of interest: – Grants/Research Support: none – Speakers Bureau/Honoraria: Loren Regier has received a speaker fee and expense support from the Alberta College of Family Physicians, Foundation for Medical Practice (PBSG) – McMaster, NaRCAD (Academic Detailing - Harvard Medical) – Consulting Fees: none – Other: Co-director, CEP Academic Detailing (ON) Program Coordinator, RxFiles Academic Detailing (SK) – No industry funding Slide 1: Option B (Presenter with NO relationships to declare)
Transcript of We All Have One - Alberta College of Family Physicians19/10/2016 2 Disclosure of Commercial Support...
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We All Have One:
Evidence-based Review of Opioids for the Tx of CNMP
& Strategies to Consider for Stopping
Loren RegierSaskatoon, SK
PEIP Conference – Oct 2016
Faculty/Presenter Disclosure
Presenter: Loren Regier
Relationships that may introduce potential bias and/or conflict of interest:– Grants/Research Support: none– Speakers Bureau/Honoraria: Loren Regier has received
a speaker fee and expense support from the Alberta College of Family Physicians, Foundation for Medical Practice (PBSG) – McMaster, NaRCAD (Academic Detailing -Harvard Medical)
– Consulting Fees: none– Other:
Co-director, CEP Academic Detailing (ON) Program Coordinator, RxFiles Academic Detailing (SK)
– No industry funding
Slide 1: Option B (Presenter with NO relationships to declare)
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Disclosure of Commercial Support
This program is presented by the Alberta College of Family Physicians (ACFP) without any commercial or in-kind support.– The ACFP provides a speaker fee and expense support for presenting
at the Practical Evidence for Informed Practice.
Slide 2: Option B (No commercial support)
Where we’re going…
Opioids – CNCP: Evidence–How much is the benefit
Opioid Discontinuation –who to wean & predictors for success
Strategies for problematic opioid use
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Evidence & Benefits
CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 https://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwisz5C6yNPPAhVkyoMKHcrGD8oQFggeM
AA&url=https%3A%2F%2Fwww.cdc.gov%2Fmedia%2Fmodules%2Fdpk%2F2016%2Fdpk-pod%2Frr6501e1er-ebook.pdf&usg=AFQjCNGu8mj_JQi5Pa_UTr0IRf9kzxeaLA
CDC Guideline 2016:Evidence for benefit of opioids
in chronic pain.
Based on 0 studies of 1 yr, there is insufficient evidence.
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What will the next Canadian Guideline
do with the Evidence?
A quick tour of some of the “evidence”?
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McNicol ED, Midbari A, Eisenberg E. Opioids for neuropathic pain. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD006146. DOI: 10.1002/14651858.CD006146.pub2 http://www.cochrane.org/CD006146/SYMPT_opioids-neuropathic-painFinnerupNB,AttalN,HaroutounianS,etal.LancetNeurol.2015;14:162-73.
DuehmkeRM,HollinsheadJ,CornblathDR.CochraneDatabaseSystRev.2006;3:CD003726.
Cochrane 2013Opioids for Neuropathic Pain
14/31 intermediate duration ~12wks– Benefit:
Effects likely overestimated (methods/quality)
33% reduction: NNT=4; 50% reduction: NNT=6NO improvement in function emotional or physical
– Harm: Discontinuation due to AE: NNH=13 Typical opioid AE’s: each NNH=4-7-13
Tramadol ~4-9 wks {Two SRs} 50% pain reduction NNT=4-6; NNH DC =8-12
A “heads up” regarding NNTs in a Pain Trial
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da Costa BR, Nüesch E, Kasteler R, Husni E, Welch V, Rutjes AWS, Jüni P. Oral or transdermal opioids for osteoarthritis of the knee or hip. Cochrane Database of Systematic Reviews 2014, Issue 9. Art. No.:
CD003115. DOI: 10.1002/14651858.CD003115.pub4. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003115.pub4/abstract
Cochrane 2014Opioids non-tramadol for OA knee/hip
22=trials, n=8275, MEQ~50mg/day; Benefit:
Pain, small effect: NNT=10 Function, small effect: NNT=11
HarmAny AE: 14Discontinue due to AE: NNH=21SAE hospitalization, persistent disability, death: NNH=111Withdrawal symptoms: NNH=66
What did “small effect” mean:
Pain: 0-10 scale: • Improvement of
3 points vs 2 for placebo
Fx 0-10 scale: • Improvement of 2 points
vs 1 point for placebo
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Cepeda MS, Camargo F, Zea C, Valencia L. Tramadol for osteoarthritis. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD005522. DOI: 10.1002/14651858.CD005522.pub2
http://www.cochrane.org/CD005522/MUSKEL_tramadol-for-osteoarthritis
Cochrane 2006Tramadol for OA knee/hip
11=trials, ~12wk, n=1939–Benefit:
Report moderate improvement: NNT=6–Harm
Discontinue due to AE: NNH=8
Meta-analyses of opioids - CNCP – 2014 Enriched vs non-enriched trial design
“Effect of a Run-in Period”
Suggest benefit OK, but harms underestimated.
Furlan A, Chaparro LE, Irvin E, Mailis-Gagnon A. A comparison between enriched and nonenriched enrollment randomized withdrawal trials of opioids for chronic noncancerpain. Pain Res Manag. 2011 Sep-Oct;16(5):337-51.
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Who to Taper & Predictors for Success.
Who to taper / discontinue?
Lack of meaningful benefit: Functional goals not met
Harm:Opioid - doing more to the patient than
for the patient
Safety of patient and societyAgreement not working, misuse, …
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Who to taper/discontinue?
PRACTICALLY
–Opioid doses have gone up & up
–Pain and function no better, and possibly worse
Opioid Taper/Discontinuation Predictors of Success
Veterans (VHA): n=550,616 2014
–20% discontinued–Medians: time, 317 days; MEQ, 26mg
Predictors of success–Younger & older age–Lower average dosing–Less than 90 days of opioid hx–Mental health & substance use disorders
Vanderlip, E. R., Sullivan, M. D., Edlund, M. J., Martin, B. C., Fortney, J., Austen, M., ... Hudson, T. (2014). National study of discontinuation of long-term opioid therapy among veterans. Pain, 155(12), 2673–2679.
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TROUP Study HealthCore & AR Medicaid
–N= 23,419 + 6,848Predictors of less likely to succeed
–High doses, >120mg MEQ: HR=0.66–Features of opioid misuse
Martin, B.C., Fan, M., Edlund, M.J. et al. Long-Term Chronic Opioid Therapy Discontinuation Rates from the TROUP Study. J GEN INTERN MED (2011) 26: 1450. doi:10.1007/s11606-011-1771-0
Opioid Taper/Discontinuation Predictors of Failure
Coping Skills & Supports–Patient/Client, Family/Friends, Clinicians
Meaning in adversityAcceptanceEnvisioning a life worth livingConnect with positive peoplePersonal growth - skills & practices
–meditation, prayer
Creating Resilience
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Tapering Timeline
More art than science…
Be prepared to take some time!
2 weeks – 3 - 6 – 12 - 24 months10% q1-2 weeksLast 1/3rd of dose, ~5 % q2-4wksAllowance for plateaus?
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Consider a Flexible Timeline Template
Prevent / TreatWithdrawal Symptoms
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Loss of Tolerance!
Strongly caution patients that:
a) they have lost their tolerance to opioids after as little as a week or two of abstinence, and
b) they are at risk for overdose if they relapse/resume their original dose.
Naloxone?
Other Challenges & Setbacks
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Summary
Evidence very limitedSmall benefits – low doses
Pain / Function Harms – especially at high doses
Tolerability / Safety
Have an exit strategyE.g. tapering – gradually with supports
Useful Links
CAMH: Video discussion of issues around how to taper. http://knowledgex.camh.net/videos/Pages/tapering_presopioids_selby2013.aspx
Opioid Taper Template & related materials at: www.RxFiles.ca
Opioid Manager tool from Canadian CNCP guideline group: http://nationalpaincentre.mcmaster.ca/opioidmanager/
RxFiles Opioid Taper Template TOOL: http://www.rxfiles.ca/rxfiles/uploads/documents/Opioid-Taper-Template.pdf
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Additional References
Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain —Part B: Recommendations for Practice, Version 5.5 April 30, 2010. [NOUGG] Accessed at: http://nationalpaincentre.mcmaster.ca/documents/opioid_guideline_part_b_v5_6.pdf
Opioid withdrawal scales, Saskatoon Health Region, Saskatchewan. http://pauliplace.com/02%20Involuntary%20DSS/03%20YIAP&MA%20hyperlinks/YIDSMAIS%2008%20SHR%20Opiate%20Withdrawal%20Scale.pdf
Butt P, McLeod M. Opioid withdrawal protocol, Saskatchewan. http://www.quadrant.net/cpss/pdf/Opioid_Withdrawal_Protocol.pdf
Constipation Q&A:http://www.rxfiles.ca/rxfiles/uploads/documents/members/Opioid-Induced-Constipation-QandA.pdf
Merrigan JM, Buysse DJ, Bird JC, Livingston EH. JAMA patient page. Insomnia.JAMA. 2013 Feb 20;309(7):733. Accessed online 21 Oct, 2013 at http://jama.jamanetwork.com/article.aspx?articleid=1653524.
Sedative Patient Information Sheet (RxFiles) http://www.rxfiles.ca/rxfiles/uploads/documents/PSYC-Sedative-PtHdout.pdf
Chronic Insomnia in Older Adults (RxFiles Q&A) http://www.rxfiles.ca/rxfiles/uploads/documents/Insomnia-Older-Adults-QandA.pdf
Gowing L, Farrell MF, Ali R, White JM. Alpha2-adrenergic agonists for the management of opioid withdrawal. Cochrane Database Syst Rev. 2014 Mar 31;3:CD002024.
Extra…Discontinuing Opioids: Do’s & Don’ts
Tobin DG, Andrews R, Becker WC. Prescribing opioids in primary care: Safely starting, monitoring, and stopping. Cleve Clin J Med. 2016 Mar;83(3):207-15.
