Alternatives to Opioids

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Alternatives to Opioids

Douglas L. Furmanek, PharmD, BCCCPDirector, Clinical Pharmacy Services

Assistant Professor – USC College of Medicine at GreenvilleAssistant Professor – SC College of Pharmacy

Department of Pharmacy Services Prisma Health Upstate, Greenville, SC

Disclosure

• I have no conflicts of interest regarding the subject matter of this presentation

Opioid Epidemic !!!

3 Waves: Rise in Overdose Deaths

4 of 5 new heroin users describe starting with prescription opioids

Total drug overdose deaths in SC increased by 3% from 2018 to 2019Compared with a 5% increase nationwide

Data source: SC Department of Health and Environmental Control, Vital Statistics

Number of

Deaths

1 CDC, National Center for Health Statistics

1131 Total Overdose Deaths

923 RX Drug-Involved876 Opioid-Involved

196 Heroin-Involved

537 Fentanyl-Involved

230 Cocaine-Involved

28 Methadone-Involved

338 Psychostimulant Involved

0

200

400

600

800

1000

1200

2014 2015 2016 2017 2018 2019

Total Overdose Deaths

https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm

Overdose Deaths in the U.S. 2018

Biopsychosocial Model

U.S. Department of Health and Human Services (2019, May). Pain Management Best Practices Inter-Agency Task ForceReport: Updates, Gaps, Inconsistencies, and Recommendations. Retrieved from U. S. Department of Health and Human

Concept of Total Pain

Multi-Modal Approach to Pain


Culture Change – Historic Practice

Adjuncts (Neurontin / Clonidine)

NSAIDs, Tylenol, Ketamine

Extended-Release Opioids

Short-acting or IV Opioids

WEAN

ING

TREA

TMEN

T

Culture Change – Future Practice

Adjuncts (Neurontin / Clonidine)

NSAIDs, Tylenol, Ketamine

Extended-Release Opioids

Short-acting or IV Opioids

Non-Pharmacologic Therapies

WEAN

ING

TREA

TMEN

T

Multimodal Pharmaceutical Approach

Kehlet H, Dahl JB. Anesth Analg. 1993;77:1048-1056

• Altering perception of pain in the central nervous system

• Inhibiting local production of pain mediators

• Interrupting neural impulses in the spinal cord

Using combinations of drugs to maximize pain relief while minimizing adverse effects

WHO Step Approach

Acetaminophen • Mild pain• Ideal for those

that should not receive NSAIDs

• Opioid-sparing• NTE 4 g/day

NSAIDs• Moderate pain• Consider

ulcerogenic and cardiovascular risk factors

• Consider alternatives in anti-coagulated patients

Opioids• Severe and

breakthrough pain

• Side effects • Ensure bowel

regimen

Acetaminophen

• Acetaminophen (paracetamol)– Mechanism: inhibition of prostaglandin synthesis in the

CNS, but not peripherally• Fewer adverse effects than other non-opioid analgesics

– Minimal anti-inflammatory effects– Suppresses fever and pain– No effect on platelet function or GI ulceration risk– Adverse effects

• Risk for hepatotoxicity at high doses due to accumulation of a toxic metabolite that forms when glutathione is depleted

– ↑ Risk with liver disease or chronic alcoholism

NSAIDs

• Mechanism– Inhibit cyclooxygenase (COX), an enzyme that

converts arachidonic acid into prostaglandins and related compounds

• Subdivided into:– First-generation: Inhibits COX-1 and COX-2– Second-generation: COX-2 selective

• Consequences of COX inhibition: – COX-1: gastric ulceration, renal impairment, bleeding– COX-2: suppresses inflammation, pain and fever

NSAIDs: Toxicity Review

NAPROXEN is the preferred agent in patients with CV risk factors because it does not appear to increase the risk of CV events

GI Toxicity

CV Risk

Non-Opioid Comparable Data

JAMA 2017 Nov 7;318(17):1661-1667. J Perioper Pract .2009 Dec;19(12):418-23

Pain Relief

Journal of the American Dental Association (1939) 144(8):898-908

Patient Satisfaction

JAMA Network Open. 2020;3(3):e200901. doi:10.1001/jamanetworkopen.2020.0901

No Difference Between the Groups

Magic in a Bottle !!

AND VS

Enhanced Recovery After Surgery (ERAS)

Enhanced Recovery After Surgery (ERAS)

Enhanced Recovery After Surgery Programs

• Key Medication Components: – Scheduled acetaminophen 24-48hrs prior to surgery to

ensure adequate blood levels– AM multi-modal approach to pain pathways– Intraoperative infusions with reduced opioid administration

• Use lowest dose-specific products to minimize waste and likelihood of administration without benefit

– PACU IV push ketamine prior to opioids for pain control

– Post-operative low-dose ketamine and/or lidocaine infusions to reduce opioid requirements

• Continue scheduled acetaminophen as a baseline therapy

Ketamine: The Quick and Dirty

• Dissociative anesthetic/hypnotic• Non-competitive inhibitor of NMDA receptor• Wide variation of dosage ranges allowing for varying

effects (dopamine)• Has been shown to reduce consumption of opioids

– Not a substitute but when used as adjunctive therapy• Low-dose infusions: 1-5mcg/kg/hr• IV push doses: 10mg every 15 min up to 30mg MAX• Monitor for: nystagmus, hallucinations, visual

disturbances, tachycardia, hypertension

Enhanced Recovery After Surgery Programs

Neuropathic Pain

• Affects 6-8% of the general population• Central and peripheral nervous system mechanisms

– Incited by inflammation, metabolic issues, or trauma• Ectopic peripheral foci • Peripheral reorganization or central sensitization

• Common symptoms– Burning– Numbness– Tingling– Stabbing– Shock-like pain– Pins and needles

Pract Neurol 2013;13(5):292-307

Approach: Neuropathic Pain

AnticonvulsantsGabapentin/Neurontin®

Pregabalin/Lyrica®[10% reduction in pain scores]

SNRIsDuloxetine/Cymbalta®[25% reduction in pain scores]

TCAsAmitriptyline/Elavil®

[40% reduction in pain scores]

SNRI = serotonin norepinephrine reuptake inhibitorTCA = tricyclic antidepressant

Neurology 2011;76(20):1758-65.Am J Med 2009;122:S22-23.

Titrate slowly 2/2 peripheral

edema, dizziness

Avoid following MI or in elderly

patients

Treatment Considerations

Number Needed to Treat (NNT) for ≥50% Pain Reduction

Medication General Neuropathic Pain

DiabeticNeuropathy

TCAs 2.6 (2.2-3.3) 3.0 (2.4-4.0)Duloxetine

(120 mg/day) --- 4.9 (3.6-7.6)

Venlafaxine 5.2 (2.7-5.9) ---Gabapentin 3.7 (2.4-8.3) 3.7 (2.4-8.3)Pregabalin

(300 mg/day) --- 6.0 (4.2-10.4)

Pregabalin(600 mg/day) --- 4.0 (3.3-5.3)

Neurol Clin 2013;31(2):337-403

Topical Anti-Pain Agents

• Capsaicin:– “Heat” from red peppers– Desensitizes and/or depletes substance P– Moderate to poor efficacy for both

nociceptive and neuropathic pain

• Menthol:– Stimulates the “cold” receptors to cause

cool sensation and eleviate pain

• Topical NSAIDs (Aspirin)• Topical Lidocaine

Comfortposition

Mobility

Music

Splinting or

traction

Caregiver assistance

Guided Imagery

Distraction

Empathy

Cold or Hot

packs

Non-pharmacologic

options

Non-Pharmacological Therapies

Non-Pharmacological Therapies

• Goals of nonpharmacologic interventions:– Decrease fear– Reduce distress and anxiety– Augment traditional pharmacological therapy to

reduce pain

• Potential barriers:– Perceived lack of time– Impact of environment (ED)– Practitioner or patient perception of benefits– Lack of knowledge or available trained staff

American Academy of Pediatrics; 2016.

Physical (Sensory) Interventions

Example Physical (Sensory) Interventions

Therapeutic exercise / Mobility

Hot and cold treatments

Positioning

Pressure Transcutaneous electrical nerve stimulation (TENS)


Therapeutic Exercise

• Bed rest was scientifically recognized and prescribed as a treatment for pain until the 1980s

• Evidence supporting the therapeutic exercise began to emerge and is now exists throughout several high-quality clinical studies

• Ultimately, therapeutic exercise is tied to the underlying diagnosis for the pain– Majority of PT related evidence supporting treatment of

musculoskeletal or spinal pain• Mobility as a simplified component of therapeutic

exercise is highly supported within the inpatient setting for escalation of discharge/recovery

Scand J Med Sci Sports. 2015;25 Suppl 3:1-72

Data to Support Therapeutic Exercise

• Depression • Anxiety & Stress• Schizophrenia • Dementia • Parkinson’s disease • Multiple sclerosis • Obesity • Hyperlipidemia • Metabolic syndrome

• Type 1 & 2 diabetes • Cerebral palsy• Hypertension • Coronary heart disease • Heart failure • Intermittent claudication • COPD• Asthma • Cystic fibrosis

Scand J Med Sci Sports. 2015;25 Suppl 3:1-72

Cold Therapy

Ice or cold packs reduce swelling and pain in strains, sprains and fractures. Do not put directly on bare skin.

Heat Therapy

• Active warming may reduce pain, anxiety, nausea, and heart rate in patients with inflammatory pain– Increasing blood flow to skin– Dilating blood vessels, increasing oxygen and

nutrient delivery to local tissues– Decreasing stiffness by increasing muscle elasticity

• Applied in 20-minute time periods– Beware of extreme heat and burns

Cognitive-Behavioral Techniques

Example Cognitive-Behavioral InterventionsPsychologic preparation, education, informationDistraction (passive or active): Video games, TV, phoneRelaxation techniques (breathing, meditation)MusicGuided imageryTraining and coachingCoping statements: “I can do this” or “this will be over soon”

An Intervention We Can’t Forget…

• Educational intervention!

Patient Education

• Set realistic pain expectations for patients • Focus on function, not pain score

– Can you get out of bed? Move to the toilet? Walk to the mailbox? – Is the pain manageable?

• Alternative therapies– Non-pharmacological therapies

• Ice, heat, or positioning• Biofeedback, imagery, or distraction• Massage, pressure and vibration

• Explain risks and benefits of opioids– Common side effects should NOT be ignored as risks!

Re-Direction or Distraction

• Utilize distraction methods vs. hyper-focusing patients on their pain levels

• Re-direct patients using the television, magazines, and other items to minimize patient focus on pain

• Re-adjust their pillows or positioning to improve comfort• Do not use a numeric pain score goal• Use “Out of bed with minimal discomfort” • Avoid “next dose due” or “last dose at”

– Patients focus on the time, and this impacts patient perspective on responsiveness of staff

Other Cognitive Therapies

• Music Therapy– “Reach for Your Playlist Instead of Popping a Pill”

• Data to support benefit in reducing pain, anxiety and medication use in various environments (ED, ICU, Post-op)

• Guided Imagery– Helps patients use imagination to divert thoughts from

the pain or procedure to a more pleasant experience

• Relaxation Techniques– Progressive muscle relaxation– Diaphragmatic breathing

Interventional Therapies


Neuromodulation

Intrathecal Delivery

• Many types of drugs:– Local Anesthetics

• Bupivacaine – Opioids

• Morphine PF• Hydromorphone PF• Fentanyl

– Clonidine– Ziconotide

Ziconotide

Epidural Steroid Injection

• Three Approaches:– Transforaminal– Interlaminar– Caudal

Chronic Pain Interventions

• DIAGNOSIS determines the injection• Most will include steroids

– NOT a “Cortisone” shot!• Diagnostic vs. Therapeutic injections

– Ensure discuss the rationale with patients

Ablation

• Radiofrequency ablation: “Burning stuff!”

Complementary Strategies


Acupuncture

• Systematic reviews have shown that acupuncture was effective for pain associated with:– Fibromyalgia– Herpes zoster– Endometriosis– Post-stroke shoulder pain

• Cochrane review of 5 RCTs (n=285) in cancer:– Benefited pancreatic cancer pain and late-stage unspecific cancer– Equivalent to conventional analgesia for stomach cancer– No difference between real vs. fake acupuncture for ovarian cancer

Paley CA Acupuncture for cancer pain in adults. Cochrane Database Syst Rev. 2015 Oct 15;2015(10)

Pilates and Yoga

• Cochrane review of 10 trials found some evidence for the effectiveness of Pilates for low back pain (LBP)– No conclusive evidence of superiority to other exercise

• A 12-week single-blind RCT trial (n=320) of yoga in adults with non-specific LBP– Compared 12 yoga classes,15 PT visits, or education– 40-week maintenance: yoga drop-in classes or PT sessions– Yoga was noninferior to PT for function and pain

• Cochrane review of 12 trials (n=1080) comparing yoga to non-exercise therapies for back pain– Minimal to moderate improvement– No conclusive evidence of superiority to other exercise

Yamato TP Pilates for low back pain. Cochrane Database Syst Rev. 2015 Jul 2;(7) Saper RB. Ann Intern Med. 2017 Jul 18;167(2):85-94

Wieland LS Yoga treatment for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017 Jan 12;1(1)

Summary

• Alternative approaches opioid for pain EXIST!!– Acceptance by patients and practitioners remain a barrier

• Communication is key!• Non-opioids can produce similar effects as opioids• Cognitive behavioral therapies can reduce pain or the

analgesic requirements• Interventional strategies often require specialized

training but can reduce the need for opioids• Complimentary medicine has mixed data, but has

been shown to reduce stress, anxiety, improve function and activity level

Summary

Thank You

Email Contact• Doug Furmanek PharmD BCCCP [email protected]

Special Thanks• Kevin Walker, MD FASA, Director Pain Management / Anesthesia • Prisma Health Opioid Stewardship Committee

mailto:[email protected]

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Thank You

Douglas L. Furmanek, PharmD, BCCCPDirector, Clinical Pharmacy Services

Assistant Professor – USC College of Medicine at GreenvilleAssistant Professor – SC College of Pharmacy

Department of Pharmacy Services Prisma Health Upstate, Greenville, SC

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Alternatives to Opioids