CDC Guidelines for Prescribing Opioids for

Chronic PainDenis G. Patterson, DO

ECHO ProjectMay 15, 2019

Contact Information

Denis G. Patterson, DONevada Advanced Pain Specialists

www.nvadvancedpain.compatterson@nvadvancedpain.com

http://www.nvadvancedpain.com/

Burden of Chronic Pain in the United States

Affects 100 million Americans (more than heart disease, cancer and diabetes combined)1

Costs society up to $635 billion annually1

Associated with 40 million doctor visits annually2

Results in 515 million lost workdays annually240% of all work absences are related to low back pain3

1. Institute of Medicine. Relieving pain in America: A blueprint for transforming prevention, care, education, and research. 2011.

2. Rich SJ. Adv Stud Pharm. 2009;6(4):115-119.3. Manchikanti L, et al. Pain Physician. 2009;12:699-802.

Chronic Pain Is Among the Top Costly Conditions

in the United States

1. Institute of Medicine. Relieving pain in America: A blueprint for transforming prevention, care, education, and research. 2011.

2. Wang Y, et al. Obesity 2008;16(10):2323-2330.

1 1

1 1 2

Chart1

Chronic pain

Heart disease

Cancer

Diabetes

Obesity

Series 1

Cost in billions of dollars (2010)

635

309

243

188

151

Sheet1

Series 1

Chronic pain635

Heart disease309

Cancer243

Diabetes188

Obesity151

To resize chart data range, drag lower right corner of range.

Changes in Pain Treatment Paradigms

• 1986 Portenoy and Foley published a seminal paper

• 1995 American Pain Society set guidelines for treating pain

• 1997 FDA allows direct-to-consumer marketing

• 1999 the VA Department launched a campaign known as “Pain is the Fifth Vital Sign”

• Joint Commission endorsed the VA campaign

The Dark Side• Since 1999, 140,000 people have died

from an overdose related to opioid pain medication in the US

• More than 16,000 deaths occurred in 2013, four times the number of overdose deaths related to these drugs in 1999

Unintentional Opiate Overdose Deaths Parallel Opioid Sales in United States, 1997–2007

• Overdose deaths– 2,901 in 1999– 11,499 in 2007

• Distribution by drug companies– 96 mg/person in 1997– 698 mg/person in 2007

Source: National Vital Statistics multiple cause of death data set and Drug Enforcement Agency ARCOS System

Overdose Deaths

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjMzI-Ds6HNAhUU8mMKHbaoAZIQjRwIBw&url=https://twitter.com/opendatazurich/status/691592058470010880&psig=AFQjCNGNqcXRknz67sc08G4WF9nbWx4fEg&ust=1465783308881196

Overdose Deaths, 2014

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjj4tXIs6HNAhVJ1mMKHVIAAR4QjRwIBw&url=http://www.antiaids.org/eng/news/world/how-the-epidemic-of-drug-overdose-deaths-ripples-across-america-10760.html&psig=AFQjCNGNqcXRknz67sc08G4WF9nbWx4fEg&ust=1465783308881196http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjj4tXIs6HNAhVJ1mMKHVIAAR4QjRwIBw&url=http://www.antiaids.org/eng/news/world/how-the-epidemic-of-drug-overdose-deaths-ripples-across-america-10760.html&psig=AFQjCNGNqcXRknz67sc08G4WF9nbWx4fEg&ust=1465783308881196

Overdose Deaths Related to Opiates, Washoe County Residents

Department of Health and Human Services

Chart1

2010

2011

2012

2013

2014

2015

Opiate Related Overdose Deaths

80

85

78

72

58

73

Sheet1

Opiate Related Overdose DeathsColumn1Column2

201080

201185

201278

201372

201458

201573

Department of Health and Human Services

Chart1

20102010

20112011

20122012

20132013

20142014

2015*2015*

Emergency Room Encounters

Inpatient Admissions

Hospital Data Related to Opiates,Washoe County Residents

493

710

564

687

596

908

919

960

884

961

1152

1126

Sheet1

Emergency Room EncountersInpatient Admissions

2010493710

2011564687

2012596908

2013919960

2014884961

2015*11521126

Time for Change

• March of 2016, The CDC published it’s Guideline for Prescribing Opioids for Chronic Pain

Target Audience• Opioid prescribing rates have increased

more for family practice, general practice, and internal medicine compared to other specialties from 2007 - 2012

• Presciptions by PCP’s account for nearly half of all dispensed opioid prescriptions

Guideline Goals

• Provide recommendations for primary care providers who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care

Recommendations

• Grouped into 3 areas of consideration:1. Determining when to initiate or continue

opioids for chronic pain2.Opioid selection, dosage, duration, follow

up and discontinuation3.Assessing risk and addressing harms of

opioid use

Determining when to initiate or continue opioids for chronic pain

• Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Providers should only consider adding opioid therapy if expected benefits for both pain and function are anticipated to outweigh risks to the patient.

Determining when to initiate or continue opioids for chronic pain

• Before starting opioid therapy for chronic pain, providers should establish treatment goals with all patients, including realistic goals for pain and function. Providers should not initiate opioid therapy without consideration of how therapy will be discontinued if unsuccessful. Providers should continue opioid therapy only if there is clinical meaningful improvement in pain and function that outweighs risks to patient safety.

Determining when to initiate or continue opioids for chronic pain

• Before starting and periodically during opioid therapy, providers should discuss with patients known risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.

Opioid selection, dosage, duration, follow up and discontinuation

• When starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting opioids.

Opioid selection, dosage, duration, follow up and discontinuation

• When opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, should implement additional precautions when increasing dosage to > 50 MME/day, and should generally avoid increasing dosage to > 90 MME/day.

Opioid selection, dosage, duration, follow up and discontinuation

• Long-acting opioid use often begins with treatment of acute pain. When opioids are used for acute pain, providers should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three or fewer days usually will be sufficient for most nontraumatic pain not related to major surgery.

Opioid selection, dosage, duration, follow up and discontinuation

• Providers should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Providers should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, providers should work with patients to reduce opioid dosage and to discontinue opioids.

Assessing risk and addressing harms of opioid use

• Before starting and periodically during continuation of opioid therapy, providers should evaluate risk factors for opioid-related harms. Providers should incorporate into the pain management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, or high opioid dosages (> 50 MME), are present.

Assessing risk and addressing harms of opioid use

• Providers should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving high opioid dosages or dangerous combinations that put him or her at risk of overdose. Providers shoulder review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.

Assessing risk and addressing harms of opioid use

• When prescribing opioids for chronic pain, providers should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.

Assessing risk and addressing harms of opioid use

• Providers should avoid prescribing opioid pain medication for patients receiving benzodiazepines whenever possible.

Assessing risk and addressing harms of opioid use

• Providers should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or Methadone in combinations with behavioral therapies) for patients with opioid use disorder.

Questions

Discussion

www.nvadvancedpain.com

CDC Guidelines for Prescribing Opioids for Chronic PainContact InformationSlide Number 3Slide Number 4Slide Number 5Burden of Chronic Pain in the United StatesChronic Pain Is Among the Top Costly Conditions �in the United StatesChanges in Pain Treatment ParadigmsThe Dark Side�Unintentional Opiate Overdose Deaths Parallel Opioid Sales in United States, 1997–2007Overdose DeathsOverdose Deaths, 2014Overdose Deaths Related to �Opiates, Washoe County ResidentsSlide Number 14Slide Number 15Time for ChangeTarget AudienceGuideline GoalsRecommendationsDetermining when to initiate or continue opioids for chronic pain�Determining when to initiate or continue opioids for chronic pain�Determining when to initiate or continue opioids for chronic pain�Opioid selection, dosage, duration, follow up and discontinuation�Opioid selection, dosage, duration, follow up and discontinuation�Opioid selection, dosage, duration, follow up and discontinuation�Opioid selection, dosage, duration, follow up and discontinuation�Assessing risk and addressing harms of opioid use�Assessing risk and addressing harms of opioid use�Assessing risk and addressing harms of opioid use�Assessing risk and addressing harms of opioid use�Assessing risk and addressing harms of opioid use�QuestionsDiscussionSlide Number 34