Safe and Effective Tapering of Opioids

OPIOIDEDUCATION

SDDEPT.OFHEALTHGRANT

• Protectagainstopioidabuse• Evaluationforopiatedependence/abuse• Opiateinitiation,monitoringandreview• Useofalternativestoopioids

SDDEPT.OFHEALTHGRANT

• Incorporatingpainassessmenttools• ProperDocumentationinpatientrecords• UseofthePDMPaspracticetool– (PrescriptionDrugMonitoringProgram)

Education

• Livepresentations• Webbasedcurriculum• “Toolkit”foropioidprescribing

SDDEPT.OFHEALTHGRANT

• Incorporatingpainassessmenttools• ProperDocumentationinpatientrecords• UseofthePDMPaspracticetool– (PrescriptionDrugMonitoringProgram)

Goals/Objectives

• Areviewofresourcesavailabletohelpthosewithaddiction

• Understandinghowtocreateaplanforsafelytaperingpatientsoffopioids

• Theutilizationofalternativestoopioids• Adiscussionofpatientmonitoringandreview

• 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?

• 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?

Statistics

Education/Resources

AddictionServicesAddictionServices

AssessmentTools

AssessmentTools

AssessmentTools

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

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

Tapering Opiates

Considerations:1.Adjusttherateanddurationofthetaperaccordingtothepatient’sresponse.2Don’treversethetaper;however,theratemaybeslowedorpausedwhilemonitoringandmanagingwithdrawalsymptoms.3Oncethesmallestavailabledoseisreached,theintervalbetweendosescanbeextendedandopioidsmaybestoppedwhentakenlessthanonceaday.

MME Calculator

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.

MME Calculator

SD Addiction Services

MME Calculator

AddictionServices

Medication“ladder”

Alternatives to opiates

MedicationAssistedTherapy

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

Patient Monitoring

• SDPDMP• UrineDrugScreen• Followup• “FunctionalAssessment”

SD Prescription Drug Monitoring, 2016

SD Prescription Drug Monitoring, 2017

Prescriptions:259,700v234,367

Hydrocodonedoses:17.4millionv14.9million

MME’s Prescribed Per Capita, 2015

MME’s Prescribed Per Capita, South Dakota, 2015

Socio-EconomicProblem

• Increaseaccesstomentalhealthandaddictionservices

• Psychosocialsupport• Opioidmaintenance:buprenorphine• Availabilityofnaltrexone