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Prisma Health Opioid Symposium
February 1, 2020
Opioid Crisis OverviewDouglas L Furmanek PharmD BCCCP
Director, Clinical Pharmacy ServicesPrisma Health Upstate
Objectives
• Review the history of opioid use relative to the current epidemic
• Describe the health system impact on the appropriate use of opioids
• Understand opioid pharmacology, morphine milligram equivalents (MMEs), and conversion between agents
• Discuss adjunctive agents used to treat pain
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History of Opioids
• Opium was first reported in 3400 B.C. in Mesopotamia (Southwest Asia)
History of Opioids
• Morphine• Isolated by a German chemist in 1803-1804
• Roughly 10X more potent than processed opium
• “Miracle Drug” used only for severe war injuries and the mentally ill
History of Opioids
• Morphine molecule’s addictive and dependency quickly escalated
• Then family tragedy hit …
• Heroin synthesized from morphine in 1874• Made commercially available by Bayer in 1898
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Opioid Similarities
morphine hydrocodone hydromorphone
codeine oxycodone heroin
Letter to the Editor
Opioid Epidemic !!!
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More than 72,000 Americans died from drug
overdoses in 2017.
2017 Opioid Prescribing Rate per 1000 Persons
11
South
Carolina
Rank: 9th
Opioid RXs (> 90 MME) Dispensed per 100 Persons
12
South Carolina
Rank: 20th
MME = Morphine Milligram Equivalents
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https://www.scdhec.gov/Health/Opioids/
Case for Change: Prisma Health
Hospital Influence on Opioid Dependency
• Studies show:
• 10% risk of chronic opioid usage after “cancer” surgery
• 5-6% risk of persistent usage of opioids post operatively
• 15-25% of post op prescriptions were consumed
• 50% of opioids used for nonmedical purposes are obtained from friends or relatives
J Clin Oncol. 2017 Dec 20;35(36):4042-4049
AMA Surg. 2017 Jun 21;152(6)
Ann Surg. 2017 Apr;265(4):709-714
4 of 5 new heroin users describe
starting with prescription opioids
Analgesics – Quick Overview
Opioid Analgesics Non‐‐‐‐Opioid Analgesic
Act centrally Act peripherally
Addiction, dependence, tolerance Not‐habit forming
Schedule II,III controlled drugs Not controlled drugs
Notable adverse effects:
sedation, respiratory
depression, constipation
Notable adverse effects: gastric
irritation, bleeding, renal toxicity
No anti‐inflammatory effects Anti‐‐‐‐inflammatory effects
No ceiling effects Ceiling effect
Anesthesia and Pain Medicine. 2010 Apr;112(4):810‐33
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Culture Change – Old Practice
Adjuncts (gabapentin / clonidine)
NSAIDs, acetaminophen
Extended Release Opioids
Short-acting or IV Opioids
TR
EA
TM
EN
T
WE
AN
IN
G
Culture Change in Prescribing Practices
Adjuncts (Neurontin / Clonidine)
NSAIDs, Tylenol
Extended Release Opioids
Short-acting or IV Opioids
Non-Pharmacologic Therapies
WE
AN
ING
TR
EA
TM
EN
T
WHO Step Approach
Acetaminophen
• Mild pain
• Ideal for those that should not receive NSAIDs
• Opioid-sparing
• NTE 4 g/day
• (consider all sources)
NSAIDs
• Mild to moderate pain
• Consider ulcerogenicprofile and cardiovascular (CV) risk when selecting agent
• Consider alternative agents in anti-coagulated patients
Opioids
• Severe and breakthrough pain
• Potential for side effects
• Ensure bowel regimen
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CultivateWell-being
Reduce Pain
Improve Quality of Life
Restore Function
SELFCARE
Multi-Dimensional Care
Psycho-Behavioral
Cognitive Behavioral TherapyAddress Mental Health
Meditation
Procedural
Nerve blocksSteroid injectionsLocal injections
Physical
ExerciseMassage
Heat / Cold TherapyAcupuncture
Yoga
*Flor H, Fydrich T, Turk DC. Pain. 1992;49:221-230.
*Gatchel RJ, Okifuji A.J Pain. 2006;7:779-793.
Kamper SJ et al. Cochrane Database Syst Rev.
2014:CD000963.
Medication
AcetaminophenNSAIDS
Adjunctive AgentsKetamine Lidocaine
Treatment of Acute Pain
• Chronic opioid use often starts with treatment of acute pain
• 1 of 8 opioid naïve patients who receive narcotics after a procedure become persistent users
• Patients traditionally use less than 15% of total opioid RX
Shortest therapeutic
duration
Immediate-
release
Lowest effective
dose
N Engl J Med 2016; 374:1501-1504
CDC Guideline for Prescribing Opioids for Chronic Pain; 2016.
http://turnthetiderx.org/treatment/
3 days or less will usually
be sufficient…
>7 days rarely needed>7 days rarely needed>7 days rarely needed>7 days rarely needed
3 days or less will usually
be sufficient…
>7 days rarely needed>7 days rarely needed>7 days rarely needed>7 days rarely needed
Practice Changes:
Re-evaluation of patient
Re-engagement in pain
management plan
Opioids
• “… any drug, natural or synthetic, that has actions similar to those of morphine”
• Considered the most effective analgesics• Mimic the action of endogenous opioid peptides (endorphins) primarily at mu receptors and some at kappa receptors
• Opioid-induced sedation / euphoria can complement pain relief
• Leads to high liability for abuse
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Opioids
Monitor for Opioid-Induced Side Effects
• Key side effects:• Respiratory depression (#1)
• Reduced respiratory effort
• Reduced respiratory rate
• Low blood pressure
• Slow heart rate
• Confusion or dizziness
• Constipation
• Upset stomach
• Dry mouth
Drug Interactions
Interacting Drugs Outcome of Interaction
CNS Depressants
Benzodiazepines
Alcohol
AntihistaminesPhenothiazines
Increased respiratory depression and sedation
Agonist-antagonist opioids Precipitation of withdrawal reaction
Anticholinergic Drugs
Atropine
Antihistamines
PhenothiazinesTricyclic antidepressants
Increased constipation and urinary retention
Hypotensive agents Increased hypotension
Monoamine oxidase inhibitors Hyperpyrexic coma
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2016: The CDC Weighs In
• SPEAK ONE COMMON LANGUAGE for opioids• Morphine Milligram Equivalents (MME)
• Close monitoring
• Reduction or tapering of daily dose
Dowell. MMWR Vol 65;No 1, 3/2016.
JAMA 2016;315(15):1624-45.
90 MME – Risk of overdose
death increases 10X
Calculating MMEs
https://www.cdc.gov/drugoverdose/prescribing/guideline.html
Putting it into Perspective
50 MME / Day
50 mg of hydrocodone 10 tablets of Norco 5/325
30 mg of oxycodone 6 tablets of oxycodone 5 mg
12 mg of hydromorphone 3 tablets of hydromorphone 4 mg
90 MME / Day
90 mg of hydrocodone 9 tablets of Norco 10/325
60 mg of oxycodone 12 tablets of oxycodone 5 mg
24 mg of hydromorphone 6 tablets of hydromorphone 4 mg
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Converting Agents
Empiric 25-50% reduction in calculated equivalent is customary
AVOID
Patch Conversion
Oral morphine (24hr) Transdermal Fentanyl
25mg 12mcg/hr
50mg 25mcg/hr
100mg 50mcg/hr
150mg 75mcg/hr
200mg 100mcg/hr
• NOT indicated for acute pain management
– Delayed onset of action (12 – 24 hours)• T1/2: 18 hours after patch removal
Effects of Opiate Exposure
• Everyone• Short Term
• Pain relief
• Long Term (interpatient variability)
• Tolerance
• ↑ ↑ Amount of drug = Same effect
• Dependence
• Physiologic reliance on drug
• Must experience withdrawal upon discontinuation of drug
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Progression to Addiction
Adjuvant Therapies
• Not typically pain medications
• May relieve discomfort
• Potentiate the effect of pain medications
• Reduce the side effect burden
• Commonly used: • Acetaminophen +/- ibuprofen• Topical agents / creams• Antidepressants • Symptom management meds (mouth coat, antipruritics)
Approach: Neuropathic Pain
Anticonvulsants
Gabapentin/Neurontin®
Pregabalin/Lyrica®
[10% reduction in pain scores]
SNRIs
Duloxetine/Cymbalta®
[25% reduction in pain scores]
TCAs
Amitriptyline/Elavil®
[40% reduction in pain scores]
SNRI = serotonin norepinephrine reuptake inhibitor
TCA = tricyclic antidepressantNeurology 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
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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
Safe Disposal of Opioids
FDA Medicines Recommended for
Disposal by Flushing
Buprenorphine Methadone
Fentanyl Methylphenidate
Diazepam Morphine
Hydrocodone Oxycodone
Hydromorphone Oxymorphone
Meperidine Tapentadol
For disposal information, specific to another medication you are taking please visit Drugs@FDA
SC Drop Boxes & Take Back Programs
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Thank You