Opioid Prescribing for Chronic Non-Cancer Pain: Weighing the Benefits &

Risks Paul C. Coelho, MD

Board Certified PM&R Subspecialty Certified Pain Medicine

Table Of Contents

1. Patient Expectations for Pain Relief with Opioids

2. Actual Pain Relief with Opioids 3. Risks of Opioids for Chronic Noncancer Pain 4. Risk Reduction Opioid Clinic

1. Opioids: Realistic Benefits

Patients Often Expect 75% for Pain Relief with Opioids

Expectation

75% Pain Relief

2. Opioids: Actual Pain Relief

Actual Pain Relief with Opioids for Chronic Non-

Cancer Pain is about 30%

Actual Pain Relief

Is More Modest about 30%

Expectation (75%) vs Reality (30%)

Patient Expectation

Medical Reality

Rising Opioid Overdose Visits in the ER

Medicine Alone Does Not Work Well for Chronic Pain

Pain Specialists Consider 30% Relief a Success

Pain Specialists Also Use Other Objective Measures

of Pain Relief

• Improved Sleep • Decreased Depression • Improved Fatigue • Improved Function • Return to Work

Pain Specialists Also Use Other Therapies for Pain

• Activity Modifications • Life-Style Changes:

• Weight-loss • Smoking Cessation • Aerobic Activity

• Physical Therapy • Treatment of Depression

• Treatment of Anxiety • Treatment of PTSD • Cognitive Behavioral Therapy • Treatment of

Addiction/Dependency • Injections • Surgery

3. Opioids: Real Risks

Common Opioid Side-Effects

Breathing Problems Nausea Heart Attacks Dizziness Falls Worsening Pain Fractures

Decreased Sex Drive Immunosupression Dependency Addiction Overdose

Oregon Ranks #1 in the Nation in Prescription

Opioid Abuse

Prescription Opioid Deaths In Oregon 2000-2011

Women Are Disproportionately Affected

By Overdose Deaths

More than 50% of patients receiving opioids for 90d will remain on opioids for years.

High Dose Opioids Use Is Associated with Addiction &

Depression

1/3rd Of Patients Treated in Addiction Clinics Come

From Pain Clinics

Prescription Opioid Deaths & Addiction Treatment

Parallel Opioid Prescribing

4. Opioids: Risk Reduction

Who Can Not Be Treated With Opioids

1. Any history of diversion (selling drugs) 2. A history of suicide attempts with medication 3. Current methadone maintenance (addiction treatment) 4. No functional improvement after a trial or chronic use of opioids 5. A history of misuse or over use as defined by multiple prescriptions from multiple different providers or sites (doctor shopping) 6. A history of frequent utilization of the emergency room for attaining opioids 7. Prior dismissal violation of an opioid agreement 8. Active substance abuse, including alcohol, in the past 12 months 9. The use of marijuana, regardless of authorization status 10. Untreated or undertreated mental health condition 11. Opioid risk score > 7

Minimize Opioid Use In Conditions For Which There Is No Objective

Marker Of Disease Chronic LBP Fibromyalgia Syndrome Chronic HA Chronic Abdominal Pain Chronic Pelvic Pain Phantom Limb Pain

Stratify Patients for Risk of Abuse

Adopt WA State Dosing Guidelines

1. Low Dose = <50 MED

2. Intermediate Dose = 50 -100MED

3. High Dose = > 100MED

Milligrams Equivalent Dose (MS04)

Examples of 100MED

MSContin 30mg TID Oxycontin 30mg po BID Fentanyl Patch 25mcg/72hrs Opana 20mg po BID Nucynta 150mg po BID *Methadone 15mg po BID

Limiting Opioids Dose for Non-Cancer Pain Saves

Lives

Limiting Opioids Dose for Non-Cancer Pain Saves

Lives

Avoid Methadone

Avoid Methadone

Avoid Benzodiazepines : Valium, Xanax, Soma

Prescribe Rescue Medications & Training To

Special Populations

Set Reasonable Expectations For

Treatment: 30% Relief

Utilize a Formal Treatment Agreement

Document Adverse Effects

Adverse Effects: 1. Constipation 2. Somnolence 3. SOB 4. Falls 5. Automobile Accidents 6. ER Visits 7. DUI’s

Document Improvement in Function/Activities

Activities: 1. Exercise 2. Playing with kids/grand kids 3. Travel 4. Household chores 5. Socializing 6. Return to work

Document Aberrant Behaviors

1. Forging, altering, or stealing prescriptions 2. Stealing, borrowing, trading, buying, or selling drugs 3. Injecting or snorting oral drugs or fentanyl/suboxone patches 4. Doctor shopping/ER visits for opioids 5. Concurrent abuse of alcohol or illicit drugs 6. Falls, accidents, or other sedation related consequences of opioid overuse 7. Frequent stolen or lost prescriptions 8. Resisting changes to medications in spite of adverse effects 9. Aggressively complaining about the need for more drugs 10. Drug hoarding 11. Unsanctioned drug escalations 12. DUI’s 13. Frequent calls to the office to request more medications or early refills 14. Requesting specific drugs by name 15. Multiple reported NSAID or opioid allergies/sensitivities 16. Clinical ambushes with aggressive, hovering family members arguing for dose escalations 17. Marijuana use regardless of authorization status 18. Refusing random urine , blood, or saliva toxicology tests 19. Refusing or ‘no-showing’ for random pill counts

Aberrant Behaviors Lead to Stopping Prescribing

1.Repeated aberrant behaviors necessitate stopping the opioid trial.

2.The Oregon Medical Board considers patients whose aberrant behavior lead to a dismissal violation with one doctor to be unsuitable for opioid treatment with another doctor.

Access the Prescription Drug Monitoring Program

With Each Visit

Acquire Random Urine Toxicology Screening

Schedule a Minimum of Quarterly Follow-Up

Physicians For Responsible Opioid

Prescribing

www.supportprop.org