1. Prescribing Opioids in 2016: Still a Pain Jeff Varnell, M.D Cheyenne Mountain Resort April 15, 2016

2. Disclosure I have no relevant financial relationships to disclose

3. Being a medical caregiver means putting your self in suffering’s way 3 Rita Charon M.D.

4. History 4

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8. Opiates In 1806 Serturner isolated the morphine alkaloid and named it after the god of dreams, Morpheus 8 Works thru at least 4 receptors throughout the body Profound effect is the mu receptor CNS Controlled Substances Act in 1970 DEA enforces

9. Rates of prescription painkiller sales, deaths and substance abuse treatment admissions (1999-2010) National Vital Statistics System, 1999-2008

10. CDC declares painkillers at epidemic levels Opioids, Anxiolytics and Sedatives

11. Number one cause accidental deaths 11

12. So where did we lose control 12

13. So where did we lose control 13

14. Instead of addressing it we….. 14

15. Who is this NOT about? 15

16. Try non opioids 16

17. Risk areas 90 days 120 morphine equivalent dosing Long acting transdermal…. Diversion 17

18. You Came This Far to See Me?

19. Short vs long acting 19

20. Risk DEA

21. This Guy Isn’t Good Enough For My Kids!

22. Risk CMB

23. Risk legal

24. Risk suicide vs. overdose

25. Risk addiction

26. Risk diversion $5 a pill streetrx.com

27. Risk as it gets harder to get prescriptions…

28. Risk long acting and altered

29. Risk mixing with benzos

30. Risk grandma’s cabinet

31. Risk pill mills

33. Risk Tug Valley 29 individuals sued 5 docs caused the addiction Caused them to commit armed robbery, fraud and theft WV supreme court 3-2 for the plaintiffs 33

34. Top ten tips 34

35. 10 - Faces of addiction

36. Addiction vs. tolerance vs. dependence Addiction Compulsive use causing personal harm Psychological dependence Rare in terminally ill or pain management Usually preexisting abuse Physical dependence Abstinence syndrome Not psychologic addiction Decrease dose 50% Q 3 days Tolerance  Decreased effectiveness over time  Actually rare - if more needs there may be a reason  Don’t label a tolerant patient addicted

37. Stages of Change 37

38. Criteria of chronic illness Genetics Pathogenesis Precipitants Environmental determinants Gender specifics Complications Relapse-Remission

39. 9 – Screen for clear DX Cancer Nec fasciitis Compartment syndrome neuropathy 39

40. 8- Screen for high risk Biggest risk factor is a personal or family history of drug/ETOH abuse Journal of pain v109 pg 113-130 2009 Abuse CAGE and SOAAP Prior abuse Borderline personality Toxicology screen An honest discussion 40

41. 8 -Screen for high risk Journal of pain v109 pg 113-130 2009 Dog ate the pills Fell done the john Pharmacist shorted Lost my luggage Allergic to everything but…. 41

42. 7 - Avoid polypharmacy 42

43. 6 - Agreements and consent 43

44. Which of the following is NOT appropriate for a pain agreement? No diversion allowed May request a tox screen at any time Notify us by Thursday if scripts are lost or destroyed Can only go to 1 pharmacy 44

45. 5 - Urine tox screen

46. 4 - PDMP 46

47. 3- Beware bright lines Check if >120 MED Transdermal Long acting >90 days 47

48. Beware Bright Lines (cont.) CDC guidelines DORA guidelines 48

49. 2 – The tough discussion Come from a caring place Avoid cops vs docs Say no mean No No offense Doc…. Screen for addiction/diversion 49

50. 1– Don’t take off if you can’t land the plane 50

51. Our challenge "....in the sufferer, let me see only the human being” – Maimonides, 13th Century

52. And How would you approach? 52

53. Thank you 53 One thing you do differently Dennis Boyle M.D. COPIC Patient Safety and Risk Management dboyle@copic.com Any questions?