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Controlled Substance Management or Doctor I need Oxy Tony Tommasello, Ph.D. University of Maryland School of Pharmacy Office of Substance Abuse Studies.

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Presentation on theme: "Controlled Substance Management or Doctor I need Oxy Tony Tommasello, Ph.D. University of Maryland School of Pharmacy Office of Substance Abuse Studies."— Presentation transcript:

1 Controlled Substance Management or Doctor I need Oxy Tony Tommasello, Ph.D. University of Maryland School of Pharmacy Office of Substance Abuse Studies

2 Program Objectives At the end of this program participants will be better able to: Screen for substance abuse Assess the severity of a patients involvement with alcohol or illicit drugs Determine the legitimacy of a patients request for opioid analgesics Justify and document the decision to prescribe or refuse to prescribe CDS

3 Lawnmower Addict L.A. is a 42 Y.O. male who broke his ankle while mowing wet grass across an incline. After several surgical attempts including failed pinning operations, his foot is rotated 60 degrees out of alignment and he has chronic pain. Prior to this injury L.A. had a history of opioid addiction. He states that he is committed to recovery and participates in 12-step N.A. meetings but he abused his last oxycodone prescription and experienced a relapse. His goal is to achieve pain relief without relapse to opioid abuse.

4 Enduring pain to avoid relapse E.P. is a 40 y.o. married male with 4 children, He has been in opioid addiction recovery for over 9 years. I received a tearful midnight call from his wife stating the E.P. was lying in bed in a fetal position, moaning in pain and refusing to take opioid analgesics after incurring a back injury while wrestling with his son who is a star member of the high school wrestling team. His goal is to never relapse to active opioid addiction.

5 Scope of the Public Health Problem An estimated 2.4 million people have used heroin at some time in their lives (NHSDA, 1998) During 1996 through 1998, an estimated 471,000 persons used heroin for the first time. Of them, 25% were under age 18 and another 47% were age (NHSDA, 1999)

6 Heroin Price Falls, Purity Increases 1980 through 1998 Price in $US Purity (% heroin) Price in $US Data from U.S. Department of Justice: Drug Enforcement Administration

7 What about abuse? According to the National Institute on Drug Abuse (NIDA), in 1999 Four million Americans reported current use of prescription drugs for non-medical purposes The most dramatic increases were found among the 12 to 25 year olds Oxycontin® and Ritalin® were among the most cited abused medications

8 Oxycontin 80mg sustained release tablet

9 Source: Number of U.S. Narcotic Analgesic-Related ED Visits,

10 Narcotic Abuse Taxes ED Resources In 2001 there were an estimated 90,232 ED visits, a 117% increase since 1994 Dependence was the most frequently mentioned motive for abuse (44% of cases) Between 2000 and 2001 Oxycodone mentions increased 70% and accounted for 53.7% of the overall increase in narcotic abuse cases during that year. Source: The DAWN report January

11 Teen Abuse of Rx Drugs National figures Curran JJ: Prescription for Disaster – The growing problem of prescription drug abuse in Maryland. Sept 2005.

12 Access to treatment is limited Of the estimated 810,000 opioid dependent persons in the U.S. only 170,000 maintenance treatment slots exist.

13 The Journey Matters

14 Therapeutic drug use: Drug use to treat or diagnose illness. Almost everyone has taken a drug at one time or another because they were sick. A direct and reliable drug effect is expected. Antibiotics kill bacteria regardless of the sick persons belief in the medicine. The drug is a known entity. There are rules. The prescription tells: what to take, how much to take, and when to take it. A person who violates the rules must own the consequences.

15 Social Drug Use Drugs are used to increase social interactions. Rules are vague or non-existent. Drug supply is uncertain Most cases of addiction result from social drug use that gets out of control.

16 A Basic Distinction High seeking = Pain relief seeking Because 6 to 15% of the U.S. population abuses drugs, the history of pain management is marked by the undertreatment [of pain in] the other 85 to 94%. Passik SD quoted in: Gilson AM and Joranson DE (2002) U.S. Policies Relevant to the Prescribing of Opioid Analgesics for the Treatment of Pain in Patients with Addiction Disease Clinical Journal of Pain 18:S91- S98. available at

17 Pain Statistics Most common reason that people seek medical care 50 million Americans are partially or totally disabled due to pain Annual cost to U.S. society estimated to exceed $100 billion 50-80% of patients with pain report that their pain is inadequately managed Risk of undertreatment is increased among those with a history of substance abuse

18 Addiction Defined Addiction is compulsive use with loss of control and continued use despite adverse consequences.

19 Elements of Compulsivity: Constant thought of drug acquisition Anticipation of opportunities to use Defer other priorities of life Unable to resist desire to use

20 Aspects of Loss of Control Inability to use in moderation consistently Easier to abstain completely Frequent episodes of excessive use

21 Continued use despite problems Loss associated with use Multiple crisis not seen as drug-related Sincere promises to self and others to quit

22 Signs of Psychological Dependence Carrying Drugs Using Drugs alone Stockpiling Drugs Concern over supply Changing friends Finding excuses to use Using at inappropriate times Willingness to take increasing risks


24 The Memory of Drugs Nature Video Cocaine Video Front of Brain Back of Brain Amygdala not lit up Amygdala activated

25 DSM IV: Substance Dependence 3 of following in 12 month period: Tolerance Withdrawal Difficulty cutting down (loss of control) Time spent drug seeking (compulsive use) Decrease in activities Continued use despite knowledge of persistent physical or psychological problems

26 Addiction Characteristics First priority is drug acquisition and use Negative consequences occur in order 1) Interpersonal relationships suffer 2) Productivity declines 3) Self-Esteem plummets 4) Health problems emerge or worsen Note: Legal problems can occur at any time.

27 Why Treatment ? Dysfunctional lifestyle of opioid addiction makes treatment a desired alternative Oral methadone and buprenorphine sublingual tablets are approved for both medical withdrawal and medical maintenance Rewards Negative consequences Utility Theory

28 Addictive Behaviors Selling prescription drugs Prescription forgery Stealing drug from others Injecting oral formulations Buying drugs on the street Resistance to change therapy despite evidence of adverse effects from the drug

29 Drug-seeking behavior misidentified by health providers as addictive behavior, when it is actually relief-seeking behavior Behaviors resembling those of drug addiction disappear when patient is given adequate doses of analgesia Pseudo-addiction

30 Pseudoaddiction Behaviors Complaints for more drug Hoarding drug during pain free periods Specific drug requests Openly seeking other sources of help Occasional unsanctioned dose increases Resistance to change in therapy

31 Ambiguous Behaviors Complaints for more drug Hoarding drug during pain free periods Specific drug requests Openly seeking other sources of help Occasional unsanctioned dose increases Resistance to change in therapy

32 Principles Physical Dependence = Addiction Pain Management with opioids Physical dependence (common) Addiction (<3%)* * Brushwood et al. (2002) Pharmacists Responsibilities in Manageing Opioids: A Resource APhA Special Report American Pharmacists Association.

33 Summary Differentiating factors Motivation for use Route of administration Frequency of use and dose Pseudo-addiction? Continued use despite problems

34 Types of Pain Nociceptive Pain resulting from actual or potential tissue damage Results from ongoing activation of primary afferent nociceptive neurons by noxious stimuli Neuropathic Results from a disturbance in function or pathologic change in a neuron Can be peripheral or central

35 Pain Characteristics

36 Non-Verbal Signs of Pain Aggressive behavior Changes in daily activities Facial expression Bodily movements Vocal Mood Physical Assessment Values Change in vital signs

37 Symptom Analysis Precipitating events Palliating events Quality Severity Pain location and radiation Temporal relationships Associated symptoms Previous treatments and their effects

38 Pain Scales Numerical Pain Scale Faces Pain Scale

39 Pain Assessment Accept the patients description Thorough assessment of each pain History, examination, investigation Assess impact of pain on ADLs and functional status Assess other factors that influence pain Physical, psychological, social, cultural, spiritual Reassessment

40 Adapted from: World Health Organization. Cancer Pain Relief Mild Moderate Severe Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone ± Adjuvants APAP/Codeine APAP/Hydrocodone APAP/Oxycodone APAP/Dihydrocodeine Tramadol ± Adjuvants Aspirin Acetaminophen NSAIDs ± Adjuvants WHO-Step Ladder

41 Patient Centered Treatment Goals What would you like to do that you cant do because of your pain? Id like to be able to do my needlework Id like to walk to the bathroom – alone I want to sleep through the night I want to go back to work I want to be able to play with my children

42 With Uncontrolled Pain … Emotional Effects Depression, anxiety, anger Cognitive Effects Somatic focus, helplessness, catastrophization Behavioral Effects Inacitvity, social/sexual dysfunction, poor sleep, loss of productivity Physical Changes Muscle tension, poor posture, circulatory impairment, obesity Increased PAIN and Dysfunction PAIN

43 Four kinds of patients Two kinds of pain No History of Abuse (Group 1)* Substance abuser in the past (Group 2)* Addict in recovery including opioid maintenance patient Active substance abuser (Group 3)* Nociceptive pain Acute Chronic Somatic Visceral Neuropathic pain Chronic Acute * Gourlay et al. (2005) Pain Medicine 6(2)

44 The CAGE Screen Have you ever felt the need to Cut Down on your drinking Have you ever been Annoyed by criticism of your drinking Have you ever felt Guilty about your drinking Have you ever needed an Eye Opener to get going in the morning.

45 CAGE 4 yes/no questions (1 yes = positive) Administered by interview Alcohol only Screens for abuse and dependence Add quantity and frequency questions to screen for at-risk drinking Sens: 43% - 94% Spec: 78% - 96%

46 Toxicology Screening Tests Purposes To identify surreptitious use To monitor known users Clinical Examples Prenatal Care Impaired Professionals Trauma/ER Qualitative results

47 Legitimate patient with no Hx of addiction (Group 1*) Manage pain (analgesic ladder) Recognize low addiction risk Differentiate physical dependence from addiction Dont mistake pain relief seeking for drug seeking - pseudoaddiction * Gourlay DL et al. (2005) Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Medicine 6(2),

48 Pain Management and Addiction Confusion over the distinction between physical dependence (a state of adaptation that produces withdrawal signs upon abrupt drug discontinuation) and addiction (DSM-IV Substance Dependence) has confounded approaches to the patient in pain.

49 Misconception: Therapeutic use of opioids is commonly associated with substance abuse or addiction Reality: In patients with no history of substance abuse the risk of addiction following therapeutic use appears to be less than 3% Misconception regarding pain management with opioids

50 Clinical Features Distinguishing Opioid Use in Patients With Pain Versus Patients Who Are Addicted to Opioids (TIP 40) Clinical features Pain Pt. Addicted Pt. Compulsive drug use Crave drug (when not in pain) Obtain or purchase drugs from nonmedical sources Procure drugs through illegal activities Escalate opioid dose without medical instruction Supplement with other opioid drugs Demand specific opioid agent Cease use when effective alternatives are available Prefer specific routes of administration Can regulate use according to supply Rare Absent Rare Unusual Rare Usually No Usually (break through pain) Common Frequent Common Not usually Yes No

51 Patient populations under-treated for pain Elderly Minorities Children Terminally ill patients with HIV/AIDS Chronic non-cancer pain Perceived as high addiction risk Gilson AM and Joranson DE (2002) U.S. Policies Relevant to the Prescribing of Opioid Analgesics for the Treatment of Pain in Patients with Addiction Disease Clinical Journal of Pain 18:S91-S98. available at

52 Addict in solid recovery (Group 2*) May refuse adequate pain pharmacotherapy Use of buprenorphine Suggest increased support group work while on analgesic pharmacotherapy Conduct urine or saliva screens for unauthorized substances Utilize pain management contract * Gourlay DL et al. (2005) Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Medicine 6(2),

53 Misconception: it is illegal to prescribe or dispense opioids for a patient with a history of substance abuse Reality: It is not illegal and the regulatory agencies do not intend to restrict appropriate therapeutic use Misconception regarding pain management with opioids

54 Management Guideline for Recovering Addicts Relapse prevention: Relapse occurs most often when practitioners are unaware of their patients opioid addiction history (TIP43 p174) Education regarding the need for drug Patients fear and staff reluctance may conspire to under-medicate A patients previous drug of abuse should not be prescribed for pain treatment ( TIP 43 p176 ) TIP 43 Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs DHHS Publication No. (SMA) Rockville, Md.

55 Undiagnosed substance abuse or addiction – active users (Group 3*) Screen all patients for substance use disorders with CAGE Ask Make pain management contingent on thorough assessment and treatment if warranted Utilize pain management contract * Gourlay DL et al. (2005) Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Medicine 6(2),

56 Management Guidelines for High Risk (Group 2) and Active User (Group 3) Identify and treat underlying medical problem(s). Use appropriate drug, dose, and route Employ non-opioids when possible Recognize abuse behaviors Dont negotiate Refer to substance abuse and pain services Disclose plan for prescription abuse (Pain management contract)

57 Drug Diverter – Not a patient Medico-legal nightmare Do a thorough pain assessment Document, document, document First time patients who request specific agents Abide by pain management ladder – dont trade off good medical practice for convenience

58 Policy Barriers to Effective Pain Management Lack of training or expertise by healthcare practitioners and limited access to pain specialists Regulatory steps to prevent drug diversion may also impede pain management (Electronic CDS prescriptions) Perceived risk by physicians that sanctions may be imposed by regulatory boards for over prescribing opioids for non-malignant conditions (Chilling Effect) Poor communication

59 Federal Food Drug Cosmetic Act and the Controlled Substances Act FFDCA CSA Pain specialists may treat a chronic pain patient currently enrolled in a narcotic treatment program with narcotics. The CSA does not set standards of medical practice. It is the responsibility of individual practitioners to treat patients according to their professional judgment for a legitimate medical purpose in accordance with generally acceptable medical standards. P. Good (2000) Chief; Liaison and Policy Section, Office of Diversion Control DEA.

60 The Pharmacists Dilemma To fill or not to fill YesNo Yes OK Dispense Resolve problem (dose, route interaction) NoResolve document problem Dont dispense Legally Valid Therapeutically Appropriate

61 Corresponding Responsibility Rule 21 CFR A prescription for a CDS to be effective must be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice. The responsibility for the proper prescribing and dispensing of CDS is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription. An order purporting to be a prescription issued not in the usual course of professional treatment or in legitimate and authorized research is not a prescription and the person knowingly filling such a purported prescription as well as the person issuing it shall be subject to the penalties provided for violations of the provisions of law relating to CDS.

62 Federal CDS schedules IHigh abuse potential No current accepted medical use May be used in research Heroin, LSD, MDMA IIHigh abuse potential Accepted medical uses Morphine, hydromorphone, methadone, oxycodone, cocaine, amphetamines IIILess abuse potential than I and II Accepted medical uses Opioid combined with non-opioids, anabolic steroids, buprenorphine IVLess abuse potential than III Accepted medical uses Benzos, Chloral hydrate, phenobarb, fenfluramine. VLess abuse potential than IV Accepted medical uses Antitussives with limited amounts of codeine

63 CDS Requirements IISigned prescriptions*; no refills; prescriber must be registered with DEA III & IV Written, oral, or faxed prescription; refill 5 times in 6 months; prescriber must be registered with DEA VWritten, oral, or faxed prescription; refill as authorized; prescriber must be registered with DEA * - Emergency prescriptions require follow up prescription, Fax may be used for home infusion/intravenous therapy, long term care facility, and hospice patients

64 Model Prescription Schedule II medication Ralph Amado, M.D North Hampton Lane Rudolph, PA AA Roger Bacon 1063 Eastlight Dr. Essex, PA Physician name, address, and DEA number Patient name and address Oxycontin 20mgs Tablets #60 (sixty) Drug name and strength Dosage form and quantity SIG: for pain take one tablets every 12 hours. Date issued: 4/18/06 Patient: Refill x 0 (none) Physician signature: Ralph Amado

65 Red Flags for Prescription Forgery The prescription is too legible Standard abbreviations are not used The prescription appears to be photocopied More that one ink color or handwriting used Erasure marks visible Paper appears to have been wet. (acetone) Odd combinations of medications Someone other than the patient presents the prescription for dispensing\

66 Prescription Drug Monitoring Programs Electronic PDMP passed in 2006 Maryland general session (SB 333 & HB 1287) and was vetoed by Gov. Ehrlich on May 26, As of April 2005, 22 states already adopted electronic PDMPs Of the various PDMP approaches (serial Rx, triplicate) electronic systems are the least intrusive and chilling on prescribing practices. Brushwood DB, Hahn KL and Rickert ED (2005) Pharmacists Responsibilities in Managing Opioids: 2005 update. American Pharmacists Association CE Monograph

67 Federation of State Medical Boards The board will judge the validity of prescribing on the physicians treatment of the patient and on available documentation, rather than on the quantity and chronicity of prescribing Evaluation of patient, treatment plan, informed consent and agreement for treatment, periodic review, consultation,medical records, compliance with regulations

68 Case: Acute Pain Patient with hx of heroin addiction who is currently receiving buprenorphine sublingual tablets (Suboxone®) comes to Acute Care Center with compound fracture of the right femur.

69 Case: Acute Pain - Issues Ability to control pain in patient receiving chronic partial antagonist therapy Risk of relapse Uncontrolled pain may delay/impair rehabilitation and recovery

70 Case: Acute Pain- Strategies Non-pharmacologic and non-opioid interventions should be optimized first Engage patient in strategies that have aided in their recovery as soon as possible Consult addiction medicine specialist When opioids are necessary, use long-acting, slower onset formulations when possible Must D/C buprenorphine in order to obtain full agonist effect of mu agonists.

71 Examples of Nonpharmacologic Interventions for Pain Cognitive- Behavioral education/instruction relaxation imagery music distraction biofeedback Physical Agents heat or cold compress massage, exercise, immobilization transcutaneous electrical nerve stimulation

72 Mechanistic stratification of antineuralgic agents. PNS = peripheral nervous system; CBZ = carbamazepine; OXC = oxcarbazepine; PHT = phenytoin; TPA = topiramate; LTG = lamotrigine; TCA = tricyclic antidepressant; NE = norepinephrine; SSRI = selective serotonin re- uptake inhibitor; SNRI = serotonin and norepinephrine re-uptake inhibitor; GBP = gabapentin; LVT = levetiracetam; NMDA = N-methyl- D-aspartate; NSAID = nonsteroidal anti-inflammatory drug. Beydoun A. Neuropathic pain: from mechanisms to treatment strategies. [Journal Article] Journal of Pain & Symptom Management. 25(5 Suppl):S1-3, 2003

73 Case: Acute Pain- Strategies Begin tapering of opioids as soon as possible but gradually to avoid any withdrawal symptoms Treat relapse if it occurs Re-start buprenorphine therapy

74 Misconception regarding pain management with opioids Misconception: patients on methadone maintenance therapy should not be experiencing pain Reality: Reluctance to provide adequate pain treatment to patients on medication assisted therapy usually is based on the mistaken belief that a maintenance dose of opioid addiction treatment medication also relieves acute pain (TIP43 p174) TIP 43 Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs DHHS Publication No. (SMA) Rockville, Md.

75 Guidelines for Methadone Patients Dont expect the patients methadone maintenance dose to provide analgesia Continue patients maintenance dose Add analgesic (opioid and otherwise) starting with usual doses Anticipate tolerance and the need for higher dose requirement

76 Sample Adult Screening Protocol Transition: Stresses and ways of coping Do you use tobacco? (if so, Are you interested in quitting?) Do you drink alcohol? Have you ever experimented with any drugs? Ask CAGE or CAGE-AID questions Ask Q/F questions on alcohol Usually takes less than one minute

77 For Especially Sensitive Situations Ask about friends first Ask about prior use first Make normalizing statements before asking questions

78 Review of Pain Classifications Acute Pain Warning that tissue injury (or disease) has occurred Subsides as healing takes place (usually less than 3 months) Often accompanied by autonomic responses – tachycardia, tachypnea, hypertension, diaphoresis, mydriasis Goal: relieve pain and allow healing to occur CURE evidence supports that pain relief may hasten healing following many types of injuries

79 Review of Pain Classifications Chronic Nonmalignant Pain May initially be elicited by injury but may persist long after healing has taken place and change in characteristics and location May occur following injury, chronic disease, or have no definable cause Examples: diabetic neuropathy, radicular or low back pain Typically persists for months to years and may be continuous (persistent) or cyclic (chronic) Goal: relief and management as cycles occur

80 Review of Pain Classifications Chronic Nonmalignant Pain Not associated with autonomic responses Frequently associated with depression, anxiety, fear, sleep disorders, anorexia, disability Likely to develop physical dependence and tolerance to analgesics Use of opioids has been controversial but becoming more widely accepted in specific circumstances Evidence that functionality improves Cognitive and motor impairment are not problems associated with chronic use Goal: relief and rehabilitation (not cure)

81 Review of Pain Classifications Malignant Pain Associated with cancer or some similar progressive, ultimately fatal disease Frequently worsens in intensity and spreads to other areas of the body as the disease progresses Not associated with autonomic responses Frequently associated with depression, anxiety, fear, sleep disorders, complications of the cancer and other symptoms including hiccups, cough, chronic nausea, shortness of breath, myoclonus, delirium as patient enters final days to weeks of life Physical dependence is assumed and patients usually require higher and higher doses of opioids due to tolerance and disease progression Goal: relief, maintain function, quality of life, palliative care

82 American Academy of Pain Medicine and American Pain Society Joint Statement 1997 Good medical practice for patients receiving chronic opioid therapy involves: Complete patient evaluation including coexisting diseases and conditions Treatment plan: inform patient of risks and benefits of opioids and conditions for prescribing. Consultation with specialists Periodic review of efficacy, AEs, functional status, QOL, medication misuse Thorough documentation

83 The VIGIL System Verification: that the pt. can take the medication responsibly and that the Rx is genuine Identification: drivers license or other ID Generalization: establish the general parameters of the provider-pt relationship Interpretation: the decision to dispense is made Legalization: ensuring adherence to legal requirements for treatment While this process takes time – most bona fide patients will accept or welcome it because it acknowledges their need for ongoing treatment with controlled substances and provides rules for safe conduct with these agents. Bogus patients will not be willing to meet these requirements.

84 Case: Chronic Nonmalignant Pain Patient with diabetic neuropathy, degenerative spinal disease, and history of cocaine (nasal) dependence. Pain described as shooting up right leg, dysesthesias, burning and numbness in both feet. Recurrent diabetic foot ulcers that required amputation of several toes. Frequently misses work due to pain. Receiving maximum doses of gabapentin and SSRI. Previously has failed trials of imipramine and carbamazepine. A trial of oxycodone 10 mg Q 4 H improves pain significantly, however his clinician feels that he should decide whether he wants to take the risk of addiction.

85 Case: Chronic Nonmalignant Pain- Issues Past substance abuse places him at greater risk for opioid abuse and dependence (10-25%) Patient seeking medical attention has a right to treatments that he may benefit from Clinicians have ethical responsibility to intervene and relieve suffering (beneficence) but should exercise knowledge, skills and experience in making intervention decisions Clinicians should not knowingly cause unwanted injury or suffering Inadequate treatment of pain has been found to be criminal negligence and malpractice in courts

86 Case: Chronic Nonmalignant Pain- Issues If patient is impaired, does he have the capacity to understand risks and make judgment? Determining etiology and pathophysiology of chronic pain syndromes if often difficult Chronic pain is often complicated by depression and anxiety which may limit patients ability to make balanced decision and other complications of unrelieved pain

87 Case: Chronic Nonmalignant Pain- Issues Unrelieved or undertreated pain may: provoke drug abuse in patients with substance abuse prevent patient from fulfilling responsibilities that impact others – salary, benefits

88 Case: Chronic Nonmalignant Pain- Strategies Non-opioid strategies should be evaluated prior to initiation of opioids including co- analgesics Individuals caring for patient should be experienced in chronic pain, substance abuse and use of opioids in patients with history of substance abuse

89 Case: Chronic Nonmalignant Pain- Strategies When opioids are considered: Patient should be informed (in writing) of potential risks and benefits and conditions of treatment and given opportunity to accept or reject opioid trial Pain Management contract

90 Case: Chronic Nonmalignant Pain- Strategies Special monitoring and clear limits regarding opioid use should be set (to avoid secondary harm of substance abuse) Prescriptions are for fixed amounts, clinicians should see patients more frequently than other patients Single pharmacies Pharmacy will not accept opioid prescriptions from other than contracted prescriber Inappropriate behavior, accelerated use of opioids etc will result in screening

91 Case: Chronic Nonmalignant Pain- Strategies Treatment goals should be clearly established – pain relief, function, quality of life Pain should be adequately treated using standardized guidelines (including use of breakthrough medications) – may lead to pseudoaddiction or abuse Opioid doses in patients with history of substance abuse frequently are higher than typical doses Underdosing may provoke or exacerbate abuse

92 Case: Chronic Nonmalignant Pain- Strategies Due to prior history of abuse, patient should connect (if not already) with AA or NA, etc or formal treatment program – some clinicians may require participation for prescriptions

93 Pharmacotherapy General Principles Around-the-clock dosing and long-acting formulations for continuous pain As-needed immediate-release analgesic supplementation for breakthrough pain Observe for end-of-dose failure Incident pain prophylaxis Spontaneous pain suggestive of visceral/neuropathic etiology Anticipate, prevent, and treat predictable SEs Constipation

94 Conclusions There is no easy formula for dealing with this common yet complex area of patient care Engage addiction specialists sooner rather than later

95 Conclusions Consider referral to pain management specialist when standard approaches fail and discomfort sets in – before the situation has escalated out of control. Employ the assistance and cooperation of a competent pharmacist who maintains a patient centered pharmacy practice.

96 Recommended Readings and Websites Gilson AM and Joranson DE. (2002) U.S. Policies Relevant to the Prescribing of Opioid Analgesices for the Treatment of Pain in Patients with Addictive Disease Clin J Pain 18: S91-S98. Brushwood DB, Finley R, Giglio JG and Heit HA (2002) APhA Special Report: Pharmacists Responsibilities in Managing Opioids: A Resource. (American Pharmacists Assocition) Gilson AM, Ryan KM, Joranson DE and Dahl JL (2004) A Reassessment of Trends in the Medical Use and Abuse of Opioid Analgesics and Implications for Diversion Control: J. Pain and Symptom Management 28(2) Websites of interest: Brushwood DB (2002): The Pharmacists Duty to Dispense Legally Prescribed and Therapeutically Appropriate Opioid Analgesics. Pharmacy Times January 2002 C.E. program. Gourlay DL et al. (2005) Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain. Pain Medicine 6(2)

97 Recommended Readings and Websites TIP 43 Center for Substance Abuse Treatment. (2005) Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs DHHS Publication No. (SMA) Rockville, Md TIP 40 Center for Substance Abuse Treatment. (2004) Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction DHHS Publication No. (SMA) Rockville, Md

98 DEA You


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