Presentation on theme: "Controlled Substance Management or “Doctor I need Oxy”"— Presentation transcript:
1Controlled Substance Management or “Doctor I need Oxy” Tony Tommasello, Ph.D.University of Maryland School of PharmacyOffice of Substance Abuse Studies
2Program ObjectivesAt the end of this program participants will be better able to:Screen for substance abuseAssess the severity of a patient’s involvement with alcohol or illicit drugsDetermine the legitimacy of a patient’s request for opioid analgesicsJustify and document the decision to prescribe or refuse to prescribe CDS
3Lawnmower AddictL.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.
4Enduring 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.
5Scope 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)
6Heroin Price Falls, Purity Increases 1980 through 1998 Purity (% heroin)Purity (% heroin)Price in $USPrice in $USData from U.S. Department of Justice: Drug Enforcement Administration
7What 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 purposesThe most dramatic increases were found among the 12 to 25 year oldsOxycontin® and Ritalin® were among the most cited abused medications
9Number of U.S. Narcotic Analgesic-Related ED Visits, 1994-2001 Source:
10Narcotic 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
11Teen Abuse of Rx Drugs National figures Curran JJ: Prescription for Disaster – The growing problem of prescription drug abuse in Maryland. Sept 2005.
12Access to treatment is limited Of the estimated 810,000 opioid dependent persons in the U.S. only 170,000 maintenance treatment slots exist.
14Therapeutic 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 person’s 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.
15Social Drug Use Drugs are used to increase social interactions. Rules are vague or non-existent.Drug supply is uncertainMost cases of addiction result from social drug use that gets out of control.
16A 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
17Pain Statistics Most common reason that people seek medical care 50 million Americans are partially or totally disabled due to painAnnual cost to U.S. society estimated to exceed $100 billion50-80% of patients with pain report that their pain is inadequately managedRisk of undertreatment is increased among those with a history of substance abuse
18Addiction DefinedAddiction is compulsive use with loss of control and continued use despite adverse consequences.
19Elements of Compulsivity: Constant thought of drug acquisitionAnticipation of opportunities to useDefer other priorities of lifeUnable to resist desire to use
20Aspects of Loss of Control Inability to use in moderation consistentlyEasier to abstain completelyFrequent episodes of excessive use
21Continued use despite problems Loss associated with useMultiple crisis not seen as drug-relatedSincere promises to self and others to quit
22Signs of Psychological Dependence Carrying DrugsUsing Drugs aloneStockpiling DrugsConcern over supplyChanging friendsFinding excuses to useUsing at inappropriate timesWillingness to take increasing risks
24The Memory of Drugs Nature Video Cocaine Video Amygdala not lit up Amygdala activatedFront of BrainBack of BrainSlide 10: The memory of drugs.This slide demonstrates something really amazing—how just the mention of items associated with drug use may cause an addict to “crave” or desire drugs. This PET scan is part of a scientific study that compared recovering addicts, who had stopped using cocaine, with people who had no history of cocaine use. The study hoped to determine what parts of the brain are activated when drugs are craved.For this study, brain scans were performed while subjects watched two videos. The first video, a nondrug presentation, showed nature images—mountains, rivers, animals, flowers, trees. The second video showed cocaine and drug paraphernalia, such as pipes, needles, matches, and other items familiar to addicts.This is how the memory of drugs works: The yellow area on the upper part of the second image is the amygdala (a-mig-duh-luh), a part of the brain’s limbic system, which is critical for memory and responsible for evoking emotions. For an addict, when a drug craving occurs, the amygdala becomes active and a craving for cocaine is triggered.So if it’s the middle of the night, raining, snowing, it doesn’t matter. This craving demands the drug immediately. Rational thoughts are dismissed by the uncontrollable desire for drugs. At this point, a basic change has occurred in the brain. The person is no longer in control. This changed brain makes it almost impossible for drug addicts to stay drug-free without professional help. Because addiction is a brain disease.Photo courtesy of Anna Rose Childress, Ph.D.Nature VideoCocaine Video
25DSM IV: Substance Dependence 3 of following in 12 month period:ToleranceWithdrawalDifficulty cutting down (loss of control)Time spent drug seeking (compulsive use)Decrease in activitiesContinued use despite knowledge of persistent physical or psychological problems
26Addiction Characteristics First priority is drug acquisition and useNegative consequences occur in order1) Interpersonal relationships suffer2) Productivity declines3) Self-Esteem plummets4) Health problems emerge or worsenNote: Legal problems can occur at any time.
27Why Treatment ?RewardsNegative consequencesUtility TheoryDysfunctional lifestyle of opioid addiction makes treatment a desired alternativeOral methadone and buprenorphine sublingual tablets are approved for both medical withdrawal and medical maintenance
28Addictive Behaviors Selling prescription drugs Prescription forgery Stealing drug from othersInjecting oral formulationsBuying drugs on the streetResistance to change therapy despite evidence of adverse effects from the drug
29Pseudo-addictionDrug-seeking behavior misidentified by health providers as addictive behavior, when it is actually relief-seeking behaviorBehaviors resembling those of drug addiction disappear when patient is given adequate doses of analgesia
30Pseudoaddiction Behaviors Complaints for more drugHoarding drug during pain free periodsSpecific drug requestsOpenly seeking other sources of helpOccasional unsanctioned dose increasesResistance to change in therapy
31Ambiguous Behaviors Complaints for more drug Hoarding drug during pain free periodsSpecific drug requestsOpenly seeking other sources of helpOccasional unsanctioned dose increasesResistance to change in therapy
32Principles Physical Dependence = Addiction Pain Management with opioidsAddiction (<3%)*Physical dependence (common)* Brushwood et al. (2002) Pharmacists’ Responsibilities in Manageing Opioids: A Resource APhA Special Report American Pharmacists Association.
33Summary Differentiating factors Motivation for useRoute of administrationFrequency of use and dosePseudo-addiction?Continued use despite problems
34Types of Pain Nociceptive Neuropathic Pain resulting from actual or potential tissue damageResults from ongoing activation of primary afferent nociceptive neurons by noxious stimuliNeuropathicResults from a disturbance in function or pathologic change in a neuronCan be peripheral or central
39Pain Assessment Accept the patient’s description Thorough assessment of each painHistory, examination, investigationAssess impact of pain on ADLs and functional statusAssess other factors that influence painPhysical, psychological, social, cultural, spiritualReassessment
40WHO-Step Ladder Severe Moderate Mild Morphine Hydromorphone Methadone LevorphanolFentanylOxycodone± AdjuvantsModerateAPAP/CodeineAPAP/HydrocodoneAPAP/OxycodoneAPAP/DihydrocodeineTramadol± AdjuvantsMildAspirinAcetaminophenNSAIDs± AdjuvantsAdapted from: World Health Organization. Cancer Pain Relief
41Patient Centered Treatment Goals “What would you like to do that you can’t do because of your pain?”“I’d like to be able to do my needlework”“I’d 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”
42With Uncontrolled Pain … Emotional EffectsDepression, anxiety, angerCognitive EffectsSomatic focus, helplessness, “catastrophization”Behavioral EffectsInacitvity, social/sexual dysfunction, poor sleep, loss of productivityPhysical ChangesMuscle tension, poor posture, circulatory impairment, obesityIncreased PAIN and DysfunctionPAIN
43Four 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 patientActive substance abuser (Group 3)*Nociceptive painAcuteChronicSomaticVisceralNeuropathic pain* Gourlay et al. (2005) Pain Medicine 6(2)
44The CAGE ScreenHave you ever felt the need to Cut Down on your drinkingHave you ever been Annoyed by criticism of your drinkingHave you ever felt Guilty about your drinkingHave you ever needed an Eye Opener to get going in the morning.
45CAGE 4 yes/no questions (1 yes = positive) Administered by interview Alcohol onlyScreens for abuse and dependenceAdd quantity and frequency questions to screen for at-risk drinkingSens: 43% - 94% Spec: 78% - 96%
47Legitimate patient with no Hx of addiction (Group 1*) Manage pain (analgesic ladder)Recognize low addiction riskDifferentiate physical dependence from addictionDon’t 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),
48Pain 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.
49Misconception regarding pain management with opioids Misconception: Therapeutic use of opioids is commonly associated with substance abuse or addictionReality: In patients with no history of substance abuse the risk of addiction following therapeutic use appears to be less than 3%
50Clinical Features Distinguishing Opioid Use in Patients With Pain Versus Patients Who Are Addicted to Opioids (TIP 40)Clinical featuresPain Pt.Addicted Pt.Compulsive drug useCrave drug (when not in pain)Obtain or purchase drugs from nonmedical sourcesProcure drugs through illegal activitiesEscalate opioid dose without medical instructionSupplement with other opioid drugsDemand specific opioid agentCease use when effective alternatives are availablePrefer specific routes of administrationCan regulate use according to supplyRareAbsentUnusualUsuallyNoUsually (break through pain)CommonFrequentNot usuallyYes
51Patient populations under-treated for pain ElderlyMinoritiesChildrenTerminally ill patients with HIV/AIDSChronic non-cancer painPerceived as high addiction riskGilson 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
52Addict in solid recovery (Group 2*) May refuse adequate pain pharmacotherapyUse of buprenorphineSuggest increased support group work while on analgesic pharmacotherapyConduct urine or saliva screens for unauthorized substancesUtilize 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),
53Misconception regarding pain management with opioids Misconception: it is illegal to prescribe or dispense opioids for a patient with a history of substance abuseReality: It is not illegal and the regulatory agencies do not intend to restrict appropriate therapeutic use
54Management 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 drugPatient’s fear and staff reluctance may conspire to under-medicate“A patient’s 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.
55Undiagnosed substance abuse or addiction – active users (Group 3*) Screen all patients for substance use disorders with CAGEAskMake pain management contingent on thorough assessment and treatment if warrantedUtilize 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),
56Management Guidelines for High Risk (Group 2) and Active User (Group 3) Identify and treat underlying medical problem(s).Use appropriate drug, dose, and routeEmploy non-opioids when possibleRecognize abuse behaviorsDon’t negotiateRefer to substance abuse and pain servicesDisclose plan for prescription abuse (Pain management contract)
57Drug Diverter – Not a patient Medico-legal nightmare Do a thorough pain assessmentDocument, document, documentFirst time patients who request specific agentsAbide by pain management ladder – don’t trade off good medical practice for convenience
58Policy Barriers to Effective Pain Management Lack of training or expertise by healthcare practitioners and limited access to pain specialistsRegulatory 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
59Federal Food Drug Cosmetic Act and the Controlled Substances Act CSAFFDCA“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.
60The Pharmacist’s Dilemma To fill or not to fill Therapeutically AppropriateYesNoOKDispenseResolve problem (dose, route interaction)Resolve document problemDon’t dispenseLegally Valid
61Corresponding Responsibility Rule 21 CFR 1306.04 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.
62Federal CDS schedules I High abuse potential No current accepted medical useMay be used in researchHeroin, LSD, MDMAIIAccepted medical usesMorphine, hydromorphone, methadone, oxycodone, cocaine, amphetaminesIIILess abuse potential than I and IIOpioid combined with non-opioids, anabolic steroids, buprenorphineIVLess abuse potential than IIIBenzos, Chloral hydrate, phenobarb, fenfluramine.VLess abuse potential than IVAntitussives with limited amounts of codeine
63CDS RequirementsIISigned prescriptions*; no refills; prescriber must be registered with DEAIII & IVWritten, oral, or faxed prescription; refill 5 times in 6 months; prescriber must be registered with DEAVWritten, 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
64Model Prescription Schedule II medication Physician name, address, and DEA numberRalph Amado, M.D.3862 North Hampton LaneRudolph, PA 38216AA620395Patient:Patient name and addressRoger Bacon1063 Eastlight Dr.Essex, PA 38604Drug name and strengthDosage form and quantityOxycontin 20mgsTablets #60 (sixty)SIG: for pain take one tablets every 12 hours.Refill x 0 (none)Physician signature: Ralph AmadoDate issued: 4/18/06
65Red Flags for Prescription Forgery The prescription is “too legible”Standard abbreviations are not usedThe prescription appears to be photocopiedMore that one ink color or handwriting usedErasure marks visiblePaper appears to have been wet. (acetone)Odd combinations of medicationsSomeone other than the patient presents the prescription for dispensing\
66Prescription Drug Monitoring Programs Electronic PDMP passed in 2006 Maryland general session (SB 333 & HB 1287) and was vetoed by Gov. Ehrlich on May 26, 2006.As of April 2005, 22 states already adopted electronic PDMPsOf 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
67Federation of State Medical Boards “The board will judge the validity of prescribing on the physician’s 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
68Case: Acute PainPatient 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.
69Case: Acute Pain - Issues Ability to control pain in patient receiving chronic partial antagonist therapyRisk of relapseUncontrolled pain may delay/impair rehabilitation and recovery
70Case: Acute Pain- Strategies Non-pharmacologic and non-opioid interventions should be optimized firstEngage patient in strategies that have aided in their recovery as soon as possibleConsult addiction medicine specialistWhen opioids are necessary, use long-acting, slower onset formulations when possibleMust D/C buprenorphine in order to obtain full agonist effect of mu agonists.
71Examples of Nonpharmacologic Interventions for Pain Cognitive-Behavioraleducation/instructionrelaxationimagerymusic distractionbiofeedbackPhysical Agentsheat or cold compressmassage, exercise, immobilizationtranscutaneous electrical nerve stimulation
73Case: Acute Pain- Strategies Begin tapering of opioids as soon as possible but gradually to avoid any withdrawal symptomsTreat relapse if it occursRe-start buprenorphine therapy
74Misconception regarding pain management with opioids Misconception: patients on methadone maintenance therapy should not be experiencing painReality: “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.
75Guidelines for Methadone Patients Don’t expect the patient’s methadone maintenance dose to provide analgesiaContinue patient’s maintenance doseAdd analgesic (opioid and otherwise) starting with usual dosesAnticipate tolerance and the need for higher dose requirement
76Sample 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 questionsAsk Q/F questions on alcoholUsually takes less than one minute
77For Especially Sensitive Situations Ask about friends firstAsk about prior use firstMake normalizing statements before asking questions
78Review of Pain Classifications Acute Pain Warning that tissue injury (or disease) has occurredSubsides as healing takes place (usually less than 3 months)Often accompanied by autonomic responses – tachycardia, tachypnea, hypertension, diaphoresis, mydriasisGoal: relieve pain and allow healing to occur CUREevidence supports that pain relief may hasten healing following many types of injuries
79Review 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 locationMay occur following injury, chronic disease, or have no definable causeExamples: diabetic neuropathy, radicular or low back painTypically persists for months to years and may be continuous (persistent) or cyclic (chronic)Goal: relief and management as cycles occur
80Review of Pain Classifications Chronic Nonmalignant Pain Not associated with autonomic responsesFrequently associated with depression, anxiety, fear, sleep disorders, anorexia, disabilityLikely to develop physical dependence and tolerance to analgesicsUse of opioids has been controversial but becoming more widely accepted in specific circumstancesEvidence that functionality improvesCognitive and motor impairment are not problems associated with chronic useGoal: relief and rehabilitation (not cure)
81Review of Pain Classifications Malignant Pain Associated with cancer or some similar progressive, ultimately fatal diseaseFrequently worsens in intensity and spreads to other areas of the body as the disease progressesNot associated with autonomic responsesFrequently 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 lifePhysical dependence is assumed and patients usually require higher and higher doses of opioids due to tolerance and disease progressionGoal: relief, maintain function, quality of life, palliative care
82American 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 conditionsTreatment plan: inform patient of risks and benefits of opioids and conditions for prescribing.Consultation with specialistsPeriodic review of efficacy, AEs, functional status, QOL, medication misuseThorough documentation
83The VIGIL SystemVerification: that the pt. can take the medication responsibly and that the Rx is genuineIdentification: driver’s license or other IDGeneralization: establish the general parameters of the provider-pt relationshipInterpretation: the decision to dispense is madeLegalization: ensuring adherence to legal requirements for treatmentWhile 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.
84Case: 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.
85Case: 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 fromClinicians have ethical responsibility to intervene and relieve suffering (beneficence) but should exercise knowledge, skills and experience in making intervention decisionsClinicians should not knowingly cause unwanted injury or sufferingInadequate treatment of pain has been found to be criminal negligence and malpractice in courts
86Case: 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 difficultChronic pain is often complicated by depression and anxiety which may limit patient’s ability to make balanced decision and other complications of unrelieved pain
87Case: Chronic Nonmalignant Pain- Issues Unrelieved or undertreated pain may:provoke drug abuse in patients with substance abuseprevent patient from fulfilling responsibilities that impact others – salary, benefits
88Case: Chronic Nonmalignant Pain- Strategies Non-opioid strategies should be evaluated prior to initiation of opioids including co-analgesicsIndividuals caring for patient should be experienced in chronic pain, substance abuse and use of opioids in patients with history of substance abuse
89Case: 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 trialPain Management contract
90Case: 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 patientsSingle pharmaciesPharmacy will not accept opioid prescriptions from other than contracted prescriberInappropriate behavior, accelerated use of opioids etc will result in screening
91Case: Chronic Nonmalignant Pain- Strategies Treatment goals should be clearly established – pain relief, function, quality of lifePain should be adequately treated using standardized guidelines (including use of breakthrough medications) – may lead to pseudoaddiction or abuseOpioid doses in patients with history of substance abuse frequently are higher than “typical” dosesUnderdosing may provoke or exacerbate abuse
92Case: 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
93Pharmacotherapy General Principles Around-the-clock dosing and long-acting formulations for continuous painAs-needed immediate-release analgesic supplementation for breakthrough painObserve for end-of-dose failureIncident pain “prophylaxis”Spontaneous pain suggestive of visceral/neuropathic etiologyAnticipate, prevent, and treat predictable SEsConstipation
94ConclusionsThere is no easy formula for dealing with this common yet complex area of patient careEngage addiction specialists sooner rather than later
95ConclusionsConsider 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.
96Recommended 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 Pharmacist’s 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)
97Recommended 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, MdTIP 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