Presentation on theme: "Optimizing Pain Relief While Reducing Risk: Finding Your Comfort Zone"— Presentation transcript:
1 Optimizing Pain Relief While Reducing Risk: Finding Your Comfort Zone Colleen O’Connell, MD FRCPC
2 Faculty/Presenter Disclosure Faculty: Colleen O’Connell, MD FRCPCRelationships with commercial interests:Grants/Research Support: industry-sponsored research by Acorda, Allergan, Biogen, Cytokinetics, Eli-Lilly, XenoportSpeakers Bureau/Honoraria: Allergan, Biogen, Boehringer, Eli Lilly, Pfizer, Purdue Pharma, ValeantConsulting Fees: Allergan, Biogen, Prairie PlantThis slide must be visually presented to the audience AND verbalized by the speaker.
3 Disclosure of Commercial Support This program has received financial support and in-kind support from Purdue Pharma in the forms of an educational grant and logistical supportPotential for conflict(s) of interest:The Speaker has received payment from Purdue PharmaPurdue Pharma developed and distributes, and benefits from the sale of products that will be discussed in this program:Buprenorphine transdermal (BuTrans®)Codeine monohydrate (Codeine Contin®)Hydromorphone hydrochloride (DILAUDID®, HYDROMORPH CONTIN®)Morphine sulfate (MS Contin®, MS•IR®)Oxycodone Hydrochloride (Oxy•IR®, OxyNEO®)Oxycodone Hydrochloride / Naloxone Hydrochloride (Targin®)Tramadol hydrochloride (Zytram XL®)This slide must be visually presented to the audience AND verbalized by the speaker.
4 Mitigating Potential Bias Potential sources of bias identified in the preceding 2 slides have been mitigated as follows:Information/recommendations provided in the following program will be evidence- and/or guideline-based and opinions of the speaker will be identified as such.Material was developed and reviewed by a steering committee composed of independent third party experts responsible for vetting the program’s needs assessment and subsequent content development to ensure accuracy and fair balance.This slide must be visually presented to the audience AND verbalized by the speaker.
5 DisclaimerThis presentation is for educational purposes only. It was developed by an independent team of subject-matter experts convened for this purpose. The opinions expressed in this presentation are not necessarily those of the sponsor, and neither product descriptions nor opinions should be attributed to the sponsor. The sponsor does not recommend any use of its products that is inconsistent with the product monographs of such products.
6 Question #1 What is your #1 barrier in dealing with CNCP patients Having enough time to do it properlyKnowing what the proper outcomes are to measureFear of the CollegeFear of creating AddictionFear of having opioids be divertedFear of the patient overdosing on opioids
7 Issues in the Management of Chronic Non-cancer Pain Results from 2012 needs assessment of 403 primary care physicians:Uncertainty with regard to assessment of chronic non-cancer pain (CNCP)Uncertainty with regard to effective treatment of chronic painPotential for opioid addiction and misusePrior negative experiences effectively managing patients with CNCPA needs assessment was conducted in June Invitations to participate in the needs assessment was sent to 29,542 Canadian physicians that practice under one or more of the following categories:Pain managementGeneral practitioner/family medicinePalliative careSports medicineEmergency medicineGeriatricsInternal medicine403 Canadian physicians completed the survey (315 English, 88 French)Questions in the questionnaire were developed by a group of Canadian physicians considered key opinion leaders in management of CNCP; questions were based on results from physician focus groups completed earlier in 2012Information also taken from evaluations submitted by participants attending “Improving Patient & Physician Satisfaction: Time Management & Communication Skills,” a current CME program that was developed based on information gathered from physician and patient focus groups in early 2012
8 Learning ObjectivesAfter attending this program, participants should be able to:Recognize the trajectory/continuum of chronic non-cancer pain (CNCP)Define an essential pain assessment strategyBreak down barriers related to the use of non-pharmacological, non-opioid, and opioid treatment options for CNCPDiscuss “success” in the management of CNCP
9 Does Julie have chronic pain? Patient Case: Julie43-year-old femaleExecutive secretary, mother of 2Breast cancer: treated with mastectomy and chemotherapyChemotherapy-induced peripheral neuropathy and myalgia x 4 yearsDoes Julie have chronic pain?
10 Definition of Chronic Non-cancer Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damagePain without apparent biological value that has persisted beyond the normal tissue healing time (most commonly reported to be ≤3 months)This definition suggests that pain is a subjective experience that interferes with the psychic and the social along with physical function. Pain is multidimensional, making it difficult to separate objective evidence of disease, i.e., the biological, and the subjective experience of discomfort and dysfunction.Reference:International Association for the Study of Pain. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Second edition (Revised) Available at: Accessed January 30, 2013.International Association for the Study of Pain
11 Overlapping Aspects of Chronic Pain PsychologicalSocialBiologicalPAIN
12 Categorizing Chronic Non-cancer Pain SuperficialSomaticNOCICEPTIVE (Inflammatory)DeepVisceralMIXEDCentralReferences:Ashby MA, Fleming BG, Brooksbank M, et al. Description of a mechanistic approach to pain management in advanced cancer. Preliminary report. Pain. 1992;51(2):Nicholson B. Differential diagnosis: nociceptive and neuropathic pain. Am J Manag Care. 2006;12(9 Suppl):SBallantyne JC. Chronic pain following treatment for cancer: the role of opioids. Oncologist. 2003;8(6):PeripheralNEUROPATHICOtherAshby MA, et al. Pain. 1992;51:Nicholson B. Am J Managed Care. 2006;12:S256-S262.Ballantyne JC. Oncologist. 2003;8:
13 Question #2What would you want to accomplish in this pain assessment visit?A measurement of pain severityA differential diagnosis of her pain conditionA measurement of her addiction riskA measurement of her functionalityAll of the above
14 Pain Assessment: OPQRS Onset (and evolution)PatternQualityRelieving / exacerbating factorsSeverityAssessment tools:Brief Pain InventoryBody Pain DiagramLANSS / DN4Onset (and evolution):Spontaneous or event-triggered?Work / motor vehicle accident?Illness / iatrogenic (post-surgical)?Evolution of pain problem over timePattern:Number and location of different painsLocation (localized or radiating)Timing (intermittent, constant, breakthrough)Rapidly progressive or stableQuality:Neuropathic pain:Burning, shooting, lancinating, tingling, pins and needlesNociceptive pain:Somatic pain: aching, sharp, well located, increased by mobilization / weight bearingVisceral pain: dull, crampy, diffuseRelieving / exacerbating factor:Movement / rest / specific positionsPhysical measures (heat, cold, massage)Anxiety / stressWeather / seasonalSeverity:Patient self-report is the best measure we have today to assess pain severityDescriptive, numeric and analog pain rating scales are availableMost common measure is the VRS (verbal rating scale): “0 – 10”DN4, Douleur Neuropathique 4. LANSS, Leeds Assessment of Neuropathic Symptoms and Signs.
15 Pain Assessment: OPQRS Onset (and evolution)Spontaneous or event-triggered?Work / motor vehicle accident?Illness / iatrogenic (post-surgical)?Evolution of pain problem over time
16 Pain Assessment: OPQRS Pattern:Number and location of different painsLocation (localized or radiating)Timing (intermittent, constant, breakthrough)Rapidly progressive or stable
17 Pain Assessment: OPQRS Quality:Neuropathic pain:Burning, shooting, lancinating, tingling, pins and needlesNociceptive pain:Somatic pain: aching, sharp, localized, increased by activity, relieved by restVisceral pain: dull, crampy, diffuse
19 Pain Assessment: OPQRS SeverityPatient self-report is the best measure we have today to assess pain severityDescriptive, numeric and analog pain rating scales are availableMost common measure is the “0 – 10” verbal rating scale (VRS)
20 Julie’s Brief Pain Inventory XX XReferenceCleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore. 1994;23(2):XMovement, stress, fatigue, working at the computerHeat, rest, massage, TENSAcetaminophen, amitriptyline48Adapted from Cleeland CS, et al. Ann Acad Med Singapore. 1994;23(2):20
21 Question #3 What type of pain is likely affecting Julie? Nociceptive NeuropathicMixed
22 Julie’s Diagnosis Neuropathic pain Possible nociceptive elements Sequelae of peripheral neuropathy; potential impact of deconditioning
23 Psychosocial History Disability Social Family configuration Level of educationType of workIncomeIsolationSecondary benefits of pain (conscious or unconscious)PsychologicalPersonal / family historyPrevious physical, sexual, and/or emotional abuseCurrent life stressorsFamily / cultural factorsCatastrophizingDisabilityIdeal pain management is multi-disciplinary and addresses not just the biological/physical aspects of pain, but also the psychological and social aspects of a patient’s history / life.
24 Physical Exam in Chronic Non-cancer Pain General exam – posture, muscular toneSpinal exam – mobility, palpation, look for trigger pointsNeurological exam – motor strength, reflexes, sensory exam (including presence of allodynia, hyperalgesia, hypo- or hyperesthesia)Inflammatory elements – pain, swelling, erythema
25 Question #4 Would you order imaging for Julie? Yes, I always order imaging in all of my pain patientsNo, I only order imaging if there are obvious signs of serious pathologyPossible, I treat each case on an individual basis
26 Non-pharmacologic Treatment Options Type of treatmentOptionsLifestyleCessation of tobacco products, weight loss, nutritional counsellingPhysicalHeat, cold, massage, exercise, manipulation, physical therapy, stretching and yoga, surgical therapies (nerve blocks, trigger point injections, spinal infusion, or stimulation), transcutaneous electric nerve stimulation, intramuscular stimulation, radiofrequency lesioningPsychological/psychiatricBiofeedback, cognitive behaviour therapy, counselling, social worker support, hypnosis, relaxationOccupationalOccupational therapy, work conditioning programsComplementary/alternativeAcupuncture, herbal remedies, massage, mindfulness meditation, reflexologyReference:Jackman RP, Purvis JM, Mallett BS. Chronic nonmalignant pain in primary care. Am Fam Physician. 2008;78(10):Jackman RP, et al. Am Fam Physician. 2008;78(10):
29 Pharmacologic Treatment Options: Chronic Neuropathic Pain Add additional agents sequentially if partial butinadequate pain relief‡TCA gabapentin or pregabalinSNRI topical lidocaine*tramadol or controlled-release opioid analgesicReference:Moulin DE, Clark AJ, Gilron I, et al. Pharmacological management of chronic neuropathic pain – Consensus statement and guidelines from the Canadian Pain Society. Pain Res Manage. 2007;12(1):13-21.fourth-line agents†*5% gel or cream – useful for focal neuropathy such as postherpetic neuralgia.†Cannabinoids, methadone, lamotrigine, topiramate, valproic acid.‡Do not add SNRIs to TCAs.SNRI, serotonin noradrenaline reuptake inhibitors. TCA, tricyclic antidepressants.Moulin DE, et al. Pain Res Manage. 2007;12(1):13-21.
30 Question #5 What are my goals for this patient? Cure Complete pain reliefComplete restoration of her function75% relief in her pain by next visitRealistic improvement in her functionality
31 Patient’s Goals of Treatment Set SMART goals at each visit:SpecificMeasurableAction-oriented / AchievableRealistic / RelevantTime-dependent goalsThink of opioid prescribing as a test or trialTake 2-hour car trip to visit momWalk through the park 2X / weekTry out a rehab yoga class
33 Screening for Medication Misuse Risk Ask questions in a routine, straightforward mannerAsk about number of drinks per day and per week and sedative useFamily history of psychiatric or addictive disordersCAGE questionnaireOpioid Risk Tool5 questions, 5 minutesSpecific to pain and opioid useQuantifies risk levelNon-confrontationalEasy to use
34 Opioid Risk Tool X X X 5 Reference: Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6:X5Adapted from: Webster LR, et al. Pain Med. 2005;6:
35 Incorporating Risk Level of Misuse/Addiction into Pain Management Group III – Preferably treat by addiction medicineMethadone or Buprenorphine is 1st choiceExhaust all other options before considering opioidsDaily dispensing weekly, less “abusable” medsGroup II – Trial of treatment by primary care physician with collaboration with Pain doctor(if available)More assessment and focus on functional goalsWritten Treatment Agreement, urine drug test 3-4 times per year, collateral information. Be prepared for contingency planFollow-up monthly, dispense every 2 weeks, choose opioids carefullyGroup I – Treatment by primary care physicianUtilize all treatment options, including opioids; focus on side effectsWritten Treatment Agreement, urine drug test 1-2 times per yearFollow-up every 2-3 months, dispense meds every 4 weeksMost patientsFewest patientsRisk level
36 Questions When Initiating Opioid Therapy Initial choice of opioid?Dose?Route of administration?Frequency?Monitoring and follow up?Safety? Adverse effects?
37 Initiating Opioid Therapy Basic considerations:Patient agePatient opioid exposure and experiencePatient fears (stigma)Caregiver and physician attitudes, preferences, and biasesComplianceConvenienceCost/coveragePharmaco-clinical considerations:Patient sensitivities/allergiesAdministration and absorption limitationsMetabolism and clearanceOpioid profileFine PG. Journal of Pain
38 Written Treatment Agreement Recommended in all guidelinesLow-cost, low-tech strategyHelps to demonstrate informed consentEffective boundary setting toolMust be readable, reasonable, and have some flexibilityTREATMENT AGREEMENTI,__________________, understand that compliance with the following guidelines is important in continuing pain treatment with Dr. __________.I understand that I have the following responsibilities:I will take medications only at the dose and frequency prescribed.I will not increase or change medications without the approval of this doctor.I will not request opioids or any other pain medicine from physicians other than from this doctor.Most guidelines on opioid prescribing recommend the use of written prescribing agreements in spite of the fact that there is actually no evidence that they change patient behaviour. With properly documented informed consent, there is a less compelling need to use one in a low risk patient. On the other hand, it would be prudent for the clinician to ask all identified high risk patients to sign one.References:Fishman S, Mahajan G, Jung SW, et al. The trilateral opioid contract. Bridging the pain clinic and the primary care physician through the opioid contract. J Pain Symptom Manage. 2002;24(3):Fishman S, Kreis PG. The opioid contract. Clin J Pain. 2002;18(4 Suppl):S70-5.Wallace LS, Keenum AJ, Roskos SE, et al. Development and validation of a low-literacy opioid contract. J Pain. 2007;8(10):Fishman S, et al. J Pain Symptom Manage. 2002;24(3): Fishman S, et al. Clin J Pain. 2002;18(4 Suppl):S70-5. Wallace LS, et al. J Pain. 2007;8(10):
39 FDA Issues Draft Guidance for Abuse-Deterrent Opioid Development ABUSE-DETERRENT FORMULATIONS (ADFs) – CategorizationPhysical/Chemical barriersPhysical barriers can prevent chewing, crushing, cutting, grating, or grindingChemical barriers can resist extraction of the opioid using common solventsAgonist/Antagonist combinationsAn opioid antagonist can be added to interfere with, reduce, or defeat the euphoria associated with abuseAversionSubstances can be combined to produce an unpleasant effect if the dosage form is manipulated prior to ingestion or a higher dosage than directed is usedDelivery SystemCertain drug release designs or the method of drug delivery can offer resistance to abuseProdrugProdrug lacks opioid activity until transformed in the gastrointestinal tractCombinationTwo or more of the above methods can be combined to deter abuseOpioid analgesics can be abused in a number of ways. For example, they can be swallowed whole, crushed and swallowed, crushed and snorted, crushed and smoked, or crushed, dissolved and injected. Abuse-deterrent formulations should target known or expected routes of abuse for the opioid drug substance for that formulation. As a general framework, abuse-deterrent formulations can be categorized as follows1. Physical/Chemical barriers – Physical barriers can prevent chewing, crushing, cutting, grating, or grinding. Chemical barriers can resist extraction of the opioid using common solvents like water, alcohol, or other organic solvents. Physical and chemical barriers can change the physical form of an oral drug rendering it less amenable to abuse.2. Agonist/Antagonist combinations – An opioid antagonist can be added to interfere with, reduce, or defeat the euphoria associated with abuse. The antagonist can be sequestered and released only upon manipulation of the product. For example, a drug product may be formulated such that the substance that acts as an antagonist is not clinically active when the product is swallowed but becomes active if the product is crushed and injected or snorted.3. Aversion – Substances can be combined to produce an unpleasant effect if the dosage 89 form is manipulated prior to ingestion or a higher dosage than directed is used.4. Delivery System (including depot injectable formulations and implants) – Certain drug release designs or the method of drug delivery can offer resistance to abuse. For example, a sustained-release depot injectable formulation that is administered intramuscularly or a subcutaneous implant can be more difficult to manipulate.5. Prodrug – A prodrug that lacks opioid activity until transformed in the gastrointestinal tract can be unattractive for intravenous injection or intranasal routes of abuse.6. Combination – Two or more of the above methods can be combined to deter abuse.The FDA has made public its draft directives outlining the research steps drug manufacturers would need to conduct in order to label an opioid as abuse deterrent. According to an FDA official, the agency is hoping to incentivize drug companies to further develop safer opioids through the increased revenues that might result from having abuse-deterrent labeling.This guidance is intended to assist sponsors who wish to develop formulations of opioid drug products with potentially abuse-deterrent properties (abuse-deterrent formulations). Specifically, the guidance explains FDA’s current thinking about the studies that should be conducted to demonstrate that a given formulation has abuse-deterrent properties, how those studies will be evaluated, and what labeling claims may be approved based on the results of those studies.January 2013
40 Novel Opioid Formulations with Potential to Reduce Abuse/Misuse CR morphine with a sequestered core of naltrexoneFDA approved August 2009Voluntarily recalled from U.S. market March 2011, “leaking core” of naltrexoneOxycodone/Naloxone CR tabletsHealth Canada NOC December 2009CR hydromorphone – tablet is non-deformableHealth Canada NOC November 2009; FDA approved March 2010CR oxycodone – reformulated (USA); CR oxycodone-resistant to crushing (Canada)FDA approved April 2010; Health Canada NOC August 2011FDA approved abuse-deterrent labelling April 20131New labelling indicates that the product has physical and chemical properties that are expected to make abuse by injection difficult and to reduce abuse via the intranasal routeIR oxycodone – new formulationFDA approved June 2011ER oxymorphone – reformulatedFDA approved December 2011FDA denied petition that original formulation not withdrawn due to safety and efficacy and allowed generics May 20132CR morphine with a sequestered core of naltrexone:Contains pellets of an extended-release oral formulation of morphine sulphate, an opioid receptor agonist, with a sequestered core of naltrexone hydrochloride, an opioid receptor antagonist. Proper use requires the capsules to be swallowed whole or the contents of the capsules to be sprinkled on apple sauce. The pellets in the capsules are not to be crushed, dissolved, or chewed before swallowing. Misuse or abuse by tampering with the formulation by crushing or chewing the pellets causes the rapid release and absorption of both morphine and naltrexone. The resulting morphine dose may be fatal, particularly in opioid-naïve individuals. In opioid-tolerant individuals, the absorption of naltrexone may increase the risk of precipitating withdrawal. There is no evidence that the naltrexone reduces the abuse liability of EMBEDA. In March 2011, Pfizer voluntarily recalled from U.S. wholesalers and retailers all dosage forms of CR morphine with a sequestered core of naltrexone because a pre-specified stability requirement was not met during routine testing. Source:Oxycodone/Naloxone CR tablets:Drug Abuse StudiesA series of clinical studies designed to explore the abuse/misuse potential of Oxycodone/Naloxone CR tablets, were conducted in dependent or non-dependent recreational opioid users. The studies included both subjective measures, e.g., Drug Liking VAS and objective measures, e.g., pupillometry. Collectively for these studies, the subjective results produced were supported by similar results in objective measures, and were consistent with the established pharmacology of naloxone. One comparison demonstrated reduced Drug Liking for Oxycodone/Naloxone CR tablets relative to oxycodone powder when each was administered intranasally. In another comparison, solutions containing a 2:1 ratio by weight of oxycodone HCl to naloxone HCl were administered by the intravenous route to explore the abuse and misuse potential of Oxycodone/Naloxone CR tablets. In this comparison, the oxycodone/naloxone solutions demonstrated reduced Drug Liking relative to the oxycodone solution alone when each was administered intravenously. The clinical significance of these results has not yet been established. If abused parenterally or intranasally by individuals dependent on opioid agonists, Oxycodone/Naloxone CR tablets are expected to produce marked withdrawal symptoms – because of the systemic opioid receptor antagonist characteristics of naloxone by these routes – or to intensify withdrawal symptoms already present. Source: Canadian Product Monograph Oxycodone Hydrochloride / Naloxone Hydrochloride Controlled Release Tablets, July 2013.CR hydromorphone – tablet is non-deformable:Tablets designed with the OROS® Push-Pull™ technology to release hydromorphone at a relatively constant rate and achieve stable plasma levels over a 24-hour period allowing for once daily administration of hydromorphone. The tablet is non-deformable and does not appreciably change in shape in the GI tract. Source: Canadian Product Monograph HYDROmorphone hydrochloride Prolonged Release Tablets, August 2013.CR oxycodone – reformulated (USA); CR oxycodone-resistant to crushing (Canada):The FDA has determined that the reformulated product has abuse-deterrent properties. The tablet is more difficult to crush, break, or dissolve. It also forms a viscous hydrogel and cannot be easily prepared for injection. The agency has determined that the physical and chemical properties of the reformulated product are expected to make the product difficult to inject and to reduce abuse via snorting. However, abuse of CR oxycodone-reformulated by these routes, as well as the oral route, is still possible. The reformulated product also may reduce incidents of therapeutic misuse, such as crushing the product to sprinkle it onto food or to administer it through a gastric tube. Source:IR oxycodone – new formulation:Formulated with Aversion® technology, which creates a unique combination of pharmaceutical ingredients that helps reduce the abuse potential from crushing, snorting or injecting the medication. Aversion® technology causes the active ingredients to gel, forming clumps instead of powder when crushed to prevent injection, and to irritate the nasal passages to prevent inhalation. FDA is requiring post approval epidemiological study to assess whether the technology results in a decrease of the consequences of misuse and abuse. Source: Acura Pharmaceuticals, INC Quarterly Report, May 2013; Oxecta Pharmacy Alert, CypressCare.comER oxymorphone – reformulated:While there is an increased ability of ER oxymorphone – reformulated to resist crushing relative to the original formulation, study data show that the reformulated version’s extended-release features can be compromised when subjected to other forms of manipulation, such as cutting, grinding, or chewing, followed by swallowing. ER oxymorphone – reformulated can be readily prepared for injection, despite the company’s claim that these tablets have “resistance to aqueous extraction (i.e., poor syringeability).” It also appears that ER oxymorphone – reformulated can be prepared for snorting using commonly available tools and methods. The postmarketing investigations are inconclusive, and even if one were to treat available data as a reliable indicator of abuse rates, one of these investigations also suggests the troubling possibility that a higher percentage of ER oxymorphone – reformulated abuse is via injection than was the case with the original formulation. Source:NOC, Notice of Compliance; CR, controlled release; ER, extended release; IR, immediate-release.1http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm htm; 2http://www.fda.gov/Drugs/DrugSafety/ucm htm.
41 Titrating Opioids: Precautions Ideally start with immediate release opioid and switch to a long-acting preparationDuring titration, temporary drowsiness can occurPatients should be advised not to drive or perform potentially hazardous activities while titrating the opioid dose – until tolerance to drowsiness occursMonitor for constipationConsider prescribing a laxative at the start of treatmentFor individuals aged >70 years, start lower and go slowerTolerance to sedation due to a dose change should occur within 4 to 10 days in most people.
43 How to Switch OpioidsUse opioid tables to calculate a total daily equianalgesic dose of the new opioidSwitch to 50-70% of the predicted dose of the new opioid and titrate to effect againDecision to cut dose and by what percentage may depend on the reason for switchORStart the new opioid and titrate while decreasing the dose of the old opioidSustained-release morphine 15 mg ≅ controlled-release oxycodone 10 mg ≅ controlled-release hydromorphone 3 mgSpeaker to give personal experiences with whatever option above that they use.ReferencesFine PG, Portenoy RK; Ad Hoc Expert Panel on Evidence Review and Guidelines for Opioid Rotation. Establishing “best practices” for opioid rotation: conclusions of an expert panel. J Pain Symptom Manage. 2009;38(3):MacPherson ML. Demystifying Opioid Conversion Calculations. Bethesda, MD: American Society of Health-System Pharmacists, IncWebster LR, Fine PG. Overdose deaths demand a new paradigm for opioid rotation. Pain Med. 2012;13(4):571-4.Fine PG, et al. J Pain Symptom Manage. 2009;38(3):MacPherson ML. Demystifying Opioid Conversion CalculationsWebster LR, et al. Pain Med. 2012;13(4):571-4.
44 When to Stop Opioid Therapy Resolution of underlying problemNo meaningful pain reliefPatient wants to discontinueDoes not achieve therapeutic goals even with effective pain relief (e.g., improved physical or social functioning)Persistent adverse effects despite careful titration and switchingOpioid hyperalgesia despite switchingNot cooperating with treatment plan (medication use or activity/goals)Persistent out-of-bounds behaviours consistent with addiction/diversionUnable to follow the treatment agreementDiagnosis of an addiction disorder and refuses referral for treatmentReferences:Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med. 2003;349(20):Benyamin R, Trescot AM, Datta S, et al. Opioid complications and side effects. Pain Physician. 2008;11(2 Suppl):SChou R, Fanciullo GJ, Fine PG, et al. Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009;10(2):Porreca F, Ossipov MH. Nausea and vomiting side effects with opioid analgesics during treatment of chronic pain: mechanisms, implications, and management options. Pain Med. 2009;10(4):Slatkin NE. Opioid switching and rotation in primary care: implementation and clinical utility. Curr Med Res Opin. 2009;25(9):Ballantyne JC, et al. N Engl J Med. 2003;349(20): Benyamin R, et al. Pain Physician. 2008;11(2 Suppl):S Chou R, et al. J Pain. 2009;10(2): Porreca F, et al. Pain Med. 2009;10(4): Slatkin NE. Curr Med Res Opin. 2009;25(9):
45 How To Stop Opioid Therapy Discuss and document (with significant other?):Withdrawal is not dangerousTypical withdrawal symptoms and time courseOffer an alternative treatment planUse caution with sedatives – withdrawal is more riskyPatients who are diverting or addicted may refuse to comply and leave your practice
46 How to Stop Opioid Therapy (cont’d) It is not life threatening unless patient is “fragile”Fast or slow10% per day, daily pharmacy dispensing10% per weekUse pharmacological aidsClonidine, loperamide, NSAID, carbamazepine, gabapentin, pregabalinMethadone (buprenorphine) taperEducating the patient is the most effective treatment!NSAID, non-steroidal anti-inflammatory drug.
47 Framing Treatment Success Make a plan with the patient to set goals for treatment successReframe success for you and the patientThere may not be big improvements, but rather small and incremental ones (i.e., there is no “cure”)Reduction of pain by 30% or 2 points on scale of 0 to 10Did the patient meet a functional goal or part of a goal?Is the patient more positive than on previous visits?Has there been even a small improvement in pain relief?Has BPI scale gone down?Has mobility improved?You must learn to accept situations that failKnow when to refer to a specialistRemember: You are treating the patient, not the painBPI, Brief Pain Inventory.
48 Essential Follow-up Documentation: The 6 As Checklist Analgesia (pain relief — BPI score)Activities (physical and psychosocial functioning — BPI interference score)Adverse effects (and your advice)Ambiguous drug-taking behaviours (and your advice)Accurate medication recordAffect (use a validated scale)Adequate follow-up documentation is essential to diagnosing an evolving addiction/diversion problem.The results of serial evaluations using clinical tools such as the BPI should be gathered here.The “6 As” provide a checklist of essential follow-up documentation, and are specifically looked for by College investigators if charts are reviewed.Document pain relief using a verbal (1 to 10) rating scale or a visual analogue scale for the best pain and worst pain since last visit.Document any changes in the patient’s function. Give some specific examples, if possible.Note any opioid side effects and what your advice to the patient is.Carefully document any episodes of early refills, lost medication, double doctoring, etc., and your response.Keep an accurate medication record of the drug, the strength, the dosing instructions, and amount to dispense. As the last entry in your visit record, write: “To last until ____” as an easy reminder the next time you see the patient.Affect: some physicians are now documenting the patient’s affect as the sixth A.References:Gourlay DK, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6:BPI, Brief Pain Inventory.Gourlay DL, et al. Pain Med. 2005;6:
49 Making a Difference for People With Pain Active listening / empathy is often most importantHelp patients find meaning in living a life with painMaintain a positive outlook / celebrate small gainsAdvocate for improved pain management resources
50 Key Take-home PointsChronic pain is more than longstanding acute pain and requires a biopsychosocial approach to assessment and treatmentUtilize a SMART goal-directed approach that focuses on functional improvementSearch out and optimize non-pharmacological treatments in your communityAll pharmacotherapy should be prescribed using an individual risk-benefit approachPrescribe opioids with universal precautions according to the Canadian Opioid GuidelinesUtilize validated clinical tools to demonstrate improved outcomes
52 Pain Assessment Tools Pain diagram Brief Pain Inventory (BPI) Visual Analogue Scale (VAS)Quality of Life Scale for PainDN4 (Douleur Neuropathique en 4 Questions)
53 Opioid Risk Assessment Tools Opioid Risk Tool (ORT)CAGE Questionnaire (adapted to include drugs)Urine Drug Screening (UDS)Screener and Opioid Assessment for Patients with Pain– Revised (SOAPP-R)Current Opioid Misuse Measure (COMM)Aberrant Drug-Related Behaviours Indicative of Opioid MisuseInterview Guide for Alcohol ConsumptionInterview Guide for Substance Use
54 Patient Management Tools The 6 As progress reportOpioid Manager (nationalpaincentre.mcmaster.ca)Switching Opioids form (nationalpaincentre.mcmaster.ca)Self-Management Toolkit (swselfmanagement.ca/smtoolkit/)The basics of helping patients better self-manage their healthStrategies to Support Self-Management in Chronic Conditions: Collaboration with Clients (rnao.ca/bpg/guidelines/self-management)Evidence-based practice guidelines published by the Registered Nurses Association of Ontario
55 Resources for Patients OrganizationChronic Pain Association of Canadachronicpaincanada.comCanadian Pain Coalitioncanadianpaincoalition.caCanadian Institute for the Relief of Pain and Disabilitycirpd.orgManaging My Painmanagingmypain.caMed School for You Chronic Pain Self-Managementmedschoolforyou.comArthritis Societyarthritis.caPatients Like Mepatientslikeme.comPain Toolkitpaintoolkit.org
56 Provincial Resources for Patients British ColumbiaPain BCpainbc.caChronic Disease Self-Management Programsselfmanagementbc.ca/chronicpainprogramAlbertaBetter Choices, Better Healthalbertahealthservices.ca/services.asp?pid=service&rid=People in Pain Networkpipain.comSaskatchewanLiveWell Chronic Disease ManagementManitobaGet Better Togetherrha-central.mb.ca/service.php?id=65
57 Provincial Resources for Patients OntarioLiving a Healthy Life Central Easthealthylifeworkshop.caLiving Well South Eastlivingwellseontario.caLiving Healthy Champlainlivinghealthychamplain.caLiving a Healthy Life South Westswselfmanagement.caTake Control Take Chargetakecontroltakecharge.caHealthy Changehealthychange.caQuebecAssociation québécoise de la douleur chroniquedouleurchronique.orgAssociation de soutien et d'information face à la douleurasid.qc.caMy Tool Box/L’ateliermytoolbox.mcgill.ca
58 Provincial Resources for Patients Atlantic CanadaAction Atlanticpaincantwait.caNew BrunswickMy Choices – My Healthgnb.ca/0053/phc/workshop-e.aspNova ScotiaYour Way to Wellnessyourway2wellness.gov.ns.caPrince Edward IslandLiving a Healthy Lifegov.pe.ca/health/livingahealthylifeNewfoundland & LabradorImproving Health: My Wayhealth.gov.nl.ca/health/chronicdisease/improving_health_my_way.html