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Prescription opioid dependence Dr Bridin Murnion Staff Specialist, Drug Health Sydney South West Area Health Service.

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Presentation on theme: "Prescription opioid dependence Dr Bridin Murnion Staff Specialist, Drug Health Sydney South West Area Health Service."— Presentation transcript:

1 Prescription opioid dependence Dr Bridin Murnion Staff Specialist, Drug Health Sydney South West Area Health Service

2 CASE 1 Mr P 44yr old married businessman Pain in knee subsequent to sporting injury Prior operative intervention 2 years prior but pain persisted Ex smoker, alcohol use minimal, occasional stimulant use in past

3 Commenced on Panadeine forte Subsequent transfer to oxycontin Pain Clinic review Referred to Drug Health by GP

4 Gait-normal Knee-unremarkable Affect-NAD Beliefs-required further operative intervention Expectations-to be pain free

5 Stated goal to cease opioids Discussed options Gradual weaning Buprenorphine assisted withdrawal Discussed potential difficulties of both approaches Gradual weaning preferred option

6 Treatment agreement Single prescriber Single dosing point Interval dispensing Dr Shopping agreements No replacement for lost or stolen scripts Occasional UDS

7 Story Evolution Use greater than stated Dose titrated upwards travelling overseas Alleged theft Decided to trial buprenorphine assisted withdrawal

8 Case 2 Mr C 27 yr old Married, working full time MVA 7yrs prior –Low back pain and pain right leg Examination-scar on right knee, allodynia R leg/ foot, weakness dorsi-flexion Investigations-unremarkable

9 Presented for opioid withdrawal management Escalating panadeine forte use, commenced nurofen plus use Few episodes of heroin use

10 Melena on presentation Hb UGIE showed multiple gastric erosions Commenced on PPI

11 Progress Completed buprenorphine assisted withdrawal Continued on buprenorphine patch Antidepressant changed from escitalopram to duoloxetine Referred pain clinic for multi-disciplinary assessment

12 CASE 3 Ms C 36yr old woman Presented to pain clinic for assessment of pelvic pain Relocated from interstate 4 months prior (leaving 6 children) On oxycontin 60mg bd

13 Denied substance abuse history, current smoker Social situation volatile Mood-anxious Referred to Drug Health for management of opioids

14 Options discussed, including OST Pt did not want OST, wanted to continue Oxycontin Agreed to this with significant reservations –Daily pick-ups –UDS –Dr Shopping –Transfer to OST would be only option available if current Rx plan not working

15 Maintained on this Rx for 6/12 Wanted to go back to SA Legal situation explained Lost to treatment for 1 year

16 Presented to ED with nausea Paracetamol hepatotoxicity and anaemia Using OTC panadeine/nurofen plus to excess NAC/UGIE/PPI Agreed to OST

17 Principles Dependence difficult diagnosis in context of chronic pain and chronic opioid use Opioid ADRBs can be difficult to recognise –May need longitudinal observation Need to stabilise opioid use and then re- assess pain Ensure compliance with legal requirements around prescribing-PSB and PBS

18 How common is it? 2.5% Australians report recent use of pain- killers for non-medical purposes 4.45% report lifetime use 15.4% had opportunity to use pain-killers for non-medical purposes Jurisdictional variations

19 Aberrant drug related behaviours (ADRB) Red Flag Selling prescription drugs Prescription forgery Obtaining prescription drugs from non-medical sources Injecting oral formulations Concurrent abuse of related illicit drugs Multiple unsanctioned dose escalations Evidence of intoxication (e.g. clinical presentation, driving, forensic) Recurrent prescription loss Acquiring from multiple Drs Yellow Flag Aggressive complaining about need for higher dose Drug hoarding during periods of reduced symptoms Unsanctioned dose escalations 1-2 times Unapproved use of drug to treat other symptoms Requesting specific drugs Reporting psychic effects not intended by clinician Portenoy RK. Opioid therapy for chronic nonmalignant pain: clinician's perspective. J Law Med Ethics. 1996;24(4):296-309

20 What proportion of Chronic Opioid Therapy (COT) patients have ADRBs? Varies from 3-30%, depending upon patient sampling, definition of ADRB and level of monitoring –Most controlled trials: 10-15% Poor identification of ADRBs unless routinely screened / assessed

21 Identifying high risk patients Patient selection-Identify risk factors for developing problems –Pain diagnosis –History & concomitant conditions Psychosocial & mental health issues History of substance abuse Prior problems with opioids: adverse events / aberrant behaviours History of childhood/sexual abuse in women –Use of non-opioid treatment approaches to chronic pain Poor uptake / response to other approaches Patient expectations Screening tools-predictive ( SOAPP, DIRE and ORT) and diagnostic (PMQ, PDUQ and COMM) ( Passik 2008) Passik SD et al Addiction-Related Assessment Tools and Pain Management: Instruments for Screening, Treatment Planning, and Monitoring Compliance Pain Med 2008 S145- S166

22 Opioids in Chronic pain: balancing risks and benefits COT should only be continued if benefits > harms Consider ‘trial of opioids’, with clear criteria of what constitutes successful / unsuccessful treatment Stop opioid if treatment ineffective or transfer to more supervised dosing if significant ADRBs Review indication for (and consider cessation of) COT every 3-6 months Clear documentation in medical records Chou R et al. Clinical Guidelines For the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain. 2009;10(2):113-230.

23 Structuring Chronic Opioid Therapy (COT) COT one aspect of comprehensive Pain Plan Identifying COT goals & monitoring outcomes Working within teams Safer prescribing and dispensing Patient agreements Chou R et al. Clinical Guidelines For the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain. 2009;10(2):113-230.

24 Assessing Efficacy and Safety of COT- 5 A’s Analgesia Activities (functional outcomes) Affect Adverse events Aberrant drug behaviours Portenoy RK Opioid therapy for chronic nonmalignant pain: a review of the critical issues. J Pain Symptom Manage. 1996;11(4):203-17

25 Structuring COT: working within teams –Chronic pain & Pall care require multidisciplinary approach –Clarity re: role of different service providers –Who is prescribing/dispensing which medications? –Addressing co-morbidities: importance of non- medical service providers –Regular communication / case conferencing

26 Structuring COT: safer prescribing & dispensing One doctor prescribing and one pharmacy dispensing opioid –‘Doctor Shopping Release Of Information form’ for high-risk patients Use of Endorsed scripts, fax & mailing Long-acting > short acting opioids “Abuse deterrent” formulations may have role Structured > prn regimens Interval dispensing –Limit ‘duration’ of dispensed medications to reduce dose escalation & ‘running short’ –Do not refill prescriptions early if patient runs out Have ‘severe pain plan’

27 Structuring COT: Patient agreements Signed agreement with patient addressing –medications from other sources –unauthorised dose escalations & ‘running short’ –use of other drugs (licit & illicit) –diversion of medications to others –attendance at appointments (medical & non- medical) –communication between health providers –conditions of COT cessation Chou R et al. Clinical Guidelines For the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain. 2009;10(2):113-230.

28 On REVIEW Assess efficacy Examine for signs of intoxication & injection Corroborative history: family & health care providers Prescription monitoring schemes Urinary Drug Screens with acknowledgement of limitations

29 SUMMARY Identify high risk patients Identify ADRBs/dependence Stabilise opioid use –OST –Non OST opioid with interval dispensing –clinical, laboratory and prescription monitoring Re-assess pain Consider non-opioid analgesics Consider non-pharmacological interventions Develop plan for opioids and treatment agreement Comply with legal requirements Monitor 5As

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