1. Opiate Management Douglas Keehn DO Adjunct Assistant Clinical Professor University Wisconsin Board Certified Anesthesia & Pain Management

2. Financial Disclosure In accordance with the ACGME standard for Commercial Support Number 6, all in control of content disclosed any relevant financial relationships. The following in control of content had no relevant financial relationships to disclose. NameRole In Meeting Douglas Keehn, DOAuthor, presenter

3. 1.Describe how cautious, evidence-based prescribing practices can lower opioid-related overdose deaths while maintaining appropriate access for medically indicated treatment of chronic pain. 2.Identify “best practice” strategies that can be used by clinicians for pain management treatment. 3.Explain evidence-based practice and policies for provider education and patient education programs being utilized across the US.

4. Papaver Somniferum

6. Morphine Codeine Heroin Hydrocodone (Vicodin, Lortab) Methadone Oxycodone (Percodan, Oxycontin) Hydromorphone (Dilaudid) Meperidine (Demerol) New opioids, Tapentadol, Buprenorphine (Butrans,etc.)

9. Source: United States General Accounting Office: Dec. 2003, OxyContin Abuse and Diversion and Efforts to Address the Problem.

10. Opioid addiction is rare in pain patients. Physicians are needlessly allowing patients to suffer because of opiophobia. Opioids are safe and effective for chronic pain. Opioid therapy can be easily discontinued.

15. CDC, National Center for Health Statistics, National Vital Statistics System, CDC Wonder. Updated with 2010 mortality Data.

17. For every 1 overdose death in 2010, there were : 733 Past Year Nonmedical Users 108 People with abuse/dependence 26 ED visits for misuse or abuse 10 Abuse treatment admissions Treatment admissions are for primary use of opioid from Treatment Exposure Data set. Emergency department visits are from DAWN (Drug Abuse Warning Network)https://dawninfo.samhsa.gov/default.asp. Abuse dependence and nonmedical use in the past month are from the National Survey on Drug use and Health.

18. There were 15,135 Wisconsin hospitalizations defined as drug-related in 2010, an increase of 38% since 2002. Drug-related hospitalizations include such diagnoses as drug psychoses, drug dependence, drug related polyneuropathy, and accidental and purposeful poisoning by drugs. Wisconsin hospital inpatient database, Office of Health Informatics, Division of Public Health, Wisconsin Department of Health Services.

19. Charges for drug-related hospitalizations in Wisconsin totaled $287 million in 2012, and increase of 126% from $127 million in 2002. Wisconsin hospital inpatient database, Office of Health Informatics, Division of Public Health, Wisconsin Department of Health Services.

20. Rate per 100,000 County Number in 20122008-20092009-2010 Dane1,251241247 Wisconsin hospital inpatient discharge database, Divisions of Public Health, Wisconsin Department of Health Services

21. Wisconsin resident death certificates, Office of Health Informatics, Division of Public Health, Wisconsin Department of Health Services; United States death certificate data compiled by the Centers for Disease Control and Prevention. http://wonder.cdc.gov/mortSQL.html

22. Wisconsin resident death certificates, Office of Health Informatics, Division of Public Health, Wisconsin Department of Health Services

23. 0.2 %0.3 % 0.7 % 1.8 % Average Daily Opioid Dose in Morphine Equivalents Dunn et al., Annals Int Med, 2010

34. Source: Couto JE, Goldfarb NI, Leider HL, Romney MC, Sharma S. High rates of inappropriate drug use in the chronic pain population. Popul Health Manag. 2009;12(4):185–190.

36. 6.2 Clinicians should evaluate patients engaging in aberrant drug-related behaviors for: appropriateness of COT referral for assistance in management discontinuation of COT (strong recommendation, low-quality evidence).

37. Biological Age ≤ 45 years Gender Family history of prescription drug or alcohol abuse Cigarette smoking Psychiatric Substance use disorder Preadolescent sexual abuse (in women) Major psychiatric disorder (eg, personality disorder, anxiety or depressive disorder, bipolar disorder)

38. Social Prior legal problems History of motor vehicle accidents Poor family support Involvement in a problematic subculture Katz NP, et al. Clin J Pain.2007;23:103-118; Manchikanti L, et al. J Opioid Manag. 2007;3:89-100. Webster LR, Webster RM. Pain Med. 2005;6:432-442.

39. Low Risk No past/current history of substance abuse Noncontributory family history of substance abuse No major or untreated psychological disorder Moderate Risk History of treated substance abuse Significant family history of substance abuse Past/comorbid psychological disorder High Risk Active substance abuse Active addiction Major untreated psychological disorder Significant risk to self and practitioner RiskWebster LR, Webster RM. Pain Med. 2005;6:432-442.

40. 7.1 Evaluate dose escalations potential causes and re- assess benefits (strong recommendation, low-quality evidence). 7.2 In patients who require high doses of COT: evaluate for opioid-related toxicities changes in health status adherence to the COT treatment plan consider more frequent follow-up visits (strong recommendation, low-quality evidence).

52. On-line Resources American Academy of Pain Medicine http://www.painmed.org/clinical_ info/guidelines.html American Pain Society http://www.ampainsoc.org/pub/cp_ guidelines.htm http://www.ampainsoc.org/links/ clinician1.htm Federation of State Medical Boards http://www.fsmb.org/RE/PAIN/ resource.html American Academy of Pain Management http://www.aapainmanage.org/ Literature/Publications.php Assessment and Risk Management Tools http://www.painedu.org/soap.asp http://www.painknowledge.org