Pain Management: Narcotics, Implantable Therapies Maher Fattouh MD Adjunct Assistant Clinical Professor University Wisconsin Medical Director, Advanced Pain Management Board Certified Anesthesia & Pain Management

1.Describe how cautious, evidence-based prescribing practices can lower opioid-related overdose deaths while maintaining appropriate access for medically needed 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.

Papaver Somniferum

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

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

Source: CDC

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

Chronic Opioid Therapy: 90 days & > 10 Rx fills and/or > 120 days supply Persons with cancer excluded Boudreau et al, Pharmacoepi Drug Safety, 2009

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.

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.

Disagreements among providers Patients getting confusing and conflicting messages At war with our patients Delays in prescription refills Patients are dying from overdoses

Breakthrough pain should be assessed prevented and/or treated. (moderate evidence, strong rec) Methadone should be initiated and titrated cautiously only by clinicians well versed in its use and risks. (moderate evidence, strong rec) Patients taking opioid analgesics should be reassessed for ongoing attainment of therapeutic goals, adverse effects, and safe and responsible medication use. (moderate evidence, strong rec)

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

7.1 When repeated dose escalations occur in patients on COT, clinicians should evaluate potential causes and re-assess benefits relative to harms (strong recommendation, low-quality evidence). 7.2 In patients who require relatively high doses of COT, clinicians should evaluate for unique opioid-related toxicities, changes in health status, and adherence to the COT treatment plan on an ongoing basis, and consider more frequent follow-up visits (strong recommendation, low-quality evidence).

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)

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: ; Manchikanti L, et al. J Opioid Manag. 2007;3: Webster LR, Webster RM. Pain Med. 2005;6:

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:

The dichotomy of “pro-opioid” and “anti- opioid” is a false one, and serves neither the practitioner, the patient or society well. The ethical clinician is “pro-health”, and makes treatment decisions with her/his patient within that context.

On-line Resources American Academy of Pain Medicine info/guidelines.html American Pain Society guidelines.htm clinician1.htm Federation of State Medical Boards resource.html American Academy of Pain Management Literature/Publications.php Assessment and Risk Management Tools