Prescribing Opioids in 2016: Still a Pain Jeff Varnell, M.D Cheyenne Mountain Resort April 15, 2016

Disclosure I have no relevant financial relationships to disclose

Being a medical caregiver means putting your self in suffering’s way 3 Rita Charon M.D.

History 4

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Opiates In 1806 Serturner isolated the morphine alkaloid and named it after the god of dreams, Morpheus 8 Works thru at least 4 receptors throughout the body Profound effect is the mu receptor CNS Controlled Substances Act in 1970 DEA enforces

Rates of prescription painkiller sales, deaths and substance abuse treatment admissions ( ) National Vital Statistics System,

CDC declares painkillers at epidemic levels Opioids, Anxiolytics and Sedatives

Number one cause accidental deaths 11

So where did we lose control 12

So where did we lose control 13

Instead of addressing it we….. 14

Who is this NOT about? 15

Try non opioids 16

Risk areas 90 days 120 morphine equivalent dosing Long acting transdermal…. Diversion 17

You Came This Far to See Me?

Short vs long acting 19

Risk DEA

This Guy Isn’t Good Enough For My Kids!

Risk CMB

Risk legal

Risk suicide vs. overdose

Risk addiction

Risk diversion $5 a pill streetrx.com

Risk as it gets harder to get prescriptions…

Risk long acting and altered

Risk mixing with benzos

Risk grandma’s cabinet

Risk pill mills

Risk Tug Valley 29 individuals sued 5 docs caused the addiction Caused them to commit armed robbery, fraud and theft WV supreme court 3-2 for the plaintiffs 33

Top ten tips 34

10 - Faces of addiction

Addiction vs. tolerance vs. dependence Addiction Compulsive use causing personal harm Psychological dependence Rare in terminally ill or pain management Usually preexisting abuse Physical dependence Abstinence syndrome Not psychologic addiction Decrease dose 50% Q 3 days Tolerance  Decreased effectiveness over time  Actually rare - if more needs there may be a reason  Don’t label a tolerant patient addicted

Stages of Change 37

Criteria of chronic illness Genetics Pathogenesis Precipitants Environmental determinants Gender specifics Complications Relapse-Remission

9 – Screen for clear DX Cancer Nec fasciitis Compartment syndrome neuropathy 39

8- Screen for high risk Biggest risk factor is a personal or family history of drug/ETOH abuse Journal of pain v109 pg Abuse CAGE and SOAAP Prior abuse Borderline personality Toxicology screen An honest discussion 40

8 -Screen for high risk Journal of pain v109 pg Dog ate the pills Fell done the john Pharmacist shorted Lost my luggage Allergic to everything but…. 41

7 - Avoid polypharmacy 42

6 - Agreements and consent 43

Which of the following is NOT appropriate for a pain agreement? No diversion allowed May request a tox screen at any time Notify us by Thursday if scripts are lost or destroyed Can only go to 1 pharmacy 44

5 - Urine tox screen

4 - PDMP 46

3- Beware bright lines Check if >120 MED Transdermal Long acting >90 days 47

Beware Bright Lines (cont.) CDC guidelines DORA guidelines 48

2 – The tough discussion Come from a caring place Avoid cops vs docs Say no mean No No offense Doc…. Screen for addiction/diversion 49

1– Don’t take off if you can’t land the plane 50

Our challenge "....in the sufferer, let me see only the human being” – Maimonides, 13th Century

And How would you approach? 52

Thank you 53 One thing you do differently Dennis Boyle M.D. COPIC Patient Safety and Risk Management Any questions?