1. PA AND NJ IARP 2016 CONFERENCE - 17 TH ANNUAL

3. Detoxing from opioids in Workman Compensation patients Wayne G. Miller, D.O., M.P.H Medical Director Valley Forge Medical Center and Hospital

4. Why consider opioid detox?

6. Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014

8. “well when you compare something to heroin, the other drug will always be shit in comparison.” from Visionary_Kpsycho

10. How did we get here?

13. ABINGDON, Va., May 10, 2007 — The company that makes the narcotic painkiller OxyContin and three current and former executives pleaded guilty today in federal court here to criminal charges that they misled regulators, doctors and patients about the drug’s risk of addiction and its potential to be abused From left, Howard R. Udell, the top lawyer for Purdue Pharma; Dr. Paul D. Goldenheim, the company’s former medical director; and Michael Friedman, Purdue’s president. Credit Photographs by Don Petersen for The New York Times

14. The United States experienced a sharp rise in prescriptions for opioid analgesics following the introduction of the Pain Management Standards. A recent study found that physicians prescribed opioids, often in high doses, in more than half of 1.14 million nonsurgical hospital admissions. According to the Centers for Disease Control and Prevention,sharp increases in opioid prescribing have led to parallel increases in opioid addiction and overdose deaths. Since the Pain Management Standards were introduced 15 years ago, more than 200,000 Americans have died from accidental overdoses involving prescription opioids Letter from PROP to TJC

15. The Joint Commission first established standards for pain assessment and treatment in 2001 in response to the national outcry about the widespread problem of undertreatment of pain. The Joint Commission’s current standards require that organizations establish policies regarding pain assessment and treatment and conduct educational efforts to ensure compliance. The standards DO NOT require the use of drugs to manage a patient’s pain; and when a drug is appropriate, the standards do not specify which drug should be prescribed. TJC – rebuttal to being “scape- goated”

16. Training in Treatment of Non- Malignant Pain  If it hurts….Give ibuprofen  If it hurts a lot….Give hydrocodone  If it REALLY hurts…..Give something stronger  If it still REALLY hurts….Give more  If it REALLY hurts for a long time….Keep giving more  If it’s getting worse no matter what I prescribe….Discharge patient

17. Nausea/vomiting Sedation/lethargy/dizziness/CNS adverse events (including risk of falls) Constipation and urinary retention Dermatological adverse events Cardiac adverse events Endocrinologic adverse events Psychiatric adverse events Dysimmune effects Hyperalgesia Adverse Effects of Opioids

18. Cost  The costs for prescription narcotics per claim are rising in the U.S. In fact, medical costs are now approximately 59 to 60 percent of workers’ compensation claims costs, according to the National Council on Compensation Insurance (NCCI). Of those medical costs, narcotic drugs account for approximately 25 percent. And the construction industry has seen the greatest increase in workers’ compensation claims resulting from narcotic painkiller addiction.

20. Difference between opioid and non- opioid costs is with workers’ compensation claims “The Soaring Cost of the Opioid Economy,” The New York Times, July 22, 2013

22. Misconceptions Regarding Opioids and Addiction.  Addiction is the same as physical dependence and tolerance  Addiction is simply a set of bad choices.  Pain protects patients from addiction to their opioid medications  Only long-term use of certain opioids produces addiction

26. In the face of all this…. FDA approved since 2014  Targiniq ER (oxycodone and naloxone)- not yet marketed  New labeling for Embeda (morphine sulfate and naltrexone hydrochloride)  Hysingla ER (hydrocodone bitartrate)  MorphaBond (morphine sulfate), an extended-release (ER) opioid analgesic – not yet marketed  Xtampza ER (oxycodone) (Zohydro ER (hydrocodone) – reformulated, not yet approved as an abuse deterrent opioid)

28. Mitigation Strategies against Opioid Diversion and Misuse.  Screening tools to identify patients with a substance- use disorder (ORT, SOAPP-R)  Use of data from the Prescription Drug Monitoring Program  Use of urine drug screening  Doctor–patient agreement on adherence

29. A bit about dosing opioids

31. Case Study Conversion factor MME Oxycontin 480 mg daily1.5720 Oxycodone 240 mg daily1.5360 Fentanyl 50 mcg/hr every 48 hr (1200 mcg/24h = 1.2 mg/24hr) 2.4 120 x100 TOTAL MME 1200 mg Conversion to methadone approx. 60 mg

32. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain  By panel consensus, a reasonable definition for high dose opioid therapy is >200 mg daily of oral morphine (or equivalent), based on maximum opioid doses studied in randomized trials and average opioid doses observed in observational studies. Some studies suggest that hyperalgesia, neuroendocrinologic dysfunction, and possibly immunosuppression may be more likely at higher opioid doses, though more evidence is needed to define these risks, their relationship to dose, and their relationship to clinical outcomes.  J Pain. 2009 Feb; 10(2): 113–130. doi: 10.1016/j.jpain.2008.10.008

33. The American Pain Society in Conjunction with The American Academy of Pain Medicine Summary of evidence There is insufficient evidence (no studies that met inclusion criteria) to evaluate benefits and harms of high (>200 mg/day) doses of opioids versus lower doses.

34. Inpatient detoxification Usually employs a fairly rapid tapering protocol in conjunction with behavioral therapy. This setting is considered for those patients who: a) are medically unstable b) fail outpatient programs c) are non-compliant d) have comorbid psychiatric illness e) require polysubstance detoxification.

35. Outpatient detoxification Commonly employs a slower tapering protocol. A taper using the prescribed short-acting opioid is frequently employed.  There is no single protocol that has been proven more efficacious than another  Regardless of the strategy used, the provider needs to be involved in the process and remain supportive of the patient and his/her family.

36. VA Suggested Tapering Regimens for Short-Acting Opioids [USVA 2003] ● Decrease dose by 10% every 3-7 days, or… ● Decrease dose by 20%-50% per day until lowest available dosage form is reached (e.g., 5 mg of oxycodone) then increase the dosing interval, eliminating one dose every 2-5 days.

37. VA Suggested Tapering Regimens for Long-Acting Agents [USVA 2003] Methadone ● Decrease dose by 20%-50% per day to 30 mg/day, then… ● Decrease by 5 mg/day every 3-5 days to 10 mg/day, then... ● Decrease by 2.5 mg/day every 3-5 days. Morphine CR (controlled-release) ● Decrease dose by 20%-50% per day to 45 mg/day, then… ● Decrease by 15 mg/day every 2-5 days. Oxycodone CR (controlled-release) ● Decrease by 20%-50% per day to 30 mg/day, then… ● Decrease by 10 mg/day every 2-5 days. Fentanyl – first rotate to another opioid, such as morphine CR or methadone.

38. Treatment of Opioid Withdrawal Symptoms  Anti-adrenergics, e.g. clonidine  Benzodiazepines  NSAIDs  Anti-spasmodics/anti-cholingerics, e.g., dicyclomine  “Muscle relaxers”  Anti-emetics  Anti-diarrheals

39. Now what?

41. Opioid are NOT the only way to manage chronic pain  Physical  Non-addictive medications  Interventional procedures  Physical therapy  Massage therapy  Yoga  Acupuncture  Biofeedback

42. Opioid are NOT the only way to manage chronic pain  Spiritual  Meditation  Mindfulness  Religious practices  Energetic  Energy medicine (both physical and spiritual  Multiple varieties (Reiki, etc)

43. Opioid are NOT the only way to manage chronic pain  Psychological  Therapy (CBT,DBT, etc.)  EMDR  Change beliefs and perceptions  The problem of catastrophizing  Emotional  Grief counseling  Healthy coping with feelings

44. Continuing Care is Essential

46. Structure  Aftercare Plan  Group therapy  Individual therapy  Spiritual Growth (12 step programs, etc)  Continued work with Pain Management Physician  Accountability  Drug testing  Prescription Drug Monitoring Program  Activities  Resocialization  Volunteerism  Anti-craving medications

47. Challenges for reducing or eliminate opioids in WC pts.  Very few health care providers with the experience and training to care for these patients  Very few health care providers willing to care for these patients  Few resources to care for those who need higher level of care than outpatient management (i.e., hospitals, chem dep treatment centers, dual diagnosis programs)  Poor integration with ”normal” health care system

48. Antagonist Therapy -naltrexone  Oral or IM (Vivitrol)  Antagonizes opioid-containing agents but no other significant drug-drug interaction  Side effects are most commonly GI (nausea, abdominal pain, decreased appetite), daytime sleepiness, fatigue, insomnia, headache  Reversible hepatotoxicity  Need to monitor LFTs

50. Risks Following Opioid Detox

51. Increased Risk of Overdose Treatment of overdoses with naloxone (Narcan)

52. Acute Pain or Need for Surgery  Have a Plan  Marshall resources – family, friends, sponsor  Communicate with surgeon or other practitioners who may be prescribing medications  Treat the pain  Closely monitor  Patients should NOT control their own medications  Increase recovery activities  Consider inpatient detox

53. Thank-you and enjoy AC!